"Those who do not find time for exercise will have to find time for illness."
Submerge a patient in a thermoneutral therapy pool, and you eliminate the temperature gradient between skin and air.
Have her close her eyes; she instantly loses the ability to determine where her body ends. Immerse her ears, and you eliminate sound.
Lift her feet from the bottom of the pool, she weighs no more than a child.
Let her body rise and fall in the water with her breath. The stress and anxiety of the day falls away.
And for patients diagnosed with fibromyalgia syndrome, the days seem to be more stressful than not.
At the therapy pool in Regions Hospital in St. Paul, Minn., there are five types of exercise classes. Three of them are for patients diagnosed with fibromyalgia. It's not terribly complicated to figure out why. You see it flash across every face of every person who comes to those three classes. Relief. Blessed relief.
Immersion alone in those warm waters brings most fibromyalgia sufferers a sense of relaxation. But there's more to it than that. Today, aquatic physical therapists and other aquatic professionals are offering fibromyalgia patients the best means to combat their symptoms: aquatic exercise.
Fibromyalgia Syndrom: What is It? 
In the U.S. alone, between three and six million people (predominately women) have a cluster of symptoms which are typical of what we now call "fibromyalgia syndrome" or FMS.
Approximately 20% of these people are formally diagnosed with FMS. These individuals experience a nightmarish combination of poor quality sleep, fatigue, anxiety, stress, whole body stiffness, and gastrointestinal complaints.
Unfortunately, the exact causes and pathophysiology of FMS are unknown. The knowledge deficit has contributed to much debate (and even a few "oh please's") over the concept of fibromyalgia syndrome. This debunking has diminished over the last three decades, as the health care community has established a distinct protocol to assist in diagnosis of FMS.
Currently, an official diagnosis of FMS should not be given unless the patient has demonstrated widespread pain for three months or more, in combination with tenderness at eleven or more of eighteen specific tender point sites. Therapists interested in reading more about the diagnosis of FMS are directed to Wolfe et al's work. 
Treatment of FMS 
Historically, FMS 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 prescribed.
Medication is often recommended by physicians, along with attendance in cognitive-behavioral intervention programs. These medicines target pain and poor sleep patterns. In addition to receiving medication, patients are often asked to answer a sleep history questionnaire to help detect symptoms of a sleep disorder such as nonrefreshing sleep or episodes of sleeplessness. Patients are then instructed in sleep preparation and habits to help restore healthy sleep patterns.
In the rehabilitative setting, traditional passive physical therapy such as massage, electrical stimulation, heat, and spray and stretch have been used to effectively treat symptoms of FMS. However, many of these techniques provide the patient with little, if any, self-management and control of FMS.
Furthermore, passive techniques may lend themselves to a dependence on long term physical therapy, which is not feasible in the current health care system.
Instead, wise physical therapists are turning their patients on to the idea of exercise — in the water. It has been demonstrated that aerobic exercise is a crucial treatment for the population of FMS patients since they tend to be physically deconditioned. This deconditioned state promotes a continued cycle of pain, fatigue, and decreased motivation, leading to further inactivity.
FMS patients who participate in a regular aquatic exercise program can break that pattern of inactivity, and recapture control over their own symptoms.
Aquatic Exercise and FMS
In a pool, it is possible to perform vigorous aerobic exercise without the weight-bearing and joint compression experienced on land.
Additionally, aquatic exercise would seem to be an excellent intervention for FMS patients due to the inherent properties of water itself. These properties include buoyancy, turbulence, viscosity, hydrostatic pressure, temperature, and surface tension.
Therapists interested in a thorough scholarly discussion of the evidence-based use of these hydrodynamic properties in the treatment of fibromyalgia are directed to the July, 1997 issue of The Journal of Aquatic Physical Therapy.
Aquatic therapy for the fibromyalgia patient can cover the spectrum of therapeutic intervention. Patients who present with specific, treatable, musculoskeletal dysfunctions such as an inability to stabilize the spine, postural imbalance, poor spinal mobility, and weak trunk musculature may be treated 1:1 in the pool by a physical therapist.
