fibromyalgia syndrome ( fms ) , which is characterized by widespread pain and fatigue , is a 
 disease that affects the connective tissues and locomotor system1,2,3 .
patients with fms also suffer from weakness , fatigue , lack of 
 energy , sleep disturbances , waking up tired in the morning ( non - restorative sleep ) , and 
 stiffness . while complaints especially in cold weather increase with the change of seasons , 
 patientswork is affected and they experience , a decrease in their quality of life4 .
it is reported that the incidence of 
 fibromyalgia is 3.4% among women and 0.5% among men , and 7080% of patients are women5 .
although it may be observed at any age groups6 , fms is often observed in sedentary women between 3050 years of 
 age7 .
it is reported that muscle 
 oxygenation changes , and psychological , biochemical , hormonal and immunological factors are 
 involved in the pathogenesis of fms8 .
in addition , irritable bowel syndrome , tension - type 
 headaches , perfectionist personality , premenstrual syndrome , sicca , female urethral 
 syndrome , and raynaud like symptoms are all associated with fms10,11,12 .
the american college of rheumatology ( acr ) suggested some criteria for the classification 
 of fibromyalgia in 1990 . according to the criteria
, widespread pain lasting longer than 3 
 months ( pain in the right and the left side and in the lower , and upper back must be located 
 in the axial skeleton ) and tenderness in at least in 11 of 18 tender points are symptomatic 
 of fms5 .
in addition , hyperemia and skin 
 discoloration are observed at the tender points of patients with fms10,11,12,13 .
there is no suggested cure for fibromyalgia , as in the treatment of common chronic 
 illnesses , so informing and educating the patients about the illness should be the focus of 
 treatment14 .
numerous studies have 
 shown that low intensity physical activity and exercise including stretching , swimming , 
 walking , jogging , and cycling are beneficial for patients with chronic pain and fms , 
 increasing fitness levels , reducing the spread of pain and tenderness , improving the quality 
 of life , and reducing depression levels15,16,17,18,19,20,21,22 .
muscular strength , endurance , and the 
 aerobic fitness levels of fms patients are lower than those of healthy controls23,24,25 .
thus , it is important to provide 
 well - structured exercise programs and physical activity for fms patients in order to reduce 
 their sedentary life style . in the study of gowans
, 20 female patients were assigned to pool exercise twice a 
 week for 30 minutes , while a control group did not do any exercise .
there were significance 
 changes in fibromyalgia impact questionnaire ( fiq ) , fatigue , pain , and improvement in 
 disease symptoms between the control and experimental groups .
alina investigated the relationship between functional capacity and a self - report of 
 quality of life with the practice of regular exercise by patients with fms , and found that 
 intervention elicited26 significant 
 differences in the quality of life and functional capacity between the regular exercise 
 group and the no - regular exercise group .
a significantly lower score for functional capacity 
 in the health assessment questionnaire ( haq ) was found in the no - regular exercise group , 
 while higher values were observed in the regular exercise group for the physical functioning 
 ( p<0.001 ) and bodily pain ( p<0.05 ) domains of 
 sf-36 .
there were no significant differences between two the groups in the physical , general 
 health , vitality , social functioning , emotion and mental health domains , and alina concluded 
 that regular exercise had a positive impact on the functional capacity and quality of life 
 of patients with fms26 .
each session consisted 
 of 45 minutes and the fms patients in the exercise group were followed for 6 months .
their 
 fiq anxiety scores showed a significant improvement compared to the control group7 . in a study of 50 patients with fms by altan et al .
, the patients were divided into 
 experimental and control groups and performed balneotherapy pool workouts .
the experimental 
 group performed a two - week training program of 2  35 minutes sessions / week consisting of 
 aerobics , flexibility and relaxation exercises .
the control group did not participate in any 
 exercise program and were only treated with spa therapy .
the experimental group showed a 
 significant level of depression . in both groups , significant improvements in pain intensity 
 stiffness , and fatigue were observed27 . 
 in the studies conducted by verstappen
fms patients were tested 
 after exercise treatments including aerobics and pool exercises10 , 11 .
the exercise 
 groups showed improvements in overall well - being compared to the control group , and both 
 study groups reported that the exercise program had not only a corrective effect on posture 
 during sitting or standing upright , due to strengthening of the muscles , but also decreased 
 pain through more balanced muscle contraction12 .
various exercise modalities such as ground - based , water - based , aerobic , pool or aquatic 
 balnotherapy , and hot water spa are used in the treatment of patients with fms28,29,30,31 . 

