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Part 2 of 2

Fibromyalgia is (or Should be) All Wet (Part 2 of 2)

Part 2: the precautions to weigh before putting a patient with fibromyalgia in the pool, from joint laxity and fatigue to chemical sensitivity and pain flares.

Published by Aquatic Therapy University5 min read

  • Chronic Pain
  • Mental Health
  • Safety
  • Research
First published June 5, 2024 on atuseminars.com

“You get 10 gallons of gas a day.” One woman with fibromyalgia used that line to explain her fatigue, and it is the best guide we know to dosing a pool session for her.

Part 2 covers the precautions we weigh before bringing a patient with fibromyalgia into the pool.

Want to go deeper? Explore the Aquatic Therapy for Chronic Pain course →

A man reclines on a blue float lounger in a pool.
For the patient with fibromyalgia, there is an abundance of evidence supporting aquatic exercise.

Part 1 covered how to establish medical necessity for aquatic therapy, with a sample statement of medical necessity. Read Part 1.

What precautions apply to the fibro patient?

There are as many different lists of precautions and contraindications as there are therapy pools. The important point to remember is this: labeling a condition a precaution allows the therapist the discretion to treat or not treat the patient. Labeling a condition a contraindication, on the other hand, takes the discretion out of the aquatic therapy provider’s hands. If a facility chooses to label something a contraindication, they must make sure never to allow a person with that condition into their pool. A contra-indication means “never, no exceptions.”

If your patient presents with any of the following conditions or diagnoses, you need to make a calculated decision about the relative potential for harm with aquatic therapy. The precautions below come from our clinical experience [Expert opinion]. For a more generalized list of all precautions and contraindications related to aquatic therapy, email us.

Ligament or capsule laxity.Patients with myalgic conditions such as fibromyalgia may have underlying ligamentous or capsular laxities. The freedom of movement which comes with buoyancy, coupled with turbulence and unpredictable movement of water, may result in the exacerbation of such laxities.

Overfatigue.Patients with FMS disorders often need to pace themselves to ensure that they are able to complete all the tasks of the day. Fatigue, like pain, is a constant presence, and this fatigue is often worse in the evening (although this depends on individual experiences). Patients who act as weekend warriors and give “my all” during an exercise program, aquatic or land, may end up neglecting their other duties because of the fatigue which sets in post-exercise. As energy occurred in spurts throughout the day, participants may conserve precious “windows of energy” for pool-time – only to crash later.

As one patient put it, ‘‘. . .you get 10 gallons of gas a day and you use them up in a certain way. . .when you are done, all of a sudden there you are standing at the kitchen sink and you just can’t stand there another second. You can’t cook anymore, you can’t wash another dish. You just have to sit down. I can’t even talk.’’ [10]

Overreaction to temperature, chemicals.Patients with FMS describe experiencing ‘‘extreme sensitivity to almost everything—to light, to sound, to temperature,’’ as well as being extremely sensitive to odors and chemicals commonly found in perfumes, cosmetics, aftershave lotion, petroleum products, household cleaners, dryer sheets, and laundry detergents. Participants report experiencing unusual skin sensitivity that they described as ‘‘burning’’ or ‘‘a really bad sunburn.’’ [1]

Immersion in water  -- especially in a pool with poor water quality or uneven disinfection patterns -- can trigger this sensitivity. Patrons who do not shower off chlorine residue or who do not use lotion to replenish the skin’s natural barriers may experience additional difficulties. In addition to concerns about water, FMS patients must be concerned about air quality. Poorly ventilated pools can cause respiratory irritation in all patrons – not just those with more sensitive systems.

Depression/ Social isolation.Fibromyalgia has a substantial negative impact on social and occupational function. Patients report disrupted relationships with family and friends, social isolation, reduced activities of daily living and leisure activities, avoidance of physical activity, and loss of career or inability to advance in careers or education. 10 Individualized sessions of  1:1 therapy will not address the root of this concern: the need for peers who understand and can commiserate with each other. Group exercise class may be more appropriate for many clients with FMS – especially those classes who make special effort to cultivate relationships and have support systems internalized.

