Aquatic Therapy Supports Fibromyalgia Patients

Fibromyalgia syndrome (FMS), a condition that is typically of insidious, adult onset affecting females more than males,1,2 is characterized by pain, fatigue and stiffness of muscles and soft tissues.1-6

Condition Defined

This condition is defined by the American College of Rheumatology as widespread pain for at least three months, pain involving the upper and lower body on both right and left sides including axial pain, and with the presence of at least 11 of 18 specific tender points on both sides of the body, above and below the waist.1,2,4

The presence of muscle spasm, nodules, skin discoloration and a non-restorative sleep pattern is also characteristic.6

There are a number of associated conditions including disruption in Stage IV sleep, headaches, temporomandibular dysfunction, mental and physical fatigue, Raynaud's phenomena, respiratory dysfunction, depression and hypersensitivity to noise, odors, heat or cold.1,4,6

Simple daily tasks including dressing, grooming and meal preparation may be challenging.7 Goals in the treatment of FMS include pain management, restoration of sleep patterns and increasing functional activity levels.4,6 Krsnich describes exercise as one of the most effective interventions for long-term management of FMS.6 An exercise program should include low-load stretching and a low-impact aerobic component.

Due to the unique properties associated with immersion, aquatic therapy has been recommended for the treatment of fibromyalgia syndrome.2,4,6,8

One benefit of aquatic physical therapy is the buoyant support of water that dramatically decreases compression stress on joints, allowing for improved flexibility with greater ease of movement, especially in concert with the increased hydrostatic pressure and reduced gravitational pull.9-11

Active, passive and assistive stretching through a greater range of motion are all possible in the supportive aquatic environment.


There is evidence supporting the use of aquatic physical therapy as an intervention technique for patients with fibromyalgia. 

Cedrashi et al was able to demonstrate significant improvements in quality of life and function following a six-week self-management program that included pool exercise and education.12

Pool exercise was a minor component in the self-management program; however, the design of the intervention was more reflective of clinical practice.

Altan et al also demonstrated improved quality of life and decreased pain with a 12-week pool-based exercise program, the effects of which lasted for up to 24 weeks.13 Components of the pool program included warm-up, activity, relaxation and a few out-of-pool exercises.

Jentoft et al demonstrated improved cardiovascular capacity, walking time and well-being, and decreased daytime fatigue, pain, anxiety and depression following a 20-week pool program.14

The pool group showed more significant improvements in more variables than did the land-based exercise group, further strengthening the argument for the use of aquatic therapy.

In their first study, Mannerkorpi et al found that six months of pool exercise combined with education sessions improved quality of life, physical function, pain severity and psychological distress.15 The exercises in this study included endurance, flexibility, coordination and relaxation.

The combination of exercise and education is again a realistic clinical intervention. A follow-up study by Mannerkorpi et al found that these improvements in symptom severity, physical function and social function lasted for up to 24 months following the completion of a six-month program.16

When looking at all of these research studies, aquatic therapy balanced with education and land-based exercise appears to be beneficial in modifying the symptoms and disability associated with FMS. In addition, all of the programs appeared to have flexibility and relaxation components. The land-based program should emphasize sleep hygiene (e.g., sleep habits, environment, preparation for bed), physical activity, relaxation, normal movement and core strengthening, primarily in the form of a home exercise program.

Session Focus

The aquatic sessions should also focus on physical activity, relaxation, normal movement patterns and core strengthening. Initially, the focus should be on pool-based activity (60 percent of the time) with supportive land-based activity (40 percent), progressing to a primarily land-based program (70 percent) with supportive pool-based activity (30 percent).

A number of specific techniques can be used in the water to assist with symptom reduction and restoration of function for individuals with fibromyalgia. Ai Chi, simple water exercise and relaxation, utilizes deep breathing and slow, broad movements of the limbs and torso. This technique may help lessen anxiety, while improving breathing and endurance.17

Watsu has been described as "an excellent alternative intervention for patients with fibromyalgia"2 and is a passive technique involving rhythmical, gentle rocking motions with repeated trunk elongation and rotation.11 BackHab is a program designed for the treatment of individuals with low-back pain, but the principles can also be applied to those with fibromyalgia.5

Program Goals

The goals of this program are to provide exercise, slowly increase cardiovascular conditioning, and tone and condition muscles in a low-impact medium, an ideal solution for individuals with FMS. The program could begin with an active warm-up using Ai Chi techniques, followed by Watsu11 for additional relaxation and stretching.17

To improve flexibility, slow sustained stretches of the major muscle groups could follow the warm-up, with specific attention paid to areas that are symptomatic during that session. This would allow for continual adjustment of the program based on the patient's symptoms.