especially , balnotherapy ( hot water therapy ) , isokinetic strength stretching , aerobic and 
 strengthening exercises are commonly used for the reduction of pain29 , 31 .
however , the 
 implementation of these exercises are generally based upon the availability of facilities , 
 so water - based exercises are very rare in turkey . this study compared the effects of home - based isometric strength and stretching , gym - based 
 aerobic and pool - based aquatic exercises programs on the physical and psychological 
 parameters of patients with fms .
the data were collected from fibromyalgia patients who were diagnosed by a specialist in 
 the clinic of physical medicine and rehabilitation department , faculty of medicine , cukurova 
 university . among the 107 patients recruited for the study ,
32 were excluded because : 9 were 
 postmenopausal , 10 were over 50  years , refused to participate in the study , one had a 
 cardiovascular problem , one had cushing syndrome , and one was under 18  years .
the study was 
 approved by the local ethics committee . after informing all the subjects about the design 
 and the risks of this study ,
the patients were randomly assigned to one of three exercise program groups and matched by 
 age and their symptoms of fms .
the exercise training programs comprised aerobic gymnastic , isometric strength - stretching , 
 and aquatic exercises , all of which aimed to increase flexibility , and muscular and aerobic 
 endurance based on graded activity .
seventy - five female patients with fms according to the acr definition between the ages of 
 1850 ( 35.08.8 ) were randomized into three groups .
the first group ( n : 25 ) performed a 
 home - based isometric strength and stretching exercise program ( issep ) lasting 15 minutes per 
 day .
the second group ( n : 25 ) attended a gymnastic - based aerobic exercise program ( aep ) with 
 group therapy two times per week32 .
the 
 third group ( n : 25 ) attended a pool - based aquatic aerobic exercise program ( aaep ) with group 
 therapy two times per week .
the durations of the exercise programs were 40 minutes for aep 
 and aaep in first month , 45 minutes in the second month and 50 minutes in the third month . 

the secondary outcome measures were : health status fiq , the six - minute 
 walk test ( 6mwt ) for endurance33 , quality 
 of life scores represented by sf-36 physical and mental component scores34 and depression as assessed by the beck 
 depression inventory ( bdi)35 .
the 
 intensity of exercise was determined according to the karvonen method and was generally 
 6080% of a subject s maximal heart rate .
heart rates were measured eight times at regular 
 intervals during the exercise program to monitor loading level during aerobic exercise 
 programs .
three - minute loadings with 
 30 seconds rest between three sets of low to moderate intensity were repeated in the first 
 month of the exercise program ( 3  3 ) . in the second month
30 seconds high intensity 
 loadings with 30 seconds rest period between four sets were performed after three minutes of 
 low intensity loading ( 3  4 ) . with reducing rest intervals from 30 to 10 seconds , 
 three - minute loadings of five sets
were repeated in the third month of the exercise program 
 ( 3  5 ) .
spss ( statistical package for social sciences ) for windows version 13.0 was used for the 
 statistical evaluation of the data .
descriptive statistics were calculated and the chi 
 square test , mann - whitney u test and kruskal - wallis test were used for two - and three - group 
 comparisons .
the wilcoxon test was also used for pairwise comparisons of pre- and post - test . 

demographic characteristics of the patients including age , weight , height , mean symptom 
 duration , mean tender point count and educational level were similar .
baseline values of the 
 patients vas , bdi , fiq , 6mwt and sf-36 scores were also similar among the three groups .
the 
 results are presented in table 1table 1.comparison of the primary and secondary outcome scores at baseline and after 12 
 weeks of trainingvariablesgroupsnbaselineafter 12 weeksmean rankmean  sdmean rankmean  sdvas / mm**issep2535.768.211.857.670.412.5aep2537.570.012.928.448.28.8aaep2540.771.513.128.148.09.3bdi**issep2541.919.410.156.422.610.0aep2539.920.512.333.59.96.2aaep2532.115.79.024.16.17.8fiq**issep2539.659.116.556.862.916.1aep2535.358.313.429.636.615.7aaep2539.160.112.127.634.917.16mwt / m**issep2534.1541.553.319.7540.453.8aep2546.7569.548.349.9628.855.5aaep2533.2543.456.444.4619.461.8mcs*issep2533.431.69.019.232.029.4aep2536.832.59.742.745.27.0aaep2543.735.27.952.249.48.3pcs**issep2534.537.37.618.036.88.4aep2546.441.88.451.253.65.4aaep2533.136.48.544.850.37.4*significant at 0.05 level , * * significant at 0.01 level , sd : standard deviation . 

