healthcare

Review
Aquatic Exercise in Physical Therapy Treatment for
Fibromyalgia: Systematic Review
Manuel Rodríguez-Huguet 1 , Carmen Ayala-Martínez 2, *, Pablo Góngora-Rodríguez 2 ,
Miguel Ángel Rosety-Rodríguez 3 , Rocío Martín-Valero 4 and Jorge Góngora-Rodríguez 1

1 Department of Nursing and Physiotherapy, University of Cádiz, 11009 Cádiz, Spain;

[email protected] (M.R.-H.); [email protected] (J.G.-R.)
2 Doctoral School, University of Cádiz, 11003 Cádiz, Spain; [email protected]
3 Move-It Research Group, Biomedical Research and Innovation Institute of Cadiz, Puerta del Mar University
Hospital, University of Cádiz, Plaza Fragela, s/n, 11003 Cádiz, Spain; [email protected]
4 Department of Physiotherapy, Faculty of Health Sciences, University of Málaga, 29071 Málaga, Spain;
[email protected]
* Correspondence: [email protected]

Abstract: Fibromyalgia is a chronic condition characterized by musculoskeletal pain. The aim of

this study was to synthesize scientific evidence on the effects of aquatic exercise programs on pain
and quality of life in individuals with fibromyalgia. This review was carried out using the following
databases in January 2024: Cochrane Library, PEDro, PubMed, SCOPUS, and Web of Science. Four
clinical trials focusing on aquatic exercise as a treatment for patients with fibromyalgia were selected.
These trials were published in English between 2019 and 2024. Pain recorded using the Visual Analog
Scale (VAS) and quality of life with the Short Form-36 Health Survey (SF-36) or Fibromyalgia Impact
on Quality of Life (FIQ) were the most commonly analyzed variables. This review was carried out
according to the PRISMA statement and was registered in PROSPERO (CRD42024510219). The
results in terms of pain and quality of life were positive. In conclusion, these findings support the
Citation: Rodríguez-Huguet, M.; incorporation of aquatic exercise into fibromyalgia physical therapy treatment. However, the benefits
Ayala-Martínez, C.; could be equivalent to those of other exercise modalities, underscoring the need for individualized
Góngora-Rodríguez, P.;
adaptation to each patient’s needs.
Rosety-Rodríguez, M.Á.;
Martín-Valero, R.;
Keywords: aquatic exercise; fibromyalgia; physical therapy
Góngora-Rodríguez, J. Aquatic
Exercise in Physical Therapy
Treatment for Fibromyalgia:
Systematic Review. Healthcare 2024, 12,
701. https://doi.org/10.3390/
1. Introduction
healthcare12060701 Fibromyalgia is a chronic condition characterized by diffuse musculoskeletal pain,
fatigue, sleep disturbances, and other cognitive and somatic symptoms such as hyperalgesia
Academic Editor: Herbert Löllgen
at specific tender points and headaches [1,2]. The symptomatology limits the functional
Received: 26 February 2024 independence of patients and diminishes their quality of life. It is a syndrome that affects
Revised: 12 March 2024 between 0.2% and 6.6% of the global population, particularly women over the age of
Accepted: 19 March 2024 50 [2,3]. The pathophysiology of this disorder is not clearly defined [2,4], which complicates
Published: 21 March 2024 diagnosis and treatment, although its origin could be related to a combination of genetic,
biological, psychological, and environmental factors [5–8].
Treatment for fibromyalgia typically involves a multidisciplinary approach, including
a combination of medications, physical therapies, stress management techniques, and
Copyright: © 2024 by the authors.
lifestyle changes. The chronic nature of the disease and its significant impact on patients’
Licensee MDPI, Basel, Switzerland.
This article is an open access article
lives result in high socioeconomic costs associated with this condition [9]. This underscores
distributed under the terms and
the necessity for further research to be conducted in order to provide effective treatments,
conditions of the Creative Commons taking into account the need for treatment to be individualized and adapted to the patient’s
Attribution (CC BY) license (https:// capabilities [10].
creativecommons.org/licenses/by/ Active exercise plays a pivotal role in the physiotherapeutic treatment of fibromyal-
4.0/). gia [11]. Though challenging for those afflicted with this condition, incorporating a regular,

