1813 01 REUMA3 Editoriale - ME/CFS Australia

62 R. Casale et al.definition of “balneotherapy” has been used onlyto define treatments with thermal or mineral waters,while the definition of hydrotherapy was reservedfor water therapy without particular thermal ormineral contents. More recently, the definition ofbalneotherapy has been applied to all therapeuticprocedures performed in water. This placed balneotherapymidway between physical therapy andcognitive behavioural therapy in as much as theenvironment (thermal resorts), the water temperature(37°C) and the execution of exercise can contributeto the positive results of this treatment inFM. The exact amount of efficacy of each singlecomponent has been challenged by a recent studyin which balneotherapy alone and balneotherapyplus water exercise did not differ in results (34). Torender evaluation more difficult, exercise in waterversus a dry environment does not result in substantialdifferences (35). Positive results can be perceivedafter 6 weeks to 6 months according to differentauthors (36-38). Sauna and mud bath treatmentshave been used with some positive results inuncontrolled studies; these results may be relatedto some sort of stress induced analgesia (39, 40).MOVEMENT AND EXERCISESThe majority of FM patients complain of severefunctional limitations in activities of daily living(41), and not surprisingly, most FM patients arephysically deconditioned (42). Active as well aspassive mobilization have been used although recentreviews do not provide clear results on theirefficacy. Active physical exercise, both aerobic andanaerobic, has been identified as one of the pivotaltreatments in FM, although patients quite oftenhave difficulties in starting and maintaining exerciseprograms (43).The internet provides access to so many types ofphysical training and exercises that is almost impossibleto take all them into account. Moreover,sometimes terms such as “movement” or “physicalexercise” are proposed without giving any specificsconcerning the type of exercise that should be done,the duration, or the intensity of the training. In thisrespect the term physical exercise is similar to theterm “drug”.In both cases describing a treatment as aerobic oranaerobic or drug is not enough, specific details ofthe treatment must be provided. A very recentmeta-analysis reviewed all studies that were identifiedon the Cochrane Central Register for ControlledTrials up to July 2005 suggesting moderateevidence that aerobic-only exercise training atAmerican College of Sports Medicine (ACSM)-recommended intensity levels has positive effectson global well-being and physical function, primarily,and, also a possible effect on pain and tenderpoints. Strength and flexibility remain underevaluated;however, strength training may have apositive effect on FM symptoms. This meta-analysissuggests that aerobic-only training has beneficialeffects on physical function and some FMsymptoms.Strength-only training may improve FM symptoms,but requires further study (44). Table I providesan overview of data from the Cochrane Reviewon exercise for FM (45). However, data on thelong-term efficacy of movement and exercise incontrolling the clinical picture are still lacking.Aerobic exercises can be performed in a traditional“dry” environment as well as in water via deepwater running programs, hydrokinesis therapy inheated water, and in the Spa environment (35, 46,47). In general, both aerobic and anaerobic exerciseshave been associated with educational andoccupational programs (48-52). While the shorttermefficacy of exercise is generally accepted, thecritical issue appears to be long-term compliance.Most studies report a lack of persistent effects associatedwith a failure to maintain the exercise program(53).Passive movements induced by manipulative techniqueshave been also used. They encompass severalmethodologies such as vertebral manipulations,finger pressure on trigger points, craniosacralmanipulation techniques and other forms of chiropractics.A controlled study on the efficacy of chiropracticshas shown a reduction in pain and disability levelsassessed using the Oswestry Pain Disability Indexand Neck Disability Index. Although positive, theseresults should be considered with caution and ageneralization of the efficacy of these practices isuntenable (54). Stretch and spray technique is apopular form of myofascial pain therapy in rehabilitation.The technique combines the effect of rapid coolingof the overlying skin using a vapocoolant such asfluorimethane with passive elongation of muscles.Despite its popularity only one study reports a reductionof pain at the trigger points measured bypressure algometer and VAS in myofascial pain patients;as far as we know no data are available onFM patients.