Received: 26 April 2020 Revised: 2 May 2020 Accepted: 6 May 2020

DOI: 10.1002/msc.1481

RESEARCH ARTICLE

Effects of water- and land-based exercises on quality of life

and physical aspects in women with fibromyalgia: A
randomized clinical trial

André Britto1 | Vandilson Rodrigues2 Alcione M. dos Santos3

| |
Marta Rizzini3 | Paula Britto4 | 4
Lucio Britto | Joa ~o B. S. Garcia 5

1
School of Medicine, Federal University of
Maranh~ao, Pinheiro, Brazil Abstract
2
Department of Morphology, Federal Introduction: Fibromyalgia (FM) is consistently associated with fatigue, sleep distur-
University of Maranh~ao, S~ao Luís, Brazil
bances, morning stiffness, and anxiety and depression, affecting physical capacities
3
Collective Health Graduate Program, Federal
University of Maranh~ao, S~ao Luís, Brazil and skills and thereby reducing quality of life. The aim of this study was to compare
4
Physiotherapy Service, Club Sante, S~
ao Luís, the effects of water-based and land-based therapies as an adjuvant treatment for
Brazil
women with FM in relation to quality of life and physical aspects.
5
Health Science Graduate Program, Federal
University of Maranh~ao, S~ao Luís, Brazil
Methods: FM women were randomized into a water-based exercise group (WG) and
land-based exercise group (LG). The interventions were conducted for 8 weeks, three
Correspondence
André Britto, School of Medicine, Estrada
times a week, and each therapy session had a 60-min duration. Evaluations were per-
Pinheiro/Pacas, Km 10, 65200-000, Pinheiro, formed before and after intervention using the Fibromyalgia Impact Questionnaire,
MA, Brazil.
Email: andre.britto@ufma.br
the Visual Analogue Scale, the number of tender points (TPs), and the Wells bench sit
and reach test score.
Funding information
Brazilian Federal Agency for Support and
Results: Both interventions produced significantly positive clinical effects in most
Evaluation of Graduate Education (CAPES) aspects evaluated. However, only WG obtained significant improvements for the var-
iables functional capacity, number of TPs, and flexibility.
Conclusions: The findings suggest that water-based exercise is effective as an adju-
vant FM treatment, including FM-related physical and psychological health aspects.

KEYWORDS

fibromyalgia, pain, quality of life, treatment, water-based exercise

1 | I N T RO D UC TI O N estimated at 2.1% in the general population (Wolfe, Brähler, Hinz, &

Fibromyalgia (FM) is a rheumatic disorder that manifests as chronic,
diffuse musculoskeletal pain, and leads a large number of patients to
seek medical and physiotherapeutic treatment (Plazier, Ost, Stassijns,
De Ridder, & Vanneste, 2015). FM is also often associated with
fatigue, sleep disturbances, morning stiffness, and anxiety and depres-
sion, affecting physical capacities and skills and thereby reducing qual-
ity of life (Arnold et al., 2019; Häuser et al., 2015; Schweiger
et al., 2017).
Using the new American College of Rheumatology (ACR) 2010
FM diagnostic criteria (Wolfe et al., 2010), the prevalence was
Häuser, 2013). A study conducted in Brazil revealed that FM was the
second most common rheumatologic disease, with a prevalence of
2.5% in the population. This condition was predominant in females, of
whom 40.8% were between 35 and 44 years old (Senna et al., 2004).
The various treatment types for FM pain aim to decrease symp-
toms, as the disease remains a challenge to experts due to its little-
known etiology (Bernardy, Klose, Welsch, & Häuser, 2018; Fink &
Lewis, 2017; Zech, Hansen, Bernardy, & Häuser, 2017). Thus, multi-
disciplinary and multiprofessional treatment that covers the various
symptoms of fibromyalgia can improve clinical outcomes (Häuser,
Clauw, & Fitzcharles, 2017; Shipley, 2010). In this context, physical