Healthcare 2024, 12, 701. https://doi.org/10.3390/healthcare12060701 https://www.mdpi.com/journal/healthcare

Healthcare 2024, 12, 701 2 of 12

supervised exercise program can yield significant benefits in symptom management. Spe-
cific exercises targeting strength, flexibility, and aerobic capacity not only aid in improving
overall physical condition, but also contribute to reducing pain, enhancing sleep quality,
and boosting emotional well-being in fibromyalgia patients [11–13]. Moreover, active
exercise can play a crucial role in promoting autonomy and enhancing the quality of life
for those affected by this condition, equipping them with practical tools to effectively
manage their condition in the long term [14]. Exercise in an aquatic environment has been
proposed as an option within the active exercise program, and its specific effects must be
assessed [11,15]. The aquatic environment is a low-impact adapted environment that could
facilitate joint mobilization and exercise and increase patient motivation.
The objective of this review was to synthesize scientific evidence on the effects of
aquatic exercise programs on pain and quality of life in individuals with fibromyalgia,
assessing their potential for inclusion in physical therapy treatment programs.

2. Materials and Methods

2.1. Review Protocol and Search Strategy
The search for this systematic review was conducted following the Preferred Re-
porting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the review
was registered with the International Prospective Register of Systematic Reviews (PROS-
PERO) with code: CRD42024510219. The search for articles was conducted in January
2024 by two reviewers, consulting the main health sciences databases. Specifically, the
following databases were used: Cochrane Library, PEDro, PubMed, SCOPUS and Web of
Science. The PICOS model was applied to establish the research question: P = population,
fibromyalgia patients; I = intervention, aquatic exercise; C = comparison, other physical
therapy treatments; O = outcomes, pain and quality of life; S = study design, randomized
clinical trials.
To enable the search in the cited databases, the DeCS/MeSH platform was initially
used to define the appropriate descriptors, which were: “aquatic exercise” and “fibromyal-
gia”. These terms were related to the Boolean operator “AND”, so the search in the
different databases began with the following structured language: “aquatic exercise AND
fibromyalgia” because this formula allows you to reproduce and update the search.

2.2. Eligibility Criteria, Study Selection and Data Collection Process

This review applied specific selection criteria, targeting randomized controlled trials
(RCTs) published in the last five years (2019 to 2024), available in English or Spanish.
The studies considered were focused on individuals diagnosed with fibromyalgia who
underwent physical therapy treatment that incorporated active exercises performed in an
aquatic environment. Once duplicate references were removed and the specified filters
were applied, the selection process proceeded to the screening of articles based on title and
abstract readings. The screening was performed by two independent reviewers (J.G.-R. and
C.A.-M.), and in cases of conflict a third reviewer (M.R.-H.) from the research team was
consulted. The reviewers verified that the articles met the previously established selection
criteria. Additionally, it was required that the articles include pain and quality of life among
their primary variables.
To ensure methodological qualities across studies, a minimum threshold of 7 points
on the PEDro scale was imposed as a criterion. The score of all selected articles was
checked on the PEDro website. The intention was to collect the most current studies with
high methodological quality. The entire sample, along with allocation within each group,
was examined in all studies. Detailed records covering variables, treatment modalities,
intervention durations, follow-up intervals, and trial results were meticulously compiled to
facilitate comprehensive scrutiny and analysis. However, a qualitative analysis was chosen
due to the heterogeneity of the treatment proposals included.
 Healthcare 2024, 12, 701 3 of 12

2.3. Quality Assessment of Studies

The methodological quality of scientific articles is an essential element to assess the
validity and reliability of the findings and thus determine the inclusion of the articles in
the review. The PEDro scale (Physiotherapy Evidence Database) is a tool widely used for
this purpose in the field of physiotherapy. This scale is made up of 11 items and evaluates
aspects such as allocation concealment, blinding of participants and evaluators, and follow-
up of lost patients, among others [16]. Despite having 11 questions to evaluate, the final
score of each article is calculated ignoring the first item, obtaining a score from 0 to 10. For
this review, only articles with a minimum score of 7 were selected.
Furthermore, thanks to the PEDro scale, it is possible to monitor the risks of bias. It
encompasses factors that facilitate the assessment of risk of bias. Specifically, items 2 and
3 address selection bias, items 5 and 6 pertain to performance bias, and item 7 focuses
on detection bias. Consequently, a high PEDro score signifies strong methodological
integrity and minimal risk of bias, while a low score suggests an increased risk of bias and
compromised methodological quality.

