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Mat Pilates is as effective as aquatic aerobic exercise in treating women with fibromyalgia: a clinical, randomized and blind trial

Mat Pilates is as effective as aquatic aerobic exercise in treating women with fibromyalgia: a... Background: The mat Pilates method is the therapeutic modalities which can be used in fibromyalgia treatment. Although there are no well-designed studies that prove the effectiveness of the mat Pilates method in this population. The objective was to evaluate the effectiveness of the mat Pilates method for improving symptoms in women with fibromyalgia. Methods: A single blind randomized controlled trial in which 42 women with fibromyalgia were randomized into two groups: mat Pilates and aquatic aerobic exercise. The exercises were performed twice a week for 12 weeks. Two evaluations were performed: one at baseline (T0), and another at 12 weeks after randomization (T12). The primary outcome was pain measured by the Visual Analogue Scale (VAS). Secondary outcomes were function (Fibromyalgia Impact Questionnaire), sleep (Pittsburgh Sleep Quality Index [PSQI]), quality of life (Short Form 36 [SF-36]), fear avoidance (Fear Avoidance Beliefs Questionnaire [FABQ-BR]) and pain catastrophizing (Pain-Related Catastrophizing Thoughts Scale [PRCTS]). Results: There was improvement in both groups in relation to pain and function (p < 0.05). The aspects related to quality of life and the FABQ questionnaire only showed improvement in the mat Pilates group (p < 0.05). There was improvement in the PSQI and PRCTS variables only in the aquatic aerobic exercise group (p < 0.05), but no differences were observed between the groups for any of the evaluated variables. Conclusion: Significant improvements were observed in the two groups in relation to the disease symptoms, and no differences were observed between mat Pilates and aquatic aerobic exercise in any of the measured variables. Trial registration: ClinicalTrials.gov Identifier (NCT03149198), May 11, 2017. Approved by the Ethics Committee of FACISA/UFRN (Number: 2.116.314). Keywords: Physiotherapy, Aerobic exercise, Rheumatology, Chronic pain * Correspondence: marcelocardoso@facisa.ufrn.br Federal University of Rio Grande do Norte, Faculty of Health Sciences of Trairi – (UFRN/FACISA), Postgraduate Program in Rehabilitation Sciences, Vila Trairi st, S/N, Centro, Santa Cruz, RN 59200-000, Brazil Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 2 of 10 Bullet points general body flexibility, core strength, posture and coordin- ation of breathing with movement [19]. The main feature is Mat Pilates improves pain and function in women its six basic principles: centralization, concentration, con- with fibromyalgia as well as aquatic aerobic exercise. trol, precision, respiration and flow [20]. This modality of Mat Pilates can be considered as a treatment option therapeutic exercise is well recommended for rehabilitating for the symptoms of women with fibromyalgia. the musculoskeletal system [21–23], but there are no well- Patient preferences should be taken into account designed studies demonstrating its benefit in treating fibro- when prescribing exercise. myalgia [2]. Even taking into consideration that the Pilates method Background is widely recommended and prescribed by health profes- Fibromyalgia (FM) is a chronic disease characterized by sionals, few studies have evaluated the effects of the generalized pain . It is triggered due to peripheral and method to treat patients with FM. These studies present central hyperexcitability mechanisms which are able to several methodological flaws which compromise their re- generate alterations in the perception of pain such as sults and suggest that studies with better methodological hyperalgesia and allodyne, muscular rigidity, reduced design be carried out with the objective of observing the functional capacity and sleep alterations [1–6]. FM has a effectiveness of the Pilates method in treating FM symp- general prevalence ranging from 0.66 to 4.4%, and a preva- toms [2, 24]. A study recently compared tai chi with aer- lence ratio of 8 women for each man, with the most fre- obic exercise and showed that tai chi was more effective quent diagnosis occurring in middle age [7]. than aerobic exercise. This study suggested that mind- FM has controversial etiopathogenesis, and its cause is body exercises may be the best option for patients with associated with genetic, environmental and neuromodu- fibromyalgia [25]. Within this context, mat Pilates may latory factors [8]. Many patients with fibromyalgia have also be considered an exercise modality that has similar high levels of stress and feelings of depression, anxiety characteristics, which would benefit the studied population. and frustration [9]. Therefore, the main objective of this study is to evalu- Thus, in addition to pharmacological treatment and ate the effectiveness of the mat Pilates method on im- educational programs, evidence has been observed over proving symptoms in women with fibromyalgia. Our the years regarding treatment with physical exercise hypothesis is that the mat Pilates method can bring [10], in which an effective treatment program consists of more benefits to improve the disease-related symptoms stretching, strength maintenance and aerobic condition- than that of aquatic aerobic exercise. We chose aquatic ing [2], with the main objective to repair the effects of a aerobic exercise for the purpose of comparison in know- lack of physical conditioning and to improve the symp- ing that aquatic aerobic exercise is a strongly recom- toms, especially those of pain and fatigue. Studies re- mended modality as a non-pharmacological treatment ported that physical exercises are beneficial, low cost for people with fibromyalgia [26]; moreover, we believe and promote improvement in pain and other symptoms that this type of exercise can be considered more fun, of fibromyalgia [11–13]. providing greater adherence to treatment and few stud- Although studies show benefits for almost all exercise ies have used aquatic aerobic exercises to compare with modalities, further evidence supports the practice of aer- other exercise modalities in treating fibromyalgia. obic exercise [14, 15]. Within this context, aquatic aer- obic exercise is considered a treatment form with good Methods results for patients with FM. In addition to the specific A single-blind randomized controlled trial was conducted benefits of physical exercise, the properties of heated according to the CONSORT (Consolidated Standards of water make the aquatic environment a suitable place for Reporting Trials) [27]. This study was registered (Clinical- performing exercises with the least possible harm to the Trials.gov Identifier: --------------) and follows the TIDieR musculoskeletal system. It provides reduced joint im- (Template for Intervention Description and Replication) pact, improved microcirculation, facilitates relaxation, checklist [28]. The study protocol and details of the decreases the number of contractions and improves exercise programs of the two groups were previously muscle strength due to its natural resistance [3, 16, 17]. published [29]. A Cochrane review showed that aerobic water exercise for FM is effective in improving overall well-being, func- Setting and participants tional capacity, pain, improved muscle strength by 37% Forty-two (42) women with FM diagnosis were selected and improved cardiovascular capacity [18]. according to the 2010 American College of Rheumatology The Pilates method has gained popularity for some classification criteria [30], between 18 and 60 years of age time. It is an exercise approach founded on the teachings and with pain between 3 and 8 on the Visual Analogue of Joseph Pilates (1880–1967), which aims at improving Pain Scale (VAS) from the waiting list of patients of the de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 3 of 10 Clinic Physiotherapy School and Basic Health Units of the large and comfortable room. Each session lasted about city. All women had medical referrals from local rheuma- 50 min and was led by a physiotherapist experienced in tologists who confirmed the disease. the technique. All the recommendations of the Trad- Women with uncontrolled