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Fibromyalgia is (or Should be) All Wet

Byline: Andrea Salzman, MS, PT

Anne Marie counts herself as one of the 2-4% of the population [1] diagnosed with fibromyalgia syndrome (FMS). Many of the people she knows think the diagnosis is made-up; but fibromyalgia is the 3rd most common rheumatic diagnosis [2], clocking in behind osteo and rheumatoid arthritis.

Like 45% of patients with fibro, Anne Marie is depressed. [3] She can’t sleep, feels stiff every morning, and is so fatigued that her work suffers. [4] Her family thinks she is lazy, her peers think she is crazy and she doesn’t know where to turn.

Establishing Medical Necessity for Aquatic Therapy

Historically, fibromyalgia has been a difficult disorder to treat in the rehabilitation profession.  In the medical setting, education on coping strategies, stress management, sleep patterns, nutrition, energy conservation, and the necessity of physical conditioning have been tried. [5] 

But what about plain old hard work? Both aerobic exercise and strengthening exercises have shown promise for the FMS patient. A deconditioned state – such as often seen in the FMS patient – can promote a continued cycle of pain, fatigue, and decreased motivation, leading to further inactivity.  

Although aerobic exercise seems to be overall more beneficial for patients with FMS than strengthening exercises, [6,7] both types of exercise offer patients and their health care professionals potential options for FM symptom management. But what if you want to make a case for performing both aerobic exercise and strength training in the warm, supportive environment of the therapy pool? What extra steps must be taken to make sure payers understand the medical necessity of the treatment plan?

The following language can be used in your documentation to support the medical necessity of aquatic therapy. If you decide on aquatic therapy as a treatment option during the initial evaluation, insert the “master statement” in the evaluation. After that, you should make the case for continuing to use aquatic therapy on an ongoing basis (daily or weekly) by using whichever “specific impairment” justification statement is appropriate.

Sample Statement of Medical Necessity:

Assessment (master statement): 

PATIENT presents with fibromyalgia syndrome and complains of debilitating fatigue, stiffness, poor quality sleep, anxiety and stress, headaches, and “pain all over.” She ranked pain at 8/10 or worse with her last attempt at aerobic exercise (walking rapidly for 5-10 minutes) and is afraid to try again. She has limitation in both spinal and shoulder ROM (see objective). She missed over 5 days of work this month and no longer attends family gatherings. She takes Amitriptyline to sleep and 1-2 Aleve daily. She has no support group at home or work and she is expressing frustration with the fact that “no one believes I hurt”. 

PATIENT’s visits will all take place 1:1 in an aquatic medium in order to capitalize on water's physical properties. Over 20 recent studies have demonstrated the benefits of aquatic therapy for this population. There is 'gold' level evidence ( [8] that supervised aerobic exercise training has beneficial effects on physical capacity and FMS symptoms. Strength training also appears to demonstrate some quantifiable benefits on FMS symptoms.

During her bout of 1:1 aquatic therapy, we will address her acute impairments and functional limitations and prepare her to exercise safely and independently in the water. After these limited goals have been met, PATIENT will be transferred to our aquatic exercise and support group.

Assessment (specific impairments):

  • Pain/Debilitating Fatigue: PATIENT is unable to sustain a moderate intensity of aerobic level of exercise — an essential component in the treatment of FMS — for >5 minutes. Exercise in water produces less joint and neural loading than the identical exercise performed on land permitting graded and reproducible application of compression forces. This environment provides greater movement freedom which helps interrupt the pain cycle. The pool offers the PATIENT a sustainable exercise environment.

  • Stiffness/ Decreased ROM: Proper positioning in water provides a low friction surface for movement, encouraging spontaneous active ROM with less restrictions than when hampered by a gravity-dominant environment. Additionally, the water can provide the “ultimate floating treatment table” – allowing a skilled therapist ease of positioning and access for stretching and joint mobilization.

  • Weakness: Water immersion provides a resistive medium that can be manipulated by a skilled therapist to either assist or resist movement. During early rehab, the immersed limb is automatically supported by buoyancy, which will assist in moving his body against gravity. As rehab progresses, movements can be accelerated to create more drag. Such activities can be structured to create more effort than the identical movements on land.

  • Poor Sleep/ Anxiety:  Aquatic exercise has been shown to produce significant reduction in both the Fibromyalgia Impact Measure and the Pittsburgh Sleep Quality Index. [9]

  • Lack of Knowledge of Aquatic Options/ Social WIthdrawal: PATIENT does not have the skill set necessary to maximize rehabilitation results while minimizing pain and fatigue. She will benefit from a short course of 1:1 instruction in aquatic therapy prior to being transferred to a group aquatic class.

Precautions for 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. For a more generalized list of all precautions and contraindications related to aquatic therapy, email the author.

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. [1] 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.


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 an abundance of riches supporting aquatic exercise. [11-39] There remains little doubt in the research world that water works miracles for the patient with fibromyalgia.

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


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 Oct 31;9:402.

2. Boissevan MD, McCain GA.  Toward an integrated understanding of fibromyalgia syndrome I: medical and pathophysiological aspects. Pain. 1991;45:227-38.  


3. Bennet R, McCain GA.  Coping successfully with fibromyalgia.  Patient Care.  1995; March 15:29-39.

4. Wolfe F et al.  The American College of Rheumatology 1990 criteria for the classification of fibromyalgia.  Arthritis and Rheumatology. 1990;33(2):160-72.

5. de Miquel CA, Campayo JG, Flórez MT, Arguelles JM, Tarrio EB, Montoya MG, Martin ÁP, Salio AM, Fuentes JV, Alberch EA, de la Cámara AG. Interdisciplinary consensus document for the treatment of fibromyalgia. Actas Esp Psiquiatr. 2010 Mar;38(2):108-20.