3. Results
3.1. Study Selection
Healthcare 2024, 12, x FOR PEER REVIEW 4 of 13
The PRISMA flow diagram (Figure 1) shows the screening process and the systematic
review phases according to the established selection criteria. The initial search offered a
total of 296 studies, of which 4 met all of the requirements and were finally selected.

Figure 1. PRISMA flow diagram. Identification of the results obtained from the databases.

Figure 1. PRISMA flow diagram. Identification of the results obtained from the databases.

The total number of results analyzed was 157 articles, after eliminating duplicate re-
sults. The type of article and the language in which they were available reduced the num-
ber of articles to 24. Finally, 20 articles were excluded due to their score on the PEDro scale
Healthcare 2024, 12, 701 4 of 12

The total number of results analyzed was 157 articles, after eliminating duplicate
results. The type of article and the language in which they were available reduced the
number of articles to 24. Finally, 20 articles were excluded due to their score on the PEDro
scale or because they were dedicated to other types of interventions not based on aquatic
exercise or studied other pathologies.

3.2. Sample Population Characteristics and Methodological Quality Assessment

In total, the combined sample size across the selected studies comprised 157 subjects,
with an average age of 48.53 years [17–20]. All participants were women; in the majority
of selected studies, female sex was established as an inclusion criterion [17,19,20], and
even when the recruitment was aimed at both sexes, the sample obtained was also entirely
women [18]. The selection of the sample was determined by a diagnosis of fibromyalgia
syndrome, following the diagnostic guidelines of the American College of Rheumatology;
individuals with another associated disease were excluded [17–20].
Table 1 shows the most relevant information of each of the selected articles, such as
the number of participants and the distribution of the groups, the clinical variables of the
study, and the follow-up time of the interventions. Table 2 includes information about the
aquatic exercise treatment, alternative interventions, and the most outstanding results of
each investigation.

Table 1. Characteristics of the trials included in the systematic review.

Participants
Author (Year) Clinical Variables Assessment Time Frequency of Treatment
(Groups)
VAS
FIQ
SF-36 Baseline
N = 54
Andrade et al. (2019) [17] BAI Post-treatment 32 sessions in 16 weeks
(27/27)
BDI 32 weeks
PPT
PSQI
VAS
N = 33 FIQ Baseline
Britto et al. (2020) [18] 24 sessions in 8 weeks
(16/17) TP Post-treatment
Flexibility
VAS
FIQ
N = 42 SF-36 Baseline
De Medeiros et al. (2020) [19] 24 sessions in 12 weeks
(21/21) FABQ Post-treatment
PRCTS
PSQI
VAS
N = 28 Baseline
Salm et al. (2019) [20] FIQ 18 sessions in 6 weeks
(14/14) Post-treatment
SF-MPQ
Abbreviations. BAI: Beck’s Anxiety Inventory; BDI: Beck’s Depression Inventory; FABQ: Fear Avoidance Beliefs
Questionnaire; FIQ: Fibromyalgia Impact on Quality of Life; PPT: Pressure Pain Threshold; PRCTS: Pain-Related
Catastrophizing Thoughts Scale; PSQI: Pittsburgh Sleep Quality Index; SF-36: Short Form-36 Health Survey;
SF-MPQ: Short Form McGill Pain Questionnaire; TP: Tender Points; VAS: Visual Analog Scale.