issep : home - based isometric strength and stretching exercise program aep : gym - based 
 aerobic exercise program , aaep : pool - based aquatic aerobic exercise program vas : 
 visual analog scale , bdi : beck depression inventory , fiq : fibromyalgia impact 
 questionnaire , 6mwt : six - minute walk test , mcs : mental component scores , pcs : physical 
 component scores .
the comparisons of the pre - and post - test results of each group are presented 
 in table 2table 2.the comparison of pre- post- test results of each groupvariablesgroupsnbaselineafter 12 weeksmean rankmean  sdmean rankmean  sdvas / mmissep**2535.768.211.857.670.412.5aep**2537.570.012.928.448.28.8aaep**2540.771.513.128.148.09.3bdiissep**2541.919.410.156.422.610.0aep**2539.920.512.333.59.96.2aaep**2532.115.79.024.16.17.8fiqissep2539.659.116.556.862.916.1aep**2535.258.213.429.636.615.7aaep**2539.160.912.127.634.917.16mwt / missep2534.1541.453.319.7540.453.8aep**2546.7569.548.349.9628.855.5aaep**2533.2543.356.444.4619.461.8mcsissep2533.431.69.019.232.09.4aep**2536.832.59.742.745.37.0aaep**2543.735.27.952.249.48.3pcsissep2534.537.37.618.036.88.4aep**2546.441.88.451.253.65.4aaep**2533.136.48.544.850.37.4*significant at 0.05 level , * * significant at 0.01 level , sd : standard deviation . 

issep : home - based isometric strength and stretching exercise program , aep : gym - based 
 aerobic exercise program , aaep : pool - based aquatic aerobic exercise program vas : 
 visual analog scale , bdi : beck depression inventory , fiq : fibromyalgia impact 
 questionnaire 6mwt : six - minute walk test , mcs : mental component scores , pcs : physical 
 component scores .
* significant at 0.05 level , * * significant at 0.01 level , sd : standard deviation . 

issep : home - based isometric strength and stretching exercise program aep : gym - based 
 aerobic exercise program , aaep : pool - based aquatic aerobic exercise program vas : 
 visual analog scale , bdi : beck depression inventory , fiq : fibromyalgia impact 
 questionnaire , 6mwt : six - minute walk test , mcs : mental component scores , pcs : physical 
 component scores * significant at 0.05 level , * * significant at 0.01 level , sd : standard deviation . 

issep : home - based isometric strength and stretching exercise program , aep : gym - based 
 aerobic exercise program , aaep : pool - based aquatic aerobic exercise program vas : 
 visual analog scale , bdi : beck depression inventory , fiq : fibromyalgia impact 
 questionnaire 6mwt : six - minute walk test , mcs : mental component scores , pcs : physical 
 component scores for vas , the issep group had the lowest mean score before the exercise program , while the 
 aaep group had the lowest score after the 12-week exercise program .
for bdi , the aaep group 
 had the lowest mean value before and after 12-week exercise program .
for fiq , the aep group 
 had the lowest mean score , while the aaep group had the lowest value after the 12-week 
 exercise program .
for 6mwt , the aep group had the highest mean value before and after the 
 exercise program .
for mental component scores of sf-36 ( mcs ) , the aaep group had the highest 
 mean score before and after the exercise program .
for physical component scores of sf-36 
 ( pcs ) , the aep group had the highest mean score before and after the exercise program .
vas and bdi values showed significant differences in their pre - and post - test values in all 
 three groups , while fiq , 6mwt , mcs and pcs values showed no significant differences between 
 pre - and post - test in the issep group . on the other hand , the results of both the aep and 
 aaep groups showed significant differences in fiq , 6mwt , mcs and pcs between pre - and 
 post - tests
fibromyalgia syndrome is a chronic musculoskeletal disorder with generalized muscular pain 
 characterized by fatigue and tenderness at specific tender points along with commonly 
 associated symptoms such as altered sleep , cognitive and emotional disturbances ( anxiety and 
 depression ) , increase of disability and decrease of quality of life .
researchers suggest 
 that the effective treatment for fibromyalgia should include medication with lifestyle 
 changes and alternative treatments28 . 
 thus , this study aimed to determine which exercise program among isometric strength and 
 stretching , and aerobic and aquatic exercises programs is the best at reducing the symptoms 
 of fibromyalgia36 , 37 .
vas was compared among the three groups and , both the aquatic ( aaep ) and gym ( aep ) groups 
 showed statistically significant improvements compared to the isometric strength - stretching 
 exercise ( issep ) group .
in addition , no statistically significant difference was found 
 between the aaep group and the aep exercise group .
when the intra - group results were 
 compared , only the issep group showed an increase in the mean value of vas , whereas both the 
 aaep and aep exercise programs improved the pain threshold with only slight differences 
 between them .
no significant difference in vas was 
 found when aep and aaep groups were compared38 . in the 48-week study conducted by ramsey et al .
, one group 
 performed aerobic exercises , while the other group participated in a home - based 
 stretch - strength exercise program , and no improvement in the values of vas was found between 
 the two groups . besides , no statistically significant difference between the groups was 
 found16 .
contrary to several previous 
 studies reporting similar treatment effect of issep and aep , our present study found no 
 difference in vas between aep and aaep16 . 