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7. Boisset-Pioro M, Esdaile JM, Fitzcharles M. Alternative medicine use in fibromyalgia syndrome. Arthritis Care Res. 1996;9:13–17.

8. Busch AJ, Barber KA, Overend TJ, Peloso PM, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003786.

9. Calandre, M.L. Rodriguez-Claro, F. Rico-Villademoros, J.S. Vilchez, J. Hidalgo, A. Delgado-Rodriguez. Effects of pool-based exercise in fibromyalgia symptomatology and sleep quality: a prospective randomised comparison between stretching and Ai Chi. Clin Exp Rheumatol. 2009 Sep-Oct;27(5 Suppl 56):S21-8.

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12. Assis MR, Silva LE, Alves AM, Pessanha AP, Valim V, Feldman D, Barros Neto TL, Natour J. A randomized controlled trial of deep water running: clinical effectiveness of aquatic exercise to treat fibromyalgia. Arthritis and Rheumatism. 2006 Feb 15;55(1):57-65

13. Baranowsky 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 Nov;30(1):1-21.

14. Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, Casimiro L, Robinson VA, McGowan J, Busch A, Poitras S, Moldofsky H, Harth M, Finestone HM, Nielson W, Haines-Wangda A, Russell-Doreleyers M, Lambert K, Marshall AD, Veilleux L; Ottawa Panel Members. Collaborators (20) Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Phys Ther. 2008 Jul;88(7):857-71.

15. Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, Casimiro L, Robinson VA, McGowan J, Busch A, Poitras S, Moldofsky H, Harth M, Finestone HM, Nielson W, Haines-Wangda A, Russell-Doreleyers M, Lambert K, Marshall AD, Veilleux L; Ottawa Panel Members.Collaborators (20) Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2. Phys Ther. 2008 Jul;88(7):873-86.

16. Busch AJ, Barber KA, Overend TJ, Peloso PM, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003786.

17. Calandre, M.L. Rodriguez-Claro, F. Rico-Villademoros, J.S. Vilchez, J. Hidalgo, A. Delgado-Rodriguez. Effects of pool-based exercise in fibromyalgia symptomatology and sleep quality: a prospective randomised comparison between stretching and Ai Chi. Clin Exp Rheumatol. 2009 Sep-Oct;27(5 Suppl 56):S21-8.

18. Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskila D, Da Silva JA, Danneskiold-Samsøe B, Dincer F, Henriksson C, Henriksson KG, Kosek E, Longley K, McCarthy GM, Perrot S, Puszczewicz M, Sarzi-Puttini P, Silman A, Späth M, Choy EH; EULAR. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr;67(4):536-41.

19. Dziedzic K, Jordan JL, Foster NE. Land- and water-based exercise therapies for musculoskeletal conditions. Best Pract Res Clin Rheumatol. 2008 Jun;22(3):407-18.

20. Evcik 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 Jul;28(9):885-90.

21. Gowans 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 Dec;45(6):519-29.

22. Gusi N, Tomas-Carus P, Hakkinen A, Hakkinen 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 and Rheumatism. 2006 Feb;55(1):66-73

23. Hall 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 May;89(5):873-83.

24. Jentoft ES, Kvalvik AG, Mengshoel AM. Effects of pool-based and land-based aerobic exercise on women with fibromyalgia/chronic widespread muscle pain. Arthritis and Rheumatism. 2001 Feb;45(1):42-47

25. Langhorst J, Musial F, Klose P, Häuser W. Efficacy of hydrotherapy in fibromyalgia syndrome--a meta-analysis of randomized controlled clinical trials. Rheumatology (Oxford). 2009 Sep;48(9):1155-9.

26. Lima TB et al. The effectiveness of aquatic physical therapy in the treatment of fibromyalgia: a systematic review with meta-analysis. Clin Rehabil. October 2013 27(10): 892-908.

27. Mannerkorpi K, Nyberg B, Ahlmen M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. The Journal of Rheumatology. 2000 Oct;27(10):2473-2481

28. Mannerkorpi 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.

29. Marcus DA. Fibromyalgia: diagnosis and treatment options. Gend Med. 2009;6 Suppl 2:139-51.

30. McVeigh JG, McGaughey H, Hall M, Kane P. The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review. Rheumatol Int. 2008 Dec;29(2):119-30.

31. 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.

32. Munguía-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 Nov-Dec;25(6):823-30.

33. Munguía-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 Dec;89(12):2250-7.

34. 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. 2010 Jun 1. doi: 10.1111/j.1600-0838.2010.01132.x. [Epub ahead of print]

35. 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 Nov 30;2:165-73.

36. Tomas-Carus P, Hakkinen A, Gusi N, Leal A, Hakkinen K, Ortega-Alonso A. Aquatic training and detraining on fitness and quality of life in fibromyalgia. Medicine and Science in Sports and Exercise. 2007 Jul;39(7):1044-1050

37. Tomas-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 Sep;48(9):1147-51.

38. Tomas-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 Apr;40(4):248-52.

39. Vitorino DF, Carvalho LB, Prado GF. Hydrotherapy and conventional physiotherapy improve total sleep time and quality of life of fibromyalgia patients: randomized clinical trial. Sleep Medicine 2006 Apr;7(3):293-29

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Check out more research on fibromyalgia here: Evcik, Deniz, et al. "Effectiveness of aquatic therapy in the treatment of fibromyalgia syndrome: a randomized controlled open study." Rheumatology international 28 (2008): 885-890. 

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