Reliance on caregiver/ Reliance on rituals.Patients with FMS can become reliant on patterns of care-giving to the extent of anxiety when these rituals are disturbed. Therapists or exercise instructors who routinely add novelty to their sessions may engender a sense of quiet desperation in those clients who long for a reliable level of exercise intensity. The persistence of pain and negative mood (depression), as it occurs in patients with fibromyalgia, can led to significant performance impairments on emotionally charged cognitive tasks. Some studies have hypothesized that chronic pain may impose a high cost on cognitive processing, undermining mainly affective processes involved in learning, memory, attention, and decision-making. [2]

Excessive pain reactions. Patients with strong pain sensitivities — such as those suffering from chronic pain syndromes like fibromyalgia — may over-react to the sensory overload present during aquatic sessions. Because a water-based exercise environment makes it possible for patients to move easily without receiving the same pain signals, patients may overdo exercise without knowledge or concern. This may encourage the patient to perform unsafe or excessively stressful movements.

Conclusion

There is not a lot of gold standard evidence which supports most physical medicine and rehabilitation. This is simply not the case for the patient with FMS; there exists a large body of research supporting aquatic exercise. 8,9,11–37 The best summary, a 2014 Cochrane review, finds small to moderate benefits, about the same as land exercise. 38 That is not a miracle, but for someone who cannot tolerate land exercise, it is a real way in.

The pool is open and the water is just fine. Now, someone needs to go tell Anne Marie.

What newer research says

  • Cochrane, 2014. 16 trials (881 people). Compared with no exercise, aquatic training improved function, pain, stiffness and strength by small to moderate amounts; compared with land exercise, results were about the same. Adverse effects were poorly reported, and none were serious.38
  • Depression, 2021 review. In 31 clinic studies, more than half of people with fibromyalgia had depression at some point in their lives, which supports the case for group classes and peer support.3

None of the precautions in this post has been tested in a trial; they are clinical reasoning [Expert opinion].

Frequently asked questions

What precautions apply to patients with fibromyalgia?

Lists vary from pool to pool. What matters is that a precaution leaves the call to the therapist, while a contraindication takes it away (Aquatic Therapy University, 2024).

Can poorly ventilated pools irritate the airways?

Yes. A poorly ventilated pool can irritate anyone's airways, not only those of sensitive patients (Aquatic Therapy University, 2024).

Do fibromyalgia patients have joint laxity?

They may. Underlying ligament or joint capsule laxity is possible in myalgic conditions such as fibromyalgia (Aquatic Therapy University, 2024).

Why do fibromyalgia patients need to pace pool sessions?

Many need to save energy so they can still manage everything else in their day (Aquatic Therapy University, 2024).

References

References

  1. Björkegren K, Wallander MA, Johansson S, Svärdsudd K. General symptom reporting in female fibromyalgia patients and referents: a population-based case-referent study. BMC Public Health. 2009;9:402. doi:10.1186/1471-2458-9-402. PubMed: 19878599.
  2. ReviewBoissevain MD, McCain GA. Toward an integrated understanding of fibromyalgia syndrome. I. Medical and pathophysiological aspects. Pain. 1991;45(3):227-238. doi:10.1016/0304-3959(91)90047-2. PubMed: 1876432.
  3. Systematic reviewKleykamp BA, Ferguson MC, McNicol E, et al. The Prevalence of Psychiatric and Chronic Pain Comorbidities in Fibromyalgia: an ACTTION systematic review. Semin Arthritis Rheum. 2021;51(1):166-174. doi:10.1016/j.semarthrit.2020.10.006. PubMed: 33383293.
  4. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33(2):160-72. doi:10.1002/art.1780330203. PubMed: 2306288.
  5. Guidelinede Miquel CA, Campayo J, Flórez MT, et al. Interdisciplinary consensus document for the treatment of fibromyalgia. Actas Esp Psiquiatr. 2010;38(2):108-20. PubMed: 21361054.
  6. Randomized controlled trialValim V, Oliveira L, Suda A, et al. Aerobic fitness effects in fibromyalgia. J Rheumatol. 2003;30(5):1060-9. PubMed: 12734907.
  7. Systematic review and meta-analysisBusch AJ, Schachter CL, Overend TJ, Peloso PM, Barber KA. Exercise for fibromyalgia: a systematic review. J Rheumatol. 2008;35(6):1130-44. PubMed: 18464301.
  8. Systematic review and meta-analysisBusch AJ, Barber KA, Overend TJ, Peloso PM, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007;2007(4):CD003786. doi:10.1002/14651858.CD003786.pub2. PubMed: 17943797.
  9. Randomized controlled trialCalandre EP, Rodriguez-Claro ML, Rico-Villademoros F, Vilchez JS, Hidalgo J, Delgado-Rodriguez A. Effects of pool-based exercise in fibromyalgia symptomatology and sleep quality: a prospective randomised comparison between stretching and Ai Chi. Clin Exp Rheumatol. 2009;27(5 Suppl 56):S21-8. PubMed: 20074435.

