Abstract
Fibromyalgia is a chronic pain condition characterized by generalized musculoskeletal pain, hyperalgesia and allodynia, commonly associated with other symptoms such as fatigue, poor sleep quality, anxiety and depression. The clinical manifestations of this rheumatic disease have significant psychosocial and economic repercussions, with a substantial impact on health status, quality of life and social activities. Currently, recommendations for the management of fibromyalgia include patient education and non-pharmacological interventions, and among the indicated treatments, clinical guidelines include several physiotherapeutic resources, essential for individuals affected by this syndrome. Research in the physiotherapy field has demonstrated its effectiveness, but there is a need to update the literature. This study aims to identify the effectiveness of physiotherapy in the treatment of individuals with fibromyalgia. We performed a literature review looking for articles dated from March 2012 to March 2022 using the terms “fibromyalgia”, “physiotherapy”, “physical therapy”, “rehabilitation” in different languages in various databases and their main information was read and collected and presented in a descriptive way. The effects of physiotherapy interventions are summarized in order to provide a reference for future research and clinical application. Research on non-pharmacological physiotherapy-oriented treatments has grown in recent years as an alternative for fibromyalgia treatment. This review allows fibromyalgia patients to receive appropriate physical therapy interventions to promote their health.
1 Introduction
Fibromyalgia is a chronic pain condition characterized by generalized musculoskeletal pain, hyperalgesia and allodynia, commonly associated with other symptoms such as fatigue, poor sleep quality, anxiety and depression (Garrido-Ardila et al., 2021). The clinical manifestations of this rheumatic disease have significant psychosocial and economic repercussions, with a substantial impact on health status, quality of life and social activities (Borchers and Gershwin, 2015). The prevalence of this disease ranges from 0.2 to 6.6% in the general population and is mostly seen in women between the ages of 20–50 (Marques et al., 2017), causing disability with high direct (e.g., drug therapy and health care) and indirect costs (e.g., lost productivity) (Mascarenhas et al., 2021).
The cause and pathogenic process of fibromyalgia are not fully understood. Genetic and environmental factors and peripheral and central mechanisms are considered to be involved in causing widespread pain and pain sensitivity in individuals with fibromyalgia (Uruş et al., 2021).
As such, diagnosis is based on the clinical criteria described by the American College of Rheumatology and have been revised in recent years (Wolfe et al., 1990; Wolfe et al., 2011; Wolfe et al., 2016). In 1990, the American College of Rheumatology created the fibromyalgia classification criteria to aid in the diagnosis and standardize patients for clinical trials. This criterion is based on the presence of diffuse pain present for at least 3 months associated with 11 tender points (the palpation of the points was removed). However, in 2011, these criteria were revised to encompass other important aspects of fibromyalgia, such as fatigue, unrefreshing sleep, cognitive symptoms, headache, depression, and abdominal pain. In 2016, a revision of the 2010/2011 criteria was proposed to correct classification errors observed in patients with regional pain, a complementary criterion of diffuse pain was added (Wolfe et al., 1990; Wolfe et al., 2010; Wolfe et al., 2011; Wolfe et al., 2014; Wolfe et al., 2016).
Current recommendations highlight that primary treatment should include patient education and non-pharmacological interventions (Macfarlane et al., 2017; Kundakci et al., 2021). In addition, non-pharmacological treatments are recommended to improve symptoms related to pain, physical function and quality of life. Among conservative treatments, clinical guidelines include non-pharmacological therapies such as exercise therapy, mind-body therapies, patient education, manual therapy, needle therapies, balneotherapy, among others (Fitzcharles et al., 2013; Macfarlane et al., 2017; Garijo et al., 2022).
It is important for researchers to show the role of physiotherapy in individuals with fibromyalgia through current information as it contributes to improving clinical practice and scientific research. The present study summarizes the relevance of physiotherapy in the treatment of fibromyalgia patients to provide a reference for future research and clinical application.