Musculoskeletal Care. 2020;1–8. wileyonlinelibrary.com/journal/msc © 2020 John Wiley & Sons, Ltd. 1
2 BRITTO ET AL.
activity can promote relaxation in tender areas and improvements in
symptoms and quality of life (Segura-Jiménez et al., 2017; Valim
et al., 2013).
Water-based exercise (WBE) facilitates movement by reducing
gravitational forces, which, combined with the action of floating and
the increased temperature of the water, optimizes the treatment of
patients with chronic pain, inflammation, and muscle spasms affecting
musculoskeletal functional capacity (Avila et al., 2017; Zamunér,
Andrade, Arca, & Avila, 2019). The effects are mainly related to pain
relief, muscle relaxation, increased range of motion, increased blood
circulation, muscle strengthening, and improvements in self-esteem
(Naumann & Sadaghiani, 2014).
WBE has been used in clinical practice as a treatment for FM
patients, but research results are still discordant. A meta-analysis of
randomized clinical trials evaluated the effectiveness of WBE for FM
and concluded that there is moderate evidence that WBE has benefi-
cial effects in relation to pain and quality of life in FM patients and
that studies have a tendency to overestimate the effects of WBE due
to methodological shortcomings (Langhorst, Musial, Klose, &
Häuser, 2009). A meta-analysis has found statistical significance in
results relating to quality of life and physical function in favor of WBE
compared with no treatment (Lima et al., 2013).
A limited number of studies have compared WBE and land-based
exercise, and in the majority of cases, the results were not able to
demonstrate clinical and significant differences due to low methodo-
logical rigor. Therefore, the aims of this study is to compare two dif-
ferent protocols (WBE and land-based exercise) for individuals with
FM with respect to quality of life, pain intensity, number of tender
points (TPs), and flexibility.
2 | METHODS
2.1 | Study design and participants
This randomized trial was conducted in S~ao Luís, Maranh~
ao, Brazil.
The study protocol was approved by the Research Ethics Committee
of the Federal University of Maranh~
ao (number 00246/11). All partici-
pants were informed about the aims and procedures of the study and
signed the terms of free and informed consent.
Participants were recruited from the Chronic Pain Clinic, Univer-
sity Hospital, Federal University of Maranh~ao (UFMA) and the Clinical
School, University Center of CEUMA, both located in S~ao Luís, Brazil.
Inclusion criteria were patients of either sex, aged 18 to 60 years,
diagnosed with FM by hospital medical staff, and who had a level of
cognition sufficient to understand the procedures and guidelines
given. Patients with associated diseases, such as structural musculo-
skeletal deformities, herniated discs and rheumatoid arthritis, were
excluded. The researchers did not alter any drug treatment used by
patients.
The sample size was obtained considering a visual pain scale
mean of 6.0, a mean effect difference of 2.0, a study power of 0.80,
and a significance level of 5%, resulting in 16 participants per group
(Evcik, Yigit, Pusak, & Kavuncu, 2008). Estimating possible losses at
20%, the sample size was therefore set at 20 subjects per group.
Contact was made through advertisements and by phone calls to
FM patients registered at both services. Of the 40 eligible patients,
seven (17.5%) refused to participate; therefore, a total of 33 subjects
were randomly assigned by lottery into two groups: the water-based
exercise group (WG), with 16 patients, and the land-based exercise
group (LG), with 17 patients (Figure 1).
2.2 | Procedures
The group distribution was performed by lottery with sealed enve-
lopes containing the initials WG and LG on first contact (before evalu-
ation time). The envelope was opened in front of the participant by
the lead researcher, who then informed the participant to which group
they would belong.
Participants from both groups filled out a form designed by
the lead researcher that contained personal identification and
socioeconomic and demographic data and medical history, such as
time of diagnosis, specialist who diagnosed, and medication use.
Preintervention evaluation was performed by an evaluator who did
not know which treatment would be followed by the patient. Both
WBE (WG) and the land-based exercise (LG) lasted 8 weeks. Fol-
lowing the last session, a postintervention evaluation was con-
ducted by the same evaluator, again blind to treatment type