Further reading (from the original post)

  1. Arnold LM, Crofford LJ, Mease PJ, et al. Patient perspectives on the impact of fibromyalgia. Patient Educ Couns. 2008;73(1):114-20. doi:10.1016/j.pec.2008.06.005. PubMed: 18640807.
  2. Randomized controlled trialAltan L, Bingöl U, Aykaç M, Koç Z, Yurtkuran M. Investigation of the effects of pool-based exercise on fibromyalgia syndrome. Rheumatol Int. 2004;24(5):272-7. doi:10.1007/s00296-003-0371-7. PubMed: 14508601.
  3. Randomized controlled trialAssis MR, Silva LE, Alves AM, et al. A randomized controlled trial of deep water running: clinical effectiveness of aquatic exercise to treat fibromyalgia. Arthritis Rheum. 2006;55(1):57-65. doi:10.1002/art.21693. PubMed: 16463414.
  4. Systematic reviewBaranowsky J, Klose P, Musial F, Häuser W, Dobos G, Langhorst J. Qualitative systemic review of randomized controlled trials on complementary and alternative medicine treatments in fibromyalgia. Rheumatol Int. 2009;30(1):1-21. doi:10.1007/s00296-009-0977-5. PubMed: 19672601.
  5. ReviewBrosseau L, Wells GA, Tugwell P, et al. Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Phys Ther. 2008;88(7):857-71. doi:10.2522/ptj.20070200. PubMed: 18497301.
  6. ReviewBrosseau L, Wells GA, Tugwell P, et al. Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2. Phys Ther. 2008;88(7):873-86. doi:10.2522/ptj.20070115. PubMed: 18497302.
  7. GuidelineCarville SF, Arendt-Nielsen L, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008;67(4):536-41. doi:10.1136/ard.2007.071522. PubMed: 17644548.
  8. Systematic reviewDziedzic K, Jordan JL, Foster NE. Land- and water-based exercise therapies for musculoskeletal conditions. Best Pract Res Clin Rheumatol. 2008;22(3):407-18. doi:10.1016/j.berh.2007.11.002. PubMed: 18519096.
  9. Randomized controlled trialEvcik D, Yigit I, Pusak H, Kavuncu V. Effectiveness of aquatic therapy in the treatment of fibromyalgia syndrome: a randomized controlled open study. Rheumatol Int. 2008;28(9):885-90. doi:10.1007/s00296-008-0538-3. PubMed: 18278501.
  10. Randomized controlled trialGowans SE, deHueck A, Voss S, Silaj A, Abbey SE, Reynolds WJ. Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia. Arthritis Rheum. 2001;45(6):519-29. doi:10.1002/1529-0131(200112)45:6<519::aid-art377>3.0.co;2-3. PubMed: 11762686.
  11. Randomized controlled trialGusi N, Tomas-Carus P, Häkkinen A, Häkkinen K, Ortega-Alonso A. 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. 2006;55(1):66-73. doi:10.1002/art.21718. PubMed: 16463415.
  12. Systematic review and meta-analysisHall J, Swinkels A, Briddon J, McCabe CS. Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease? A systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2008;89(5):873-83. doi:10.1016/j.apmr.2007.09.054. PubMed: 18452734.
  13. Jentoft ES, Kvalvik AG, Mengshoel AM. Effects of pool-based and land-based aerobic exercise on women with fibromyalgia/chronic widespread muscle pain. Arthritis Rheum. 2001;45(1):42-7. doi:10.1002/1529-0131(200102)45:1<42::AID-ANR82>3.0.CO;2-A. PubMed: 11308060.
  14. Systematic review and meta-analysisLanghorst J, Musial F, Klose P, Häuser W. Efficacy of hydrotherapy in fibromyalgia syndrome--a meta-analysis of randomized controlled clinical trials. Rheumatology (Oxford). 2009;48(9):1155-9. doi:10.1093/rheumatology/kep182. PubMed: 19608724.
  15. Systematic review and meta-analysisLima TB, Dias JM, Mazuquin BF, et al. The effectiveness of aquatic physical therapy in the treatment of fibromyalgia: a systematic review with meta-analysis. Clin Rehabil. 2013;27(10):892-908. doi:10.1177/0269215513484772. PubMed: 23818412.
  16. Randomized controlled trialMannerkorpi K, Nyberg B, Ahlmén M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. J Rheumatol. 2000;27(10):2473-81. PubMed: 11036846.