The detailed characteristics of each intervention and the statistical results of each study
are indicated in the following sections.
Table 3 represents the total score of each investigation on the PEDro scale and its indi-
vidual assessment for each item. In this way, the methodological quality and the possible
risk of bias have been assessed, obtaining a score of 8 in all of the articles analyzed [17–20].
Therefore, the consistency of the clinical trials studied was appropriate, and the risk of bias
Healthcare 2024, 12, 701 5 of 12

can be considered low. The main deficiency is observed in the blinding of patients and
therapists, which is especially complicated in this type of intervention.
Table 2. Interventions and results of the trials that were included in the systematic review.

Author (Year) Aquatic Exercise Treatment Alternative Treatment Results

45′ per session (stretching the muscles ↓ VAS
of the limbs and neck; walking ↓ FIQ
The control group was
exercises and lateral displacement; ↑ SF-36
instructed to maintain their
Andrade et al. (2019) [17] lower limb exercises sitting on floats; ↓ BAI
baseline levels of
jumping on a trampoline; exercises on =BDI
physical activity
an aquatic cycle; resistance exercises ↑ PPT
of upper limbs; floating relaxation). =PSQI
60′ per session (warm-up, ↓ VAS
60′ per session (warm up; active
active stretching, ↓ FIQ
Britto et al. (2020) [18] stretching; strengthening exercises for
strengthening, and relaxation ↓ TP
limbs; floating relaxation).
equivalent to aquatic exercise) ↑ Flexibility
50′ per session of mat Pilates
↓ VAS
40′ per session (warm up; six mobility (9 main exercises based on
↓ FIQ
exercises of limbs with coordination core motor control and lower
↑ SF-36
De Medeiros et al. (2020) [19] between flexion of upper and lower limb mobility, series of
↓ FABQ
limbs; cool down. Intensity exercises 8 repetitions, progression
=PRCTS
moderated by the Borg scale). from 1 to 3 series; 3 relaxation
=PSQI
exercises, 30′ for each)
50′ per session (stretching exercise;
aerobic warm-up; passive stretching; ↓ VAS
Aquatic therapy in
Salm et al. (2019) [20] aerobic aquatic fast walking, running, ↓ FIQ
both groups
and jumping; strength exercise of ↓ SF-MPQ
limbs and trunk; cool down).
Abbreviations. BAI: Beck’s Anxiety Inventory; BDI: Beck’s Depression Inventory; FABQ: Fear Avoidance Beliefs
Questionnaire; FIQ: Fibromyalgia Impact on Quality of Life; PPT: Pressure Pain Threshold; PRCTS: Pain-Related
Catastrophizing Thoughts Scale; PSQI: Pittsburgh Sleep Quality Index; SF-36: Short Form-36 Health Survey;
SF-MPQ: Short Form McGill Pain Questionnaire; TP: Tender Points; VAS: Visual Analog Scale; ↑: increase;
↓: decrease.

Table 3. PEDro score details.

Author (Year) PEDro Scale

1 2 3 4 5 6 7 8 9 10 11 Score
Andrade et al. (2019) [17] Y Y Y Y N N Y Y Y Y Y 8/10
Britto et al. (2020) [18] Y Y Y Y N N Y Y Y Y Y 8/10
De Medeiros et al. (2020) [19] Y Y Y Y N N Y Y Y Y Y 8/10
Salm et al. (2019) [20] N Y N Y Y N Y Y Y Y Y 8/10
Abbreviations. N: No; Y: Yes. Details of items. 1: Eligibility criteria; 2: Random allocation; 3: Concealed allocation;
4: Baseline comparability; 5: Blind subjects; 6: Blind therapists; 7: Blind assessors; 8: Adequate follow-up;
9: Intention-to-treat analysis; 10: Between-group comparisons; 11: Point estimates and variability. Note: Eligibility
criteria (item 1) does not contribute to total score. Score was checked on PEDro website.

