Exercise Guidelines for Fibromyalgia Patients

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Fibromyalgia syndrome (FMS) is a condition characterized by widespread pain, abnormal pain processing, sleep disturbance and fatigue. It is commonly associated with psychological distress and co-morbid conditions. Impaired cognition is common in individuals with FMS, and is often referred to as fibrofog.¹ According to the U.S. Centers for Disease Control and Prevention, the prevalence of FMS is 3.4% in women and 0.5% in men.² The 2010 ACR preliminary diagnostic criteria are used for clinical diagnosis and severity classification of FMS.³ Diagnosis is based on the following criteria:³

• Widespread Pain Index (WPI) >7 and a symptom severity scale (SS) >5 or WPI 3–6 and SS >9;
• Symptoms have been present at a similar level for at least three months; and
• The patient does not have a disorder that would otherwise explain the pain.

There is no cure for fibromyalgia, and management of patients with FMS is aimed at reducing symptoms and optimizing function. Ideal treatment encompasses both non-pharmacological and pharmacological strategies, with emphasis on maintaining function and patients playing an active role in their care.⁴

According to the 2012 Canadian Guidelines for Management of FMS, regular physical activity should form the cornerstone of treatment, and this approach received the highest grade of recommendation.⁴

The Ottawa Panel Evidence-Based Clinical Practice Guidelines for the Management of FMS recommend both aerobic exercises and strengthening exercises.^5,6 The Ottawa panel review included 16 studies of a variety of aerobic fitness interventions.⁵ These aerobic exercise interventions were found to result in improvements in a variety of outcomes, including: pain relief, psychological well-being, endurance, anxiety, self-efficacy, depression, quality of life, muscle strength, cardio respiratory fitness, physician general awareness and flexibility.

The Ottawa Panel, in a review of five selected randomized controlled trials, also found that strengthening exercises resulted in clinical benefits in muscle strength, pain relief, physical disability, depression and quality of life at end of treatment at 12 weeks.⁶

Similarly, a study by García-Martínez et al compared 12 women with FMS who completed a 12-week program of combined aerobic, strength and flexibility exercise with a usual care control group.⁷ They found the exercise program was effective in improving functional capacity and psychological status. Plus, subjects in the exercise group experienced benefits in self-esteem and self-concept, which were related to gains in health-related quality of life.

Due to the nature of FMS, individuals with this condition are generally less physically active, having lower perceived functional ability, and demonstrate impaired functional performance.^1,8 The main reason for reduced fitness in individuals with FMS is thought to be their lowered overall activity level.⁹ However, an exercise approach that is too vigorous will result in increased pain and fatigue for individuals with FMS. Therefore, to gain optimal benefits from exercise and ensure long-term adherence, care must be taken to prevent exercise-related pain and discomfort and adverse effects related to exercise such as musculoskeletal injury and fatigue.¹ A carefully graded, individualized and gradual intensity progression for deconditioned individuals with fibromyalgia toward “moderate” intensity is recommended.

Due to patients’ complaints of pain and fatigue, finding the correct dosage of exercise and ensuring adherence can be clinically challenging. Many patients will benefit from close monitoring and supervision from healthcare professionals, such as physical therapists.

Strengthening programs should begin with lower resistance than age-predicted norms.¹ Busch et al recommend the intensity and duration of exercise sessions should be reduced when significant post-exertion pain or fatigue is experienced and the intensity increased by 10% after two weeks of exercise without exacerbating symptoms.¹

To facilitate adherence, exercise of the patient’s choice is encouraged and should be adjusted according to the individual’s ability. This may be an aerobic, strengthening, water, home-based or group program, depending on availability to an individual patient.⁴ Self-efficacy is important for adherence and may be facilitated in group exercise sessions to provide support and motivation.

Aquatic Physical Therapy

Aquatic therapy is a commonly used treatment technique for individuals with FMS. A systematic review by Lima et al found that aquatic physical therapy resulted in an improvement in quality of life, physical function and stiffness when compared with no treatment after 20 weeks. However, when comparing aquatic vs. land physical therapy, there were no significant differences noted in pain or depression.¹⁰

When prescribing an aquatic therapy program, a number of different factors must be included to achieve the best results for the patient. The temperature should not exceed 30ºC when performing aerobic activities, such as running in water.¹⁰ However, because warm water has many favorable effects for individuals with FMS, exercises, such as stretching, mobility and strengthening, that do not have a strong aerobic component that would result in the patient overheating, should be performed at greater than 32ºC.

Busch et al concluded that although land- and water-based exercises may have similar outcomes based on some measures, exercising in water may be preferable to land-based exercise for individuals who are severely deconditioned or who have high levels of pain.¹

Multimodal Approach

To maximize outcomes, a multimodal approach tailored to each individual patient’s needs should be used. Physical therapy for patients with FMS should include education, aerobic exercise and strengthening exercise.9 Although not as strongly supported in the literature, patients with FMS may also benefit from manual therapy techniques, such as joint, soft tissue and myofascial mobilization.^9,11

Physical therapy interventions should be individualized to each patient’s needs, as determined by a thorough history and clinical examination. Nijs et al also recommend that patients be educated about the nature of their symptoms and illness and that education be used to introduce and implement various other treatment options, such as activity management and stress management.¹¹

Bourgault et al recently studied the effects of a program that combined exercise therapy and educational/psychological tools for self-management of FMS. Twenty-three patients received intervention and were compared with 20 patients on a wait list.¹² Patient empower­ment and active patient participation were integral components of the intervention, teaching patients to self-manage their illness and to take control over their pain management. Results after 11 weeks of treatment indicated that this interdisciplinary self-management intervention for FMS was effective in improving the patients’ global impression of change in terms of pain, functioning and QOL as well as in increasing their perceived pain relief, both at the end of the program and at three months post-intervention.

Martins et al found patients with FMS benefited from a weekly interdisciplinary program (WIP) consisting of educational activities, physical therapy, stretching, ergonomics, posture guidance combined with cognitive-behavioral strategies and approaches to psychosocial and occupational factors.¹³ The team included a physician, occupational therapist, physiotherapist, social worker and psychologist. The WIP group showed an increase in functional capacity and motivation for exercise, as well as greater control of such symptoms as sleep, anxiety and depression. Depression and anxiety were both decreased in the WIP group compared with the control group, and better sleep patterns were noted in participants in the weekly program.¹³

Holistic Approach

Holistic forms of exercise, such as tai-chi, yoga and Pilates, may be especially beneficial for those with fibromyalgia due to the potential psychosocial and emotional benefits.¹

Pilates: Pilates is an increasingly popular exercise approach that focuses on improving overall body flexibility and strength, with a strong emphasis on core strength, improved posture and effective breathing techniques, all of which are commonly impaired in patients with FMS.¹⁴ Due to the low-impact nature of Pilates, patients with fatigue may tolerate it better than other forms of aerobic exercise.

Altan et al performed a study in which they compared pain, Fibromyalgia Impact Questionnaire (FIQ) scores, number of tender points, algometric score, chair test and Nottingham Health Profile (NHP) (assessed Quality of Life) for a group that participated in Pilates and a group that performed only a home exercise program. Measurements were taken pretest, immediately post-test (12 weeks), and at a 12-week follow-up (24 weeks). Results showed that in the Pilates group there was an improvement in pain and FIQ at 12 weeks, and FIQ continued to improve at 24 weeks. There was also an improvement in number of tender points, NHP and algorithmic score. The control group, which consisted of a home exercise program, showed no improvement in pain or FIQ at either the 12- or 24-week follow-up. However, there was an improvement in number of tender points and algorithmic score at both 12 and 24 weeks.¹⁴

Tai-Chi: Tai-chi is a form of exercise that offers low to moderate activity and also contains breathing, relaxation and mental concentration. It’s thought to result in improved balance, coordination, gait, muscle strength and flexibility. A low- to moderate-intensity tai-chi program for 12 weeks has been shown to decrease pain in individuals with FMS after individual sessions and may have a cumulative effect in pain reduction after longer-term participation (longer than 16 weeks).¹⁵

Summary

Non-pharmacological approaches to the treatment of patients with fibromyalgia should include a strong emphasis on exercise and patient education. A wide range of exercise approaches—from traditional aerobic and strengthening programs to mind-body focused approaches—may be useful. Active patient participation, adherence to exercise and ability to self-manage symptoms are integral to maximizing patient outcomes. Additional research is needed to develop optimal exercise modes and dosage for individuals with FMS.

Marie B. Corkery, PT, DPT, MHS, is an associate clinical professor in the Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston.

Lauren Tarsi, DPT, graduated from Northeastern University in May 2015 with her clinical doctorate degree in physical therapy. Dr. Tarsi enjoys working with patients in the outpatient orthopedic and neurological setting.

References

1. Busch AJ, Webber SC, Brachaniec M, et al. Exercise therapy for fibromyalgia. Curr Pain Headache Rep. 2011 Oct;15(5):358–367.
2. Centers for Disease Control & Prevention. Arthritis: Fibromyalgia.
3. Wolfe F, Clauw DJ, Fitzcharles M-A, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. (Hoboken). 2010 May;62(5):600–610.
4. Fitzcharles M-A, Ste-Marie PA, Goldenberg DL, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: Executive summary. Pain Res Manag. 2013 May–June;18(3):119–126.
5. Brosseau L, Wells GA, Tugwell P, et al. Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: Part 1. Phys Ther. 2008 Jul;88(7):857–871.
6. Brosseau L, Wells GA, Tugwell P, et al. Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: Part 2. Phys Ther. 2008 Jul;88(7):873–886.
7. García-Martínez AM, De Paz JA, Márquez S. Effects of an exercise programme on self-esteem, self-concept and quality of life in women with fibromyalgia: A randomized controlled trial. Rheumatol Int. 2012 Jul;32(7):1869–1876.
8. Munguía-Izquierdo D, Legaz-Arrese A. Assessment of the effects of aquatic therapy on global symptomatology in patients with fibromyalgia syndrome: A randomized controlled trial. Arch Phys Med Rehabil. 2008 Dec;89(12):2250–2257.
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10. Lima TB, Dias JM, Mazuquin BF, et al. The effectiveness of aquatic physical therapy in the treatment of fibromyalgia: A systematic review with meta-analysis. Clin Rehabil. 2013 Oct;27(10):892–908.
11. Castro-Sánchez AM, Matarán-Peñarrocha GA, Arroyo-Morales M, et al. Effects of myofascial release techniques on pain, physical function and postural stability in patients with fibromyalgia: A randomized controlled trial. Clin Rehabil. 2011 Sep;25(9):800–813.
12. Bourgault P, Lacasse A, Marchand S, et al. Multicomponent Interdisciplinary Group Intervention for Self-Management of Fibromyalgia: A mixed-methods randomized controlled trial. PLoS One. 2015;10(5):e0126324.
13. Martins MRI, Gritti CC, Junior RDS, et al. Randomized controlled trial of a therapeutic intervention group in patients with fibromyalgia syndrome. Rev Bras Reumatol (English Ed). 2014 May–Jun;54(3):179–184.
14. Altan L, Korkmaz N, Bingol U, Gunay B. Effect of pilates training on people with fibromyalgia syndrome: A pilot study. Arch Phys Med Rehabil. 2009 Dec;90(12):1983–1988.
15. Segura-Jimenez V, Romero-Zurita A, Carbonell-Baeza A, et al. Effectiveness of Tai-Chi for decreasing acute pain in fibromyalgia patients. Int J Sport Med. 2014 May;35(5):418–423.