(Figure 1).
2.3 | Evaluations
All evaluations were performed before and after the interventions by
a single physical therapist, who was duly trained, and all evaluations
were conducted under the same conditions throughout the process.
The aim of the study was to evaluate the effectiveness of WBE in
relation to the impact of FM on quality of life, pain intensity, number
of TPs, and torso flexibility. To that end, the following measuring
instruments were used:
1 Fibromyalgia Impact Questionnaire (FIQ): This questionnaire of
10 items measures self-reported quality of life of FM patients. The
final scores for each item of the FIQ range from 0 (no impairment)
to 10 (maximum impairment). This instrument has been determined
to be easy to understand and to apply and is also reliable in mea-
suring the functional capacity and health status of Brazilian FM
patients, thus better assisting the diagnosis and treatment of this
syndrome (Burckhardt, Clark, & Bennett, 1991).
2 Visual Analogue Scale (VAS): This scale evaluates pain intensity and
consists of a line 10 cm in length and conventionally numbered
0 to 10, with (0) equal to no pain and (10) the worst pain imagin-
able, where the patient, without seeing the numbers on the scale, is
asked to describe pain intensity at the time (Boonstra, Preuper,
Balk, & Stewart, 2014).
BRITTO ET AL.
FIGURE 1 Flowchart of study recruitment
3 Digital TP palpation: This test measures TPs distributed over the
body, using digital palpation according to the ACR Fibromyalgia
classification criteria (Wolfe et al., 1990).
4 Wells bench sit and reach test: This test evaluates the level of
linear flexibility of the torso, with a linear and quantitative mea-
sure that satisfactorily evaluates the flexibility of the hip, back,
and posterior muscles of the lower and upper limbs. The individ-
ual must sit on the Wells bench with outstretched legs and with
plantar regions against the base of the box (Burckhardt
et al., 1991).
The patients were instructed to project themselves slowly with
one hand placed above the other, as far as possible, maintaining
this position momentarily. The participants then kept their hands
parallel, checking that they had advanced with both hands. The fin-
gertips remained overlapped and pushed the measuring portion of
the sit and reach box. Participants were allowed to expire and put
their head between their arms or to project themselves forward
when attempting to reach the farthest point. The examiners made
sure that the participants' knees were extended and had not been
pushed down. Participants were not allowed to hold their breath
or push the measuring portion of the bench to obtain higher
scores during the test. The best of the three scores—the farthest
point reached by the fingertips, in centimeters—was recorded for
each subject. The classification of this test is as follows: up to
11 cm of subject flexibility is considered poor, 12–13 below aver-
age, 14–18 average, 19–21 above average, and above 22 excellent
(Wilder et al., 2006).
3
2.4 | Interventions
The interventions, WBE and land-based exercise programs, were con-
ducted for 8 weeks, three times a week, and each therapy session had
a 60-min duration. The therapeutic intervention in both groups con-
sisted of an initial warm-up for 10 min, active stretching for 10 min,
strengthening for 30 min and relaxation for 10 min. The pool was 8 m
long, 4 m wide, and 1.65 m deep, and the water temperature was
approximately 33 C.
During the warm-up phase, participants in the WG performed
mobility and slow walking exercises in the pool. Assisted stretching
activity of the entire posterior and anterior muscle chain was per-
formed with three repetitions and lasted 15 to 25 s for each muscle
group. The strengthening exercises for the lower limbs were per-
formed with a shin guard in three sets of 15 repetitions of each move-
ment, and noodle floats were used for the upper limbs, also with three
sets of 15 repetitions of each movement. The relaxation phase took
place using flotation techniques.
The LG was submitted to a land exercise program that also
included warm-up, active stretching, strengthening, and relaxation
under the supervision of a physical therapist. The training intensities
and muscle groups worked were similar in the two groups.
2.5 | Statistical analysis
Data were analyzed using the statistical software STATA 10.0 (Stata
Corp., College Station, TX, United States). Economic and demographic
4 BRITTO ET AL.

