Content uploaded by Joseph Mcveigh
Author content
All content in this area was uploaded by Joseph Mcveigh
Content may be subject to copyright.
REVIEW ARTICLE
The effectiveness of hydrotherapy in the management
of fibromyalgia syndrome: a systematic review
Joseph G. McVeigh ÆHelen McGaughey Æ
Melissa Hall ÆPatricia Kane
Received: 1 May 2008 / Accepted: 1 August 2008
Springer-Verlag 2008
Abstract Hydrotherapy is often used in the treatment of
fibromyalgia syndrome (FMS), however there has been
limited evaluation of its effectiveness. The aim of this
systematic review was therefore to examine the effective-
ness of hydrotherapy in the management of FMS. AMED,
BNI, CINAHL, The Cochrane Library, EMBASE, MED-
LINE, ProQuest, PubMed, Science Direct and Web of
Science were searched (1990–July 2006). Key words used
‘fibromyalgia’ and ‘hydrotherapy’, ‘balneotherapy’, ‘aqua
therapy’, ‘pool therapy’, ‘water therapy’, ‘swimming’,
‘hydrogalvanic’, ‘spa therapy’, ‘physiotherapy’, ‘physical
therapy’ and ‘rehabilitation’. Searches were supplemented
with hand searches of selected journals. Randomised con-
trolled trials (RCTs) were assessed for methodological
quality using the van Tulder scale. Ten RCTs met the
inclusion criteria. Mean methodological quality was 4.5/9
on the van Tulder scale. Positive outcomes were reported
for pain, health-status and tender point count. There is
strong evidence for the use of hydrotherapy in the man-
agement of FMS.
Keywords Fibromyalgia Hydrotherapy
Systematic review Physiotherapy
Introduction
Fibromyalgia syndrome (FMS) is a chronic non-articular
rheumatological condition characterised by widespread
musculoskeletal pain, increased pain at tender points and is
often accompanied by symptoms such as fatigue, non-
restorative sleep, stiffness, depression and anxiety [1].
Although figures vary to some extent, in western society
FMS has an estimated prevalence of 2%; affecting women
(3.4%) six times more commonly than men (0.5%) [2].
Management of FMS is difficult and treatment is predom-
inantly symptomatic, consequently a wide variety of
interventions are used in the management of the condition
[3,4]. In a recent comprehensive review of the effectiveness
of a variety of pharmacological and non-pharmacological
interventions in FMS, Goldenberg et al. [3] found that with
respect to medications there was strong evidence for the use
of tricyclic antidepressants, modest evidence for Tramadol
and a number of duel serotonin and norepinephrine reuptake
inhibitors in FMS.
With respect to the non-pharmacological interventions,
exercise intervention constitutes one of the mainstays of
FMS management, and commonly includes hydrotherapy
interventions [5]. Indeed a survey of the physiotherapy
management of patients with FMS in Northern Ireland
reported that exercise and hydrotherapy were the most
commonly used treatment approaches [6]. A number of
reviews have investigated the importance of physical
exercise in this condition [5,7–10]. Busch et al. [7] for
example, reported that there was moderate to strong evi-
dence that exercise interventions produced only short-term
J. G. McVeigh (&)
School of Health Sciences, Health and Rehabilitation Sciences
Research Institute, University of Ulster,
Newtownabbey BT37 0QB, Northern Ireland, UK
e-mail: j.mcveigh@ulster.ac.uk
H. McGaughey P. Kane
Physiotherapy Department, Musgrave Park Hospital, Belfast
Health and Social Care Trust, Belfast, Northern Ireland, UK
M. Hall
Physiotherapy Department, Craigavon Area Hospital, Southern
Health and Social Care Trust, Portadown, Northern Ireland, UK
123
Rheumatol Int
DOI 10.1007/s00296-008-0674-9
improvements in fitness and tender point pain in those with
FMS. They also concluded that the effects of aerobic
training on pain, fatigue, and sleep are weak and incon-
sistent. Similarly in a comprehensive review of the non-
pharmacological management of FMS (25 RCTs) Sim and
Adams [8] reported that strong evidence did not emerge for
any single intervention. However, they reported that there
was preliminary support for the use of aerobic exercise in
the management of FMS, particularly when delivered as
part of a multimodal package. More recently Jones et al. [9]
in a review of 46 exercise based studies, which included
seven exclusively pool-based studies, reported that the
strongest evidence supported the role of exercise in the
management of FMS symptoms. However, van Koulil et al.
[10] in a review of 30 RCTs of cognitive behavioural
therapies and exercise programmes for FMS concluded that
non-pharmacological treatment interventions in FMS have
only limited effects.
Although hydrotherapy interventions have been inclu-
ded in the cited reviews [5,8–11], only Gowans and
deHueck [12] have specifically investigated the effects of
hydrotherapy in FMS. However, this review included only
those studies (eight RCTs) where participants had pool
based exercise; hydrotherapy without exercise was not
included in the Gowans and deHueck [12] review conse-
quently no conclusions on the benefits or otherwise of
hydrotherapy alone can be made. The aim of this current
review therefore was to evaluate the effectiveness of all
hydrotherapy interventions in the management of patients
with FMS.
Methods
An electronic database search of AMED, BNI, CINAHL,
The Cochrane Library, EMBASE, MEDLINE, ProQuest,
PubMed, Science Direct and Web of Science was conducted
in July 2006. In order to try to standardize the patient sample
included, the search was conducted from 1990 (the date of
publication of the American College of Rheumatology’s
(ACR) classification criteria for FMS [1]) to July 2006.
Searches were also limited to human trials published in the
English language. Key words searched, in combination
with ‘fibromyalgia’ (e.g. fibromyalgia and hydrotherapy),
were ‘hydrotherapy’, ‘balneotherapy’, ‘aqua therapy’, ‘pool
therapy’, ‘water therapy’, ‘swimming’, ‘hydrogalvanic’,
‘spa therapy’, ‘physiotherapy’, ‘physical therapy’ and
‘rehabilitation’.
The database search was supplemented by a manual
search of: The Annals of the Rheumatic Diseases, British
Medical Journal, Physiotherapy, Arthritis and Rheumatism,
Rheumatology, Journal of Rheumatology, Clinical Journal
of Rheumatology and Physical Therapy. Journals were
searched from 1990 - June 2005. Reference lists of all
relevant articles were examined for additional studies.
After reviewing the abstracts, articles were classified
highly relevant, moderately relevant or irrelevant. Highly
relevant articles were RCTs in which intervention subjects
had a form of water-based therapy, and all participants
were diagnosed with FMS. Moderately relevant articles
were those that failed to meet the ‘highly relevant’ criteria
yet provided background information regarding FMS. All
other articles were deemed irrelevant to this review.
