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Fibromyalgia Syndrome: The Beneficial Effects of Exercise
This article highlights positive outcomes for a convenience sample of six women (49–64 years of age) with fibromyalgia syndrome (FMS) who participated in an exercise program over 5 years. This group showed improvement with various FMS symptoms, fitness, and psychosocial factors early in the program, then showed further improvement as a result of adding new exercises to the protocol during the fourth and fifth years. Data suggest that certain people with FMS can improve their functional capacity with exercise over time, and move to even higher levels of physical function while aging and coping with FMS. Practical advice is provided for rehabilitation nurses regarding exercise and FMS.
Fibromyalgia syndrome (FMS) is a widespread, chronic pain condition with much comorbidity. FMS patients spend considerable amounts of money for various treatments in an attempt to feel and function better. The most recent data suggest that the prevalence of FMS—using American College of Rheumatology diagnostic criteria—is more than six times greater for women than men in the over-50 age group (Wolfe, Ross, Anderson, Russell, & Herbert, 1995). The overall prevalence is estimated to be 2% of the total population, but climbs to 3.4% for all women and 7% for women 60–79 years old. FMS is now diagnosed in all age groups including children (Wolfe et al.). The estimated prevalence for all types of widespread pain is 10.6% in the general population with regional pain prevalence estimated at 20.1% (Wolfe et al.). It is possible that some of these people may have undiagnosed FMS or are beginning to develop FMS, which would increase some of the aforementioned percentages.
Information reported here comes from a larger university-based, service and research exercise program for people with FMS in its 6th year of operation. Participants are referred by local physicians or respond to newspaper recruitment advertisements. There is no charge for participation. Data supporting the efficacy of this program have been reported elsewhere (Karper, et al., 2002; Karper & Stasik, 2003). In an attempt to disseminate program information and outcomes, an effort has been made to reach frontline practitioners who work with FMS patients. Rehabilitation nurses are one group with influence on chronic pain sufferers. Increasingly, rehabilitation nurses and physiatrists are treating large numbers of people with FMS and other chronic pain disorders.
The goal is to examine various fitness components, FMS symptoms, and psychosocial outcomes resulting from program participation. The authors have attempted to establish an optimal exercise protocol for these participants, noting that more than just exercise may affect the outcomes (e.g., participant social interaction). New activities were added to the exercise protocol 2 years ago, resulting in good outcomes with four people who had been with the program since 1998 and two people who began the program in 1999. These participants had benefited from the program over the years but had reached a plateau on some of the measures. What could stimulate even higher functioning without increasing pain and fatigue?
The past exercise protocol has been described in detail by Karper and Stasik (2003). Participants walked for approximately 25 min before engaging in 30–35 min of light dumbbell, circuit weight training along with other dynamic strengthening and range-of-motion exercises.
The new activities recently added at each session have focused on increasing core body strength and range of motion. These were added because the participants’ low back and pelvic muscle areas were weak and very tight; strengthening and stretching these areas might reduce their fatigue and pain. They sensed that adequate support from increased core body strength would make movement easier. The walk time was later reduced to 15 min at the beginning of each session. Because the authors could compare the data from these six participants before and after the changes, versus studying newer participants, this article describes the revised exercise protocol and the positive data trends for the six female participants in this study.
The six White women, chosen from a convenience sample, ranged in age from 49–64 years. They were married with children, and two of them had grandchildren. Their socioeconomic class is best characterized as middle to lower-upper class. All were physician-diagnosed with FMS. All of them suffered from conventional FMS symptoms (e.g., total body pain with tender points, fatigue, sleep problems, cognitive deficits) and many of the usual comorbidities (e.g., irritable bowel syndrome, depression, headache syndrome, and interstitial cystitis). They all transported themselves to the program and all of them took a number of prescription drugs to control their symptoms. During the 2 years of the new exercise, attendance ranged from 60%–80% of all sessions, except for one participant whose attendance dropped to 58% during the last year. This person had many family obligations. These women were not engaged in organized or systematic exercise outside of the program, except for one woman who walked regularly in a local park during the last year.