data are presented using descriptive statistics. The normality of quan-
titative variables was analyzed using the Shapiro–Wilk test. To com-
pare the variables before and after treatment, either Student's t test
for paired samples or the Wilcoxon test was used. For comparison
between groups, either Student's t test for independent samples or
the Mann–Whitney test was used. Categorical variables were com-
pared between the groups using the chi-square and Fisher's exact
tests. The significance level adopted was 5%.
In the intragroup analysis, significant differences were observed in
both groups for the variables relating to pain, fatigue, sleep, morning
stiffness, anxiety, and depression. The work absences variable was
only significant in the WG, and the variable ability to work was only
significant in the LG. Comparison of the FIQ scores between the WG
and the LG (intergroup analysis) revealed a significant difference for
the functional capacity variable only, which showed an improvement
after WBE (p = 0.015; Table 2).

3 | RESULTS 3.3 | TPs and pain levels analysis

3.1 | Participant demographics
All study participants were women aged between 35 and 56 years.
The two groups did not differ with respect to age, marital status, or
income (p > 0.05). The levels of education between 9 and 11 years
and greater than or equal to 12 years were higher in the WG
(43.75%). The LG had a predominance of individuals with levels of
education greater than or equal to 12 years (70.59%). Incomes lower
than or equal to one minimum monthly wage (mmw) were predomi-
nant in both groups (Table 1).
3.2 | Comparison of FIQ between WG and LG
The total FIQ scores relating to the effect of FM on quality of life
decreased after WBE (p = 0.005) and land-based exercises (p = 0.006).
The numbers of TPs decreased in both treatments when compared
before and after therapy, reaching statistical significance only in the
group that underwent WBE (p = 0.008). Pain, evaluated by the VAS,
decreased significantly in both groups. However, intergroup compari-
sons revealed no differences before or after either WBE or land-based
exercise (Table 3).
3.4 | Flexibility analysis between WG and LG
Flexibility did not differ between the WG and the LG before the inter-
ventions (p = 0.434), with most participants being ranked below aver-
age and poor in this regard. After the interventions, there was a
significant difference between groups (p = 0.001), with flexibly consid-
ered average to excellent in 12 (75%) participants in the WG and in
one (5.88%) in the LG (Table 4).

TABLE 1 Sociodemographic data of the study groups

4 | DISCUSSION
p
Variables WG (n = 16) LG (n = 17) value
FM is a serious health problem that has socioeconomic implications
Age in years (mean ± SD) 50.25 46.18 0.303
and negative effects at the individual, family, and social levels. There-
± 6.09 ± 10.84
fore, treatment interventions are sought that are effective in reducing
Civil status, n (%) 0.566
its symptoms and may represent an integrated solution that is both
Single 6 (37.50) 4 (23.53)
easily accessible and relatively inexpensive. This study evaluated qual-
Married 6 (37.50) 9 (52.94)
ity of life, pain, and flexibility before and after two physical therapy
Othera 4 (25.00) 4 (23.53) interventions in the treatment of FM: WBE and land-based exercise.
Educational level, n (%) 0.047* Both activities produced significant positive clinical effects in most
<8 years 2 (12.50) 4 (23.53) evaluated aspects for quality of life (FIQ) and pain intensity (VAS).
Between 9 and 7 (43.75) 1 (5.88) However, for the variables functional capacity (FIQ), work absences
11 years (FIQ), number of TPs (digital palpation), and flexibility (Wells sit and
≥12 years 7 (43.75) 12 (70.59) reach test), only WBE obtained significant values, being effective as
Income, n (%) 0.760 an adjuvant treatment for women with FM.
No income 3 (18.75) 1 (5.88) Several studies have evaluated the effects of WBE versus no
≤1 mmw 6 (37.50) 8 (47.06) treatment on FM patients (Bidonde et al., 2014; Naumann &
Between 1 and 3 mmw 1 (6.25) 2 (11.76) Sadaghiani, 2014; Zamunér et al., 2019), and most found improve-