hypertension, decompen- itional Pilates method were followed in relation to its six sated cardiorespiratory disease, history of exercise- principles to carry out the exercise program, namely: induced syncope or arrhythmias, decompensated dia- centralization, concentration, control, precision, breath- betes, severe psychiatric illness, history of regular exer- ing and flow. cise (at least twice a week) in the last 6 months or any Nine exercises (Fig. 2a.1 to a.9) were performed for another condition that made the patient unable to per- the main muscle groups with progressions each month. form physical exercises were excluded. The exercises were initially performed in 1 series of 8 repetitions in the first month. Then they were performed in 2 sets of 10 repetitions in the second month. Finally, Sample size calculation they were performed in 3 sets of 8 repetitions in the last The sample size was calculated based on the pain variable month. to find a difference of ±2.0 points between the interven- Three Swiss ball relaxation exercises were performed tion groups on the VAS [31], with a standard deviation of in 1 set of 30 s each (Fig. 2a.10 to a.12) at the end of 2.5 points [32]. A sample of 42 participants was necessary each session. The exercises were demonstrated and to reach a statistical power of 80% with a 5% alpha, allo- taught to women, but without an adaptation period. cating 21 into each group. The sample calculation was performed using Gpower3.1 software. Aquatic aerobic exercise group (AAEG) The AAEG patients performed aquatic aerobic exercises Randomization, concealed allocation and blinding at a swimming pool with a temperature of 31 degrees The randomization was performed through the website celsius. Each session lasted about 40 min and was di- www.randomization.com. An independent researcher rected by a physiotherapist experienced in water who did not participate in any other study procedures exercises. performed the randomization process. The program consisted of six main exercises (Fig. 2b.1 After the initial evaluation, the participants were referred to b.6) lasting 30 min with different intensity exercises to the physiotherapist in charge of the intervention and moderated by the Borg scale [33]. Two warm-up exer- were allocated to one of two groups by means of simple cises and two cool-down exercises were performed be- randomization using opaque and sequentially numbered fore and after the program. Participants were instructed sealed envelopes in order to maintain allocation secrecy. to report subjective perception of respiratory effort dur- The intervention groups were: Mat Pilates group ing the sessions. The patients reported when it was pos- (MPG; n = 21) and Aquatic Aerobic Exercise Group sible to increase the speed of the exercises in each (AAEG; n = 21). The two groups were submitted to session. treatments twice a week for 12 weeks. The flow diagram The exercise programs can be viewed in Fig. 2. of the study is summarized in Fig. 1. The researchers responsible for the interventions were Evaluations blinded to the participants’ initial assessments, and the Both groups were evaluated by blind evaluators who researcher responsible for evaluations was blinded to the were previously trained for applying the instruments. group allocation. The evaluations were performed at baseline and 12 In addition, data collected during participant evaluations weeks after randomization. were not disclosed to investigators responsible for interven- tions, and participants were instructed to not disclose their Primary outcome experience or information related to the intervention. Finally, the researcher responsible for statistical ana- Pain - visual analogue scale (VAS) Pain intensity was lysis performed the analysis blindly. Once the interven- assessed, where 0 is “no pain” and 10 is “the worst pain tion was completed, they received an Excel data table possible” [31]. A 2-point decrease on a 0–10 pain inten- with all the necessary data without identification of the sity scale can be considered a clinically important subjects or the groups. improvement for individual patients [34]. Interventions Secondary outcomes Mat Pilates group (MPG) The MPG patients performed exercises based on the Disease-related quality of life Disease-related quality Mat Pilates method in a group of up to 4 women in a of life was assessed by a validated Fibromyalgia Impact de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 4 of 10 Fig. 1 Flowchart of study Questionnaire (FIQ) for the Brazilian population. The Sleep quality Sleep quality was measured by the Bra- ten items of the FIQ were normalized to vary from zero zilian version of the Pittsburgh Sleep Quality Index to 100. Each item has different scores (the functional (PSQI). This instrument consists of 19 questions re- capacity item was added and divided by 30, the two garding quality and sleep disorders in the last month. items from zero to 7 divided by seven, and items from The scores can vary from zero to 3 for each compo- zero to 10 divided by 10) [35]. Changes of 14% change nent with the maximum score being 21 points, and in the total score of the FIQ are clinically relevant [36]. scores above 5 indicate poor quality of the individ- ual’s sleep [39]. Overall quality of life Quality of life was assessed using the Brazilian version of the Short Form-36 Health Survey Catastrophic thoughts on pain Catastrophic thoughts (SF-36). This questionnaire consists of eight areas of qual- on pain were evaluated from the Brazilian version of the ity of life: functional capacity, role physical, pain, general Catastrophic Thoughts on Pain Scale (PRCTS), which is health status, vitality, role social, emotional aspects and composed of 9 items staggered on a Likert scale ranging mental health. Scores range from zero to 100, with a from zero to 5 points associated with the words “almost higher score representing better quality of life [37, 38]. never” and “almost always” at the ends. The total score de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 5 of 10 Fig. 2 Exercises program: a.1 to a.12 for Mat Pilates Group and b.1 to b.6 for Aquatic Aerobic Exercise Group is the sum of the items divided by the number of items BR). The scale is composed of 16 items, wherein items 1, 8, answered, with the minimum score being zero and max- 13, 14 and 16 are excluded in the sum of the final score. imum 5. There are no cut-off points, and higher scores The score must be obtained in isolation in each of the sub- indicate greater presence of catastrophic thoughts [40]. scales, with the distribution of the points of the subscale re- lated to the work (FABQ Work) done by adding items 6, 7, Fears and beliefs Fears and beliefs related to physical and 9, 10, 11, 12 and 15 (total ranging from zero to 42) and the occupational activities were evaluated by the Brazilian ver- subscale related to physical activities (FABQ Phys), adding sion of the Fear Avoidance Beliefs Questionnaire (FABQ- items 2, 3, 4 and 5 (total ranging from zero to 24) [41]. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 6 of 10 Statistical analysis Table 1 Mean, standard deviation (SD) values of all analyzed variables of the two groups of patients with fibromyalgia at Data were analyzed by SPSS software 20.0. The normal baseline distribution and homogeneity of the variances of the vari- Variable mean (SD) AAEG MPG P ables were verified using the Kolmogorov-Smirnov test (n = 21) (n = 21) and the Levene test, respectively. Estimates of average ef- Mean ± SD Mean ± SD fect (differences between groups) for all variables were cal- Age (years) 50.7 (9.7) 45.5 (10.6) 0.10 culated using the ANOVA mixed model. This analysis model incorporated the intervention groups (MPG x BMI (kg) 30.4 (5.2) 27.8 (4.7) 0.10 AAEG), time (baseline and 12 weeks) and the group × VAS 7.5 (1.8) 7.5 (1.6) 0.86 time interaction. When a significant F value was found, FIQ 67 (16) 68 (14) 0.88 the Bonferroni post-hoc test was applied in order to iden- SF36 tify the differences. The intention-to-treat analysis was Role social 49.5 (24.5) 54.2 (21.3) 0.51 used to assess the response to intervention, with the last General health status 29.7 (22.6) 38.2 (19.2) 0.20 evaluation repeated as needed. A 95% confidence interval and a statistical