2 Literature search
The terms fibromyalgia AND (physiotherapy OR “physical therapy” OR rehabilitation) were used as keywords in English, Portuguese and Spanish. The searches were not limited only to titles and abstracts, we chose to leave them free, appearing in all fields of the articles. In addition, some specific physical therapy interventions were sought manually. Searches were conducted on the Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature in Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, Web of Knowledge ISI, Physiotherapy Evidence Database (PEDro), Excerpt Medical Database (Embase), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and SPORTDiscus for articles dated from March 2012 to March 2022. In addition, in order not to leave relevant articles out of the searches, we also searched other databases for articles related to the objective of the study. The articles were searched in all the indicated databases and then the main information was read and collected.
3 Physiotherapy in fibromyalgia
The different physical therapy modalities contribute to improving the quality of life of individuals with fibromyalgia (Melo et al., 2020). Below are described different physiotherapy modalities for the treatment of fibromyalgia.
3.1 Physiotherapy modalities for treating fibromyalgia
3.1.1 Exercise
Fibromyalgia patients are generally intolerant to physical activity and tend to lead a sedentary lifestyle, increasing the risk of additional morbidity (Bidonde et al., 2017). Physical exercise is an important component in the treatment of fibromyalgia and given that its impact on psychological well-being is well established, several studies point to it as a means of reducing medication. In addition, individuals who engage in regular physical exercise exhibit better well-being compared to their sedentary counterparts, who share a negative self-perception of health. Another benefit of physical exercise is its effectiveness in reducing pain and fatigue. People with fibromyalgia have lower aerobic endurance and muscle strength, which can limit their ability to perform activities of daily living (Sauch Valmaña et al., 2020).
The European Alliance of Associations for Rheumatology (EULAR) strongly recommends exercise, mainly due to its effect on pain, physical function and well-being, availability, relatively low cost, and lack of safety concerns. Furthermore, EULAR underscores that there is consistent evidence in regard to aerobic and strengthening exercises, but insufficient data to suggest superiority of one over the other; and land and water exercises appear equally effective (Macfarlane et al., 2017).
Aerobic exercise can be performed without the need for suitable equipment or a proper environment, making it an affordable form of exercise for individuals with fibromyalgia. A Cochrane review (Bidonde et al., 2017) showed that aerobic exercise can improve quality of life, pain, stiffness and physical function compared to a control group, but does not appear to improve fatigue. The literature also reports that aerobic exercise is associated with reduced anxiety in adults with fibromyalgia. These findings support current knowledge and understanding of the role of aerobic-only exercises in the treatment of this disease. These exercises appear to be well tolerated and can be integrated into the treatment of adults with this condition. Thus, it is suggested that individuals with fibromyalgia can engage in simple and accessible physical activities without exacerbating pain and other symptoms, with an emphasis on aerobic training interventions such as walking, which seems well tolerated. As such, it makes sense to encourage walking since it is a free accessible activity (Bidonde et al., 2017).
The EULAR highlights that aerobic exercise is associated with improvements in pain and physical function (Macfarlane et al., 2017). A systematic review of high-quality clinical trials showed that aerobic exercise (eg., Nordic walking) reduced general fatigue and long-term physical fatigue (Garijo et al., 2022). It is important to highlight that The Borg CR-10 Scale can be used as an additional parameter for prescribing exercise intensity in aerobic training protocols for women with fibromyalgia, that is, the intensity of the physical exercise level is effective when the exercises are practiced in conjunction with the scale with this population (Andrade et al., 2017).