The New Exercise Program
Each exercise session lasted approximately 60 min, 5 days per week for these participants. After walking, participants engaged in circuit, dumbbell weight training as done in previous years. At each of eight stations (a different exercise was performed at each station), 6–12 repetitions were completed. The weight used by various participants ranged from 1–12 lbs in each hand. The eight exercises were wall or counter-top pushup, arm curl (bilateral), triceps extension (both arms separately), chair stand, pelvic tilts, shoulder shrugs, and lateral arm raises (bilateral). After completion of the circuit, the group completed range-of-motion and calisthenic-type exercises. These included heel raises, wrist flexion-extensions, finger flexion-extensions, standing side bends, and three neck range-of-motion exercises. Ten repetitions were completed for each of these exercises (see Table 1).
Next the group was led through yoga exercises performed on a gym mat and held for 10–15 s. These included sitting with the soles of feet together, holding both feet and bending forward, lying supine with one knee pulled up to the chest and the other leg straight (this was done for both sides), lying supine and holding both knees to the chest at the same time, and lying supine while rolling both hips to one side and simultaneously moving both knees (held together) to the mat to the side where the hips were rolled. With this last position, the body remained supine from the waist up with both shoulders held flat on the mat while both arms were held straight out to the sides on the mat (this was practiced on both sides). In addition, a rather complicated yoga posture known as the half twist (seated) was performed to stretch the lateral portions of the mid-body (Belling, 2003). After these new activities were completed, participants moved to the supine position again and repeated the exercise that involves holding both knees to the chest.
At the beginning of the 2nd year, more exercises were added to increase anterior, lateral, and posterior core body strength (McGill, 2001). These were three static bridging exercises, each held for 10 to 15 s. For the first one, the body was held prone and supported on both elbows and forearms and toes of both feet only. For the second one, the body was held on one side, then the other side, supported on one elbow or forearm and the side of one foot only for each side. For the third one, the body was held supine supported on the shoulders and both feet only. The bridging exercises were not easy to execute. It is difficult to hold one’s body perfectly straight in these positions, especially for people who have chronic pain and fatigue. During these sessions, the participants complained frequently about the discomfort caused by the side positions (i.e., body weight on one foot and one elbow or forearm). However, these activities did not produce delayed onset muscle soreness.
The evaluation methods described here were used to collect beginning, mid-year, and end-of-year information on fitness components. The year 2000–2001 averages of beginning, mid-year and end-of-year data were compared with the years 2001–2002 and 2002–2003 averages to see whether participants improved after being exposed to the new activities. Comparing yearly averages made sense because FMS symptoms fluctuate considerably over time because of numerous flare-ups. The fitness components examined were walk capacity, arm strength, grip strength, lower-body muscle strength, and upper-body muscle strength. Information on psychosocial components (perceived levels of stress, depression, and quality of life; QoL) was collected at the end of every week. Information on FMS symptoms (participant ratings of upper- and lower-body pain, fatigue, mental fogginess, and sleep quality) was collected three times every week each year. Average ratings for each year were compared for each of these factors.
Measurement of Study Variables
Grip strength was measured with a grip dynamometer (Stoelting, Chicago, IL). Participants sat in a chair with their dominant hand lying palm up on the same-side thigh. The first author steadied the dynamometer, and participants squeezed maximally on command. Three attempts were measured and each participant’s best score was used for evaluation.
Arm strength was measured while participants were seated in a chair (Osness et al., 1990). They were instructed to perform as many arm curls with a 4-lb dumbbell or 5-lb dumbbell (Rikli & Jones, 1999) as possible in 30 s. Participants were closely monitored to verify that they were reaching full extension and touching their shoulders during each curling motion. Participants were not permitted to swing their arms during the extension of the curl.
Upper-body strength was measured using a home-made, wall push-up test. Participants stood completely vertical, facing a wall with arms fully extended in front of them at breast level, shoulder width apart with palms of both hands flat on the wall. Keeping their hands on the wall, both feet were moved back 17% of their height in inches measuring from the arch on each foot. This placed everyone at a standardized push-up angle. They were asked to do as many push-ups as possible in 15 or 30 s (some people could not continue for 30 s). For each push-up, the participant’s nose had to touch the wall, with her back held straight, followed by complete arm extension.