Inclusion/exclusion criteria
To be included in the review, studies had to be an RCT, in
the English language; participants had to be at least
18 years of age and had to be diagnosed with FMS
according to the 1990 ACR criteria [1]. Additionally the
treatment group had to have undertaken a water-based
intervention which constituted more than 50% of the
treatment, furthermore the control group must not have
participated in water-based activity. Participants should
have been assessed in at least one of three outcomes: pain,
function, or quality of life (QoL); and participants should
have been followed up for a minimum of 6 weeks post
intervention. Articles were excluded if insufficient infor-
mation was available to permit methodological evaluation
or if complex multimodal programmes were used. Articles
were also excluded if participants had any concomitant
medical condition.
Three reviewers (MH, HMcG, PK) independently applied
the inclusion/exclusion criteria to papers identified from the
literature search as highly relevant before combining results.
A consensus method was used to solve any dispute regarding
the inclusion or exclusion of a study. A fourth reviewer was
consulted (JMcV) to resolve disagreements.
Methodological quality
Articles fulfilling the inclusion criteria were subsequently
assessed for methodological quality using the criteria list and
operational instructions outlined and recommended by van
Tulder et al. [13] (Table 1). This list, originally devised for
back pain was modified in its terminology for FMS. The van
Tulder scale assesses internal validity criteria, descriptive
criteria and statistical criteria. Each criterion was scored yes
(Y), no (N) or do not know (DK) with an answer of yes
scoring one point. Due to the nature of the intervention
neither the patient nor the care provider can be blinded to the
intervention, therefore two of the van Tulder criteria (e and h;
Table 1) were not included in the overall scoring; the max-
imum score available was therefore 17. For the purpose of
Rheumatol Int
123
this review the internal validity criteria as recommended by
van Tulder et al. [14] was used to determine overall quality
with a maximum score of nine available. RCTs scoring
greater than 50% (C5 of 9) were arbitrarily considered high
quality, and those scoring\5, low quality [13]. A pilot test of
the scale as recommended by van Tulder et al. [13] was
performed on selected articles not included in the review to
ensure all reviewers agreed on a common interpretation of
the scale items and their operationalisation.
Each article was scored independently by three
reviewers (MH, HMcG, PK), findings compared, and
again a fourth reviewer (JMcV) was consulted to resolve
disagreements.
Data extraction
Data extraction was completed independently by three
reviewers (MH, HMcG, PK) to ensure no significant
information was omitted, a combined extraction table was
then compiled (Table 2).
Study outcomes
The outcome of each study was determined by the results
of the primary outcome measures, i.e. those examining
pain, function and QoL. A study was rated positive if
participants receiving the intervention demonstrated
greater improvements over the control group. Conversely,
a study was deemed negative if there were no between-
group differences, or if the control group exhibited greater
improvements. Finally, if contradictory results existed
between outcome measures, studies were deemed
inconclusive.
Due to the heterogeneous nature of the interventions, a
meta-analysis was considered inappropriate, and a quali-
tative review was undertaken. Conclusions regarding the
effectiveness of each modality, and hydrotherapy as a
whole were drawn based on a rating system commonly
used in systematic reviews [16].
•Strong evidence—multiple relevant, high quality RCTs
with generally consistent findings.
•Moderate evidence—generally consistent findings in
one relevant, high quality RCT and one or more
relevant, low quality RCTs or by generally consistent
findings in multiple low quality RCTs.
•Limited or conflicting evidence—one relevant RCT (of
high or low quality) or inconsistent findings in multiple
RCTs.
•No evidence—no RCTs available.
Table 1 Criteria list for
methodological quality
assessment (van Tulder et al.
[15])
Internal validity criteria: b, e, f,
g, h, i, j, l, n, p
Descriptive criteria: a, c, d, k, m
Statistical criteria: o, q
Patient selection
(a) Were the eligibility criteria specified? Y/N/DK
(b) Treatment allocation
1) Was a method of randomisation performed?
2) Was the group allocation concealed?
Y/N/DK
Y/N/DK
(c) Were the groups similar at baseline regarding the most important prognostic indicators? Y/N/DK
Interventions
(d) Were the index and control interventions explicitly described? Y/N/DK
(e) Was the care provider blinded to the intervention? Y/N/DK
(f) Were co-interventions avoided or comparable? Y/N/DK
(g) Was the compliance acceptable in all groups? Y/N/DK
(h) Was the patient blinded to the intervention? Y/N/DK
Outcome
(i) Was the outcome assessor blinded to the intervention? Y/N/DK
(j) Were the outcome measures relevant? Y/N/DK
(k) Were adverse effects described? Y/N/DK
(l) Was the withdrawal/dropout rate described and acceptable? Y/N/DK
(m) Timing follow-up measurements
1) Was a short-term follow-up measurement performed?
2) Was a long-term follow-up measurement performed?
Y/N/DK
Y/N/DK
(n) Was the timing of the outcome assessment in both groups comparable? Y/N/DK
Statistics
(o) Was the sample size for each group described? Y/N/DK
(p) Did the analysis include-an-intention to treat analysis? Y/N/DK
(q) Were point estimates and measures of variability presented for the primary outcome? Y/N/DK
Rheumatol Int
123
Table 2 Data extraction table
Author Sample
size
Dropouts Referral source Intervention Outcome measures Patient
assessment/
follow up
Results/comments Internal
validity
score
Buskila et al.
[26]
A: 24
B: 24
NS
NS
Outpatient clinic A: Balneotherapy: 20 min in sulphur pool at
37C910 days
B: No treatment
Both groups stayed at the Dead Sea for 10 days
-VAS: for pain,
anxiety,
depression, fatigue,
morning stiffness
and global well-
being.
-FIQ
-FDI
-Dolorimeter
-TPC
•Baseline
•10 days
•1 month
post Rx
•3 months
post Rx
Significant between group improvements in pain and TPC
in favour of A. Still seen after 3 months. Significant
improvements in pain, fatigue, stiffness, anxiety,
function (FDI) over time in A ?B, persisting for at
least 3 months in A. Reduction of TPP for both.
Conclusion: Balneotherapy found to be effective and safe
in the management of FMS.