in addition , bircan et al . reported that aerobic exercise and strength exercise were 
 similarly effective at improving symptoms , tender point count , fitness depression , and 
 quality of life in fms39 . when bdi was compared among the three groups , no significant difference before the exercise 
 program
however , a significant decrease was found after the exercises in the 
 mean values of the aaep and aep groups .
the aep group showed more significant improvement 
 than the aaep group in the level of depression .
conversely , assis et al . found no 
 significant improvement in bdi after the exercise program38 . in our study
both the aaep and aep exercise programs had a 
 significant effect on depression levels , but aep was more effective than aaep at decreasing 
 the depression level .
similar to our results , sanudo et al.40 reported bdi scores decreased by 8.58 
 ( p<0.001 ) and 6.44 points ( p<0.001 ) in a supervised 
 aerobic exercise group and a combined program of supervised aerobic , muscle strengthening , 
 and flexibility exercises , respectively .
similarly , santiago and lacomba reported that 
 aquatic and combined exercise , and alternative activities seemed to be better for the 
 treatment of depression41 . among the exercise groups , both the aaep and aep exercise groups showed more improvement 
 than the issep group in the mean value of fiq .
also , no statistically significance 
 difference was found between the aaep and aep exercise groups .
reported that the level of improvement in the aaep group was higher than that of the aep 
 group38 . in the study of mannerkorpi
, the effect of aquatic training on fiq of fms patients was investigated with a 
 combination of six sessions education , which resulted in significant differences in the mean 
 value of fiq as compared to the control42 .
found a significant difference in fiq between the groups in their 
 studies17 . in the present study there 
 was a significant improvement in fiq in both the aaep and aep groups , but there was no 
 difference between the two groups .
this result suggests that both of the exercise programs 
 were equally effective at improving physical functioning , increasing quality of the life , 
 and decreasing of pain .
, 
 who compared an exercise program of exclusively aerobic exercise , with another of combined 
 exercise , and found similar improvements of around 14% in fiq40 . in previous studies ,
better results were obtained by the aquatic program , however , in the 
 present study no significant difference was observed17 .
showed that aquatic and home - based land exercise 
 therapy was beneficial for pain reduction at the end of treatment , and after a long - term 
 follow up of 3 months .
additional benefits of aquatic exercises may be related to the water 
 itself , as well as the benefits derived from the social aspects of exercising with others 
 outside of the home43 .
the comparison of 
 our three groups revealed that both the aaep and aep groups showed statistically significant 
 improvements in 6mwt as compared to the issep exercise group .
no statistically significant 
 difference was found between the aaep and aep groups , indicating that both aaep and aep had 
 equally positive effects on walking ability .
although the 6mwt is a simple , safe and low cost test that has gained much attention in the 
 clinical and scientific fields33 , 44 , 45 , researchers have reported that a substantial number of women with 
 fms show increased pain intensity and perceived effort compared to controls46 .
combined six sessions 
 of education investigated the effect of aquatic training on the 6mwt distance of fms 
 patients .
the 6mwt distance of the aquatic training group was significantly longer than that 
 of the controls42 , suggesting that 
 patients with fibromyalgia might benefit from aerobic fitness training .
the pcs of sf-36 was compared across the three groups . both the pool - based aquatic and 
 gym - based aerobic exercise groups showed more improvement than the home - based isometric 
 strength - stretching exercises group .
however , no statistically significant difference was 
 found between the pool and gym groups .
found no statistically significant 
 difference groups in the sf-36 physical health scores of two groups38 .
in the literature only the study conducted by jentoft et 
 al . reported a result similar and comparable to that of our study .
they did not find 
 statistically significant differences in the physical health scores when the groups were 
 compared17 .
both the pool and gym 
 exercise programs provided similar increases in the quality of life .
both the pool - based and gym - based 
 groups showed statistically significant differences , but the home - based exercise group did 
 not . when the pool and gym groups were compared , a more significant difference was found in 
