# Exercise as it relates to Disease/The effects of swimming on pain and function in patients with Fibromyalgia

This is a critical appraisal of the original research article: Swimming Improves Pain and Functional Capacity of Patients With Fibromyalgia.

## What is the background of this research?

Fibromyalgia (FM) is a chronic syndrome characterised by extensive pain, fatigue, memory problems, and sleep disturbances. Nonpharmacological treatment, such as aerobic exercises, both in and out of the water, have been found to provide benefit and control over regular symptoms and functional limitations of patients with FM.
Physical activity (PA) has been linked to increases in self-efficacy affecting their ability to manage pain and undertake beneficial PA. Participants with FM that participated in regular PA had higher social, mental, and physical health than participants with less PA.
The purpose of this study was to assess the effects of swimming on the functional movement, aerobic capacity, pain management, and quality of life within individuals with FM. Research into cost-effective, easily-administered treatments could increase symptom management and functionalility in individuals with FM and allow for a higher quality of life.

## Where is this research from?

Undertaken with the American Congress of Rehabilitation Medicine (ACRM). It was conducted at the rheumatology outpatients clinics of Universidade Federal de São Paulo.
The primary investigator of this research study is Giovana Fernandes, Mestranda. Giovana Fernandes works at Universidade Federal de São Paulo. Other investigators, such as Fabio Jennings and Jamil Natour have previous experience researching interventions around PA and/or rheumatology.
Researchers seemed appropriate and non-contradictory to the study.

## What kind of research was this?

This research was conducted as a randomised control trial (RCT).
The use of RCTs in interventions involving FM and PA have increased in number and effectiveness within the last few years. However, using RCTs in this genre of research comes with limitations such as ethical and practical concerns, infeasibility, cost inefficiency, and factors such as researcher bias etc.
Participants' were split into two groups, a swimming group (SG) and a walking group (WG) by a computer program. This was safeguarded by a researcher not participating in the study.
There are concerns around the appropriateness of walking as a comparability to swimming. Results may be corrupt and unreliable if compared to PAs largely differing to swimming.

## What did the research involve?

The 75 participants involved in this study were all female, aged between 18 - 60 years and were recruited via announcements in newspapers and via radio.
The inclusion criteria:
* FM classifications based on the American College of Rheumatology.
* A score between 4 and 8cm on a visual analogue scale (VAS).
* Ability to swim.
* Have no change in medication in relation to FM within the last 3 months.
The exclusion criteria:
* Uncontrolled cardiorespiratory disease.
* Contraindications for PA.
* Serious psychiatric disorders.
* Uncontrolled diabetes mellitus.
* Previous participation in regular PA (≥30min 3 times a week) in the last 3 months.
* Inflammatory rheumatic disease.
Participants undertook a spiroergometric test.
Both groups undertook a 5-minute warmup, 40-minutes of exercise and a 5-minute cool down. These sessions were held 3 times a week for 12 weeks.
The SG performed freestyle. Participants' heart rate (HR) was monitored using a waterproof Polar HR monitor.
The WG performed these sessions in the open air whilst being monitored by an HR monitor.
Individuals participated in groups of 4-8 and were supervised by 2 trainers specialised in rheumatology. Trainers had diary cards to record the participants adherence to the program.
Participants were evaluated 3 times during the study, before the exercise programs (t0), at 6 weeks (t6), and 12 weeks into the program (t12).
Another concern is the participant's ability to maintain the intensity (70% VO2peak) for 50 minutes given their potential lack of previous PA due to their FM condition. Participants were likely to have varying physical abilities and be affected by FM differently, making specific, fatiguing PA difficult.
The variables used include:
* VAS
- Pain levels.
* Fibromyalgia Impact Questionnaire (FIQ)
- Quality-of-life questionnaire (health circumstances).
* Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)
- Generic quality-of-life questionnaire.
* Timed Up & Go test (TUG)
- Functional ability.
* Spiroergometric test
- Aerobic capacity measured (treadmill and ramp protocol).
* Analgesic log
- Analgesics taken by each participant.
- Paracetamol was prescribed (500mg up to 4 times a day - when required by participant).