(outcome: positive)
4
Do
¨nmez
et al. [34]
A: 16
B:14
0
1
Outpatient clinic A: Spa Therapy: thermal
pool baths 36 ±1C920 min 96 days/week for
2 weeks. Pressurized shower at 37C or classical massage,
for 15 min each on alternate days
B: No treatment
Both groups continued with their regular medication
-VAS: pain, anxiety,
fatigue, well-being,
sleep problems,
gastrointestinal
symptoms
-Dolorimeter;
-Point pressure
threshold
-FIQ
-BDI
•Baseline
•2 weeks
•1 month
post Rx
•3 months
post Rx
•6 months
post Rx
•9 months
post Rx
Significant between group improvements in FIQ score (up
to 9 months), pain, TPC (1 month), fatigue and global
assessment found in A only. Pain significantly lower at
6?9 mths for A ?B. Significant improvement in
TPC, global assessment, sleep, pain, anxiety, FIQ score,
fatigue and BDI found in A, compared to baseline. Also
sleep, TPC, anxiety, pain, global assessment, gastric
symptoms, fatigue and BDI improved in B. Conclusion:
Spa therapy may improve FIQ score, relieve pain and
decrease tender point count in addition to regular
medication.
(outcome: Positive)
6
Evcik et al.
[27]
A: 22
B:20
0
0
Unknown A: Balneotherapy: at 36C 20 min/day, 59/week for
3 weeks
B: No treatment
Both groups continued normal daily activities
-Digital pressure:
number of tender
points.
-VAS: pain
-FIQ
-BDI
•Baseline
•3 weeks
•6 months
post Rx
Statistically significant improvements from baseline for A
and between group improvements in TPC, VAS, BDI
(up to 6 months) and FIQ scores for Group A (up to
6 months, except BDI).
Conclusion: Balneotherapy is effective and a possible
alternative method in managing FMS.
(outcome: positive)
5
Gowans et al.
[31]
A: 23
B:22
3
1
Physician A: Pool exercise: for 30 mins (at 60–70% max HR) 29/
week, for 6 weeks, comprised of aerobic endurance and
flexibility exercises. Plus 2 1 h MDT educational group
sessions/week 96 weeks.
B: No treatment
-Modified 6MWT
-Borg rate of
perceived exertion
-ASES
-FIQ
-Knowledge of FMS
Management
(Questionnaire)
•Baseline
•6 wks
•3 mths post
Rx
Significant improvements in aerobic capacity (6 MWT),
well-being (FIQ) and fatigue in A compared to B.
Improvements in well-being and aerobic capacity still
found 3 mths post Rx. Significant improvements from
baseline in A for well-being, aerobic capacity, fatigue,
FMS knowledge.
Conclusion: short-term exercise combined with education
can produce immediate and sustained benefits.
(outcome: positive)
4
Rheumatol Int
123
Table 2 continued
Author Sample
size
Dropouts Referral source Intervention Outcome measures Patient
assessment/
follow up
Results/comments Internal
validity
score
Gusi et al.
[30]
A: 18
B: 17
1
0
Local
FM association
A: Pool exercise: 33C for 60 mins, 39/week for
12 weeks, comprised of stretching, aerobic exercise (at
65–75% max HR), mobility & lower limb strengthening
exercises.
12/52 detraining period post intervention.
B: No treatment- continued normal daily activities
-Isokinetic muscle
strength
-EQ-5D
-Pain VAS
-Spare time and
work activities
questionnaire
•Baseline
•12 weeks
•12 weeks
post
treatment
Statistically significant between group improvements in
pain, EQ-5D scale and 4/5 dimensions of EQ-5D
(mobility, self-care, pain/discomfort, anxiety/
depression), concentric strength (left knee flexion and
bilateral knee extension) post intervention in favour of
A. 12/52 post treatment statistically significant
improvements remained in left knee flexors and EQ-5D
self-care and anxiety/depression in addition to eccentric
right knee extension.
Conclusion: Therapy reduced pain and improved HRQOL
and muscle strength.
(outcome: positive)
5
Jentoft et al.
[32]
A: 22
B: 22
4
6
GP A: Pool-based exercise: modified Norwegian Aerobic
Fitness Model (pool =34C)
B: Land-based exercises: original Norwegian Aerobic
Fitness Model
(Both groups exercised 60 min 2x/week for 20 weeks.
Consisting of body awareness training, ergonomics, warm-
up, cool-down, stretching and relaxation. 40–50% of
sessions at 60–80% max HR)
-FIQ
-VAS: exercise
induced pain
-TPC
-Dolorimeter: tender
-Point pain
-ASES
-Bicycle ergometer:
CV capacity
-Hand held
manometer: grip
strength
-Shoulder muscle
-endurance
-Walking time over
100 m
•Baseline
•20 weeks
•6 months
post Rx
Both groups: significant within group improvements in
fatigue, stiffness, CV capacity ?walking time. A:
additional within group improvements in physical
impairment, days feeling good, pain, anxiety and
depression. Only statistically significant difference
between groups was improved grip strength in favour of
B. At 6 months grip strength deteriorated in A and CV
capacity in B. At 6 months: 85% participating in regular
physical activity.
Conclusion: Physical capacity can be improved with
exercise. Exercising in a pool may offer additional benefits.
(outcome: inconclusive)
6
Mannerkorpi
et al. [33]
A: 37
B: 32
9
2
Primary health care
and rheumatology
clinics
A: Pool exercise: 35 min comprised of endurance,
flexibility, co-ordination and relaxation exercises 1/
week for 6 months and 6 91 h education sessions
focusing on coping strategies and importance of
physical activity
B: Control group
(Both groups continued baseline medical treatment
throughout programme)
– FIQ
– SF-36
– MPI-S
– ASES
– QoL questionnaire
– 6 MWT
– Chair test
– Shoulder ROM
– Grip strength
– Shoulder abduction
Endurance
– AIMS
– Pain diagram
•Baseline
•6 mths
•6 mths post
Rx*
•24 months
post Rx*
* Reported in
follow-up
study
Mannerkorpi
et al. [33]
Significant improvements in FIQ total score, aerobic
performance (6 MWT), grip strength, physical function,
anxiety, depression, general health, social function, pain
severity, distress and quality of life in A compared to B.
At 6 months: significant deterioration in shoulder
function in both groups, and also QoL for B.
Improvements in symptom severity, physical function,
QoL still seen at 6 months post Rx and improvements in
pain, fatigue, walking ability and social function still
evident at 24 months. 50% in A reported increased
activity levels post Rx.
Conclusion: consequences of FM can be improved
following a 6 month programme of pool exercises and
education.