≥3 mmw 6 (38.00) 6 (35.29) ments in the severity of FM symptoms in the exercise group, demon-
strating decreases in pain intensity and the number of TPs and
Abbreviations: LG, land-based exercise group; mmw, monthly minimum
improvements in quality of life. Moreover, the addition of WBEs for
wage; SD, standard deviation; WG, water-based exercise group.
a
Divorced and widowed. women with FM is cost effective in terms of both health care costs
*
Statistically significant differences (p < 0.05). and societal costs (Gusi & Tomas-Carus, 2008).
BRITTO ET AL. 5

TABLE 2 Mean values obtained in the pretreatment and posttreatment evaluations of the aspects examined by the FIQ

Water-based exercise (WG) Land-based exercise (LG) WG versus LG

Before After Before After

Before After
FIQ variable Mean ± SD Mean ± SD p value a
Mean ± SD Mean ± SD p valuea p valueb p valueb
Functional capacity 3.48 ± 2.11 3.04 ± 1.82 0.065 4.49 ± 2.10 4.67 ± 1.82 0.208 0.125 0.015*
Well-being 2.50 ± 3.63 3.12 ± 3.51 0.234 1.51 ± 1.92 1.93 ± 2.47 0.466 0.825 0.516
*
Faults at work 3.93 ± 4.38 2.14 ± 2.99 0.020 4.02 ± 3.85 4.01 ± 3.61 0.490 0.947 0.134
Difficulty at work 5.10 ± 3.31 5.24 ± 2.99 0.403 7.84 ± 1.88 6.93 ± 2.58 0.003* 0.015 0.093
Intensity of pain 7.84 ± 2.05 6.74 ± 2.28 0.001* 8.76 ± 1.41 7.72 ± 2.25 0.001* 0.080 0.082
*
Fatigue 6.54 ± 3.40 5.93 ± 3.36 0.002 7.37 ± 2.81 7.25 ± 2.67 0.039* 0.330 0.234
* *
Stiffness 8.06 ± 1.85 7.24 ± 1.91 <0.001 8.05 ± 1.69 7.04 ± 2.52 0.005 0.828 0.814
Morning tiredness 7.36 ± 2.09 6.20 ± 2.19 0.003* 7.42 ± 2.24 6.49 ± 2.35 <0.001* 0.772 0.481
* *
Anxiety 5.75 ± 3.37 4.81 ± 3.45 0.032 7.29 ± 2.64 6.51 ± 3.02 0.008 0.144 0.108
Depression 5.66 ± 3.59 4.70 ± 3.05 0.021* 6.96 ± 2.74 6.25 ± 2.45 0.002* 0.248 0.120
* *
Total FIQ 5.62 ± 1.49 4.92 ± 1.54 0.005 6.35 ± 1.35 5.88 ± 1.50 0.006 0.149 0.061

Abbreviations: FIQ, Fibromyalgia Impact Questionnaire; SD, standard deviation.

a
Paired Student's t test or Wilcoxon test.
b
Student's t test or Mann–Whitney test.
*
Statistically significant differences (p < 0.05).

TABLE 3 Numbers of tender points and pain level before and after the interventions between water- and land-based exercise groups

Number of tender points Level of pain according to VAS

Before* After* Before* After*

Group Mean ± SD Mean ± SD p valuea Mean ± SD Mean ± SD p valuea

WG 13.81 ± 3.99 11.75 ± 3.89 0.008* 7.11 ± 2.40 5.79 ± 2.62 <0.001*
LG 13.29 ± 3.14 12.11 ± 3.62 0.116 6.97 ± 2.09 5.89 ± 1.97 0.020*
p valueb 0.680 0.780 0.848 0.907

Abbreviations: LG, land-based exercise group; VAS, Visual Analogue Scale; WG, water-based exercise group.
a
Paired Student's t test (intragroup comparison).
b
Student's t test (intergroup comparison).
*
Statistically significant differences (p < 0.05).