3.3. Outcomes, Measurements, and Assessment Time

The analyzed articles recorded changes in the clinical manifestations of fibromyalgia
syndrome and other associated study variables. The assessment of pain through the Visual
Analog Scale (VAS) scale was the most common study variable, appearing in all of the
selected results [17–20]; likewise, Salm et al. (2019) [20] also included pain monitoring
using the Short Form McGill Pain Questionnaire (SF-MPQ). Furthermore, the research by
Andrade et al. (2019) [17] used the VAS to estimate fatigue and well-being.
Along the same lines, the assessment of health-related quality of life and the impact of
fibromyalgia on the quality of life were widely studied. Thus, the Short Form-36 Health
Healthcare 2024, 12, 701 6 of 12

Survey (SF-36) was included in two of the clinical trials [17,19], and the Fibromyalgia
Impact on Quality of Life (FIQ) questionnaire was used in all studies [17–20].
It is possible to highlight that De Medeiros et al. (2020) [19] valued beliefs, fear, and
catastrophism with the Fear Avoidance Beliefs Questionnaire (FABQ) and Pain-Related
Catastrophizing Thoughts Scale (PRCTS), as well as sleep quality with the Pittsburgh Sleep
Quality Index (PSQI), which was also included in another article [17]. On the other hand,
Britto et al. (2020) [18] included an assessment of the digital palpation of tender points
according to standardized guidelines and also valued flexibility with Well’s bench sit and
reach test. Salm et al. (2019) [20] incorporated infrared thermography analysis and studied
biochemical markers with the analysis of the serum level of cytokines. In addition, Andrade
et al. (2019) [17] assessed the Pressure Pain Threshold (PPT), Beck’s Anxiety Inventory
(BAI), Beck’s Depression Inventory (BDI), and other variables related to intensity and
response to exercise, such as oxygen uptake (VO2 ) and the submaximal cardiopulmonary
exercise test (CPET).
Regarding the follow-up time of the interventions, three of the selected studies exclu-
sively carry out a baseline and post-treatment evaluation [18–20], and one of the investiga-
tions used a longer-term follow-up, with an evaluation 32 weeks after the start of the study
and 16 weeks after the end of treatment [17].

3.4. Interventions, Protocols and Effects of Treatments

The treatment proposals analyzed coincide in including individualized interventions
or sessions in small groups under the supervision of a physiotherapist specialized in aquatic
exercise [17–20]. The intervention protocols of Britto et al. (2020) [18] and De Medeiros
et al. (2020) [19] included a comparison of an aquatic exercise treatment versus another
exercise modality on land, such as Pilates exercises on the floor [19] or an exercise program
(warm-up, active stretching, strengthening, and relaxation) on land [18]. However, Salm
et al. (2019) [20] included aquatic therapy in both groups. In that case, active exercise was
accompanied by a temperature-raising therapeutic procedure in one group and a placebo
T-shirt therapy in the other.
Moreover, Andrade et al. (2019) [17] described the full design of the protocol in a
previous publication [21], and included a control group instructed to maintain their baseline
levels of physical activity. With respect to the facilities and characteristics of the aquatic
environment, specific pools were used for aquatic exercise with dimensions between 8 and
12 m long, 4 and 6 m wide, and 1.20 and 1.65 m deep [18,20]. The water temperature in all
interventions was between approximately 30 ◦ C and 33 ◦ C [17–20].
The duration of the intervention varied in the different articles, with two or three
exercise sessions per week (on alternate days), extending the program for 6, 8, 12, or
16 weeks [17–20]. The effective treatment time of each session was 40 min [19], 45 min [17],
50 min [20], or 60 min [18]. All treatment protocols included a warm-up based on mobility
exercises inside or outside the aquatic environment [17–20], and also included cool-down
exercises or a return to calm through floating relaxation [17,18].
One of the studies [17,21] based its treatment on a warm-up with stretching the muscles
of the limbs and neck and walking exercises with lateral displacement (15 min), followed
by aerobic exercises in three levels (30 min): lower limb exercises sitting on floats; jumping
on a trampoline; exercises on an aquatic cycle; and resistance exercises of the upper limbs.
It was also the protocol with the highest number of sessions in total [22].
Another of the clinical trials [18] included stretching exercises of the entire posterior and
anterior muscle chain through three repetitions of 15 to 25 s and three sets of 15 repetitions
for each strength exercise, using shin guards for the lower limbs and floats for the upper
extremities. Likewise, another treatment option of aerobic exercises included 6 mobility
exercises in the pool versus a total of 12 exercises of mat Pilates focused on trunk control
with limb mobility, also using a Pilates ball for relaxation at the end of the session [19].
Otherwise, the last one of the aquatic exercise proposals was associated with an increase
in temperature through far-infrared (FIR) therapy versus a placebo method (participants in
Healthcare 2024, 12, 701 7 of 12