(outcome: positive)
3
Rheumatol Int
123
Table 2 continued
Author Sample
size
Dropouts Referral source Intervention Outcome measures Patient
assessment/
follow up
Results/comments Internal
validity
score
Neumann
et al. [28]
A: 24
B: 24
NS
NS
Outpatient clinic A: Balneotherapy: 20 min daily 910 days in 37C pool
B: Control group: no treatment
(Both groups stayed at the Dead Sea for 10 days)
– SF-36
– AIMS
– Rheumatology
Attitudes index
– VAS scales from the
HAQ for pain,
fatigue, sleep
disturbance,
gastroenterological
problems and global
severity
•Baseline
•10 days
•1 month
Post Rx
•3 months
post
Rx
Significant improvement in fatigue in A compared to B.
Both groups improved significantly over time in global
severity, pain, fatigue, 4/8 subscales on SF-36 (up to
3 months), anxiety and depression (returned to baseline
after 3 months). Overall group A reported greater and
longer lasting improvements.
Conclusion: staying at the Dead Sea in addition to
Balneotherapy can improve the QOL in patients with FM.
(outcome: positive)
4
Yurtkuran
and
Celiktas
[29]
A: 20
B: 20
NS
NS
Unknown A: Balneotherapy- 20 min/day, 59/week for 2 weeks at
37C, followed by relaxation exercises
B: Relaxation exercises only
– Pain: analogue
scores
– Pressure algometry
scores using
1 kg/cm
2
– Temperature-rectal
– Blood pressure
– Pulse rate
•Baseline
•2 weeks
•4 weeks
•6 weeks
No between group analysis performed.
Significant changes in pain and pressure scores for group A
at end of treatment and at 2 ?6 weeks. Pain scores
differed significantly at 2 ?6 weeks only in Group B, with
no significant changes in pressure. Conclusion:
Balneotherapy may be used as an alternative treatment for
FMS.
(outcome: positive)
4
Zijlstra et al.
[35]
A: 84
B: 86
27
10
Out-patients A: Spa Rx 7–8 3 h sessions over 15 days involving 4 out
of: Turkish bath; hot packs with algae; massage lying
under shower; whirlpool; underwater jetstream massage;
pool exercise and massage. Plus 7 1 h group exercise
sessions including warm-up, stretching, low impact
aerobic exercise aimed at 70% max HR. Light exercise
encouraged.
B: Control group: continued physician directed Rx as usual
– RAND 36-item
health survey
– VAS- for general
health and sleep
quality.
– Tender points score
– Graded tender point
score (4 kg pressure)
– FIQ
– BDI
– MPQ-DLV
– Checklist individual
strength (fatigue)
– Modified 6MWT-
physical fitness and
HR monitoring
•Baseline –
1 week
before Rx
•Pre-Rx
•Post Rx
•3 months
Post Rx
•6 months
Post Rx
•12 months
Post Rx
A: reported significant improvements in FIQ score, general
health, 6 MWT distance, fatigue, pain, physical
components of RAND-36 compared to B. A: also
improved additionally in sleep, depression scores and all
subscales of RAND-36 from baseline.
Conclusion: A combination of thalassotherapy, exercise
and patient education may provide temporary benefits for
FM symptoms.
(outcome: positive)
4
6MWT 6 min walk test, AIMS Arthritis impact measurement scales, ASES Arthritis self-efficacy scale, BDI Becks depression index, FM fibromyalgia, FMS fibromyalgia syndrome, FIQ fibromyalgia impact questionnaire, FDI
functional disability index, HAQ health assessment questionnaire, hr hour, HR heart rate, HRQOL health related quality of life, MPQ McGill pain questionnaire, MPQ-DLV p McGill pain questionnaire Dutch language version, min
minute, mth month, MPI-S Swedish version of the multidimensional pain inventory, MDT multidisciplinary team, NS not specified, QoL quality of life, ROM range of movement, Rx treatment, TPC tender point count, TPP tender point
pain, VAS visual analogue scale
Rheumatol Int
123
Results
Search strategy
The search strategy identified more than 1,900 articles.
Nineteen studies were identified as highly relevant, ten of
which fulfilled the inclusion criteria and were included in
the final review. Nine articles were excluded: five because
the treatment groups main intervention was not water
based [17–21], two because they did not undertake a fol-
low-up greater than 6 weeks [22,23], one because
participants had a concomitant chronic disease present and
failed to perform a follow up at six weeks [24], and one
article because the control group participated in water-
based activity [25].
Of the ten articles which met the inclusion/exclusion
criteria interventions used included balneotherapy [26–29],
pool exercise [30–33] and spa therapy [34,35]. The trials
are summarised in Table 2.
Methodological quality of studies
The methodological quality of the studies ranged from
three to six on the van Tulder scale of internal validity
(Table 3), with a mean of 4.5 (standard deviation 0.92).
The three reviewers agreed on approximately 80% of the
criteria with all disagreements solved by consensus. Four
studies [27,30,32,34] were of high quality, scoring higher
on the van Tulder scale with respect to description of
randomisation, use of co-interventions and in these studies
a long-term follow up was conducted. The six remaining
studies were deemed low quality [26,28,29,31,33,35].
Most studies failed to report or include, an intention to
treat analysis [26,28–35] or conceal treatment allocation
[26–34]. All participants were randomised in the included
trials, however, only four studies [32–35] specified the
method used, one of which [33] described randomisation
by sequential allocation according to age (and symptom
duration) a method deemed inappropriate by van Tulder
et al. [13]. In five studies the outcome assessor was blind
to the intervention [26,28,29,32,34] and five studies
reported on adverse effects. Two reported no side effects
[27,29], and three reported adverse effects including mild
and transient rash [26], sunburn and mild gastroenteritis
[35] and a deterioration in shoulder function [33]. It should
also be noted that failure to report on key information
resulted in 35.6% of the total internal validity criteria
scoring a ‘do not know’ (Table 3).
Participants
Participants’ age across the studies ranged from 18 to
72 years, and disease duration ranged from 5.4 months to
42 years. Gowans et al. [31] and Yurtkuran and Celiktas
[29] did not specify the disease duration of participants.
Over 90% of the participants involved in the included
studies were women. Six studies involved women only [26,
28,30,32–34] and four studies included both women and
men [27,29,31,35].