TABLE 4 Evaluation of flexibility before and after the The few studies that have compared water- and land-based phys-
interventions between the water- and land-based exercise groups ical activities have reported small differences in the various evaluated
aspects (Assis et al., 2006; Hecker, Melo, Tomazoni, Martins, & Leal-
Before interventions After interventions
Junior, 2011; Thomas & Blotman, 2010; Vitorino, de Carvalho, & do
WG LG WG LG Prado, 2006). A meta-analysis investigating the effectiveness of differ-
Flexibility n (%) n (%) n (%) n (%)
ent types of exercise in the treatment of FM indicated that there is no
Poor 12 (75.00) 15 (88.24) 2 (12.50) 9 (52.94)
evidence that exercises performed in water produce results superior
Below average 2 (12.50) 2 (11.76) 2 (12.50) 7 (41.18) to those performed on the ground (Häuser et al., 2010). However,
Average 2 (12.50) 0 5 (31.25) 1 (5.88) other studies suggest that aquatic exercise provides slight additional
Above average 0 0 4 (25.00) 0 benefits in reducing pain (Cazzola, Atzeni, Salaffi, Stisi, &
Excellent 0 0 3 (18.75) 0 Cassisi, 2010) and the number of days feeling unwell and in improving
p = 0.434 p = 0.001* pain, anxiety, and depression (Saltskår Jentoft, Grimstvedt Kvalvik, &
Marit Mengshoel, 2001). The durations of the interventions in these
Abbreviations: LG, land-based exercise group; WG, water-based exercise
group. studies ranged from 3 to 23 weeks but failed to show that the longer
*
Statistically significant differences (p < 0.05), Fisher's exact test. the treatment, the better the results would be. Studies have
6 BRITTO ET AL.
demonstrated that WBE provided greater benefits in relation to sleep
and pain with 3 and 5 weeks of intervention, respectively (Evcik
et al., 2008; Vitorino et al., 2006).
A long follow-up study comparing WBE with nonintervention
concluded that 8 months of WBE was effective in improving the phys-
ical and mental health of FM patients but with a similar magnitude to
short treatment programs (Tomas-Carus et al., 2008). Another shorter
study investigated a 3-month intervention with WBE and land-based
exercise and demonstrated positive effects on the pain thresholds at
various TPs and in flexibility for women with FM (Carbonell-Baeza
et al., 2011). Similarly, the present study showed satisfactory effects
in reducing the number of TPs and improving flexibility, along with
improving quality of life after two months of intervention.
In this study, the total FIQ scores, referring to the impact of FM
on quality of life, decreased significantly after WBE and land-based
exercise, demonstrating that physical exercise, regardless of type, pos-
itively influences the quality of life of women with FM. Several studies
in the literature demonstrate the benefits of exercise on quality of life
of individuals with FM (Evcik et al., 2008; Hecker et al., 2011;
Naumann & Sadaghiani, 2014). With regard to pain, some studies have
found positive results regarding intensity (VAS; Andrade, Zamuner,
Forti, Tamburús, & Silva, 2019; Naumann & Sadaghiani, 2014), and
others regarding the number of TPs (palpation; Evcik et al., 2008;
Munguía-Izquierdo & Legaz-Arrese, 2007; Munguía-Izquierdo &
Legaz-Arrese, 2008). In this study, there were good results in terms of
both pain intensity and number of TPs, the latter being significant only
for the aquatic intervention (intragroup analysis). In WBE, heat and
hydrostatic pressure reduce nociceptive stimulation by stimulating
mechanoreceptors and thermal receptors. Heat also increases blood
flow, which reverses ischemia in tissue and promotes the removal of
chemical mediators of inflammation, facilitating muscle relaxation and
thereby decreasing pain (Wu, Hong, & Chou, 2015).
In comparing WBE and land-based exercise, the self-reported
functional capacity variable (FIQ) showed significant results after the
WBE (intergroup analysis). This result is likely explained by the high
correlation between pain and the functional capacity level of individ-
uals with FM. Pain is a debilitating feature and can be considered one
of the leading causes of disability, potentially jeopardizing the activi-
ties of daily living of FM patients (Ambrose & Golightly, 2015). After
WBE, there were significant reductions in both pain intensity and
number of TPs, resulting in the improved functional capacity of these
women, that is, greater ease in performing activities of daily living.
Although not associated with objective tests, the satisfactory
evaluation of functional capacity obtained from the FIQ for WBE
gives us important clinical information, pointing us toward a treatment
that may prevent or delay disability in FM patients (Homann, Goes, da
Silva Timossi, & Leite, 2011).
The flexibility levels (via the Wells sit and reach test) between the
WG and LG did not differ before the interventions and were below
average and poor for most participants (87.5% in the WG and 100%
in the LG). After the interventions, there was a significant difference
between groups, with flexibility considered average to excellent in
75% of participants in the WG and in only 6% of the participants in
the LG. Improved flexibility can have a positive impact on FM, pro-
moting an improvement in parameters associated with FM, such as
poor quality of sleep, joint stiffness, and reduced functional capacity
(Thomas & Blotman, 2010).
It is difficult to compare the results for flexibility with other stud-
ies because of the different evaluation methods used and the small
number of studies available. A study did not obtain any significant
increase in flexibility when they compared WBE and transcutaneous
electrical nerve stimulation in FM patients (Silva, Suda, Marçulo,
Paes, & Pinheiro, 2008). Other study with 8 months of intervention,
the WG showed a decrease of 53% in stiffness in relation to the non-
intervention group (Tomas-Carus et al., 2008). No study was found
evaluating comparative flexibility between water- and land-based
activities.
In this regard, WBE, by promoting muscle relaxation and pain
reduction, improved flexibility and, consequently, the execution of
ADLs after 2 months of treatment, but the present study has limita-
tions that require discussion. One such limitation was the absence of
a follow-up. Monitoring the patients to determine if the variables
remain unchanged after WBE and for how long would go a long way
towards fortifying the still conflicting evidence regarding optimal
treatment time. Although WBE promoted a relevant improvement in
FM symptoms in this study, the bulk of the gains achieved with
shorter protocols tend to be lost after a similar period of inactivity,
and consequently, continuous activity is highly recommended (Gusi &
Tomas-Carus, 2008).
Another limitation is the small sample size, which may have
decreased statistical power to detect changes in some variables. How-
ever, our study showed beneficial effects on the majority of variables,
and changes resulting from the treatment effects were easily
detected. Our results are consistent with the literature, although our
conclusions should be considered with caution because of the limited
sample size.
Psychological and behavioral changes also affect many FM
patients; thus, mood disorders, such as depression, anxiety, and irrita-
bility, are common. The responses of these variables to physical activ-
ity in this study were positive in both groups; however, these
responses were limited by the fact that they were evaluated only by
self-reporting (FIQ). Therefore, it would be important to perform an
evaluation with more specific and complete instruments that can bet-
ter capture health status changes in FM patients to provide more solid
evidence of the effects.
5 | C O N CL U S I O N S
This study suggests that WBE is effective as an adjuvant FM treat-
ment. Significant improvements were observed across all evaluated
dimensions, including physical and psychological health aspects relat-
ing to FM. Thus, regular WBE can be adopted as an approach to FM
treatment optimization, as it promotes pain reduction, reduces the
effects of other symptoms, and restores physical capacity while
maintaining functionality and promoting improved quality of life.
BRITTO ET AL.
ACKNOWLEDGEMEN TS
The authors thank the women who volunteered to participate in the
study and the medical staff from the Chronic Pain Clinic, University
Hospital, Federal University of Maranh~
ao. This study was supported
by the Brazilian Federal Agency for Support and Evaluation of Gradu-
ate Education (CAPES).
The authors declare no conflict of interest.
ORCID
Vandilson Rodrigues https://orcid.org/0000-0002-6785-7864
Alcione M. dos Santos https://orcid.org/0000-0001-9711-0182
~ B. S. Garcia
Joao https://orcid.org/0000-0002-3597-6471
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How to cite this article: Britto A, Rodrigues V, dos Santos AM,
et al. Effects of water- and land-based exercises on quality of
life and physical aspects in women with fibromyalgia: A
randomized clinical trial. Musculoskeletal Care. 2020;1–8.
https://doi.org/10.1002/msc.1481