 the pool group than in the gym group .
two studies presented similar results , reporting no 
 significant difference in terms of mcs17 , 38 .
the results of our present study suggest 
 that gym exercise programs lead to improvement of the mcs of fms patients , and that , 
 different from other studies , the aquatic program was more efficient than the other programs 
 in this regard . in a study conducted by van santen et al .
, 37 fms patients were divided into two groups and 
 one group with 19 members exercised with higher intensity while the other group with 18 
 members performed aerobic exercises of lower intensity18 .
their showed low intensity exercises provided a medium - level 
 improvement in the quality of life and physical health after 20 weeks , but it had no effect 
 on the general health and psychological state of the patients ; also , the high intensity 
 exercises had no statistically significant effect on the quality of life or physical 
 health18 . in the study of salek et al .
, 
 patients were assigned to two groups , and one group of patients did exercises while the 
 other group was given antidepressants and analgesics .
when the pre - treatment and the 
 post - treatment measurements after 16 weeks were compared , it was found that the level of 
 sore points and pain had improved 48% in the group that exercised regularly , and 39% in the 
 group that did not exercise .
water - based exercises are not only an important effective treatment for fms7 , 9 , 27 , but they are also important and effective 
 tools for improving isometric , isotonic , and isokinetic strength in young women47 , 48 .
significant improvements in isokinetic knee extensor and flexor 
 torques in the elderly after a water - based program were reported49 .
it was also reported that isokinetic muscle contraction 
 in the water provided excellent rate of strength gain over range of motion and with a low 
 possibility of muscle injury compared to isometric and isotonic muscle contractions28 , 31 .
the results of our present study show that the issep group demonstrated only slight 
 improvements between pre - and post - test in fiq , 6mwt , mcs and pcs , while significant 
 improvements ( p<0.01 ) in all variables were observed in the aep and aaep groups with 
 respect to their baseline values .
the issep group showed significant improvements 
 ( p<0.01 ) only vas and bdi between pre - and post - test ( table 2 ) .
the aaep group had statistically better results than the aep and issep groups for all 
 variables .
significant differences among the three groups were derived from the low 
 improvements of the issep group , issep with the exception of 6mwt distance .
both the aaep 
 and aep groups had significantly higher scores of mcs and pcs than the issep group . in conclusion ,
aaep also had 
 additional effects on the sf-36 mental health score and the bdi .
aaep was also significantly 
 more effective in the treatment of fms than to aep and issep .
the superiority of aaep as a 
 treatment method for fms may originate from its lack of impact force on the joints , and the 
 use of only concentric or isokinetic contractions during shallow and deep water 
 exercises28 . further research is required to assess the advantages and disadvantages of issep , aaep and 
 aep in the treatment of fms using experimental groups matched for health status , symptoms , 
 body structure , physical fitness and age , and a long - term follow - up .
 [ purpose ] there are various treatment modalities for fibromyalgia syndrome ( fms ) , which 
 is characterized by widespread pain and fatigue . the aim of this study was to investigate 
 the effects of aquatic , aerobic and isometric strength - stretching exercises on the 
 physical and psychological parameters of patients with fms . 
 [ subjects and methods ] seventy 
 five female patients with fms were randomly selected and divided into three groups . 
 
 patients ( 1850 years ) were treated for 3 months using one of three methods : a home - based 
 isometric strength and stretching exercise program ( issep ) , a gym - based aerobic exercise 
 program ( aep ) , and a pool - based aquatic aerobic exercise program ( aaep ) . 
 items evaluated 
 were : the number of tender points , visual analog scale ( vas ) , fibromyalgia impact 
 questionnaire ( fiq ) , the six - minute walk test ( 6mwt ) , sf-36 physical and mental health 
 scores , and the beck depression inventory ( bdi ) . [ results ] 
 the results revealed that aaep 
 was the most effective treatment of the three . 
 all of the groups showed significant 
 improvements in all variables between pre - and post - test , except the mean values of vas and 
 bdi in issep . 
 [ conclusion ] the results suggest that aquatic aerobic exercise program is 
 more effective than aep and issep in the treatment of fms . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION