Вплив гідрокінезотерапії на стан пацієнтів з long-term фіброміалгією

Since a number of studies pointed to generalized joint hypermobility in at least a subgroup of FMS patients (11-14), it was somewhat surprising that the pool training program contained flexibility exercises [prevalence rates for generalized joint hypermobility among FMS subjects were 18/66 (27. 3%), 4/56 (7. 14%), and 8/22 (36. 4%) ]. Part from the latter issue, the physical therapy program as applied in the present investigation complies with our current understanding of FMS. Indeed, a number of studies pointed to altered central pain processing in patients with FMS (15-17), substantiating the inclusion of explanatory theories for long-lasting pain into the educational program. In addition, given the high prevalence of opportunistic infections in FMS subjects (18-20), instructing patients to adapt the exercise training with respect to their individual pain and fatigue threshold is highly recommended. Finally, usage of pool exercise therapy might be able to decrease irrational fear of movement (kinesiophobia), as seen in a large subgroup of FMS patients (21). Physical activity is likely to cause exacerbations of symptoms in FMS patients. As a consequence, many FMS subjects avoid physical activity in order to prevent exacerbations. This becomes problematic when the patient's fear of movement (and consequent avoidance behavior) is in disproportion to the expected exacerbations. Then strategies aiming at reducing kinesiophobia are indicated. Since the participants of the present study reported joy about a mode of physical training that did not increase pain, pool exercises might teach FMS subjects that they are still capable of performing at least some forms of physical activity without exacerbating their symptoms. This way, the irrational fear of movement might be transformed into rational fear of movement.

The trial was well designed, few trial weaknesses were identified. First, the treatment program was compared to no intervention. Consequently, the observed effects might be, at least in part, attributed to the placebo effect. Indeed, recognition from what the patient believes to be an expert in FMS will increase positive results. Furthermore, the attention given by the instructor and other patients will increase motivation and subsequently positive outcome. Comparing pool exercise and patients' education with placebo or a distinct intervention (for instance the education program without the pool exercise therapy) would have increased the validity of the observed effectiveness. Second, a high number of patients in the treatment group did not complete the physical therapy program (9/37 = 24% compared to 2/32 = 6% in the control group). Reasons for dropping out of the study are briefly discussed, but an intention-to-treat analysis was not performed. In the Discussion section, the authors indicated that the dropouts were not included in the post-treatment analyses. Third, patients were instructed to continue their baseline medical treatment throughout the six months treatment period. This way, bias related to the effects of co-interventions was diminished but not excluded. Fourth, neither the exact water temperature, nor the depth of immersion of the body into the water were reported. Given these methodological considerations, these results should be interpreted with some caution. Still, this randomized controlled clinical trial, including a long-term follow-up period, provides new evidence supporting pool therapy and patient's education for patients with primary FMS. In order to make the physical therapy profession more evidence based, these kind of well designed, long-term follow-up trials examining the effectiveness of treatment protocols that are in accordance to our current understanding of the disorder of interest, should be encouraged.

These results are in accordance with two earlier reports. Bailey et al. (22) in their uncontrolled trial found improved aerobic fitness, pain, self-efficacy, and disability in 149 FMS subjects after a 12 weeks interdisciplinary program [comprising of 36 sessions of self-management techniques, group-building, goal-setting, education/counseling, graded stretching, strengthening, and aerobic training (hydrotherapy) ]. In another study, 47 women fulfilling the American College of Rheumatology criteria for FMS were randomized to either a pool-based, or a land-based 20-weeks exercise program (23). Both the pool-based and the land-based exercise program consisted of body awareness training, ergonomics, warm-up exercises, aerobic dance, cooling down exercises, muscle stretching exercises, strengthening exercises, and relaxation training. Both groups improved substantially, with the pool-based group showing some additional effects on symptoms. At six-months follow-up, little extinction of the initial effects were observed (23). Taken together, evidence supporting the inclusion of pool-based physical therapy into the management of FMS is increasing.

 

 

Mannerkorpi K, Nyberg B, Animen M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. J Rheumatol 2000; 27: 2473-81.

Mannerkorpi K, Ahlmen M, Ekdahl C. Six- and 24-month follow-up of pool exercise therapy and education for patients with fibromyalgia. Scand J Rheumatol 2002; 31: 306-10.

Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J Rheumatol 1994; 21: 714-20.

Martin L, Nutting A, Macintosh BR, Edworthy SM, Butterwick D, Cook J. An exercise program in the treatment of fibromyalgia. J Rheumatol 1996; 23: 1050-3.

Buckelew SP, Conway R, Parker J, et al. Biofeedback/relaxation training and exercise intreventions for fibromyalgia: a prospective trial. Arthritis Care Res 1998; 11: 196-209.

Wigers SH, Stiles TC, Vogels PA. Effect of aerobic exercise versus stress management treatment in fibromyalgia. A 4. 5 year propsective study. Scand J Rheumatol 1996; 25: 77-86.

Isomeri R, Mikkelson M, Latikka P, Kammonen K. Effects of amitriptyline and cardiovascular fitness training on pain in patients with primary fibromyalgia. J Musculoskel Pain 1993; 1: 253-60.

McCain GA, Bell DA, Mai FM, Halliday PD. A controlled study of effects of a supervised cardiovascular fitness training program on the manifestations of primary fibromyalgia. Arthritis Rheumatism 1988; 31: 1135-41.

Gowans SE, deHueck A, Voss S, Richardson M. A randomized, controlled trial of exercise and education for individuals with fibromyalgia. Arthritis Care Res 1999; 12: 120-8.

Geytenbeek J. Evidence for effective hydrotherapy. Physiotherapy 2002; 88: 514-21.

Fitzcharles M-A. Is hypermobility a factor in fibromyalgia? (editorial) J Rheumatol 2000; 27: 1587-9.

Hudson N, Fitzcharles MA, Cohen M, Starr MR, Esdaile JM. The association of soft-tissue rheumatism and hypermobility. Br J Rheumatol 1998; 37: 382-6.

Acususo-Diaz M, Collantes-Eslevez E. Joint hypermobility in patients with fibromyalgia syndrome. Arthritis Care Res 1998; 11: 39-42.

Karaaslan Y, Haznedaroglu S, Óztürk M. Joint hypermobility and primary fibromyalgia: a clinical enigma. J Rheumatol 2000; 27: 1774-6.

Banic B, Petersen-Felix S, Andersen OK, Radanov BP, Villiger PM, Arendt-Nielsen L, Curatolo M. Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia. Pain 2004; 107: 7-15.

Price DD. Staud R, Robinson ME, Mauderli AP, Cannon R, Vierck CJ. Enhanced temporal summation of second pain and its central modulation in fibromyalgia patients. Pain 2002; 99: 49-59.

Staud R, Vierck CJ, Cannon RL, Mauderli AP, Price DD. Abnormal sensitization and temporal summation of second pain (wind-up) in patients with fibromyalgia syndrome. Pain 2001; 91: 165-75.

Nasralla MY, Haier J, Nicolson NL, et al. Examination of Mycoplasmas in blood of 565 chronic illness patients by polymerase chain reaction. Int J Med Biol Environ 2000; 28: 15-23.

Nasralla M, Haier J, Nicolson GL. Multiple mycoplasmal infections detected in blood of patients with Chronic Fatigue Syndrome and/or Fibromyalgia. Eur J Clin Microbiol Infect Dis 1999; 18: 859-65.

Nicolson GL, Nasralla MY, Franco AR, et al. Role of mycoplasmal infections in Fatigue Illnesses: Chronic Fatigue and Fibromylagia Syndromes, Gulf War Illness and Rheumatoid Arthritis. J Chronic Fatigue Syndr 2000; 6: 23-39.

Goubert L, Crombez G, Van Damme S, et al. Confirmatory factor analysis of the Tampa Scale for Kinesiophobia: Invariant two-factor model across low back pain patients and fibromyalgia patients. Clin J Pain 2004; 20: 103-10.

Bailey A, Starr L, Alderson M, Moreland J. A comparative evaluation of a Fibromyalgia rehabilitation program. Arthritis Care Res 1999; 12: 336-40.

Jentoft ES, Kvalvik AG, Mengshoel AM. Effects of pool-based and land-based aerobic exercise on women with Fibromyalgia/Chronic widespread muscle pain. Arthritis Care Res 2001; 45: 42-7.