the intervention group wore t-shirts printed with FIR-emitting ceramic microparticles while
subjects in the placebo group wore t-shirts with another composition) [20]. This exercise
program included stretching, warm up in water with walking movements, aerobic and
strength exercises (walking, running, and jumping, for example: pedaling, kicking the water,
relay races, or alternative jumps) and a cool down [20].
In the intervention of Andrade et al. (2019) [17] described in Andrade et al. (2017) [21],
exercise control was regulated by heart rate, ventilatory anaerobic threshold, and VO2
levels, so that participants went through three levels of aerobic exercise in the main phase
of training. The protocol of Salm et al. (2019) [20] measured the intensity of exercise and
adapted the sessions using the heart rate, and De Medeiros et al. (2020) [19] moderated the
aerobic exercise on the Borg scale.
The effects obtained from the interventions can be considered positive for the state
of health and well-being of patients with fibromyalgia [17–20]. Clinical symptoms, based
mainly on pain analysis, improved with aquatic exercise treatment. Specifically, Andrade
et al. (2019) [17] indicated a statistically significant reduction in pain on the VAS scale
(p = 0.05), an impact on quality of life with the FIQ scale (p < 0.01), and also an increase
in PPT (p = 0.05) after treatment. However, after the intervention, this research did not
find a statistical correlation between the beneficial effects of the intervention on the clinical
manifestations of the disease and changes in markers of exercise intensity and body com-
position [17]. In addition, in the comparison between groups, the aquatic exercise group
presented higher PPT (p < 0.01) and well-being (p = 0.03) and lower FIQ (p < 0.01) and VAS
pain (p = 0.02) compared to the control group, but no significant differences were observed
for the exercise group after the detraining period (p > 0.05) in the intergroup analysis.
Therefore, in the difference in means and interaction between groups and follow-
up over time, statistically significant differences appeared in favor of the training group
compared to the control group. Also, the global score of the SF-36 scale increased in the
aquatic treatment groups after the intervention, although the effects on each item will have
to be analyzed in depth [17,19].
On the other hand, De Medeiros et al. (2020) [19] showed positive results in reducing
pain in both treatment groups, both in an aquatic environment (p = 0.001) and with the mat
Pilates treatment (p = 0.01). Benefits were also found in the scores obtained in the FIQ for
both groups (mean difference = 0.91, p = 0.002 for the aquatic exercise group; and a mean
difference = 1.6, p = 0.001 for the mat Pilates group) [19].
Britto et al. (2020) [18] reported a significant reduction in pain by the VAS for both
exercise groups, aquatic and land, without appreciable differences in the intergroup com-
parison. In this study, a statistically significant value was reached in the intragroup mean
difference for the aquatic exercise group (p < 0.001), changing from a mean of 7.11 ± 2.40
to 5.79 ± 2.62. The reduction of tender points in the aquatic exercise group stands out
(p = 0.008), and changes were observed in the impact of fibromyalgia on the quality of life
via FIQ for the water (p = 0.005) group and land group (p = 0.006).
Finally, the investigation of Salm et al. (2019) [20] indicated that a combination of
temperature increase techniques with aquatic exercise seemed to increase the benefits
obtained. Both groups obtained significant changes in pain assessment with the SF-MPQ
(p < 0.05), and a significant reduction in pain was found in VAS (p < 0.0007) with the aquatic
exercise and FIR treatment.