When compared to aerobic training, it is uncertain whether flexibility exercises improve outcomes such as quality of life, pain intensity, fatigue, stiffness and physical function because the quality of short- and long-term evidence is very low. This is due to studies with small samples and issues related to an unclear and high risk of bias (selection, performance and detection bias) (Kim et al., 2019). However, flexibility exercises are often incorporated into programs targeting individuals with fibromyalgia in the context of current practice, although, in some cases, they can be included in warmup and/or cool-down regimens, rather than being a stand-alone treatment intervention. In the scientific literature, flexibility exercises are being used in clinical trials as a control group, or as part of a relaxation intervention, which may further reinforce the lack of recognition of these exercises as a treatment in their own right
Evidence suggests that moderate and moderate-to-high intensity resistance training improves muscle function, pain, sensitivity and strength in women with fibromyalgia; however, evidence quality is considered low. Recognizing that resistance training can improve well-being and symptoms may help promote this type of exercise as part of a balanced conditioning program for fibromyalgia patients and decrease fear-avoidance regarding possible increases in post-exercise muscle soreness. It is important to note that older (post-menopausal) women with fibromyalgia have the neuromuscular ability to gain strength, which may help improve and maintain functional mobility and reduce the risk of falls. A balanced conditioning program may also help reduce the risk of comorbidity and promote a more active lifestyle (Busch et al., 2013).
Aquatic training improves well-being and symptoms and may be a key factor in managing fibromyalgia (Bidonde et al., 2014). The movements performed in the aquatic environment, due to the heat and buoyancy of the water, relieve stress on the joints, being indicated for patients with chronic pain ( et al., 2012). Aquatic physiotherapy, generally practiced in water heated between 32 and 33°C, is strongly indicated for the treatment of fibromyalgia. During immersion, sensory stimuli compete with painful stimuli, decreasing the pain cycle (Santos et al., 2020). Improvements in symptoms through aquatic exercise can be explained based on its vasodilating action, analgesia through the release of endorphins, increased capillarization, muscle trophism and oxygen consumption, in addition to a decrease in body weight. At the same time, the relaxation obtained with hot water reduces muscle contractures, helping to improve microcirculation (López-Rodríguez et al., 2012). In addition, this type of exercise improves the self-esteem of individuals with fibromyalgia (Santos et al., 2020).
Improvement in pain may be in part due to the water temperature, which provides immediate benefits for muscle aches or stiffness that often limit exercise tolerance on land. This decrease in symptoms can increase self-efficacy for exercise, mood, and sleep, among others, which may translate into an overall improvement in quality of life. Water exercises can make exercising more attractive, especially for unfit individuals. As such, exercise in warm water may be particularly beneficial as an initial exercise for sedentary individuals without exacerbating pain. The feeling of pleasure that arises from exercising in warm water may also improve adherence (Bidonde et al., 2014).
Another exercise option is the modified Pilates method, since it contains exercises to mobilize, stretch and strengthen muscles. Modified Pilates, currently the most widely used approach by physical therapists, is adapted to the practitioner and divided into levels of progression that emphasize the curvatures of the spine during exercises (Franco et al., 2019; Medeiros et al., 2020). Studies show that Pilates can be better than short-term home exercises and connective tissue massage for pain-pressure and anxiety thresholds (Ekici et al., 2017), but similar to yoga exercises (Palekar and Basu, 2014) and a control group without intervention (Komatsu et al., 2016); however, most of these are still pilot studies.
A systematic review of high-quality clinical trials provides moderate to strong evidence that active therapies, such as land and water aerobic exercise therapy, muscle strengthening, exergames, and other combinations of non-pharmacological treatments, improve long-term pain intensity, disability and physical performance. Short-term sleep function and quality, anxiety, and depression in individuals with fibromyalgia (Garijo et al., 2022).
Exercise programs have been consistently recommended for the management of fibromyalgia. Exercise is also one of the treatment approaches used in the clinical practice of physical therapists (Garrido-Ardila et al., 2021). Clinical trials indicate the benefits of exercise, especially in the form of aerobic exercise, resistance or flexibility training, and moderate-intensity resistance training, when compared to no exercise, has been shown to improve pain, sensitivity, physical functioning, and muscle strength. Aquatic exercise, defined as performing exercises in waist-deep or chest-level water, was also found to be effective in improving pain, stiffness, muscle strength and general well-being compared to no exercise; however, these results were similar in land exercises (Busch et al., 2007; Busch et al., 2013; Bidonde et al., 2014; Chinn et al., 2016).