  17. Randomized controlled trialMannerkorpi K, Ahlmén M, Ekdahl C. Six- and 24-month follow-up of pool exercise therapy and education for patients with fibromyalgia. Scand J Rheumatol. 2002;31(5):306-10. doi:10.1080/030097402760375223. PubMed: 12455823.
  18. ReviewMarcus DA. Fibromyalgia: diagnosis and treatment options. Gend Med. 2009;6 Suppl 2:139-51. doi:10.1016/j.genm.2009.01.004. PubMed: 19406366.
  19. Systematic reviewMcVeigh JG, McGaughey H, Hall M, Kane P. The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review. Rheumatol Int. 2008;29(2):119-30. doi:10.1007/s00296-008-0674-9. PubMed: 18751709.
  20. Meiworm L, Jakob E, Walker UA, Peter HH, Keul J. Patients with fibromyalgia benefit from aerobic endurance exercise. Clin Rheumatol. 2000;19(4):253-7. doi:10.1007/s100670070040. PubMed: 10941802.
  21. Randomized controlled trialMunguía-Izquierdo D, Legaz-Arrese A. Exercise in warm water decreases pain and improves cognitive function in middle-aged women with fibromyalgia. Clin Exp Rheumatol. 2007;25(6):823-30. PubMed: 18173915.
  22. Randomized controlled trialMunguía-Izquierdo D, Legaz-Arrese A. Assessment of the effects of aquatic therapy on global symptomatology in patients with fibromyalgia syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2008;89(12):2250-7. doi:10.1016/j.apmr.2008.03.026. PubMed: 19061736.
  23. Ortega E, Bote ME, Giraldo E, García JJ. Aquatic exercise improves the monocyte pro- and anti-inflammatory cytokine production balance in fibromyalgia patients. Scand J Med Sci Sports. 2012;22(1):104-12. doi:10.1111/j.1600-0838.2010.01132.x. PubMed: 20536907.
  24. Perraton L, Machotka Z, Kumar S. Components of effective randomized controlled trials of hydrotherapy programs for fibromyalgia syndrome: A systematic review. J Pain Res. 2009;2:165-73. doi:10.2147/jpr.s8052. PubMed: 21197303.
  25. Randomized controlled trialTomas-Carus P, Häkkinen A, Gusi N, Leal A, Häkkinen K, Ortega-Alonso A. Aquatic training and detraining on fitness and quality of life in fibromyalgia. Med Sci Sports Exerc. 2007;39(7):1044-50. doi:10.1249/01.mss.0b0138059aec4. PubMed: 17596770.
  26. Randomized controlled trialTomas-Carus P, Gusi N, Häkkinen A, Häkkinen K, Raimundo A, Ortega-Alonso A. Improvements of muscle strength predicted benefits in HRQOL and postural balance in women with fibromyalgia: an 8-month randomized controlled trial. Rheumatology (Oxford). 2009;48(9):1147-51. doi:10.1093/rheumatology/kep208. PubMed: 19605373.
  27. Randomized controlled trialTomas-Carus P, Gusi N, Häkkinen A, Häkkinen K, Leal A, Ortega-Alonso A. Eight months of physical training in warm water improves physical and mental health in women with fibromyalgia: a randomized controlled trial. J Rehabil Med. 2008;40(4):248-52. doi:10.2340/16501977-0168. PubMed: 18382819.
  28. Randomized controlled trialVitorino DF, Carvalho LB, Prado GF. Hydrotherapy and conventional physiotherapy improve total sleep time and quality of life of fibromyalgia patients: randomized clinical trial. Sleep Med. 2006;7(3):293-6. doi:10.1016/j.sleep.2005.09.002. PubMed: 16564209.

Newer research

  1. Systematic review and meta-analysisBidonde J, Busch AJ, Webber SC, et al. Aquatic exercise training for fibromyalgia. Cochrane Database Syst Rev. 2014;2014(10):CD011336. doi:10.1002/14651858.CD011336. PubMed: 25350761.

How to cite this article

First published June 5, 2024 on atuseminars.com · Last updated October 19, 2026 · Permanent URL: https://www.aquatictherapyuniversity.com/blog/fibromyalgia-is-or-should-be-all-wet-part-2

How to cite

Aquatic Therapy University. (2024, June 5). Fibromyalgia is (or Should be) All Wet (Part 2 of 2). Aquatic Therapy University Blog. ATU Educational Services, LLC. https://www.aquatictherapyuniversity.com/blog/fibromyalgia-is-or-should-be-all-wet-part-2

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