## What were the basic results?

- For both the SG and WG improvements were seen in most variables.
- There were no statistically significant variables within aerobic capacity aside from absolute Vo2peak between the groups. This is theorised to be due to different physiological requirements between aquatic and land environments.
This aspect further raises the question about the appropriateness of walking as a PA comparative group within the study. Would a closer, more comparable PA yield more reliable results?
| Variables | SG (n=39) | WG (n=36) | Between-Group P∗ |
| VAS | | | .658 |
| t0 | 6.4±1.3 | 6.2±1.6 | |
| t6 | 4.2±2.5 | 4.3±2.6 | |
| t12 | 3.1±2.7 | 3.6±2.8 | |
| FIQ | | | .362 |
| t0 | 5.59±1.29 | 5.72±1.80 | |
| t6 | 4.13±1.57 | 4.55±1.86 | |
| t12 | 3.41±1.86 | 3.79±2.05 | |
| TUG | | | .373 |
| t0 | 6.98±1.20 | 7.01±1.08 | |
| t6 | 6.26±1.00 | 6.56±93 | |
| t12 | 6.01±91 | 6.22±78 | |
| SF-36 Subscales | SG (n=39) | WG (n=36) | Between-Group P∗ |
| Physical functioning | | | .661 |
| t0 | 64.4±21.1 | 64.0±26.4 | |
| t6 | 69.7±20.4 | 67.1±26.4 | |
| t12 | 76.2±20.3 | 72.6± 27.7 | |
| Physical role functioning | | | .923 |
| t0 | 32.1±35.3 | 34.0±41.0 | |
| t6 | 58.3±39.5 | 50.7±41.6 | |
| t12 | 59.0±39.9 | 62.5±43.3 | |
| Bodily pain | | | .531 |
| t0 | 33.6±16.8 | 41.0±24.6 | |
| t6 | 46.7±20.5 | 48.7±27.1 | |
| t12 | 53.2±26.3 | 51.4±25.3 | |
| General health state | | | .318 |
| t0 | 56.4±22.9 | 49.1±26.0 | |
| t6 | 62.9±24.6 | 60.08±27.9 | |
| t12 | 66.3±24.1 | 59.5±26.2 | |
| Vitality | | | .096 |
| t0 | 40.9±22.1 | 37.1±21.9 | |
| t6 | 55.9±21.2 | 45.1±24.5 | |
| t12 | 59.9±20.6 | 53.1±25.4 | |
| Social role functioning | | | .546 |
| t0 | 56.8±27.2 | 59.9±27.3 | |
| t6 | 71.1±27.1 | 71.2±27.5 | |
| t12 | 80.8±24.5 | 72.0±30.9 | |
| Emotional role functioning | | | .057 |
| t0 | 40.2±39.9 | 52.8±48.7 | |
| t6 | 62.4±41.3 | 75.9±39.5 | |
| t12 | 65.0±39.0 | 80.6±37.7 | |
| Mental health | | | .781 |
| t0 | 55.7±18.2 | 51.1±20.2 | |
| t6 | 63.1±18.6 | 65.7±20.6 | |
| t12 | 68.0±19.2 | 66.8±21.7 | |
| Aerobic Capacity | SG (N=39) | WG (N=36) | Between- Group P∗ |
| Absolute Vo2peak (L/min) | | | .015 |
| t0 | 1.97±30 | 1.81±36 | |
| t12 | 1.97±30 | 1.80±27 | |

## What conclusions can we take from this research?

Regular PA decreases symptomatic pain, increases functional movement, and quality-of-life in FM patients. There were no statistically significant differences in results between SG and WG aside from absolute Vo2peak. There are concerns about the reliability of these results due to the lack of comparability of the two groups.
The reliability of these results is threatened by the expected intensity the participants were to perform at a constant rate. No information on further improvement/ adherence to any regular PA by participants was stated in the research article. This implies improvements after the 12-week program were unaccounted for, limiting the results to a 3-month period of regular exercise.

## Practical advice

Different exercise intensities could be implemented in research studies.
Modifications throughout the program could be implemented.
Conducted over a larger period.
Could be compared with other PAs or interventions (such as a conventional drug treatment program).

## Further information/ resources

https://onlinelibrary.wiley.com/doi/full/10.1002/art.21693
https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/fibromyalgia
https://fibromyalgiaaustralia.org.au/practitioners/pain-management/
https://www.mecfscanberra.org.au/

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Swimming Improves Pain and Functional Capacity of Patients With Fibromyalgia: A Randomized Controlled Trial - ScienceDirect
* ↑ Fibromyalgia: A Clinical Review | Dementia and Cognitive Impairment | JAMA | JAMA Network
* ↑ A randomized controlled trial of deep water running: Clinical effectiveness of aquatic exercise to treat fibromyalgia - Assis - 2006 - Arthritis Care &amp; Research - Wiley Online Library
* ↑ Quality of life issues for fibromyalgia patients - Bernard - 2000 - Arthritis Care &amp; Research - Wiley Online Library
* 1 2 3 Fibromyalgia, physical activity, and daily functioning: The importance of efficacy and health‐related quality of life (wiley.com)
* 1 2 Effects of Swimming in the Treatment of Fibromyalgia - Full Text View - ClinicalTrials.gov
* ↑ The placebo effect and its determinants in fibromyalgia: meta-analysis of randomised controlled trials | SpringerLink
* 1 2 General Practice - 17 jan 1998 (nih.gov)
* ↑ Biomechanics of Swimming : Exercise and Sport Sciences Reviews (lww.com)
* ↑ Biomechanics of Swimming : Exercise and Sport Sciences Reviews (lww.com)
* ↑ Toward the identification of symptom patterns in people with fibromyalgia - Wilson - 2009 - Arthritis Care &amp; Research - Wiley Online Library
* 1 2 Physical exercise in fibromyalgia and related syndromes - ScienceDirect