Aquatic Therapy is Better Than Land-Based Therapy for Women with Fibromyalgia

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Aquatic therapy for women with fibromyalgia in Spain is better than land-based therapy for reducing pain levels and improving sleep quality, as seen at the 6-week follow-up.

A new study found aquatic therapy is better than land-based therapy for reducing pain intensity and improving sleep quality for women with fibromyalgia.1

“Regarding pain intensity, significant differences were not found between the groups post-treatment, but a significant difference was observed at follow-up, in favor of [aquatic therapy],” wrote investigators, led by Sabela Rivas Neira, from the Universiade de Coruña in Spain.

The chronic musculoskeletal pain condition associated with sleep disturbance and fatigue has a prevalence of 2.5% in Spain, a greater percentage than the prevalence in the US among adults. Fibromyalgia affects 2% of the US adult population, approximately 4 million people, according to the Centers for Disease Control and Prevention (CDC). 2

Investigators conducted a single-blind, randomized controlled, equivalence trial aiming to compare the effectiveness of aquatic therapy and land-based therapy for reducing pain in women with fibromyalgia. Neira recruited participants from the Association of Fibromyalgia, Chronic Fatigue Syndrome and Multiple Chemical Sensitivity of a Coruña in Spain by telephone (February – March 2016).1

Participants were included if they were female, aged 35 – 64 years, and had a fibromyalgia diagnosis meeting both the 1990 and 2010 American College of Rheumatology Criteria. They had a mean age of 50 years. Additionally, participants had a median body mass index (BMI) of 27 and a median symptom duration of 11 years.

Women with fibromyalgia (n = 40) were randomized 1:1 in either the aquatic therapy group or the land-based therapy group. Both exercise programs consisted of 60-minute sessions 3 times a week for 12 weeks, led by a trained physiotherapist.

The primary outcome was pain intensity, measured by the visual analogue scale. The secondary outcomes included pressure pain threshold (algometer), quality of life (Revised Fibromyalgia Impact Questionnaire), sleep quality (Pittsburgh Sleep Quality Index), fatigue (Multidimensional Fatigue Inventory), and physical ability (6-Minute Walk Test). The team assessed patients at baseline, 12 weeks, and 18 weeks.

The 2 therapies were matched by exercise features with 4 blocks: 15 minutes of warm-up, 25 minutes of proprioceptive exercises, 8 minutes of stretching, and 12 minutes of relaxation. Aquatic therapy took place in a 120 cm deep pool at a sports complex.

Exercise intensity grew over the weeks; therapy began with an intensity of 3-4 points on the modified Borg scale. Intensity was increased in blocks 1 and 2 at the end of the fifth week with more repetitions and fewer breaks. Exercises were modified for each participant, so their Borg score did not exceed 5.

Although the team observed no differences between the two therapy types of post-treatment, they did notice at the follow-up, a significant difference was found for the aquatic group (P = .016). The posthoc analysis showed the aquatic therapy brought more improvements in pain intensity [2.7 (interquartile range [IQR], 1.5 – 4.9) vs 5.5 (IQR, 3.3 – 7.6); P = .023; large effect, Cohen’s d = 0.8; 95% confidence interval [CI], 0.1 – 1.5] and sleep quality [12.0 (IQR, 7.3 – 15.3) vs 15.0 (IQR, 13.0 – 17.0); P = .030; large effect, Cohen’s d = 0.8; 95% CI, 01 – 1.5].

When assessing for secondary outcomes, investigators saw there was a significant increase in pressure pain threshold for both groups but only participants with aquatic therapy had a maintained therapeutic effect during the follow-up (P = .002).

The team also saw improvements in quality of life for the aquatic group with significant reductions in the total FIQR score post-treatment, compared to the land-based therapy (P = .001). Additionally, for sleep quality, they observed a significant difference between the groups at follow-up (large effect size, Cohen’s d=0.8; 95% CI, 0.1 – 1.5) but the Friedman test did not find any significant differences.

Investigators found significant differences in the “reduced activity” category for both groups. However, general fatigue differences were found only in the land-based therapy group (P = .003). Furthermore, they saw a significant change in functional capacity post-treatment for both aquatic therapy (P = .001) and land-based therapy (P < .001), as well as at the follow-up.

“The present results showed a longer-lasting therapeutic effect for the AT group, although the follow-up period cannot be considered medium term,” investigators wrote. “The duration and frequency of the study interventions may have allowed the unique thermal and mechanical properties of the aquatic environment to act for a long time, increasing activation of the descending pain inhibitory system and ultimately promoting changes in pain processing.”

The study included limitations, as investigators highlighted. For instance, the study had a small sample size so the results should be interpreted with caution, and it is more difficult to perform passive relaxation in water due to the instability of the environment.

“Although both therapies improved pain at the end of treatment, the therapeutic effect was maintained for longer in the [aquatic therapy] group,” investigators wrote. “Thus, regular AT can be adopted as a complementary approach to [fibromyalgia] treatment, as it may promote pain reduction and enhance sleep quality and could be beneficial for restoring physical capacity while improving [quality-of-life].”


  1. Rivas Neira S, Pasqual Marques A, Fernández Cervantes R, Seoane Pillado MT, Vivas Costa J. Efficacy of aquatic vs land-based therapy for pain management in women with fibromyalgia: a randomised controlled trial. Physiotherapy. Published online February 17, 2024. doi:10.1016/
  2. Fibromyalgia. Centers for Disease Control and Prevention. Accessed March 15, 2024.