Table 3 Methodological quality scores
Study ab(i) b(ii) cdefg hijklm(i) m(ii) nop qInternal validity
score
Total
score
Buskila et al. [26]YDK DK YYNYDKNY YYDK YY Y Y DK N 410
Donmez et al. [34]YYY YYNYDKNY YNYYY Y Y DK Y 614
Evcik et al. [27]YDK DK YYNYDKNDK Y Y YYY YYY Y513
Gowans et al. [31]YDK DK YYNNY NDK Y N YYY YYN Y410
Gusi et al. [30]YDK DK YYNYY NDK Y N YYY YYN Y512
Jentoft et al. [32]YYDKNYNYY NY YNNYY YYN Y612
Mannerkorpi et al. [33]YNDKYYNNN NDK Y Y YYY YYN Y311
Neumann et al. [28]YDK DK YNNYDKNY YNDK YY Y Y DK Y 49
Yurtkuran and Celiktas,
[29]
YDK DK YNNYDKNY YYDK YN Y Y DK Y 410
Ziljstra et al. [35]YYY YYNNY NDK Y Y NYY N Y DK Y 412
Internal validity criteria: b(i), b(ii), f, g, i, j, l, n, p (e and h excluded)
Descriptive criteria: a, c, d, k, m
Statistical criteria: o, q
Yyes
Nno
DK do not know
Rheumatol Int
123
The average number of participants in the treatment
group post-randomisation and before any withdrawals was
29 (range 16–84), with only two studies [33,35] having
groups with greater than 25 participants. Three studies
failed to specify if all participants completed the study [26,
28,29], and two studies had drop out rates of 22.7% [32]
and 21.8% [35]. It should be noted that 36 of the 37 par-
ticipants who withdrew/dropped out of the trial by Ziljstra
et al. [35] did so after randomisation but before the start of
treatment. Reasons cited for withdrawing or dropping out
of programmes included: personal reasons (family illness,
time constraints, child care, job implications), patients not
returning for post treatment assessment and the diagnosis
of a concomitant chronic condition.
Interventions
Duration of interventions ranged from 20 min/day for
10 days [26] to treatment once a week for 6 months [33].
Balneotherapy
One high quality [27] and three low quality studies [26,28,
29] reported positive outcomes after evaluating the effec-
tiveness of balneotherapy. They found balneotherapy to be
an effective, safe [26] possible alternative treatment for
FMS [27,29] that can improve patients’ QoL [28].
Two studies [26,28] had similar methodology and
subject demographics, however due to the different aims
and outcome measures used in these studies they were
considered separately. Both studies reported a reduction in
FMS related symptoms for up to three months post treat-
ment, and within each study both intervention groups had
significant improvements (P\0.05) over time in pain,
fatigue and anxiety. Evcik et al. [27] also reported signif-
icant between-group improvements in the beck depression
inventory (BDI) score, tender point count (TPC), pain, and
total fibromyalgia impact questionnaire (FIQ) score, with
improvements lasting up to 6 months post treatment. Sig-
nificant improvements in TPC, pain [26], and fatigue [28]
were reported by these authors at 3 months.
Within-group improvements were found in pain [26–29],
TPC, functional disability index (FDI) score [26], social
functioning, mental health, fatigue, general well being,
anxiety, depression, and vitality [28] with improvements
lasting between 8 weeks [29] and 3 months [26]. These
improvements were greater in the treatment group com-
pared to the control group. Improvements noted in the
control group were explained by temporary changes in
lifestyle combined with a less stressful atmosphere when
staying at the Dead Sea [26,28]. The interventions were
largely comparable, with the exception of Yurtkuran and
Celiktas [29] who incorporated relaxation exercises,
although this was controlled for. Taken together, these
studies demonstrate that there is moderate evidence for the
use of balneotherapy in the treatment of FMS.
Pool-based exercise
Four RCTs evaluated the effect of pool-based exercise in
FMS. One high quality [30] and two low quality [31,33]
studies reported positive findings, and one high quality
study [32] reported inconclusive findings. Treatment ses-
sions ranged from 30 min [31] to 60 min [30,32] and
programme duration from 6 weeks [31] to 6 months [33].
Programmes were similar in nature each including aerobic
and flexibility exercises [30–33] with two studies [31,33]
incorporating additional educational sessions.
Gowans et al. [31] found significant between-group
differences (P\0.05) in aerobic capacity and the ‘feel
bad’ and ‘morning fatigue’ subscales of the FIQ in favour
of the treatment group after 6 weeks. Whilst Mannerkorpi
et al. [33] noted significant between-group improvements
(P\0.05) in FIQ-total score, physical function, anxiety, 6-
min walk test, grip strength, general health, social func-
tioning, pain, QoL, depression and affective distress post
treatment for the intervention subjects. Mannerkorpi et al.
[33] also reported a within group deterioration in shoulder
endurance in both groups with an additional decrease in
QoL in the control group. At 24 months, the treatment
group continued to have significant within group
improvements in pain, fatigue, walking and social function
[36]. A between group analysis could not be performed as
the control group were offered the treatment programme
after the initial 6 months.
Gusi et al. [30], using a 12 week pool exercise pro-
gramme, reported significant between group improvements
in pain, EQ-5D score, four out of the five dimensions of
EQ-5D scale (mobility, self-care, pain/discomfort, anxiety/
depression) and concentric strength (left knee flexion
(60
o
/s) and bilateral knee extension (60
o
/s) in favour of the
treatment group post intervention. Twelve weeks post
treatment significant improvements remained in left knee
flexors and the EQ-5D self-care and anxiety/depression
subscales in addition to eccentric right knee extension
(60
o
/s).
Jentoft et al. [32] comparing land and pool based exer-
cise interventions, noted more within group differences for
the pool-based group; however, the only between group
significant difference was grip strength (P\0.05), and this
was in favour of the control group.
Three studies concluded [30,31,33] that pool exercise
improves the signs and symptoms of FMS with immediate
and sustained effects. Jentoft et al. [32] recognised that
pool exercise may offer additional benefits but found no
significant differences between performing a land or pool-
Rheumatol Int
123
based exercise programme. Consequently there is moderate
evidence to support the additional benefits that exercising
in a pool may offer FMS patients.
Spa therapy
Two RCTs, one high quality [34] and one low quality [35],
evaluated spa therapy and reported positive between-group
improvements (P\0.05) in FIQ total score, TPC, fatigue,
and general well being. Between-group improvements
lasted at least three months, with improvements in total
FIQ score still evident at 6 months [34] and improvements
in the modified 6 min walk test still significantly better at
12 months [35]. Ziljstra et al.’s. [35] complex programme
of thalassotherapy, exercise and education makes com-
parison with Do
¨nmez et al. [34] difficult as the
interventions described in the two studies are very differ-
ent. However both studies used similar outcome measures
and performed long-term follow-up assessments. Both
studies [34,35] concluded that spa therapy improved FIQ
scores and relieved pain providing temporary benefits for
patients with FMS. There is moderate evidence to support
that spa therapy is an effective treatment in the manage-
ment of FMS.