Walk capacity was measured by asking participants to walk one fourth of a mile as fast as possible (Osness et al., 1990) or walk as far as possible for six min (Rikli & Jones, 1999). A modified form of the referenced walk test (440 yards vs. 880 yards) was used because the quarter-mile test was more manageable for some than the 800-yard or 6-min test. Scores equaled the time it took to walk the prescribed distance (one fourth of a mile) or the distance they covered (6-min walk).
Lower-body strength was measured with the chair-stand test (Rikli & Jones, 1999). Participants stood up as many times as possible from a seated position with arms folded across their chest. Their scores were the number of times they stood up in 30 s. With some of these tests, there were warm-ups and practice trials.
Perceived stress, perceived depression, perceived QoL, upper- and lower-body pain, fatigue, mental fogginess, and sleep quality information were gathered by asking subjects to rate their perceived stress separately, depression, and QoL level experienced each 7-day period. They rated upper- and lower-body pain, fatigue, mental fogginess, and sleep quality each 48-hr period over the course of each year. Although longer instruments exist to measure the aforementioned factors, a single 10-point visual analog scale was developed by the first author to measure each of them and thereby reduce participant burden. A score of 10 indicated no depression, excellent QoL, an absence of pain, no fatigue, a feeling of being completely mentally alert, and of having very restful sleep. Conversely, a score of 1 indicated the worst stress and depression imaginable, terrible QoL, severe pain, severe fatigue, total cognitive incapacity, and a feeling of not having slept at all.
Burkhardt and Bennett (1999) suggested that visual analog scales are a good way to evaluate the perceptions of those with FMS because of the unpredictable and constantly changing nature of the syndrome. Participants in this program reported that standardized instruments they used in the past consistently failed to capture how they really felt relative to the factors that were evaluated in this study. Thus, an analog scale appeared to be a good tool choice.
Table 2 displays the comparison of outcomes for these six women between 2000–2001 (before the new exercises), 2001–2002, and 2002–2003 (after the new exercises). Because the purpose is to show a composite picture of change, asterisks are used in the table instead of actual raw scores. (Actual raw scores are available from the first author upon request). Because statistical treatment of these data would have been improper, and, therefore, presenting a statistical significance level was not possible, it is important to note that change in a positive direction, no matter how small, is clinically significant. This was because participants said that any movement forward was helpful for them and that the factors and symptoms that were being evaluated were considered by them to be an improvement. Small positive scores or rating changes seemed to be associated with meaningful and functional change. These small changes are important because these women had already posted gains on many of the measured factors over the previous years that they were in the program. To be able to alter the protocol and move them forward even further, regardless of the size of the gain, is a success not reported previously in the FMS literature. Because these women had a condition that could cause progressive functional decline over time and because they were aging each year, no change in a negative direction (remaining the same) on evaluation criteria should probably be viewed as a positive result. Inspection of Table 2 reveals that all of the participants posted numerous positive results during the period in which the new exercises were added as compared with before they were added.
Table 3 contains the ranges of group scores or rating changes for each factor that was evaluated comparing differences between 2000–2001 to 2000–2003, except for walk capacity where two individual changes (one for the 440-yard test and one for the 6-min walk test) are given for differences between 2000–2001 and 2002–2003 for the only two participants who improved on that factor.
The results suggest that these particular women were able to hold their previously attained levels on much of the evaluation criteria, or they progressed as a result of the new activities. This was accomplished while coping with pain, fatigue, related conditions, and the aging process. It is worth mentioning that improvement was noted during 2001–2002 where four of the factors were scored as same on the table. This was because the 2002–2003 scores returned to the 2000–2001 levels. Only two subjects improved their walking capacity, probably because of the reduced walk time in the new exercise program. Subject one walked in a park outside of the program, which may explain her positive results. It is also no surprise that a number of subjects moved forward on the fitness components. We continued to offer progressive strength training during 2001–2002 and 2002–2003 when FMS symptoms and comorbid conditions permitted. Therefore, subjects became a little more fit, and they moved slightly forward on the symptom and psychosocial factors.