significance level of 5% were used. Vitality 36.2 (18.9) 34.6 (17.5) 0.78 Functional capacity 28.5 (16.6) 34.0 (17.1) 0.30 Results Role physical 17.8 (30.7) 23.7 (28.8) 0.52 Some patients dropped-out of the intervention. The Emotional aspects 22.2 (33.9) 44.4 (46.3) 0.08 MPG presented 3 follow-up losses during the study, Pain 29.4 (18.0) 33.3 (17.2) 0.47 while the AAEG presented 2 losses in T12. It is import- Mental health 47.1 (22.7) 57.5 (21.9) 0.14 ant to emphasize that the performed analysis was of the total sample with an intention-to-treat analysis. Treat- PSQI TOTAL 12.3 (4.1) 10.3 (3.8) 0.11 ment adherence percentage was 85.7% for the MPG and PRCTS 3.04 (1.2) 2,64 (1.2) 0.29 90.5% for the AAEG groups. FABQ_Work 27.5 (12.6) 25.0 (10.8) 0.49 Table 1 shows the homogeneity between the groups in FABQ_Phys 12.6 (7.0) 13.0 (7.1) 0.83 the baseline for all analyzed variables. AAEG Aquatic Aerobic Axercise Group, MPG Mat Pilates Group, BMI Body mass Table 2 shows the mean and standard deviation values index, VAS Visual analogic pain scale, FIQ Fibromyalgia impact questionnaire, of the analyzed variables in the two evaluated moments SF36 Short Form-36 Health Survey, PSQI TOTAL Pittsburgh Sleep Quality Index, PRCTS Scale of catastrophic thoughts on pain, FABQ_Work Fear Avoidance (T0 and T12) in the two groups evaluated. Beliefs Questionnaire_Related to work, FABQ_Phys Fear Avoidance Beliefs The results for FIQ showed improvement in both Questionnaire related to their physical activities groups, with a mean difference (MD) = 0.91, 95% confi- dence interval (CI) = 0.36/1.4, (p = 0.002) for the AAEG treatment for 12 weeks for women with fibromyalgia, and MD = 1.6 95%CI = 1.1/2.2, (p = 0.001) for the MPG. promoting improvement in pain and quality of life. In addition, there was also improvement in pain assessed These results were intragroup, without significant differ- by the VAS, with MD = 1.8, 95%CI = 0.74/2.8, (p = 0.001) ences between the groups. Thus, the strength of this for the AAEG and MD = 1.3, 95%CI = 0.22/2.3, (p = 0.01) study lies in showing the benefits of two different exer- for the MPG (Table 2). cise modalities for women with fibromyalgia. Addition- The MPG showed improvement in the following SF-36 ally, fibromyalgia patients may have the option of domains: vitality (MD = − 9.14 95%CI = 0.06/18.2, p = choosing mat Pilates or aquatic aerobic exercise to im- 0.04), functional capacity (MD = -9.5, 95%CI = -18.2/− prove their symptoms. The mat Pilates presented 0.06, p = 0.04) and pain (MD = -11.5, 95%CI = -21.0/− 2.0, intragroup results in improving the vitality, functional p = 0.02). In the FABQ-Phys, there was improvement in capacity and pain domains of SF-36, favoring improve- the activities domain (MD = 4.9, 95%CI = 1.6/8.2, p = ment in patients’ quality of life, as well as in the field of 0.005). For the AAEG, there were improvements in PSQI- FABQ-BR activities, which leads to reducing fears and total (MD = 2.7, 95%CI = 1.0/4.3, p =0.02) and in PRCTS beliefs related to physical activities. (MD = 0.74, 95%CI = 0.3/1.1, p = 0.01) (Table 2). The aquatic aerobic exercise provided positive Table 3 presents the analysis between groups at 12 intragroup results in the improvement of PSQI-total re- weeks after randomization. No difference was detected ferring to quality of life and sleep quality, and a reduc- between the groups in the performed evaluations for all tion of catastrophic thoughts towards the disease as variables. evaluated by the PRCTS. Also, there were significant intragroup results in both groups for quality of life in re- Discussion lation to the disease evaluated by the FIQ and in the The mat Pilates method and the aquatic aerobic exercise pain evaluated by the VAS. Furthermore, the groups in the present study were effective as a form of showed homogeneity for all analyzed variables. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 7 of 10 Table 2 Mean values and standard deviation (SD) of the analyzed variables in the two evaluation moments (T0 and T12) in the two evaluated groups Variables AAEG MPG (n = 21) (n = 21) Mean ± SD Mean ± SD (CI 95%) (CI 95%) T0 T12 p T0 T12 p VAS 7.5 (1.8) 5.6 (2.4) 0.001* 7.5 (1.6) 6.2 (1.4) 0.01* FIQ 67 (16) 58 (16) 0.002* 68 (14) 51 (17) 0.001* SF36 Role social 49.5 (24.5) 53.6 (32.3) 0.15 54.2 (21.3) 64.2 (22.1) 0.11 General health status 29.7 (22.6) 37.0 (22.3) 0.21 38.2 (19.2) 39.0 (23.6) 0.30 Vitality 36.2 (18.9) 42.6 (17.6) 0.16 34.6 (17.5) 43.8 (19.5) 0.04* Functional capacity 28.5 (16.6) 33.9 (18.0) 0.25 34.0 (17.1) 43.5 (22.0) 0.04* Role physical 17.8 (30.7) 21.9 (32.4) 0.15 23.7 (28.8) 36.2 (38.6) 0.17 Emotional aspects 22.2 (33.9) 34.6 (41.2) 0.45 44.4 (46.3) 43.6 (43.6) 0.50 Pain 29.4 (18.0) 37.9 (20.3) 0.08 33.3 (17.2) 44.9 (18.4) 0.02* Mental health 47.1 (22.7) 55.0 (19.3) 0.11 57.5 (21.9) 65.9 (27.8) 0.09 PSQI TOTAL 12.3 (4.1) 9.5 (3.7) 0.002* 10.3 (3.8) 9.9 (3.7) 0.64 PRCTS 3,04 (1.2) 2.3 (1.5) 0.001* 2,64 (1.2) 2.5 (1.4) 0.60 FABQ_Work 27.5 (12.6) 30.3 (11.2) 0.33 25.0 (10.8) 25.8 (14.0) 0.40 FABQ_Phys 12.6 (7.0) 10.9 (8.4) 0.32 13.0 (7.2) 8.1 (6.9) 0.005* AAEG Aquatic aerobic Exercise Group, MTG Mat Pilates Group, VAS Visual analogue pain scale, FIQ Fibromyalgia impact questionnaire, SF36 Short Form-36 Health Survey, PSQI TOTAL Pittsburgh Sleep Quality Index, PRCTS Scale of catastrophic thoughts on pain, FABQ_Work Fear Avoidance Beliefs Questionnaire_Related to work, FABQ_Phys Fear Avoidance Beliefs Questionnaire related to their physical activities *Significant difference (p < 0.05) Therefore, it is known that the recommendations mechanisms which provide these results are those speci- for practicing physical exercise in treating FM are evi- fied in the review by Lima et al. (2017), who propose dent in the literature. The EULAR review (2017) pro- that there is a balance between inhibition and excitation vides a strong recommendation for exercise use, in the central nervous system, which determines whether especially because of its effect on pain, physical func- exercise promotes analgesia or promotes pain . Several tion and well-being, availability, relatively low cost, factors, such as physical conditioning level, physical ac- and lack of safety concerns. However, it was not pos- tivity levels and state of the injury or pain condition in- sible to distinguish between the aerobic or strength fluence this balance [44]. benefits [42]. In the study by Altan et al. (2009), the Pilates method There is no superior exercise intervention according as a form of treatment for the intervention group three to Macfarlane et al. [42]. There is also no evidence to times a week for 12 weeks achieved significant improve- suggest superiority of one over another . This corrobo- ments in VAS values (p < 0.000), while the performance rates the results presented in our study, in which the frequency of twice a week in the present study was suffi- MPG did not obtain statistically significant different cient to obtain significant intragroup results in the VAS results when compared to the AAEG, which proves that values (p = 0.01) [2]. one modality does not overlap with the other. The method was also studied in other chronic pain According to a study that applied treatment in conditions, in which there is evidence that Pilates was which the patients were instructed to contract their more effective than minimal intervention to improve local musculature (“central stability”)beforestarting pain, disability, function and overall recovery impression any specific exercise on the ground and in water for in the short term, and there was no conclusive evidence 6 months presented benefits for improving pain, which showed that it is superior to other forms of exer- showing similarity with the findings of our study in cise [45]. Also, the systematic review by Miyamoto the AAEG [3]. (2013) presents evidence that the exercises based on the The Pilates method is a recommended form of exer- Pilates method are more effective than no treatment or cise for healthy individuals and for those involved in re- minimal intervention in the treatment of chronic non- habilitation [43]. In view of this, we believe that the specific low back pain [46]. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 8 of 10 Table 3 Differences among T12 assessment groups for all between the two groups for FIQ scores, only finding analyzed variables results for VAS (P < 0.001) [49]. A Cochrane review Variables Differences between groups (2014) which evaluated sleep through PSQI found Adjusted with mean difference (CI 95%) moderate evidence of sleep improvement in the group T12 that performed aquatic aerobic exercise [18]. How- (CI 95%). p ever, better results were obtained in the AAEG in the AAEG VS MPG p present study. This is due to the therapeutic proper- VAS −0.61 (−1.8 to 0.6) 0.61 ties of heated water, which cause the least possible FIQ 0.67 (− 0.37 to 1.72) 0.20 damage during exercise, providing less impact on the joints, facilitating relaxation, improving muscle tone SF36 and microcirculation [16, 20]. Social role −10.5 (− 27.8 to 6.7) 0.22 Pain can directly impact the quality of life of this General health status −2.0 (−16.3 to 12.2) 0.77 population. In relation to this outcome, similar findings Vitality −1.2 (− 12.7 to 10.4) 0.83 were found in some studies which reported positive re- Functional capacity −9.6 (−22.2 to 2.9) 0.13 sults [2, 16, 50]. Physical role −14.3 (−36.5 to 7.9) 0.20 In our study we found significant results in the “activ- ities” domain (FABQ-BR instrument) for the MPG for Emotional aspects −9.0 (− 35.5 to 17.5) 0.49 which it was only an intragroup difference, however in Pain −7.0 (−19.0 to 5.0) 0.25 our opinion these results are derived from the principles Mental health −10.8 (−25.7 to 4.1) 0.15 of centralization, concentration, control, precision, flow PSQI TOTAL −0.33 (−2.7 to 2.0) 0.77 and respiration present in the mat Pilates modality. PRCTS −0.22 (−1.1 to 0.69) 0.63 It is worth remembering that the results of the FABQ_Work 4.4 (−3.4 to 12.3) 0.26 present study are limited to the studied population and cannot be extrapolated to other populations. FABQ_phys 2.8 (−2.0 to 7.6) 0.24 Moreover, the study presents some important limita- AAEG Aquatic aerobic exercise group, MPG Mat Pilates group, VAS Visual analogue pain scale, FIQ Fibromyalgia impact questionnaire, SF36 Short Form- tions regarding the small size of the sample and the 36 Health Survey, PSQI TOTAL Pittsburgh Sleep Quality Index, PRCTS Scale of short execution period, so perhaps more promising catastrophic thoughts on pain, FABQ_Work Fear Avoidance Beliefs Questionnaire_Related to work, FABQ_Phys Fear Avoidance Beliefs results could be observed with the one segment Questionnaire related to their physical activities greater than 12 weeks. Also, an important limitation was the comparison of different modalities, loads and For the outcomes found in applying aquatic aerobic intensities imposed on the different systems affected exercise, we consider that the mechanisms provided by by fibromyalgia. Still, no objective assessment of phys- water immersion are directly related to the present re- ical fitness was used in the aquatic aerobic exercise sults. These include reduced impact on joints, increased group. The mat Pilates program was performed with blood flow to muscles and the spread of metabolic waste great repetition variability between months, and so from muscle to blood, as well as a reduction in the time other studies should focus on comparing different needed to transport oxygen, nutrients and hormones to progression protocols. We found some problems in the fatigued body [47]. relation to the protocol of this study that was previ- According to Becker (2009), numerous studies of ously published, however we could not reach the fibromyalgia patients have shown reductions in pain, the sample and the proposed evaluation times as found in impact of fibromyalgia, mood disorders, and improve- the protocol publication. However, even though the ment in sleep patterns, as well as aquatic groups typic- obtained results and the effectiveness of the two ther- ally showed faster, more and longer improvements after apies were positive, it is necessary to conduct new the study when compared to ground-based exercise studies with a larger sample number and longer programs [48]. execution time. In a study conducted by Evcik (2008), the use of the 60-min aquatic therapy performed three times a week for 5 weeks versus the home exercise program Conclusion obtained significant intragroup results at the 12th The mat Pilates method and aquatic aerobic exercise week for aquatic therapy, with FIQ having a p-value = were effective after 12 weeks of treatment for patients 0.002 and VAS p = 0.000. Our study obtained similar with FM in improving pain. The MPG did not obtain results for the AAEG, with values of p =0.002 for statistically significant different results when compared FIQ and p = 0.001 for VAS. In addition, Evcik et al. to the AAEG, which proves that one modality does not also did not present statistically significant differences overlap with the other. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 9 of 10 Acknowledgements 7. Marques AP, do Espírito Santo AD, Berssaneti AA, et al. Prevalence of We thank the PROPESQ/UFRN for Internal Financing (numbers 01/2017 - Call fibromyalgia: literature review update. Rev Bras Reumatol (English Ed). 2017; for Research Grants of UFRN for the granted scholarships) and we thank all 57:356–63. the women with fibromyalgia who participated in this study. 8. Häuser W, Fitzcharles MA. Facts and myths pertaining to fibromyalgia. Dialogues Clin Neurosci. 2018;20(1):53–62. 9. Hadlandsmyth K, Dailey DL, Rakel BA, et al. Somatic symptom presentations Authors’ contributions in women with fibromyalgia are differentially associated with elevated M.C.S., planned the study and drafted the manuscript; S.A.M., R.M.N., and depression and anxiety. J Health Psychol. 2017;1359105317736577. https:// J.B.S.M., collected the data; H.J.A.S., participated in its design and doi.org/10.1177/1359105317736577. coordination; C.A.A.L., performed the statistical analysis. All authors read and 10. Roger-Silva D, Natour J, Moreira E, et al. A resistance exercise program approved the final manuscript. improves functional capacity of patients with psoriatic arthritis: a randomized controlled trial. Clin Rheumatol. 2018;37:389–95. Funding 11. Valim V, Natour J, Xiao Y, et al. Effects of physical exercise on serum levels “This study was partly financed by the Coordenação de Aperfeiçoamento de of serotonin and its metabolite in fibromyalgia: a randomized pilot study. Pessoal de Nível Superior - Brasil (CAPES) – Master’s degree scholarship, Rev Bras Reumatol (English Ed). 2014;53:538–41. Finance Code 001.” 12. Assunção Júnior JC, de Almeida Silva HJ, da Silva JFC, et al. Zumba dancing can improve the pain and functional capacity in women with fibromyalgia. Availability of data and materials J Bodyw Mov Ther. 2018;22:455–9. We declare that the data collected during this research is found in databases 13. Silva HJA, Assunção Júnior JC, de Oliveira FS, et al. Sophrology versus of Excel and SPSS software. They are currently in the possession of resistance training for treatment of women with fibromyalgia: A responsible researchers who undertake to make them available to third randomized controlled trial. J Bodyw Mov Ther. 2019;23(2):382–89. parties, if requested. To do so, we kindly ask you to send the request email https://doi.org/10.1016/j.jbmt.2018.02.005. to: marcelocardoso@facisa.ufrn.br. 14. Busch AJ, Barber KAR, Overend TJ, et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007:CD003786. 15. Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based Ethics approval and consent to participate recommendations for the management of fibromyalgia syndrome. Ann This study was approved by the Ethics Committee of Federal University of Rheum Dis. 2008;67:536–41. Rio Grande do Norte, Faculty of Health Sciences of Trairi – (FACISA/ UFRN). 16. Fernandes G, Jennings F, Nery Cabral MV, et al. Swimming improves pain The ethical principles agreed in the Declaration of Helsinki will be respected and functional capacity of patients with fibromyalgia: a randomized for all study procedures. Respect for individuals will be insured and their controlled trial. Arch Phys Med Rehabil. 2016;97:1269–75. autonomy will be maintained. Participants will be informed of the study 17. López-Rodríguez MDM, Castro-Sánchez AM, Fernández-Martínez M, et al. objectives, its risks and benefits. Participants will be free to abandon the Comparación entre biodanza en medio acuático y stretching en la mejora study at any time without the obligation of giving any explanation. de la calidad de vida y dolor en los pacientes con fibromialgia. Aten Participants must sign the informed consent before the study begins. Primaria. 2012;44:641–50. 18. Bidonde J, Busch AJ, Webber SC, et al. Aquatic exercise training for Consent for publication fibromyalgia. Cochrane Database Syst Rev. 2014:CD011336. 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Mat Pilates is as effective as aquatic aerobic exercise in treating women with fibromyalgia: a clinical, randomized and blind trial