Using BackHab principles for core strengthening and exercise, the general conditioning and strengthening portion of the aquatic program could include a progressive walking program.

The water session would end with additional Watsu and Ai Chi activities to promote additional relaxation prior to returning to the full gravity of land-based living.

A well structured program of aquatic-based relaxation, flexibility and general exercise activities combined with land-based education, relaxation and general exercise will optimize functional recovery and outcomes.

Emphasis on relaxation, posture and the importance of activity will help restore normal function. A combination approach of education, aquatic physical therapy and traditional land-based physical therapy appears to be the most effective way to assist these patients in reaching their goals. 


1. Hulme, J. (2000). Fibromyalgia: A Handbook for Self Care and Treatment, 3rd Ed. Phoenix Publishing.

2. Vargas, L. (2004). Aquatic Therapy Interventions and Applications. Idyll Arbor, Inc.

3. Stedman's Medical Dictionary for the Health Professions and Nursing, 5th Ed. Lippincott, Williams & Wilkins, 2005.

4. Chaitow, L. (2003). Fibromyalgia Syndrome: A Practitioner's Guide to Treatment. 2nd Ed. Churchill Livingstone.

5. Sova, R. (1996). BackHab: The Water Way to Mobility and Pain Free Living. DSL, Ltd.

6. Krsnich-Shriwise, S. (1997). Fibromyalgia Syndrome: An Overview. Physical Therapy, 77(1). www.ptjournal.org/Jan97/krsnich.cfm.

7. Bates, A., & Hanson, N. (1996). Aquatic Exercise Therapy. W.B. Saunders Co.

8. Mannerkorpi, K., & Iversen, M. (2003). Physical exercise in fibromyalgia and related syndromes. Best Practices in Research and Clinical Rheumatics, 17(4), 629-647.

9. Essert, M. (2001). Water works: Aquatic therapy can help treat a variety of painful conditions. ADVANCE for Directors of Rehabilitation, 10(1), 43-46.

10. Sova, E. (2000). Aquatics: The Complete Reference Guide for Aquatic Fitness Professionals. DSL, Ltd.

11. Cole, A., & Becker, B. (2004). Comprehensive Aquatic Therapy. Elsevier, Inc.

12. Cedrashi, C., Desmeules, J., et al. (2004). Fibromyalgia: A randomised, controlled trial of a treatment programme based on self management. Annals of Rheumatic Disorders, 63, 290-296.

13. Altan, L., Bingöl, U., et al. (2004). Investigation of the effects of pool-based exercise on fibromyalgia syndrome. Rheumatology International, 24, 272-277.

14. Jentoft, E., Kvalvik, A., & Mengshoel, A. (2001). Effects of pool-based and land-based aerobic exercise on women with fibromyalgia/chronic widespread muscle pain. Arthritis Care Research, 45, 42-47.

15. Mannerkorpi, K., Nyberg, B., Ahlmén, B., & Ekdahl, C. (2000). Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. Journal of Rheumatology, 27, 2473-2481.

16. Mannerkorpi, K., Ahlmén, B., & Ekdahl, C. (2002). Six-and 24-month follow-up of pool exercise therapy and education for patients with fibromyalgia. Scandinavian Journal of Rheumatology, 31, 306-310.

17. Sova, R., & Kunno, J. (1999). Ai Chi: Balance, Harmony, & Healing. DSL, Ltd.

Janet Gangaway works at the University of Hartford as an assistant professor of PT and academic coordinator of clinical education. She practices aquatic and orthopedic physical therapy at University Physical Therapy LLC, also at the University of Hartford. She has 17 years of experience as a physical therapist and is board-certified in orthopedic physical therapy. She is also a certified and licensed athletic trainer.


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