Furthermore, dance-based training programs can be an effective intervention for people with fibromyalgia, leading to a significant reduction in pain level with an effect size that can be considered large. However, findings and conclusions from this meta-analysis should be interpreted with caution due to the small number of articles and considerable heterogeneity (Murillo-García et al., 2018). In this regard, more controlled studies are needed to investigate the effectiveness of these complementary methods to help treatment providers provide evidence-based fibromyalgia treatment recommendations (Verkamp et al., 2013; Alciati et al., 2021).
Exercise is effective for fibromyalgia along with cognitive behavioral therapy, education in coping strategies, and non-pharmacological interventions. Physiotherapists are prepared to promote safe and healthy physical activity, and this knowledge is necessary to propose strategies that support individuals with fibromyalgia to become physically active and maintain physical activity habits (Larsson et al., 2020).
3.1.2 Manual therapy
Manual therapy has been defined in different styles. One refers to the manipulation of soft tissue and joints and another to the systematic mapping of soft tissue with rhythmic pressure to prevent, develop, maintain, rehabilitate or increase physical function or relieve pain. In physiotherapy practice, manual therapy plays an important role in the treatment of patients with musculoskeletal disorders, such as chronic back pain, migraines, anxiety, hypertension, depression and many other physical and psychological conditions that have been shown to respond positively to manual therapy. Connective tissue massage, an important element of manual therapy, deals with the skin and subcutaneous tissue. However, most literature reports show the benefits of manual therapy in healthy people, with few studies addressing these effects in individuals with fibromyalgia (Bervoets et al., 2015; Nadal-Nicolás et al., 2020).
Massage is the therapeutic modality used by 75% of individuals with fibromyalgia; however, only moderate evidence supports this intervention, since it can be extremely painful, although many patients still prefer it due to its potential long-term benefits. Massage intensity should be moderate to be beneficial and avoid pain (Bervoets et al., 2015;, 2020).
Massage therapy has been widely used for fibromyalgia as a complementary and alternative treatment. It can improve pain, anxiety, depression and sleep disturbances by the complex interplay of physical and mental modes of action (Imamura et al., 2012). A systematic review showed that massage therapy lasting ≥5 weeks provided immediate beneficial effects in improving pain, anxiety and depression and should considered a treatment for fibromyalgia (Li et al., 2014). In addition, a manual therapy protocol was effective in improving pain intensity, pressure pain sensitivity, the impact of fibromyalgia symptoms, sleep quality, and depressive symptoms (Castro-Sánchez et al., 2014).
Myofascial release has been used for individuals with fibromyalgia because ascending nociceptive pathways possibly involved in the central sensitization process, modulating the pain experience. However, there is uncertainty about its effectiveness compared to other interventions, given that manual therapy still exhibits non-specific effects. A systematic review investigated the effectiveness of manual therapy on pain, disease impact, and quality of life in individuals with fibromyalgia compared to a control group or other treatments. The results for fibromyalgia treatment were inconclusive and insufficient to support and recommend this intervention due to low-to-moderate evidence quality. To date, myofascial release has been the most widely used modality, but only general osteopathic treatment achieved a clinically relevant improvement in pain when compared to controls (Schulze et al., 2020).
Myofascial release is an emerging treatment for various conditions, with evidence regarding its symptom-relieving mechanisms. There is limited evidence on the effects of this type of intervention on fibromyalgia symptoms, with a systematic review showing moderate evidence for its effect on improving pain, sleep, and quality of life. However, more high-quality RCTs should be conducted in different geographic locations to generalize the findings (Ughreja et al., 2021).
In order to verify the effectiven