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Abstract

Background: The mat Pilates method is the therapeutic modalities which can be used in fibromyalgia treatment. Although there are no well-designed studies that prove the effectiveness of the mat Pilates method in this population. The objective was to evaluate the effectiveness of the mat Pilates method for improving symptoms in women with fibromyalgia. Methods: A single blind randomized controlled trial in which 42 women with fibromyalgia were randomized into two groups: mat Pilates and aquatic aerobic exercise. The exercises were performed twice a week for 12 weeks. Two evaluations were performed: one at baseline (T0), and another at 12 weeks after randomization (T12). The primary outcome was pain measured by the Visual Analogue Scale (VAS). Secondary outcomes were function (Fibromyalgia Impact Questionnaire), sleep (Pittsburgh Sleep Quality Index [PSQI]), quality of life (Short Form 36 [SF-36]), fear avoidance (Fear Avoidance Beliefs Questionnaire [FABQ-BR]) and pain catastrophizing (Pain-Related Catastrophizing Thoughts Scale [PRCTS]). Results: There was improvement in both groups in relation to pain and function (p < 0.05). The aspects related to quality of life and the FABQ questionnaire only showed improvement in the mat Pilates group (p < 0.05). There was improvement in the PSQI and PRCTS variables only in the aquatic aerobic exercise group (p < 0.05), but no differences were observed between the groups for any of the evaluated variables. Conclusion: Significant improvements were observed in the two groups in relation to the disease symptoms, and no differences were observed between mat Pilates and aquatic aerobic exercise in any of the measured variables. Trial registration: ClinicalTrials.gov Identifier (NCT03149198), May 11, 2017. Approved by the Ethics Committee of FACISA/UFRN (Number: 2.116.314). Keywords: Physiotherapy, Aerobic exercise, Rheumatology, Chronic pain * Correspondence: marcelocardoso@facisa.ufrn.br Federal University of Rio Grande do Norte, Faculty of Health Sciences of Trairi – (UFRN/FACISA), Postgraduate Program in Rehabilitation Sciences, Vila Trairi st, S/N, Centro, Santa Cruz, RN 59200-000, Brazil Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 2 of 10 Bullet points general body flexibility, core strength, posture and coordin- ation of breathing with movement [19]. The main feature is Mat Pilates improves pain and function in women its six basic principles: centralization, concentration, con- with fibromyalgia as well as aquatic aerobic exercise. trol, precision, respiration and flow [20]. This modality of Mat Pilates can be considered as a treatment option therapeutic exercise is well recommended for rehabilitating for the symptoms of women with fibromyalgia. the musculoskeletal system [21–23], but there are no well- Patient preferences should be taken into account designed studies demonstrating its benefit in treating fibro- when prescribing exercise. myalgia [2]. Even taking into consideration that the Pilates method Background is widely recommended and prescribed by health profes- Fibromyalgia (FM) is a chronic disease characterized by sionals, few studies have evaluated the effects of the generalized pain . It is triggered due to peripheral and method to treat patients with FM. These studies present central hyperexcitability mechanisms which are able to several methodological flaws which compromise their re- generate alterations in the perception of pain such as sults and suggest that studies with better methodological hyperalgesia and allodyne, muscular rigidity, reduced design be carried out with the objective of observing the functional capacity and sleep alterations [1–6]. FM has a effectiveness of the Pilates method in treating FM symp- general prevalence ranging from 0.66 to 4.4%, and a preva- toms [2, 24]. A study recently compared tai chi with aer- lence ratio of 8 women for each man, with the most fre- obic exercise and showed that tai chi was more effective quent diagnosis occurring in middle age [7]. than aerobic exercise. This study suggested that mind- FM has controversial etiopathogenesis, and its cause is body exercises may be the best option for patients with associated with genetic, environmental and neuromodu- fibromyalgia [25]. Within this context, mat Pilates may latory factors [8]. Many patients with fibromyalgia have also be considered an exercise modality that has similar high levels of stress and feelings of depression, anxiety characteristics, which would benefit the studied population. and frustration [9]. Therefore, the main objective of this study is to evalu- Thus, in addition to pharmacological treatment and ate the effectiveness of the mat Pilates method on im- educational programs, evidence has been observed over proving symptoms in women with fibromyalgia. Our the years regarding treatment with physical exercise hypothesis is that the mat Pilates method can bring [10], in which an effective treatment program consists of more benefits to improve the disease-related symptoms stretching, strength maintenance and aerobic condition- than that of aquatic aerobic exercise. We chose aquatic ing [2], with the main objective to repair the effects of a aerobic exercise for the purpose of comparison in know- lack of physical conditioning and to improve the symp- ing that aquatic aerobic exercise is a strongly recom- toms, especially those of pain and fatigue. Studies re- mended modality as a non-pharmacological treatment ported that physical exercises are beneficial, low cost for people with fibromyalgia [26]; moreover, we believe and promote improvement in pain and other symptoms that this type of exercise can be considered more fun, of fibromyalgia [11–13]. providing greater adherence to treatment and few stud- Although studies show benefits for almost all exercise ies have used aquatic aerobic exercises to compare with modalities, further evidence supports the practice of aer- other exercise modalities in treating fibromyalgia. obic exercise [14, 15]. Within this context, aquatic aer- obic exercise is considered a treatment form with good Methods results for patients with FM. In addition to the specific A single-blind randomized controlled trial was conducted benefits of physical exercise, the properties of heated according to the CONSORT (Consolidated Standards of water make the aquatic environment a suitable place for Reporting Trials) [27]. This study was registered (Clinical- performing exercises with the least possible harm to the Trials.gov Identifier: --------------) and follows the TIDieR musculoskeletal system. It provides reduced joint im- (Template for Intervention Description and Replication) pact, improved microcirculation, facilitates relaxation, checklist [28]. The study protocol and details of the decreases the number of contractions and improves exercise programs of the two groups were previously muscle strength due to its natural resistance [3, 16, 17]. published [29]. A Cochrane review showed that aerobic water exercise for FM is effective in improving overall well-being, func- Setting and participants tional capacity, pain, improved muscle strength by 37% Forty-two (42) women with FM diagnosis were selected and improved cardiovascular capacity [18]. according to the 2010 American College of Rheumatology The Pilates method has gained popularity for some classification criteria [30], between 18 and 60 years of age time. It is an exercise approach founded on the teachings and with pain between 3 and 8 on the Visual Analogue of Joseph Pilates (1880–1967), which aims at improving Pain Scale (VAS) from the waiting list of patients of the de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 3 of 10 Clinic Physiotherapy School and Basic Health Units of the large and comfortable room. Each session lasted about city. All women had medical referrals from local rheuma- 50 min and was led by a physiotherapist experienced in tologists who confirmed the disease. the technique. All the recommendations of the Trad- Women with uncontrolled hypertension, decompen- itional Pilates method were followed in relation to its six sated cardiorespiratory disease, history of exercise- principles to carry out the exercise program, namely: induced syncope or arrhythmias, decompensated dia- centralization, concentration, control, precision, breath- betes, severe psychiatric illness, history of regular exer- ing and flow. cise (at least twice a week) in the last 6 months or any Nine exercises (Fig. 2a.1 to a.9) were performed for another condition that made the patient unable to per- the main muscle groups with progressions each month. form physical exercises were excluded. The exercises were initially performed in 1 series of 8 repetitions in the first month. Then they were performed in 2 sets of 10 repetitions in the second month. Finally, Sample size calculation they were performed in 3 sets of 8 repetitions in the last The sample size was calculated based on the pain variable month. to find a difference of ±2.0 points between the interven- Three Swiss ball relaxation exercises were performed tion groups on the VAS [31], with a standard deviation of in 1 set of 30 s each (Fig. 2a.10 to a.12) at the end of 2.5 points [32]. A sample of 42 participants was necessary each session. The exercises were demonstrated and to reach a statistical power of 80% with a 5% alpha, allo- taught to women, but without an adaptation period. cating 21 into each group. The sample calculation was performed using Gpower3.1 software. Aquatic aerobic exercise group (AAEG) The AAEG patients performed aquatic aerobic exercises Randomization, concealed allocation and blinding at a swimming pool with a temperature of 31 degrees The randomization was performed through the website celsius. Each session lasted about 40 min and was di- www.randomization.com. An independent researcher rected by a physiotherapist experienced in water who did not participate in any other study procedures exercises. performed the randomization process. The program consisted of six main exercises (Fig. 2b.1 After the initial evaluation, the participants were referred to b.6) lasting 30 min with different intensity exercises to the physiotherapist in charge of the intervention and moderated by the Borg scale [33]. Two warm-up exer- were allocated to one of two groups by means of simple cises and two cool-down exercises were performed be- randomization using opaque and sequentially numbered fore and after the program. Participants were instructed sealed envelopes in order to maintain allocation secrecy. to report subjective perception of respiratory effort dur- The intervention groups were: Mat Pilates group ing the sessions. The patients reported when it was pos- (MPG; n = 21) and Aquatic Aerobic Exercise Group sible to increase the speed of the exercises in each (AAEG; n = 21). The two groups were submitted to session. treatments twice a week for 12 weeks. The flow diagram The exercise programs can be viewed in Fig. 2. of the study is summarized in Fig. 1. The researchers responsible for the interventions were Evaluations blinded to the participants’ initial assessments, and the Both groups were evaluated by blind evaluators who researcher responsible for evaluations was blinded to the were previously trained for applying the instruments. group allocation. The evaluations were performed at baseline and 12 In addition, data collected during participant evaluations weeks after randomization. were not disclosed to investigators responsible for interven- tions, and participants were instructed to not disclose their Primary outcome experience or information related to the intervention. Finally, the researcher responsible for statistical ana- Pain - visual analogue scale (VAS) Pain intensity was lysis performed the analysis blindly. Once the interven- assessed, where 0 is “no pain” and 10 is “the worst pain tion was completed, they received an Excel data table possible” [31]. A 2-point decrease on a 0–10 pain inten- with all the necessary data without identification of the sity scale can be considered a clinically important subjects or the groups. improvement for individual patients [34]. Interventions Secondary outcomes Mat Pilates group (MPG) The MPG patients performed exercises based on the Disease-related quality of life Disease-related quality Mat Pilates method in a group of up to 4 women in a of life was assessed by a validated Fibromyalgia Impact de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 4 of 10 Fig. 1 Flowchart of study Questionnaire (FIQ) for the Brazilian population. The Sleep quality Sleep quality was measured by the Bra- ten items of the FIQ were normalized to vary from zero zilian version of the Pittsburgh Sleep Quality Index to 100. Each item has different scores (the functional (PSQI). This instrument consists of 19 questions re- capacity item was added and divided by 30, the two garding quality and sleep disorders in the last month. items from zero to 7 divided by seven, and items from The scores can vary from zero to 3 for each compo- zero to 10 divided by 10) [35]. Changes of 14% change nent with the maximum score being 21 points, and in the total score of the FIQ are clinically relevant [36]. scores above 5 indicate poor quality of the individ- ual’s sleep [39]. Overall quality of life Quality of life was assessed using the Brazilian version of the Short Form-36 Health Survey Catastrophic thoughts on pain Catastrophic thoughts (SF-36). This questionnaire consists of eight areas of qual- on pain were evaluated from the Brazilian version of the ity of life: functional capacity, role physical, pain, general Catastrophic Thoughts on Pain Scale (PRCTS), which is health status, vitality, role social, emotional aspects and composed of 9 items staggered on a Likert scale ranging mental health. Scores range from zero to 100, with a from zero to 5 points associated with the words “almost higher score representing better quality of life [37, 38]. never” and “almost always” at the ends. The total score de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 5 of 10 Fig. 2 Exercises program: a.1 to a.12 for Mat Pilates Group and b.1 to b.6 for Aquatic Aerobic Exercise Group is the sum of the items divided by the number of items BR). The scale is composed of 16 items, wherein items 1, 8, answered, with the minimum score being zero and max- 13, 14 and 16 are excluded in the sum of the final score. imum 5. There are no cut-off points, and higher scores The score must be obtained in isolation in each of the sub- indicate greater presence of catastrophic thoughts [40]. scales, with the distribution of the points of the subscale re- lated to the work (FABQ Work) done by adding items 6, 7, Fears and beliefs Fears and beliefs related to physical and 9, 10, 11, 12 and 15 (total ranging from zero to 42) and the occupational activities were evaluated by the Brazilian ver- subscale related to physical activities (FABQ Phys), adding sion of the Fear Avoidance Beliefs Questionnaire (FABQ- items 2, 3, 4 and 5 (total ranging from zero to 24) [41]. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 6 of 10 Statistical analysis Table 1 Mean, standard deviation (SD) values of all analyzed variables of the two groups of patients with fibromyalgia at Data were analyzed by SPSS software 20.0. The normal baseline distribution and homogeneity of the variances of the vari- Variable mean (SD) AAEG MPG P ables were verified using the Kolmogorov-Smirnov test (n = 21) (n = 21) and the Levene test, respectively. Estimates of average ef- Mean ± SD Mean ± SD fect (differences between groups) for all variables were cal- Age (years) 50.7 (9.7) 45.5 (10.6) 0.10 culated using the ANOVA mixed model. This analysis model incorporated the intervention groups (MPG x BMI (kg) 30.4 (5.2) 27.8 (4.7) 0.10 AAEG), time (baseline and 12 weeks) and the group × VAS 7.5 (1.8) 7.5 (1.6) 0.86 time interaction. When a significant F value was found, FIQ 67 (16) 68 (14) 0.88 the Bonferroni post-hoc test was applied in order to iden- SF36 tify the differences. The intention-to-treat analysis was Role social 49.5 (24.5) 54.2 (21.3) 0.51 used to assess the response to intervention, with the last General health status 29.7 (22.6) 38.2 (19.2) 0.20 evaluation repeated as needed. A 95% confidence interval and a statistical significance level of 5% were used. Vitality 36.2 (18.9) 34.6 (17.5) 0.78 Functional capacity 28.5 (16.6) 34.0 (17.1) 0.30 Results Role physical 17.8 (30.7) 23.7 (28.8) 0.52 Some patients dropped-out of the intervention. The Emotional aspects 22.2 (33.9) 44.4 (46.3) 0.08 MPG presented 3 follow-up losses during the study, Pain 29.4 (18.0) 33.3 (17.2) 0.47 while the AAEG presented 2 losses in T12. It is import- Mental health 47.1 (22.7) 57.5 (21.9) 0.14 ant to emphasize that the performed analysis was of the total sample with an intention-to-treat analysis. Treat- PSQI TOTAL 12.3 (4.1) 10.3 (3.8) 0.11 ment adherence percentage was 85.7% for the MPG and PRCTS 3.04 (1.2) 2,64 (1.2) 0.29 90.5% for the AAEG groups. FABQ_Work 27.5 (12.6) 25.0 (10.8) 0.49 Table 1 shows the homogeneity between the groups in FABQ_Phys 12.6 (7.0) 13.0 (7.1) 0.83 the baseline for all analyzed variables. AAEG Aquatic Aerobic Axercise Group, MPG Mat Pilates Group, BMI Body mass Table 2 shows the mean and standard deviation values index, VAS Visual analogic pain scale, FIQ Fibromyalgia impact questionnaire, of the analyzed variables in the two evaluated moments SF36 Short Form-36 Health Survey, PSQI TOTAL Pittsburgh Sleep Quality Index, PRCTS Scale of catastrophic thoughts on pain, FABQ_Work Fear Avoidance (T0 and T12) in the two groups evaluated. Beliefs Questionnaire_Related to work, FABQ_Phys Fear Avoidance Beliefs The results for FIQ showed improvement in both Questionnaire related to their physical activities groups, with a mean difference (MD) = 0.91, 95% confi- dence interval (CI) = 0.36/1.4, (p = 0.002) for the AAEG treatment for 12 weeks for women with fibromyalgia, and MD = 1.6 95%CI = 1.1/2.2, (p = 0.001) for the MPG. promoting improvement in pain and quality of life. In addition, there was also improvement in pain assessed These results were intragroup, without significant differ- by the VAS, with MD = 1.8, 95%CI = 0.74/2.8, (p = 0.001) ences between the groups. Thus, the strength of this for the AAEG and MD = 1.3, 95%CI = 0.22/2.3, (p = 0.01) study lies in showing the benefits of two different exer- for the MPG (Table 2). cise modalities for women with fibromyalgia. Addition- The MPG showed improvement in the following SF-36 ally, fibromyalgia patients may have the option of domains: vitality (MD = − 9.14 95%CI = 0.06/18.2, p = choosing mat Pilates or aquatic aerobic exercise to im- 0.04), functional capacity (MD = -9.5, 95%CI = -18.2/− prove their symptoms. The mat Pilates presented 0.06, p = 0.04) and pain (MD = -11.5, 95%CI = -21.0/− 2.0, intragroup results in improving the vitality, functional p = 0.02). In the FABQ-Phys, there was improvement in capacity and pain domains of SF-36, favoring improve- the activities domain (MD = 4.9, 95%CI = 1.6/8.2, p = ment in patients’ quality of life, as well as in the field of 0.005). For the AAEG, there were improvements in PSQI- FABQ-BR activities, which leads to reducing fears and total (MD = 2.7, 95%CI = 1.0/4.3, p =0.02) and in PRCTS beliefs related to physical activities. (MD = 0.74, 95%CI = 0.3/1.1, p = 0.01) (Table 2). The aquatic aerobic exercise provided positive Table 3 presents the analysis between groups at 12 intragroup results in the improvement of PSQI-total re- weeks after randomization. No difference was detected ferring to quality of life and sleep quality, and a reduc- between the groups in the performed evaluations for all tion of catastrophic thoughts towards the disease as variables. evaluated by the PRCTS. Also, there were significant intragroup results in both groups for quality of life in re- Discussion lation to the disease evaluated by the FIQ and in the The mat Pilates method and the aquatic aerobic exercise pain evaluated by the VAS. Furthermore, the groups in the present study were effective as a form of showed homogeneity for all analyzed variables. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 7 of 10 Table 2 Mean values and standard deviation (SD) of the analyzed variables in the two evaluation moments (T0 and T12) in the two evaluated groups Variables AAEG MPG (n = 21) (n = 21) Mean ± SD Mean ± SD (CI 95%) (CI 95%) T0 T12 p T0 T12 p VAS 7.5 (1.8) 5.6 (2.4) 0.001* 7.5 (1.6) 6.2 (1.4) 0.01* FIQ 67 (16) 58 (16) 0.002* 68 (14) 51 (17) 0.001* SF36 Role social 49.5 (24.5) 53.6 (32.3) 0.15 54.2 (21.3) 64.2 (22.1) 0.11 General health status 29.7 (22.6) 37.0 (22.3) 0.21 38.2 (19.2) 39.0 (23.6) 0.30 Vitality 36.2 (18.9) 42.6 (17.6) 0.16 34.6 (17.5) 43.8 (19.5) 0.04* Functional capacity 28.5 (16.6) 33.9 (18.0) 0.25 34.0 (17.1) 43.5 (22.0) 0.04* Role physical 17.8 (30.7) 21.9 (32.4) 0.15 23.7 (28.8) 36.2 (38.6) 0.17 Emotional aspects 22.2 (33.9) 34.6 (41.2) 0.45 44.4 (46.3) 43.6 (43.6) 0.50 Pain 29.4 (18.0) 37.9 (20.3) 0.08 33.3 (17.2) 44.9 (18.4) 0.02* Mental health 47.1 (22.7) 55.0 (19.3) 0.11 57.5 (21.9) 65.9 (27.8) 0.09 PSQI TOTAL 12.3 (4.1) 9.5 (3.7) 0.002* 10.3 (3.8) 9.9 (3.7) 0.64 PRCTS 3,04 (1.2) 2.3 (1.5) 0.001* 2,64 (1.2) 2.5 (1.4) 0.60 FABQ_Work 27.5 (12.6) 30.3 (11.2) 0.33 25.0 (10.8) 25.8 (14.0) 0.40 FABQ_Phys 12.6 (7.0) 10.9 (8.4) 0.32 13.0 (7.2) 8.1 (6.9) 0.005* AAEG Aquatic aerobic Exercise Group, MTG Mat Pilates Group, VAS Visual analogue pain scale, FIQ Fibromyalgia impact questionnaire, SF36 Short Form-36 Health Survey, PSQI TOTAL Pittsburgh Sleep Quality Index, PRCTS Scale of catastrophic thoughts on pain, FABQ_Work Fear Avoidance Beliefs Questionnaire_Related to work, FABQ_Phys Fear Avoidance Beliefs Questionnaire related to their physical activities *Significant difference (p < 0.05) Therefore, it is known that the recommendations mechanisms which provide these results are those speci- for practicing physical exercise in treating FM are evi- fied in the review by Lima et al. (2017), who propose dent in the literature. The EULAR review (2017) pro- that there is a balance between inhibition and excitation vides a strong recommendation for exercise use, in the central nervous system, which determines whether especially because of its effect on pain, physical func- exercise promotes analgesia or promotes pain . Several tion and well-being, availability, relatively low cost, factors, such as physical conditioning level, physical ac- and lack of safety concerns. However, it was not pos- tivity levels and state of the injury or pain condition in- sible to distinguish between the aerobic or strength fluence this balance [44]. benefits [42]. In the study by Altan et al. (2009), the Pilates method There is no superior exercise intervention according as a form of treatment for the intervention group three to Macfarlane et al. [42]. There is also no evidence to times a week for 12 weeks achieved significant improve- suggest superiority of one over another . This corrobo- ments in VAS values (p < 0.000), while the performance rates the results presented in our study, in which the frequency of twice a week in the present study was suffi- MPG did not obtain statistically significant different cient to obtain significant intragroup results in the VAS results when compared to the AAEG, which proves that values (p = 0.01) [2]. one modality does not overlap with the other. The method was also studied in other chronic pain According to a study that applied treatment in conditions, in which there is evidence that Pilates was which the patients were instructed to contract their more effective than minimal intervention to improve local musculature (“central stability”)beforestarting pain, disability, function and overall recovery impression any specific exercise on the ground and in water for in the short term, and there was no conclusive evidence 6 months presented benefits for improving pain, which showed that it is superior to other forms of exer- showing similarity with the findings of our study in cise [45]. Also, the systematic review by Miyamoto the AAEG [3]. (2013) presents evidence that the exercises based on the The Pilates method is a recommended form of exer- Pilates method are more effective than no treatment or cise for healthy individuals and for those involved in re- minimal intervention in the treatment of chronic non- habilitation [43]. In view of this, we believe that the specific low back pain [46]. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 8 of 10 Table 3 Differences among T12 assessment groups for all between the two groups for FIQ scores, only finding analyzed variables results for VAS (P < 0.001) [49]. A Cochrane review Variables Differences between groups (2014) which evaluated sleep through PSQI found Adjusted with mean difference (CI 95%) moderate evidence of sleep improvement in the group T12 that performed aquatic aerobic exercise [18]. How- (CI 95%). p ever, better results were obtained in the AAEG in the AAEG VS MPG p present study. This is due to the therapeutic proper- VAS −0.61 (−1.8 to 0.6) 0.61 ties of heated water, which cause the least possible FIQ 0.67 (− 0.37 to 1.72) 0.20 damage during exercise, providing less impact on the joints, facilitating relaxation, improving muscle tone SF36 and microcirculation [16, 20]. Social role −10.5 (− 27.8 to 6.7) 0.22 Pain can directly impact the quality of life of this General health status −2.0 (−16.3 to 12.2) 0.77 population. In relation to this outcome, similar findings Vitality −1.2 (− 12.7 to 10.4) 0.83 were found in some studies which reported positive re- Functional capacity −9.6 (−22.2 to 2.9) 0.13 sults [2, 16, 50]. Physical role −14.3 (−36.5 to 7.9) 0.20 In our study we found significant results in the “activ- ities” domain (FABQ-BR instrument) for the MPG for Emotional aspects −9.0 (− 35.5 to 17.5) 0.49 which it was only an intragroup difference, however in Pain −7.0 (−19.0 to 5.0) 0.25 our opinion these results are derived from the principles Mental health −10.8 (−25.7 to 4.1) 0.15 of centralization, concentration, control, precision, flow PSQI TOTAL −0.33 (−2.7 to 2.0) 0.77 and respiration present in the mat Pilates modality. PRCTS −0.22 (−1.1 to 0.69) 0.63 It is worth remembering that the results of the FABQ_Work 4.4 (−3.4 to 12.3) 0.26 present study are limited to the studied population and cannot be extrapolated to other populations. FABQ_phys 2.8 (−2.0 to 7.6) 0.24 Moreover, the study presents some important limita- AAEG Aquatic aerobic exercise group, MPG Mat Pilates group, VAS Visual analogue pain scale, FIQ Fibromyalgia impact questionnaire, SF36 Short Form- tions regarding the small size of the sample and the 36 Health Survey, PSQI TOTAL Pittsburgh Sleep Quality Index, PRCTS Scale of short execution period, so perhaps more promising catastrophic thoughts on pain, FABQ_Work Fear Avoidance Beliefs Questionnaire_Related to work, FABQ_Phys Fear Avoidance Beliefs results could be observed with the one segment Questionnaire related to their physical activities greater than 12 weeks. Also, an important limitation was the comparison of different modalities, loads and For the outcomes found in applying aquatic aerobic intensities imposed on the different systems affected exercise, we consider that the mechanisms provided by by fibromyalgia. Still, no objective assessment of phys- water immersion are directly related to the present re- ical fitness was used in the aquatic aerobic exercise sults. These include reduced impact on joints, increased group. The mat Pilates program was performed with blood flow to muscles and the spread of metabolic waste great repetition variability between months, and so from muscle to blood, as well as a reduction in the time other studies should focus on comparing different needed to transport oxygen, nutrients and hormones to progression protocols. We found some problems in the fatigued body [47]. relation to the protocol of this study that was previ- According to Becker (2009), numerous studies of ously published, however we could not reach the fibromyalgia patients have shown reductions in pain, the sample and the proposed evaluation times as found in impact of fibromyalgia, mood disorders, and improve- the protocol publication. However, even though the ment in sleep patterns, as well as aquatic groups typic- obtained results and the effectiveness of the two ther- ally showed faster, more and longer improvements after apies were positive, it is necessary to conduct new the study when compared to ground-based exercise studies with a larger sample number and longer programs [48]. execution time. In a study conducted by Evcik (2008), the use of the 60-min aquatic therapy performed three times a week for 5 weeks versus the home exercise program Conclusion obtained significant intragroup results at the 12th The mat Pilates method and aquatic aerobic exercise week for aquatic therapy, with FIQ having a p-value = were effective after 12 weeks of treatment for patients 0.002 and VAS p = 0.000. Our study obtained similar with FM in improving pain. The MPG did not obtain results for the AAEG, with values of p =0.002 for statistically significant different results when compared FIQ and p = 0.001 for VAS. In addition, Evcik et al. to the AAEG, which proves that one modality does not also did not present statistically significant differences overlap with the other. de Medeiros et al. Advances in Rheumatology (2020) 60:21 Page 9 of 10 Acknowledgements 7. Marques AP, do Espírito Santo AD, Berssaneti AA, et al. Prevalence of We thank the PROPESQ/UFRN for Internal Financing (numbers 01/2017 - Call fibromyalgia: literature review update. Rev Bras Reumatol (English Ed). 2017; for Research Grants of UFRN for the granted scholarships) and we thank all 57:356–63. the women with fibromyalgia who participated in this study. 8. Häuser W, Fitzcharles MA. Facts and myths pertaining to fibromyalgia. Dialogues Clin Neurosci. 2018;20(1):53–62. 9. Hadlandsmyth K, Dailey DL, Rakel BA, et al. Somatic symptom presentations Authors’ contributions in women with fibromyalgia are differentially associated with elevated M.C.S., planned the study and drafted the manuscript; S.A.M., R.M.N., and depression and anxiety. J Health Psychol. 2017;1359105317736577. https:// J.B.S.M., collected the data; H.J.A.S., participated in its design and doi.org/10.1177/1359105317736577. coordination; C.A.A.L., performed the statistical analysis. All authors read and 10. Roger-Silva D, Natour J, Moreira E, et al. A resistance exercise program approved the final manuscript. improves functional capacity of patients with psoriatic arthritis: a randomized controlled trial. Clin Rheumatol. 2018;37:389–95. Funding 11. Valim V, Natour J, Xiao Y, et al. Effects of physical exercise on serum levels “This study was partly financed by the Coordenação de Aperfeiçoamento de of serotonin and its metabolite in fibromyalgia: a randomized pilot study. Pessoal de Nível Superior - Brasil (CAPES) – Master’s degree scholarship, Rev Bras Reumatol (English Ed). 2014;53:538–41. Finance Code 001.” 12. Assunção Júnior JC, de Almeida Silva HJ, da Silva JFC, et al. Zumba dancing can improve the pain and functional capacity in women with fibromyalgia. Availability of data and materials J Bodyw Mov Ther. 2018;22:455–9. We declare that the data collected during this research is found in databases 13. Silva HJA, Assunção Júnior JC, de Oliveira FS, et al. Sophrology versus of Excel and SPSS software. They are currently in the possession of resistance training for treatment of women with fibromyalgia: A responsible researchers who undertake to make them available to third randomized controlled trial. J Bodyw Mov Ther. 2019;23(2):382–89. parties, if requested. To do so, we kindly ask you to send the request email https://doi.org/10.1016/j.jbmt.2018.02.005. to: marcelocardoso@facisa.ufrn.br. 14. Busch AJ, Barber KAR, Overend TJ, et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007:CD003786. 15. Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based Ethics approval and consent to participate recommendations for the management of fibromyalgia syndrome. Ann This study was approved by the Ethics Committee of Federal University of Rheum Dis. 2008;67:536–41. Rio Grande do Norte, Faculty of Health Sciences of Trairi – (FACISA/ UFRN). 16. Fernandes G, Jennings F, Nery Cabral MV, et al. 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