Comparison of the diagnoses, the outpatient clinics they visited, and the number of visits of patients with and without a diagnosis of fibromyalgia syndrome: Do patients with fibromyalgia syndrome come to the hospital more often?

OBJECTIVES: Fibromyalgia syndrome (FMS) has a wide spectrum of symptoms that includes all body parts. So FMS is a great imitator. This brings to mind the possibility that fibromyalgia patients visit outpatient clinics in many departments more than non-fibromyalgia patients. However, there is not enough data on this subject. This study aims to compare the number of outpatient visits of patients with FMS with those without a diagnosis of FMS and to examine their diagnoses. METHODS: The diagnoses of 140 patients (70 with fibromyalgia and 70 controls), and departments of the outpatient clinics they visited were analyzed retrospectively. In the control group, patients who visited the same outpatient clinic with the complaint of knee pain, but who did not have FMS and who had never been diagnosed with FMS before, were recruited as age- and gender-matched. RESULTS: The total number of outpatient clinic visits, as well as the number of visits to physical medicine and rehabilitation, obstetrics and gynecology, general surgery, internal medicine, and psychiatry departments, were significantly higher in fibromyalgia group patients compared to the control group. In addition, the number of diagnoses in the 5th chapter (mental, behavioral, and neurodevelopmental disorders, F01-F99) of International Classification of Diseases-10 was significantly higher in the fibromyalgia group. CONCLUSION: It should be kept in mind that patients with FMS visit more hospitals and outpatient clinics than other patients. Physicians and patients should be informed about this issue to reduce unnecessary health costs.

Do the presence, size, and shape of plantar calcaneal spurs have any significance in terms of pain and treatment outcomes in patients with plantar fasciitis?

BACKGROUND: : The purpose of this study was to determine the effect of the presence, size, or type of calcaneal spurs on pain or the outcomes of extracorporeal shock wave therapy (ESWT) therapy in patients with plantar fasciitis. METHODS: Seventy-four patients with unilateral plantar fasciitis who had no pain in the contralateral foot, either currently or in the past, were included in the study. The length, base width, type, and presence of plantar calcaneal spurs in both heels of the patients were determined using radiography. A total of five sessions of ESWT (3 bar, 2000 shocks/session, 12 Hz frequency) with an interval of 3 days were performed on the painful sides of the patients. Symptom duration and numerical rating scale (NRS) scores were recorded pretreatment and 1 week and 12 weeks after treatment. RESULTS: : Spurs were detected in 85.1% of painful feet and 71.6% of painless feet, this difference was statistically significant (p = 0.046). There was no significant correlation between the type of the spurs and whether the foot was painful. Patients with spur sizes of >5 mm or with horizontal and hooked spurs had a higher NRS decrease than patients with spur sizes of ≤5 mm or with a vertical spur. Symptom duration, spur length, and base width were found to be correlated with pretreatment NRS scores. DISCUSSION: The presence and size of calcaneal spurs are associated with pain. However, it should be kept in mind that a high rate of spurs can also be found in painless feet, so spur is not the only factor that causes pain. Patients with a spur size of ≤5 mm or a vertical spur have less pain relief with ESWT.

Does osteoporosis cause pain even without a fracture? An observational study.

INTRODUCTION/BACKGROUND: Osteoporotic fractures are usually painful. However, data on whether osteoporosis without fracture causes pain are insufficient. This study aims to determine whether osteoporosis without fracture is the cause of pain. METHODOLOGY: Patients aged over 18 years who visited the Physical Medicine and Rehabilitation outpatient clinic of a tertiary university hospital for dual-energy X-ray absorptiometry scan and were suitable for dual-energy X-ray absorptiometry scan without a history of fracture were included in the study. Patients with a history of fractures or those with fracture/fracture sequelae on X-rays were excluded. The cervical, lumbar, and thoracic spine and general body pains of the patients were questioned and dual-energy X-ray absorptiometry results were recorded. RESULTS: The study was conducted with 139 patients. Lumbar bone mineral density and T score values of the patients were found to be negatively correlated with the numerical rating scale levels of the cervical, thoracic, lumbar spine, and general body pain. Hip total bone mineral density and T score values were also negatively correlated with numerical rating scale scores of the lumbar and thoracic spine and general body pain. When the patients were divided into two groups as those with and without osteoporosis, it was found that the cervical, lumbar, thoracic spine, and general body pain numerical rating scale levels of the patients with osteoporosis were significantly higher than the group without osteoporosis. CONCLUSION: The results of this study showed that osteoporosis might be associated with pain even though there is no fracture.

Is Low-Dose Dextrose Prolotherapy as Effective as High-Dose Dextrose Prolotherapy in the Treatment of Lateral Epicondylitis? A Double-Blind, Ultrasound Guided, Randomized Controlled Study.

OBJECTIVES: To investigate the effects of prolotherapy (PrT) on pain, functionality, clinical improvement and to compare the 5% low and 15% high dose dextrose PrT in chronic lateral epicondylitis. DESIGN: A double-blind, parallel groups, randomized controlled study. SETTINGS: Outpatient Clinic. PARTICIPANTS: Sixty patients (N=60), aged 44.30±10.31 years old, with chronic lateral epicondylitis were allocated randomly into 3 groups. INTERVENTIONS: To Group 1 5% dextrose PrT, to Group 2 15% dextrose PrT, to Group 3 0.9% saline injections were done at 3 times (weeks 0, 3, 6), to the entheses of forearm extensors and annular ligament. MAIN OUTCOME MEASURES: The primary outcomes were handgrip strength, visual analog scale-rest (VAS-R), visual analog scale-activity (VAS-A), pressure-pain threshold, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH). The secondary outcomes were clinical improvement (Disease Global Assessment Questionnaire), side effects, and complications. Primary outcomes were collected at baseline week 0, week 3, and 12. Secondary outcomes were collected at weeks 3 and 12. RESULTS: In Group 2, VAS-A and VAS-R (at week 3), handgrip strength and pressure-pain threshold (at week 12) were significantly different than other groups (P<.05). In Groups 1 and 2, there was a difference in primary outcomes at week 12 than baseline (P<.05). In Group 3, there was no difference in VAS-R, VAS-A, and handgrip strength at weeks 3 and 12 than baseline (P>.05). CONCLUSION: In chronic lateral epicondylitis, 5% and 15% dextrose PrT is more effective in pain, handgrip strength, functionality, and clinical improvement than %0.9 saline. There was no difference in functionality, clinical improvement, side effects, and complications between the PrT groups. 15% dextrose PrT was more effective in handgrip strength and pressure-pain threshold at week 12 and pain at week 3. We recommend 15% dextrose PrT based on this study.

Comparison of the effectiveness of conventional physical therapy and extracorporeal shock wave therapy on pain, disability, functional status, and depression in patients with chronic low back pain.

Objectives: The aim of this study was to compare the effectiveness of conventional physical therapy (transcutaneous electrical nerve stimulation, hot pack, and therapeutic ultrasound) and extracorporeal shock wave therapy (ESWT) on pain, disability, functional status, and depression in patients with chronic low back pain (LBP). Patients and methods: Ninety-one patients with chronic LBP were included in the study and randomized to groups that received ESWT or conventional physiotherapy; of these, 70 completed the study (37 males, 33 females; mean age: 46.4±13.3 years; range, 18 to 65 years). Outcome measures included the Visual Analog Scale, the pressure pain algometer, Oswestry Disability Index (ODI), Health Assessment Questionnaire (HAQ), fingertip-to-floor distance, and the Beck Depression Inventory. The assessments were made before treatment and at the first and 12th weeks after treatment. Results: Extracorporeal shock wave therapy was more effective than conventional physical therapy in terms of Visual Analog Scale scores, the pressure algometer, ODI, HAQ, and fingertip-to-floor distance at the first and 12th week. Conclusion: Extracorporeal shock wave therapy is superior to conventional physical therapy in terms of improving pain, spinal mobility, and functional status in patients with chronic LBP.

Superior cluneal nerve entrapment neuropathy due to lower crossed syndrome: A case with low back pain.

The superior cluneal nerve (SCN) is a sensory nerve known to be originated from the dorsal rami of the lower thoracic and lumbar nerve roots. One of the overlooked causes of low back pain (LBP) is the SCN Entrapment Neuropathy (SCNEN). SCNEN may also be associated with SCN stretching due to lumbar movement and the poor body posture through an increase in the paravertebral muscle tonus. A 59-year-old female patient presented with chronic LBP localized on the right iliac crest and radiating to the right buttock, groin, and leg. She had increased lumbar lordosis and anterior pelvic tilt. She had a tender point over the right iliac crest, and the pain was radiating to the buttock and posterolateral thigh (Tinel sign +). She was diagnosed with lower crossed syndrome and SCNEN, and a therapeutic nerve block was performed. Clinicians should consider SCNEN as a possible diagnosis of LBP.

Evaluation of musculoskeletal adverse effects in patients on systemic isotretinoin treatment: A cross-sectional study.

Objectives: This study aims to investigate the frequency of musculoskeletal adverse effects in acne vulgaris patients receiving systemic isotretinoin treatment. Patients and methods: Between January 2016 and December 2017, a total of 200 severe acne patients (22 males, 178 females; mean age: 21.8±0.4 years; range, 15 to 53 years) who were on isotretinoin treatment were retrospectively analyzed. Data including age, sex, body mass index (BMI), duration of disease, diagnosis, and comorbidities were recorded. Back pain severity was evaluated with the Visual Analog Scale (VAS). Results: The treatment period was mean 8.5±0.1 (range, 6 to 12) months. The dose of isotretinoin was mean 0.6±0.1 (range, 0.5 and 1) mg/kg. Musculoskeletal side effects were seen in 99 (49.5%) patients. Back pain was reported during the treatment period in 78 (78.7%) patients. The diagnosis was mechanical back pain in 31 (39.7%) and inflammatory back pain in 47 (60.3%) patients. The moderate-severe back pain group received higher cumulative isotretinoin doses than the mild back pain group (p=0.003). The BMI values did not show a significant difference between the patients with and without back pain (p=0.55). There was no significant correlation between the BMI and VAS scores (p=0.06). The VAS scores were found to be correlated with age (p=0.04). Sacroiliitis was diagnosed in four (4%) patients. One (1%) patient was diagnosed with enthesitis. Creatine kinase elevation was reported in 18 (18.1%) patients, while three (3%) patients described myalgia of mild severity. Conclusion: Low back pain is one of the most common musculoskeletal side effects of isotretinoin treatment that usually resolves with dose reduction. The cumulative dose of isotretinoin does not seem to play a role in the development of back pain, but can determine pain severity. Pain severity is directly correlated with the increasing age. Evaluation of the patients for musculoskeletal side effects during isotretinoin use is important in clinical practice, as it is a common occurrence.

Evaluation of the physical and emotional effects of the COVID-19 pandemic on patients with fibromyalgia and chronic low back pain: A multicenter cross-sectional controlled study.

Objectives: This study aimed to investigate the physical and emotional effects of the coronavirus disease 2019 pandemic in patients with fibromyalgia syndrome (FMS) and chronic low back pain (CLBP) patients. Patients and methods: The cross-sectional controlled study was performed with 1,360 participants (332 males, 1,028 females; mean age: 42.3±12.5 years; range, 18 to 65 years) between September 2020 and February 2021. The participants were evaluated in three groups: the FMS group (n=465), the CLBP group (n=455), and the healthy control group (n=440). Physical activity, pain levels, and general health status before and during the pandemic were evaluated in all participants. Stress levels were analyzed with the perceived stress scale (PSS) in all groups, and disease activity was analyzed with the fibromyalgia impact questionnaire (FIQ) in patients with FMS. Results: Patients with FMS had worsened general health status and pain levels during the pandemic compared to the other groups (p<0.01). The FMS group showed significantly higher PSS scores than those in other groups (p<0.01). There was a weak-positive correlation between FIQ and PSS parameters in patients with FMS (p<0.05, r=0.385). Conclusion: The general health status, pain, and stress levels of the patients with FMS and CLBP tended to worsen during the pandemic. This high-stress level appeared to affect disease activity in patients with FMS.

The relationship between muscle size, obesity, body fat ratio, pain and disability in individuals with and without nonspecific low back pain.

Patients with nonspecific low back pain (NSLBP) may face motor control problems and health disability barriers during various tasks. However, studies investigating the extent of these disadvantages, and possible associated factors are quite limited in patients with NSLBP. To compare motor control performances and physical assessment domains between patients with NSLBP and asymptomatic controls. Twenty-seven patients with NSBLP and 27 age- and sex-matched asymptomatic controls participated in this cross-sectional study. Ultrasonographic imaging was used to determine abdominal and multifidus muscles thicknesses and adipose tissue rate. Visual analog scale was used to assess LBP severity. Body mass index (BMI) and Oswestry Disability Index (ODI) scores of the participants were physical assessment domains of LBP. BMI values were greater in the NSLBP group compared to the asymptomatic participants. ANCOVA revealed a significant interaction effect regarding external abdominal oblique and multifidus lumborum muscles thickness, and abdominal adipose tissue (p = 0.015; p = 0.001; p = 0.006), respectively in terms of two groups. The thicknesses of these muscles were lesser in the NSLBP group compared with the control group. Similarly, abdominal adipose tissue was higher in the NSLBP group. The stepwise multiple regression analysis demonstrated that the Oswestry Disability Index and abdominal adipose tissue rate were significant and independent factors of the low back pain severity with 73.5% of the variance. The study results indicate that increased disability and fat infiltration are possible determinants influencing pain severity, although further research is required. Examining musculoskeletal properties of lumbar region could provide information about the limitation in patients with NSBLP.

Does balneotherapy provide additive effects to physical therapy in patients with subacute supraspinatus tendinopathy? A randomized, controlled, single-blind study.

This study assessed the additional contribution of balneotherapy on physical therapy in subacute supraspinatus tendinopathy. Ninety patients with subacute supraspinatus tendinopathy were included. They were randomized into two equal groups. In group 1 (n = 45), transcutaneous electrical nerve stimulation (TENS), hot pack, ultrasound treatments, and Codman's and range of motion (ROM) exercises were performed. In group 2 (n = 45), balneotherapy was added to the treatment program. In both groups, shoulder active ROM and handgrip strength were measured. Pain was evaluated using a Visual Analogue Scale (VAS) (rest, sleep, movement); functional assessment and quality of life were measured respectively with the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), and the Short Form-36 health survey (SF 36) form. All measurements were repeated before and after 15 treatment sessions. There were statistically significant differences between the before and after assessment parameters in group 1 (all p < 0.05), but not for SF-36 General Health Perceptions, SF-36 Mental Health sub-parameters, and handgrip strengths. However, there were statistically significant differences between all the evaluation before and after the treatment in group 2 (all p < 0.05). When the two groups were compared in terms of alpha gains, statistically significant differences were observed in favor of group 2 in all measurements (all p < 0.05) except for SF-36 Emotional Role Difficulty and SF-36 Mental Health sub-parameters. This study shows that the addition of balneotherapy to physical therapy for subacute supraspinatus tendinopathy can make additional contributions to shoulder ROM, pain, handgrip strength, functional status, and quality of life.

The effect of balneotherapy on body mass index, adipokine levels, sleep disturbances, and quality of life of women with morbid obesity.

To investigate the effect of balneotherapy on body mass index, adipokine levels, sleep disturbances, and quality of life in women with morbid obesity. Fifty-four women with morbid obesity were included in the study. The body mass indexes (BMI) and waist/hip ratios (WHR) of the women were calculated. Subcutaneous fat thickness was measured using a *skinfold meter, and the percentage of adipose tissue was calculated. The *Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality, and the Nottingham Health Profile (NHP) was used to assess quality of life. In addition to routine biochemical tests, leptin, adipokine, visfatin from blood, and cortisol from saliva samples were studied. Participants were given 15 sessions of balneotherapy for 20 min each. After treatment, the laboratory and clinical parameters of the participants were *reevaluated. There was no statistically significant difference of BMI, WHR, and percentage of adipose tissue between before and after treatment measurements (p Ëƒ 0.05).There was a statistically significant improvement in PSQI and NSP scores (p Ë‚ 0.001). The levels of blood glucose, leptin, and visfatin were significantly decreased, and adiponectin was significantly increased after treatment (p = 0.047, p Ë‚ 0.001, p Ë‚ 0.001, and p Ë‚ 0.001, respectively).There was no statistically significant changes in salivary cortisol levels (p = 0.848). Patients with diabetes showed a statistically significant decrease in glucose levels after treatment (p = 0.017).There was a statistically significant decrease in low-density lipoprotein cholesterol levels in patients with dyslipidemia compared with pre-treatment (p = 0.018). Balneotherapy improves sleep and quality of life of women with morbid obesity. After balneotherapy, glucose, leptin, adiponectin, and visfatin levels may change positively.

The Effects of Balneotherapy on Oxidant/Antioxidant Status in Patients With Fibromyalgia: An Observational Study.

OBJECTIVES: This study aims to evaluate whether there was a difference between oxidative stress index (OSI), total antioxidant status (TAS), and total oxidant status (TOS) values between patients with fibromyalgia syndrome (FMS) and healthy controls, and to show the effect of balneotherapy on clinical conditions such as pain, depression, and quality of life in patients with FMS and oxidative stress. PATIENTS AND METHODS: Thirty-five females (mean age 39.9±5.8 years; range, 18 to 50 years) with fibromyalgia and 35 healthy females (mean age 37.9±6.6 years; range, 18 to 50 years) were included in the study. The TAS, TOS, and OSI of patients with FMS and healthy controls were measured. Disease severity was evaluated using the Fibromyalgia Impact Questionnaire, pain levels were evaluated using a visual analog scale (VAS), mood was evaluated using the Beck Depression Inventory (BDI), and quality of life was evaluated using the Short Form 36 (SF-36). Patients with FMS were given 15 sessions of balneotherapy. After treatment, the laboratory and clinical parameters of the patients were reevaluated. RESULTS: Although the TAS levels of patients with FMS were not significantly different from those of the control group (p=0.114), the TOS and OSI levels were higher than those of the control group (p<0.001). The VAS, BDI, and SF-36 parameter scores of patients with FMS were significantly higher than those of the control group (p<0.001). A statistically significant decrease (p<0.001) in TOS and OSI levels of patients with FMS was detected after balneotherapy; however, the TAS levels of patients with FMS did not change significantly (p=0.538). All clinical parameters showed significant improvement with balneotherapy (p<0.001). CONCLUSION: An oxidative disorder was detected in patients with FMS compared with the control group. Balneotherapy showed antioxidant activity and decreased oxidative stress while also improving clinical parameters and quality of life.

Validity and interrater/intrarater reliability of the Turkish version of the postural assessment scale for stroke patients (PASS-Turk).

Background: There is no Turkish version of the Postural Assessment Scale for Stroke patients (PASS). Objectives: To translate and make the cross-cultural adaptation of the PASS into the Turkish language and evaluate the reliability and validity of the Turkish version (PASS-Turk). Methods: Sixty patients with stroke who had survived the three-week acute period were included in the study. The first researcher applied the scale to the participants twice with 5-day intervals. The second researcher applied the scale once at the same time with the first researcher. The reliability of PASS-Turk and its subsections was evaluated using Cronbach's alpha coefficient. In addition, item-total correlation and test-retest reliability were calculated. The interobserver agreement was assessed using the intraclass correlation coefficient. The construct validity of PASS-Turk was assessed using Pearson's product-moment correlation and principal component analyses. The Berg Balance Scale (BBS) and motor subscale of the Functional Independence Measure (FIM) were used for validity. Results: The Cronbach's alpha coefficients of the PASS-Turk scale were 0.903 for the subsection of "maintaining posture," 0.940 for the subsection of "changing a posture," and 0.953 for the total PASS-Turk scale. The first and second researcher evaluations were perfectly consistent with each other in terms of PASS-Turk total scores (ICC = 0.999, 95% CI: 0.998-0.999, and p < .001). A strong positive correlation was found between PASS-Turk and BBS and the motor subscale of FIM. Conclusion: PASS-Turk is a valid and reliable scale for the evaluation of posture and balance of patients with stroke.

Short-Term Effects of Steroid Injection, Kinesio Taping, or Both on Pain, Grip Strength, and Functionality of Patients With Lateral Epicondylitis: A Single-Blinded Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to compare the efficacy of steroid injection and kinesio taping (KT) in the treatment of lateral epicondylitis. DESIGN: A total number of 84 patients were randomized into three groups. Group 1 was given steroid injection, group 2 received KT, and group 3 received both. Pain was measured using a visual analog scale, functional status was measured using a quick form of the Disabilities of Arm, Shoulder and Hand questionnaire, pain-free grip strength was measured using a dynamometer, and the pressure pain threshold was measured using an algometer. All evaluations were performed before treatment and at the third and twelfth weeks after the treatment. RESULTS: Twenty-eight patients were included in each group. A statistically significant difference was found between the pretreatment and posttreatment evaluations of all groups in the third and twelfth weeks after treatment. When group 1 and group 2 were compared, there was a significant difference only in pain-free grip strength measured in the twelfth week. The results of treatment in group 3 patients were significantly better in almost all evaluation parameters compared with the other groups. CONCLUSION: In the treatment of lateral epicondylitis, KT alone was found to be as effective as steroid injection alone. However, co-administration of steroid injection and KT is more effective compared with each treatment alone.

Comparison of the short-term effects of the conventional motorized traction with non-surgical spinal decompression performed with a DRX9000 device on pain, functionality, depression, and quality of life in patients with low back pain associated with lumbar disc herniation: A single-blind randomized-controlled trial.

OBJECTIVES: This study aims to compare the efficiency of conventional motorized traction (CMT) with non-surgical spinal decompression (NSD) using the DRX9000™ device in patients with low back pain associated with lumbar disc herniation (LDH). PATIENTS AND METHODS: Between March 2009 and September 2009, a total of 48 patients (29 females, 19 males; mean age 43.1±9.8 years; range, 18 to 65 years) were randomized into two groups. The first group (n=24) underwent CMT and the second group (n=24) underwent NSD for a total of 20 sessions over six weeks. The patients were evaluated before and after the treatment. Pain was assessed using the Visual Analog Scale (VAS), functional status using the Oswestry Disability Index (ODI), quality of life using the Short Form-36 (SF-36), state of depression mood using the Beck Depression Inventory (BDI), and the global assessment of the illness using the Patient's Global Assessment of Response to Therapy (PGART) and Investigator's Global Assessment of Response to Therapy (IGART) scales. RESULTS: There was no significant difference in the evaluation outcomes before the treatment between the groups. However, a statistically significant decline was found in the VAS, ODI, and BDI scores after the treatment in both groups (all p<0.001). Except for two subgroups, no significant changes were observed in the SF-36 form. Assessment of "marked improvement" was globally most frequently reported one in both groups. No significant difference was observed in the evaluation outcomes after treatment between the groups. CONCLUSION: Our study results show that both CMT and NSD are effective methods in pain management and functional status and depressive mood improvement in patients with LDH, and NSD is not superior to CMT in terms of pain, functionality, depression and quality of life.

Which Non-Pharmacological Treatment is More Effective on Clinical Parameters in Patients With Fibromyalgia: Balneotherapy or Aerobic Exercise?

OBJECTIVES: This study aims to determine the effects of non-pharmacological therapies, namely balneotherapy, exercise, and the combined use of balneotherapy and exercise, on total myalgic score (TMS), sleep quality, health status, and signs of depression in patients with fibromyalgia syndrome, and to compare the efficacies of these treatment programs with respect to the above parameters. PATIENTS AND METHODS: A total of 120 female subjects (mean age 37.21±12.45 years; range 18 to 63 years) diagnosed with fibromyalgia were enrolled. The patients were randomized into three groups with 40 patients in each (group 1: balneotherapy group, group 2: balneotherapy + exercise group, and group 3: exercise group). The patients underwent the treatment program for five days a week for a total of three weeks. Clinical parameters, Fibromyalgia Impact Questionnaire, Pittsburgh Sleep Quality Index, TMS, and Beck Depression Scale were evaluated at pre-treatment and post- treatment periods, and at the third-month control visit. RESULTS: There were no differences between the groups with respect to Fibromyalgia Impact Questionnaire, Pittsburgh Sleep Quality Index, TMS and Beck Depression Scale scores on pre-treatment evaluation, while the combined use of balneotherapy + aerobic exercise was more effective on TMS (p<0.001), health status (p=0.009), and level of depression (p<0.001) in post-treatment evaluation. A better state of well-being with respect to sleep quality was achieved by balneotherapy and balneotherapy + exercise groups. The third-month comparisons, on the other hand, demonstrated that the balneotherapy + exercise group had a greater state of well-being with respect to TMS (p<0.001) and general health status (p<0.001). Balneotherapy + exercise and exercise therapy benefited signs of depression to a better degree (p<0.001). Balneotherapy and combined balneotherapy + exercise therapy produced more effective results in terms of sleep quality (p<0.001). TMS regressed to near baseline levels (p=0.397), while Fibromyalgia Impact Questionnaire levels rose to near baseline levels at the third-month control in the exercise therapy group (p=0.070). CONCLUSION: The combined application of balneotherapy + exercise therapy, which are two of the recommended non-pharmacological treatments, may have superior and more sustained effects than administering either therapy alone.