4. Discussion
Current evidence reflects fibromyalgia as a syndrome characterized by chronic and
widespread musculoskeletal pain, accompanied by other medical disorders, which together
decrease the quality of life of patients [1,4,13,23]. There are various treatment options,
among which the importance of physical exercise stands out [24,25], with aquatic therapy
being notable. Water provides an ideal medium for exercise as it allows joint mobilization
with reduced effort, presenting low-impact exercises that place less stress on the joints and
muscles [26]. Thanks to the various properties of water, various activities and movements
Healthcare 2024, 12, 701 8 of 12

can be carried out that are more challenging to perform in dry environments [26,27]. For
this reason, aquatic therapy is considered a treatment option to enhance the physical and
psychological aspects affected by fibromyalgia.
The analysis of the selected articles supports the implementation of aquatic exercise as
a treatment modality for people with fibromyalgia. In general, the results obtained in these
investigations showed that it is possible to reduce pain and the impact of fibromyalgia on
the quality of life of patients, since statistically significant differences were observed with
exercise programs in water and on land [17–20]. This reinforces the current trend of global
monitoring and intervention of patients with fibromyalgia syndrome, so that patients are
actively involved in the treatment, and patients have tools to control their symptoms.
The sociodemographic characteristics of the sample were similar in the four studies
analyzed [17–20]; the study population was composed of women from the fourth decade
of life, which coincides with the usual age and sex distribution of fibromyalgia [3,10,28]. In
addition, there is consensus on using standardized guidelines and established diagnostic
criteria for the assessment of fibromyalgia and the inclusion of patients in clinical trials,
mainly using the American College of Rheumatology recommendations [10,17–20,29].
It is also necessary to highlight the high methodological quality of the selected studies;
all articles obtained a confirmed score of 8/10 on the PEDro scale [17–20]. This condition
gives the results high reliability and minimizes the risk of bias. The four clinical trials had
an adequate randomization process, the follow-up and analysis of results were appropriate,
and the initial distribution of the groups was homogeneous, allowing baseline comparabil-
ity. However, the characteristics of the interventions did not make it possible to blind the
patients and therapists; only the article of Salm et al. (2019) [20] blinded the patients, as the
aquatic exercise treatment was included in both groups.
Pain (VAS and SF-MPQ) and the impact of fibromyalgia on quality of life (SF-36 or FIQ)
were the most studied variables [17–20]. The assessment of these characteristics becomes
relevant in the clinical setting, and this constitutes the priority objective of this review. It
allows the results obtained to be transferred to clinical practice. In addition, the inclusion
of other variables such as tender points can be highlighted [18], although this assessment is
no longer used in the most current guidelines [10,30].
The duration of the interventions (in effective exercise time per session, in total number
of sessions, and in weekly distribution) was relatively similar in all analyzed articles,
although Salm et al. (2019) [20] concentrated the sessions in 6 weeks and Andrade et al.
(2019) [17] opted for 16 weeks of treatment. And only this article conducted a long-term
follow-up after a detraining period [17].
Andrade et al. (2019) [17] conducted a comparison between an aquatic exercise group
and a control group with inactivity, and it showed benefits in the group that exercised and
offered values similar to the baseline when they were subjected to detraining, both in the
variables of clinical symptoms and in the control of physical performance. The studies of
Britto et al. (2020) [18] and De Medeiros et al. (2020) [19] support the inclusion of exercise
in aquatic or land mode. All of this suggests that the symptoms of fibromyalgia could
be linked to physical inactivity, with exercise being the basic element of treatment, with
low cost and high effectiveness. The effect of exercise could be associated with changes
in body composition [31], so Salm et al. (2019) [20] analyzed biochemical markers in the
patients. The combination of exercise with changes in body temperature attributable to
complementary techniques [32,33] could also modify body composition.
Therefore, aquatic exercise can be considered as a beneficial option for patients with
fibromyalgia; the results obtained could be associated with the facilitation of movement
in the aquatic environment [34,35]. Performing exercise in water helps improve muscle
strength, flexibility, and cardiovascular resistance, within a low-impact environment that
allows the intensity to be adapted to the needs of each individual. Furthermore, the
changes found could be associated with the patients’ comfort in performing the exercise in
an aquatic environment, and the ability to float, considering that it could be more attractive
given that many patients experience exercise rejection.
Healthcare 2024, 12, 701 9 of 12

