Rivas Neira et al. (2024)

Pain Management in Fibromyalgia: Comparing Aquatic versus Land-based Exercise

This study examined 2 methods of exercise therapy for pain management in fibromyalgia patients

Aquatic therapy seemed more effective compared to land-based exercise in reducing pain at the 18-week follow-up

A small sample size and the per-protocol analyses may limit the interpretation of the effects


Fibromyalgia is characterized by widespread pain patterns that are attenuated by central nervous system sensitization. For fibromyalgia patients, the recommendation of engaging in exercise therapy is widely accepted. Exercise modalities were found effective in pain management in fibromyalgia syndrome. Different modalities may be suitable for pain reduction and improving the quality of life of these people. Positive effects have been reported for both aquatic and land-based exercise interventions. However, these modalities haven’t been compared against one another in high-quality trials for their effectiveness. That’s what this study aimed to do.



To study the effectiveness of exercise for pain management in fibromyalgia syndrome, this study recruited women between the ages of 35-64 years who had an established diagnosis of fibromyalgia based on the American College of Rheumatology criteria (ACR).

The included participants were randomly assigned to aquatic therapy or land-based exercise.

Components of the Aquatic exercise included:

Pain Management in Fibromyalgia
From: Rivas Neira et al., Physiotherapy (2024)


The Land-based exercise consisted of:

Pain Management in Fibromyalgia
From: Rivas Neira et al., Physiotherapy (2024)


The primary outcome measure was pain intensity using a visual analog scale. Secondary outcomes included pressure pain threshold, quality of life, sleep quality, fatigue, and physical ability. All outcomes were assessed at baseline, post-treatment (12 weeks), and follow-up (18 weeks).


Forty women with fibromyalgia were randomly assigned to the aquatic therapy group (n = 20) or the land-based exercise group (n = 20). Both groups participated in 60-minute exercise sessions three times per week for 12 weeks. They were 50 years on average and had fibromyalgia symptoms for a mean of 11 years. The baseline characteristics revealed no significant differences between the groups.

Pain Management in Fibromyalgia
From: Rivas Neira et al., Physiotherapy (2024)


Aquatic therapy was found more effective for pain management in fibromyalgia at the 18-week follow-up but not at 12 weeks compared to land-based exercise. The corresponding effect size was large (d=0.8), but the confidence interval was wide (95% CI 0.1-1.5).

Pain Management in Fibromyalgia
From: Rivas Neira et al., Physiotherapy (2024)


Questions and thoughts

The secondary outcomes revealed that the only significant between-group difference between aquatic therapy and land-based therapy was seen for the Pittsburgh Sleep Quality Index. Only a little evidence is available on this questionnaire’s minimal clinical important difference (MCID). In a cohort of people undergoing rotator cuff repair, the minimal detectable change (MDC) was 3.5, and the MCID was 4.4 points. A difference of 3 points lies below the threshold of the MCID and the MDC, so is thus irrelevant.

The findings may be generalizable to women with fibromyalgia within the specified age range of 35 to 64 years, and symptom duration. The specialized setting from which the participants were recruited may limit the generalizability to general practice.

This study provides evidence that aquatic therapy can be an effective treatment for pain management in fibromyalgia. The structured exercise protocols used in the study can be adapted and implemented in clinical practice, emphasizing the benefits of aquatic environments for patients with fibromyalgia.


Talk nerdy to me

The study’s rigorous methodology, including randomized allocation and single-blind design, strengthens the validity of its findings. The use of standardized outcome measures and a well-defined intervention protocol ensures the reliability of the results. However, the small sample size and high adherence rate should be noted when interpreting the findings.

Candidates who were regularly physically active prior to the study were excluded from participating in the study. This is a good approach to create more homogeneity in the population, including only or mostly inactive people.

A finding that may have negatively affected the homogeneity of participants is the way fibromyalgia was diagnosed. People who had a diagnosis based on either the 1990 or 2010 American College of Rheumatology criteria were eligible for inclusion. Yet, both criteria are different of one another. The 1990 Criteria emphasizes tender points and requires the presence of widespread pain and pain at a specific number of tender points (11 or 18). According to the 2010 criteria a broader range of symptoms, including pain, fatigue, and cognitive symptoms, using the widespread pain index and symptom severity scale is required, while no tender point examination is necessary.

A limitation of this study, besides the small sample size, lies in the per-protocol analysis. Of the 40 participants, 5 people were lost to follow-up, which may have impacted the findings. Per-protocol analyses tend to overestimate the effects, so maybe the between-group difference is actually smaller than pointed out in this study.


Take-home messages

This study supports the use of water-based exercise as a superior option to land-based exercise for long-term pain management in fibromyalgia. The unique properties of water, such as hydrostatic pressure and temperature, may contribute to these benefits by enhancing sensory and motor functions while reducing pain perception. Although both therapies were effective post-treatment, the aquatic therapy demonstrated a more sustained effect at follow-up, suggesting its potential as a long-term intervention strategy for fibromyalgia. Recently, we wrote another research review about how to differentiate fibromyalgia syndrome from small fiber neuropathy. Read it here.



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. 2024 Jun;123:91-101. doi: 10.1016/j.physio.2024.02.005. Epub 2024 Feb 17. PMID: 38447497. 



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