Outcome measures
In total, 36 different outcome measures were used across
the ten RCTs included in this review. The number of
outcome measures used by each study ranged from three
[27]to11[33] with the FIQ, visual analogue scale (VAS)
measuring pain and measurement of tender point count/
pressure used most frequently.
All studies assessed pain [26–35], eight assessed fatigue
[26–28,31–35], and only four assessed sleep disturbance
[27,28,34,35]. Notably, only three studies assessed all of
the three most common symptoms of FMS i.e. pain, fatigue
and sleep [28,34,35].
Of the 36 outcome measures used 21 different outcome
measures were used only once, resulting in little stan-
dardisation between the studies. Despite pain being
assessed in all ten trials, there was a lot of variation in how
this was measured. Six trials used a VAS [26,27,29,30,
32,34], whilst others used the McGill pain questionnaire
[35], the Multidimensional Pain Inventory [33] and the
pain subscale of the FIQ [31–33,35], the Arthritis self-
efficacy scale (ASES) [33] and the health assessment
questionnaire (HAQ) [28]. In terms of other outcomes,
seven trials measured health status using the FIQ, five
measured psychological status, and four measured QoL
[28,30,33,35].
Although some studies used the same outcome measure,
studies varied in how these were applied; additionally some
trials used only subscales as opposed to the complete scale.
This was found with the FIQ [26,28,31–33], AIMS [28,
33], HAQ [26,28], checklist of individual strength [35] and
the MPI [33].
Study outcomes
Nine of the RCTs included in this review reported positive
outcomes for the use of hydrotherapy in FMS [26–31,33–
35]. Three of the nine RCTs reporting positive outcomes
were of high methodological quality [27,30,34], therefore,
there is strong evidence to support the use of hydrotherapy
in the management of FMS.
Discussion
The aim of this review was to evaluate the effectiveness of
hydrotherapy in the management of FMS, and to provide
recommendations for future physiotherapy practice and
research. The results demonstrate that various forms of
hydrotherapy: balneotherapy, spa therapy, and pool-based
exercises can be effective in the treatment of FMS.
Improvements were demonstrated in FMS symptoms such
as pain, health status, anxiety, fatigue, in addition to
function and aerobic capacity. However, for the most part,
improvements tended to be short term. Of the ten RCTs
identified in this area most were low quality, common
methodological limitations were, small sample size leading
to under-powered studies, and poor follow up.
Methodological quality
The studies included in this review had some methodo-
logical limitations. Particularly this review found that
many studies failed to report details that would allow
scoring of internal validity (35.6% of internal validity
criteria scored ‘do not know’; Table 3). This finding echoes
that reported in a review of multidisciplinary rehabilitation
in FMS, where 34% of the internal validity criteria scored
‘‘do not know’’ [37]. Clearly describing all aspects of
methodology is necessary to allow more accurate estima-
tion of quality [38].
Study populations
Adequate sample sizes are important in the detection of
between-group differences [32] with larger samples having
greater power to detect if a difference exists [39]. The
sample sizes described were generally small, a failing
previously identified in the FMS literature [8]. High drop
Rheumatol Int
123
out rates in FMS studies contribute to small sample sizes
and are a feature of many FMS trials. Drop out rates were
generally clearly explained but Busch et al. [7] recom-
mends the need to better understand the characteristics of
those patients. Compared to other FMS trials where drop-
out/withdrawal rates have been as high as 21.0% [40],
17.7% [41] and 17.5% [21], the average rate of 11.2%
found in this review is fairly low. This may be attributed to
the inpatient nature or short duration of some studies and
the sense of pleasure reported during exercising in water
[33], all of which may influence compliance.
Co-interventions
Three trials [31,33,35] reported the inclusion of co-
interventions. Evidence has shown that composite treat-
ments are associated with greater improvements [8], for
example, educational programmes when combined with
exercise are more effective than either treatment alone [17,
20]. However, this prevents firm conclusions being drawn
regarding treatment efficacy if co-interventions are not
comparable, as it is impossible to attribute effects to a
specific intervention [42].
Similarly, the multi-modal nature of spa therapy incor-
porates several effective evidence-based interventions, for
example massage [43] and heat packs [44]. The evidence
for other modalities is limited, with some shown to provide
no significant beneficial effects [44]. Once again, the use of
multiple interventions may lead to false conclusions in
interpreting the effectiveness of each individual modality.
The interventions used across the studies in this review
were largely heterogeneous with little standardisation in
terms of the mode, duration, and frequency of treatment
used in the management of patients with FMS. A recent
review [45] has noted that such variable treatment proto-
cols can hinder the comparison of studies.
The variety of measures used in FMS demonstrated in
this review strengthens the call by some researchers for
greater consistency in the measurement of outcomes in
FMS [46]. The FIQ is the only outcome measure specifi-
cally developed and extensively validated for FMS [47]
and was the most common measure used within this
review. It is reported to be the most responsive outcome
measure for perceived clinical improvements [48]. Inclu-
sion of the FIQ in all FMS clinical trials, as recommended
would allow greater comparability across clinical trials
[46,48].
A common problem in FMS studies is the failure to
conduct a long-term follow up [7,8], an issue once again
highlighted in this review. Indeed two RCTs identified
as being ‘highly relevant’ to this review [22,23] were
excluded because they failed to perform a long-term
follow-up.
Limitations of this review
Due to limited resources only those studies published in
English were included, therefore excluding potentially
relevant trials published in other languages. Also searches
were limited to published articles only; as there is a ten-
dency for editors to publish studies with positive findings
[49] this review may be subject to publication bias.
Also to ensure greater homogeneity amongst partici-
pants only studies published after 1990 (post the ACR 1990
classification criteria) were included. Potentially relevant
papers published before this date may have been excluded.
Finally, this review did not assess clinical appropriateness
or cost-effectiveness, but instead concentrated on statistical
significance. It is conceded that statistical significance may
not always reflect clinical significance; this may be a
subject for further investigation.
Further research
This review has highlighted areas for further research.
Additional RCTs are required: to separate the effect of
chemicals and heat in hydrotherapy [26], to identify ther-
apy cost effectiveness [34], to identify additional benefits
of exercising in water [32] and to determine if effects of
hydrotherapy are sustainable enough to be clinically ben-
eficial [31].
Conclusion
This review is the first to evaluate hydrotherapy, in all its
forms, in the management of FMS. Strong evidence
emerged for the effectiveness of hydrotherapy in the
treatment of FMS, with improvements particularly noted in
pain, health status and TPC. Due to the heterogeneous
nature of the interventions, it is difficult to make specific
recommendations for clinical practice, however, it appears
that hydrotherapy (with or without exercise) has a positive
role to play in the management of FMS.