Hakkinen, Hakkinen, Hannonen, and Alen (2001) concluded that women with FMS have the same training potential as healthy women regarding progressive strength training. However, the most important aspect of these results may be the improvement on the FMS symptoms and psychosocial factors. King, Wessel, Bhambhani, Sholter, and Maksymowych (2002) found that women with FMS can improve their perceived ability to cope with their symptoms when they follow the treatment protocol in a combination that includes exercise and education. As a result of investigating high- and low-intensity aerobic training in subjects with FMS, van Santen et al. (2002) have speculated that low intensity, pleasant, long-duration programs keyed to subjects’ pain thresholds may stand the best chance of physical and psychosocial symptom improvement. This program was low-intensity and of long duration, and this may help to explain the positive outcomes. Rooks, Silverman, and Kantrowetz (2002) reported that exercise effects on women with FMS positively contributed to FMS symptom severity reduction. Finally, Jones, Burckhardt, Clark, Bonnett, and Potempa (2002) found that flexibility training alone and flexibility training with strength training could elicit improvement in overall FMS disease activity. These subjects consistently reported that stretching and strength training helped them. They believed their total body deteriorated when they were absent from the program.
Recommendations for Practice
It is improper to generalize to a larger population from the results of one study with a small number of subjects participating in an uncontrolled trial. It is difficult to collect data in a conventional manner from FMS subjects because of the complexity of the syndrome. Many factors negatively affect internal and external validity. However, rehabilitation nurses should know that the FMS research literature and this research support that exercise can positively affect physical and psychosocial function for many people with FMS. Indeed, appropriate exercise is one of the few treatments that seem to consistently help large numbers of people with FMS. These program outcomes data over 5 years (Karper, Hopewell, & Hodge, 2002; Karper & Stasik, 2003) have reliably supported the efficacy of a program encompassing exercise, education about FMS, and resource support 3–5 times per week for approximately 60 min per session. It appears from these attendance records that participants need to attend at least 60% of the sessions in a 5-day per week program to obtain moderate benefits.
The information reported in this article supports a program that contains aerobic exercise, strength training (dynamic and static), and range-of-motion (stretching) activity with the majority of the time spent with strength and range-of-motion exercise each session. In addition, all exercise should be low impact and should not produce discomfort or considerable delayed onset muscle soreness during a 48- to 72-hr follow-up. Regarding comfort, participants seem to do best with a slow, steady exercise cadence. It should also be noted that the authors recommend a 5-day- versus 3-day-per-week program whenever possible, because the latter is recommended by fitness professionals to produce better health outcomes. Attending 5 days per week establishes more of an attendance habit versus attending 3 days per week. In this regard, range-of-motion exercises should ideally be performed every day to maintain the entire range. Participants reported that they benefit from the increased group support 5 days per week versus 3 days per week.
Finally, it is important to mention that the non-exercise components of the program (i.e., education and resource support) may have an effect on all of the program outcomes. A study is presently being designed to investigate these aspects. Karper (2002) examined these non-exercise components elsewhere. In conclusion, the information provided here will motivate rehabilitation nurses to instruct their FMS patients that exercise is extremely important for the successful management of their condition. Rehabilitation nurses play an increasing, primary role as advisors relative to the start-up of group exercise programs for FMS patients at agencies in their communities.
About the Authors
William B. Karper, EdD, is associate professor with Behavioral Health and Fitness Laboratory, Department of Exercise and Sport Science, School of Health and Human Performance, University of North Carolina–Greensboro, Greensboro, NC. Direct correspondence to him at firstname.lastname@example.org.
Caroline R. F. Jannes, MS, Ghent, Belgium is a post graduate assistant, University of North Carolina–Greensboro, Greensboro, NC.
Janis L. Hampton, MS, is assistant professor of health, physical education, and recreation at Duke University, Durham, NC.
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