Therapeutic physical exercise plays a fundamental role in the approach of patients

with fibromyalgia, being part of the global approach to the pathology, including a pro-
gram adapted to the needs and preferences of each person within the physical therapy
treatment [14,36]. Aquatic exercise can be considered a safe and easy-to-apply exercise
modality if the necessary facilities are available. This treatment could reinforce therapeutic
adherence, which is especially important [14]. However, the implementation of these
exercise programs depends on the availability of pools that allow aquatic exercise and the
specialization of the therapists. Sometimes, these circumstances could impair the access of
patients to the aquatic exercise modality, being limited by socioeconomic factors. If access
to a pool for aquatic exercise is not possible, it is advisable to opt for other forms of exercise
that may be equivalent [36].
On the other hand, the comfortable temperature of the water, the adaptation of the
exercise to the participant, and individualized supervision could be other important factors
to motivate the patient [26,27]. It is also convenient to highlight the effects on general well-
being, patient relaxation, and the emotional state, because aquatic treatment is related to a
better mood, and the treatments include cool-down exercises with floating maneuvers [18].
Likewise, within a global treatment, aquatic exercise could be related to other therapies
with effects on pain modulation, such as transcranial direct current stimulation [37–39],
or exergame or virtual reality therapies that encourage movement and adherence to exer-
cise [40–42]. All of these therapies could be alternated and have a place in the treatment. It
would also be advisable to compare the effects associated with each therapy.
The main strength of this review is the analysis of studies with high methodological
quality; this makes it possible to translate the results to the healthcare environment. As well,
the inclusion of different treatment methodologies based on aquatic exercise, including
aerobic and strength exercise, is another strength. On the contrary, certain limitations could
be indicated, such as the limited follow-up time in the articles, the lack of blinding of
the interventions, the absence of placebo in most studies, or the different aquatic exercise
approaches proposed with other associated therapies. Likewise, it should be noted that all
studies were carried out on women and on a similar age range. This type of population
coincides with the usual fibromyalgia patients, but it could represent a limitation since the
generalization of the results could be constrained; for example, the severity of symptoms
could be different in chronic pain in both sexes.
Also, the selected search strategy can be considered limited by its simplicity, never-
theless, the search strategy is easily reproducible, so that the results can be replicated and
updated in the future by both clinicians and researchers. The intention was that the search
formula could offer the most notable results focused on aquatic exercise and fibromyalgia,
and that it would be standardized for all databases that were used. Despite selecting a
low number of articles, it is necessary to point out that the search was exhaustive and only
articles of high methodological quality were selected.
It is advisable to continue conducting future research, in which it could be convenient
to carry out a comparative statistical analysis between other treatment therapies with
the inclusion of other variables related to physical condition, such as strength levels or
electromyographic activity, and use a longer-term follow-up. Based on the studies analyzed
as a reference, it is possible to recommend aquatic exercise programs of between 6 and
16 weeks, with training of at least 40 min on alternate days. It seems advisable that the
programs be based on aerobic and strength exercise, with mobility of the upper and lower
limbs, regulating the intensity through heart rate and the perception of effort on the Borg
scale. Future lines of research should delve deeper into these guidelines. At a clinical level,
it is advisable to adapt the program to each patient based on general recommendations.

5. Conclusions
Aquatic therapy offers physical and psychological benefits in the treatment of fi-
bromyalgia. However, in some instances, the results of this type of approach may not be
superior to other exercise options for this pathology. Therefore, it is important to individu-
Healthcare 2024, 12, 701 10 of 12

alize treatment to the needs of patients. Consequently, it is possible to recommend aquatic

exercise according to the modalities described in the articles included in this review.

Author Contributions: Conceptualization, J.G.-R. and C.A.-M.; methodology, J.G.-R. and M.R.-H.;
software, P.G.-R.; validation, R.M.-V., M.Á.R.-R. and M.R.-H.; formal analysis, P.G.-R.; investigation,
J.G.-R. and C.A.-M.; resources, M.Á.R.-R.; data curation, R.M.-V.; writing—original draft preparation,
P.G.-R. and C.A.-M.; writing—review and editing, J.G.-R. and M.R.-H.; visualization, M.Á.R.-R. and
R.M.-V.; supervision, M.R.-H. and J.G.-R.; project administration, M.R.-H. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data are contained within the article.
Conflicts of Interest: The authors declare no conflicts of interest.

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