References
1. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C,
Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P,
Fam AG, Farber SJ, Fiechtner JJ, Franklin CM, Gatter RA, Hamaty
D, Lessard J, Lichtbroun AS, Masi AT, McCain GA, Reynolds WJ,
Romano TJ, Russel IJ, Sheon RP (1990) The American College of
Rheumatology 1990 criteria for the classification of fibromyalgia:
report of the multi-centre criteria committee. Arthritis Rheum
33:160–172. doi:10.1002/art.1780330203
2. Wolfe F, Ross K, Anderson J, Russell IJ, Herbert L (1995)
The prevalence and characteristics of fibromyalgia in the
Rheumatol Int
123
general population. Arthritis Rheum 38:19–28. doi:10.1002/art.
1780380104
3. Goldenberg DL, Burckhardt C, Crofford L (2004) Management
of fibromyalgia syndrome. JAMA 292:2388–2395. doi:10.1001/
jama.292.19.2388
4. Burckhardt CS, Goldenberg D, Crofford L, Gerwin R, Gowens S,
Jackson K, Kugel P, McCarberg W, Rudin N, Schanberg L,
Taylor AG, Taylor J, Turk D (2005) Guideline for the manage-
ment of fibromyalgia syndrome pain in adults and children.
American Pain Society, Clinical practice guideline no. 4
5. Mannerkorpi K, Iversen MD (2003) Physical exercise in fibro-
myalgia and related syndromes. Baillieres Best Pract Res Clin
Rheumatol 17:629–647. doi:10.1016/S1521-6942(03)00038-X
6. McVeigh JG, Archer S, Hurley D, Basford JR, Baxter GD (2004)
Physiotherapy management of fibromyalgia syndrome: a survey
of practice in Northern Ireland. Int J Ther Rehabil 11:71–77
7. Busch A, Schachter CL, Pelosso PM, Bombardier C (2002)
Exercise for treating fibromyalgia syndrome (Cochrane Review).
In: The Cochrane Library, issue 2. Update Software, Oxford
8. Sim J, Adams N (2002) Systematic review of randomised
controlled trials of nonpharmacological interventions for fibro-
myalgia. Clin J Pain 18:324–336. doi:10.1097/00002508-
200209000-00008
9. Jones KD, Adams D, Winters-Stone K, Burckhardt CS (2006) A
comprehensive review of 46 exercise treatment studies in fibro-
myalgia (1988–2005). Health Qual Life Outcomes 4:67. doi:
10.1186/1477-7525-4-67
10. van Koulil S, Effting M, Kraaimaat FW, van Lankveld W, van
Helmond T, Cats H, van Riel PL, de Jong AJ, Haverman JF,
Evers AW (2007) Cognitive-behavioural therapies and exercise
programmes for patients with fibromyalgia: state of the art and
future directions. Ann Rheum Dis 66:571–581. doi:10.1136/ard.
2006.054692
11. Hadhazy VA, Ezzo J, Creamer P, Berman BM (2000) Mind-body
therapies for the treatment of fibromyalgia. A systematic review.
J Rheumatol 27:2911–2918
12. Gowans SE, deHueck (2007) Pool exercise for individuals with
fibromyalgia. Curr Opin Rheumatol 19:168–173. doi:10.1097/
BOR.0b013e3280327944
13. van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM, Edito-
rial Board of the Cochrane Collaboration Back Review Group
(1997a) Method guidelines for systematic reviews in the Coch-
rane Collaboration Back Review Group for Spinal Disorders.
Spine 22:2323–2330. doi:10.1097/00007632-199710150-00001
14. van Tulder MW, Koes BW, Bouter LM (1997) Conservative
treatment of acute and chronic nonspecific low back pain: a
systematic review of randomised controlled trials of the most
common interventions. Spine 22:2128–2156. doi:10.1097/
00007632-199709150-00012
15. van Tulder MW, Malmivaara A, Esmail R, Koes B (2000)
Exercise therapy for low back pain: a systematic review within
the framework of the Cochrane Collaboration Back Review
Group. Spine 25:2784–2796. doi:10.1097/00007632-200011010-
00011
16. Bigos S, Bowyer OR, Braen GR, Brown K, Deyo R, Haldeman S,
Hart JL, Johnson EW, Keller R, Kido D, Liang MH, Nelson RM,
Nordin M, Owen BD, Pope MH, Schwartz RK, Stewart DH,
Susman J, Triano JJ, Tripp LC, Turk DC, Watts C, Weinstein JN
(1994) Acute low back problems in adults. Clinical practice
guidelines no.14. AHCPR publication no. 95-0642. Agency for
Health Care Policy and Research, Public Health Service, US
Department of Health and Human Services, Rockville, MD
17. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A (1994) A
randomised, controlled trial of education and physical training for
women with fibromyalgia. J Rheumatol 21:714–720
18. Cedraschi C, Desmeules J, Rapiti E, Baumgartner E, Cohen P,
Finckh A, Allaz AF, Vischer TL (2004) Fibromyalgia: a
randomised, controlled trial of a treatment programme based on
self-management. Ann Rheum Dis 63:290–296. doi:10.1136/ard.
2002.004945
19. Gowans SE, deHueck A, Voss S, Silaj A, Abbey SE, Reynolds
WJ (2001) Effect of a randomised, controlled trial of exercise on
mood and physical function in individuals with fibromyalgia.
Arthritis Rheum 45:519–529. doi:10.1002/1529-0131(200112)
45:6\519::AID-ART377[3.0.CO;2-3
20. King SJ, Wessel J, Bhambhani Y, Sholter D, Maksymowych W
(2002) The effects of exercise and education, individually or
combined, in women with fibromyalgia. J Rheumatol 29:2620–
2627
21. van Santen M, Bolwijn P, Verstrappen F, Bakker C, Hidding A,
Houben H, van der Heijde D, Landewe
´R, van der Linden S
(2002) A randomised clinical trial comparing fitness and bio-
feedback training versus basic treatment in patients with
fibromyalgia. J Rheumatol 29:575–581
22. Assis MR, Silva LE, Alves AMB, Pessanha AP, Valim V,
Feldman D, Neto TLB, Natour J (2006) A randomised control
trial of deep water running: clinical effectiveness of aquatic
exercise to treat fibromyalgia. Arthritis Rheum 55:57–65. doi:
10.1002/art.21693
23. Vitorino DFM, Carvalho LBC, Prado GF (2006) Hydrotherapy
and conventional physiotherapy improve total sleep time and
quality of life of fibromyalgia patients: randomised controlled
trial. Sleep Med 7:293–296. doi:10.1016/j.sleep.2005.09.002
24. Sukenik S, Baradin R, Codish S, Neumann L, Flusser D, Abu-
Shakra M, Buskila D (2001) Balneotherapy at the dead sea area
for patients with psoriatic arthritis and concomitant fibromyalgia.