This treatment may incorporate task simulation, joint and soft tissue mobility via a specialty technique such as Watsu® , or spinal stabilization via the Bad Ragaz Ring or Halliwick Methods.
After resolving specific dysfunctions, these patients are most often referred to a group class. Why? They just seem to do better in a group.
Patients with FMS often do battle with the unbelief of the health care system, their coworkers, their spouses. People with fibromyalgia often "look fine" to the world. A group exercise class not only provides a means of routine physical activity, it also provides a support system and a sounding board. It's also cheaper.
Group classes should be focused on two things: moderate aerobic activity and stress relief or relaxation. There has been a significant volume of work on the benefit of aerobic activity for the FMS population.
An aquatic exercise class which does not urge its members to elevate their heart rates and work aerobically for at least 20-30 minutes is neglecting the one intervention which is known to be beneficial.
Group classes are often too large to allow the physical therapist to work on relaxation individually with participants. However, each participant can learn techniques such as the vertical Watsu Water Breath Dance to maximize their own ability to relax into the water. (See sidebar for description).
Physical therapists who do not have access to a warm water therapy pool at their own facility should consider referral of FMS patients to another site which does offer group aquatic classes after 1:1 treatment is completed.
Ideally, all FMS patients should be encouraged to participate in consistent exercise at least four times per week, even in the presence of fatigue and stiffness. Aquatic facilities can make this a reality by offering daily class times and flexible scheduling (e.g., one morning class and one evening class) so patients can select four or more classes to attend each week.
Additionally, facilities which offer educational venues, such as monthly support groups, are more likely to keep patients excited and motivated to take the time to take care of the one person they most often neglect: themselves.
Sidebar: Watsu Water Breath Dance in Vertical (or "Surrendering to the Water") 
The patient is instructed to stand with legs spread into abduction, lungs inhaling and exhaling, allowing the body to rise and fall with each breath, collapsing into a squatting position in the water. As the patient inhales, the body naturally rises in the water as the lungs inflate.
As the patient exhales, the body collapses much like a puppet with all his strings cut (what I call the "Pinocchio syndrome"). The therapist instructs the exhaling patient to allow the body to sink into the water up to the chin. As the patient learns to let the water and his breath create the movement, he is instructed to close his eyes and let the water support him.
This technique can be used at the beginning or end of a FMS exercise class to teach participants how to maximize the relaxation effects of immersion in warm water.
1. Poteat AL, Bjerke MD, Johnston TD, Mairs JP. Evidence-based aquatic therapy: building a case for use of aquatic physical therapy for fibromyalgia populations. Journal of Aquatic Physical Therapy. 1996;5(2):8-16.
2. Wolfe F et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum. 1990;33(2):160-172.
3. Dull H. "Watsu." In Ruoti RG, Morris DM, Cole AJ: Aquatic Rehabilitation. Philadelphia, PA: Lippencott-Raven; 1997.
The information presented in this article is meant to be a summary and educational in nature. It is not meant to serve as a substitute for legal advice.
Andrea Poteat Salzman, MS, PT is the owner of two businesses, the Aquatic Resources Network and Concepts in Physical Therapy. She has received both the prestiguous Aquatic Therapy Professional of the Year Award (Aquatic Therapy and Rehabilitation Institute) and the Tsunami Aquatic Therapy Award.
Salzman is well-regarded within the industry as:
- Editor-in-Chief of an aquatic therapy trade journal and newsletter;
- Author of over a dozen publications, including the soon-to-be-released Evidence-Based Aquatic Therapy textbook;
- Freelance author and columnist;
- Aquatic therapy seminar instructor;
- Adjunct faculty and research advisor, St. Catherine Physical Therapy Program, Minneapolis, MN;
- Immediate past manager of therapeutic aquatics, St. Paul Ramsey Medical Center, St. Paul, MN;
- Researcher and grant recipient examining aquatic exercise vs. land-based exercise.
She may be reached via e-mail at firstname.lastname@example.org