Isr Med Assoc J 3:147–150
25. Altan L, Bingo
¨l U, Aykac¸ M, Koc¸ Z, Yurtkuran M (2004)
Investigation of the effects of pool-based exercise on fibromy-
algia syndrome. Rheumatol Int 24:272–277. doi:10.1007/s00296-
003-0371-7
26. Buskila D, Abu-Shakra M, Neumann L, Odes L, Shneider E,
Flusser D, Sukenik S (2001) Balneotherapy for fibromyalgia
at the dead sea. Rheumatol Int 20:105–108. doi:10.1007/
s002960000085
27. Evcik D, Kizilay B, Go
¨kc¸en E (2002) The effects of balneo-
therapy on fibromyalgia patients. Rheumatol Int 22:56–59. doi:
10.1007/s00296-002-0189-8
28. Neumann L, Sukenik S, Bolotin A, Abu-Shakra M, Amir M,
Flusser D, Buskila D (2001) The effects of balneotherapy at
the dead sea on the quality of life of patients with
fibromyalgia syndrome. Clin Rheumatol 20:15–19. doi:10.1007/
s100670170097
29. Yurtkuran M, Celiktas M (1996) A randomized, controlled trial
of balneotherapy in the treatment of patients with primary
fibromyalgia syndrome. Phys Med Rehab Kuror 6:109–112
30. Gusi N, Tomas-Carus P, Ha
¨kkinen A, Ha
¨kkinen K, Ortega-
Alonso A (2006) Exercise in waist-high warm water decreases
pain and improves health-related quality of life and strength in
the lower extremities in women with fibromyalgia. Arthritis
Rheum 55:66–73. doi:10.1002/art.21718
31. Gowans SE, deHueck A, Voss S, Richardson M (1999) A ran-
domized, controlled trial of exercise and education for individuals
with fibromyalgia. Arthritis Care Res 12:120–128. doi:10.1002/
1529-0131(199904)12:2\120::AID-ART7[3.0.CO;2-4
32. Jentoft ES, Kvalvik AG, Mengshoel AM (2001) Effects of
pool-based and land-based aerobic exercise on women with
fibromyalgia/chronic widespread muscle pain. Arthritis Care
Res 45:42–47. doi:10.1002/1529-0131(200102)45:1<42::AID-
ANR82>3.0.CO;2-A
Rheumatol Int
123
33. Mannerkorpi K, Nyberg B, Ahlme
´n M, Ekdahl C (2000) Pool
exercise combined with an education program for patients with
fibromyalgia syndrome. A prospective, randomized study.
J Rheumatol 27:2473–2481
34. Do
¨nmez A, Karagu
¨lle MZ, Tercan N, Dinler M, _
Is¸sever HL,
Karagu
¨lle M, Turan M (2005) Spa therapy in fibromyalgia: a
randomised controlled clinic study. Rheumatol Int 26:168–172.
doi:10.1007/s00296-005-0623-9
35. Zijlstra TR, van de Laar MAFJ, Bernelot Moens HJ, Taal E,
Zakraoui L, Rasker JJ (2005) Spa treatment for primary fibro-
myalgia syndrome: a combination of thalassotherapy, exercise
and patient education improves symptoms and quality of life.
Rheumatology 44:539–546. doi:10.1093/rheumatology/keh537
36. Mannerkorpi K, Ahlme
´n M, Ekdahl C (2002) Six- and 24-month
follow-up of pool exercise therapy and education for patients
with fibromyalgia. Scand J Rheumatol 31:306–310. doi:10.
1080/030097402760375223
37. Karjalainen KA, Hurri H, Jauhiainen M, Koes BW, Malmivaara
A, Roine R, van Tulder M (1999) Multidisciplinary rehabilitation
for fibromyalgia and musculoskeletal pain in working age adults
(Cochrane Review). In: The Cochrane Library, issue 3. Update
Software, Oxford
38. de Vet HCW, de Bie RA, van der Heijden GJMG, Verhagen AP,
Sijpkes P, Knipschild PG (1997) Systematic reviews on the basis
of methodological criteria. Physiotherapy 83:284–289. doi:10.
1016/S0031-9406(05)66175-5
39. Geytenbeek J (2002) Evidence for effective hydrotherapy.
Physiotherapy 88:514–529. doi:10.1016/S0031-9406(05)60134-4
40. Valim V, Oliveira L, Suda A, Silva L, de Assis NTB, Feldman D,
Natour J (2003) Aerobic fitness effects in fibromyalgia. J Rheu-
matol 30:1060–1069
41. Richards SCM, Scott DL (2002) Prescribed exercise in people
with fibromyalgia: parallel group randomised controlled trial.
BMJ 325:185–187. doi:10.1136/bmj.325.7357.185
42. Offenba
¨cher M, Stucki G (2000) Physical therapy in the treat-
ment of fibromyalgia. Scand J Rheumatol 113:S78–S85. doi:
10.1080/030097400446706
43. Brattberg G (2003) Connective tissue massage in the treatment of
fibromyalgia. Eur J Pain 3:235–245. doi:10.1016/S1090-3801
(99)90050-2
44. Samborski W, Stratz T, Sobieska M, Mennet P, Muller W,
Schulte-Monting J (1992) Intraindividual comparison of effec-
tiveness of whole-body cold therapy and hot-packs therapy in
patients with generalized tendomyopathy (fibromyalgia). Z
Rheumatol 51:25–31
45. Dawson KA, Tiidus PM (2005) Physical activity in the treatment
and management of fibromyalgia. Crit Rev Phys Rehabil Med
17:53–64. doi:10.1615/CritRevPhysRehabilMed.v17.i1.30
46. Mease P (2005) Fibromyalgia syndrome: review of clinical pre-
sentation, pathogenesis, outcome measures, and treatment.
J Rheumatol 75:S6–S21
47. Burckhardt CS, Clark SR, Bennett RM (1991) The fibromyalgia
impact questionnaire: development and validation. J Rheumatol
18:728–733
48. Dunkl PR, Taylor AG, McConnell GG, Alfano AP, Conaway MR
(2000) Responsiveness of fibromyalgia clinical trial outcome
measures. J Rheumatol 27:2683–2691
49. Helewa A, Walker JM (2000) Critical evaluation of research in
physical rehabilitation: towards evidence-based practice, 1st edn.
Saunders, Philadelphia
Rheumatol Int
123
