Exercise prescription for the patients with Fibromyalgia

American College of Rheumatology (ACR) and Swedish Fibromyalgia Association have published summary paper on fibromyalgia (FM). Fibromyalgia (FM) is a complex and chronic pain syndrome characterized by chronic widespread pain (axial plus upper and lower segment plus left- and right-sided pain), tende
esss, sleep disturbance and fatigue. Pain is located particularly in muscles, but also in joints. The prevalence in the general population is about 2%, of which 80% are women (1, 2).

To make the diagnosis of FM, some criteria need to be fulfilled: widespread pain for at least 3 months, the pain will be in the left- and right side of the body, above and below the waist and axial (spine). Pain on palpation in at least 11 of 18 defined tender points. All points palpated bilaterally with a force equivalent to approx. 40N/cm2 (about 4 kg) (1).

Dominant symptoms are generalized; migrating pain mainly from muscle and joint maximum- pain varies over time, generalized tende
ess and muscular fatigue, tiredness (70%), sleep disturbance (75%) and morning stiffness (70%). Other symptoms include cognitive difficulties (poor memory / concentration), stress intolerance and secondary psychological symptoms such as depression and anxiety. FM is comorbid with several others symptoms as functional gastrointestinal disorders, irritable bladder, vaginal dryness, tension headaches, temporomandibular disorders and bruxism. Disturbances in pain modulation in the central nervous system have been demonstrated in people with FM. This is thought to explain the generalized, migrating pain and tende
ess, but probably due to a complex interaction between peripheral (sensitization of primary nociceptors) and central nervous system (central sensitization, a failure in endogenous pain modulatory system, neuroendocrine disorders) factors (1,2).

The book Physical activity in the prevention and treatment of disease (FYSS) writes a chapter on pain that many patients with FM move too little because of general fatigue and pain. Inactivity is considered a major reason why these patients have reduced physical capacity, muscle strength and maximal oxygen uptake. The functional ability of muscles does not appear to be impaired (3). Several studies have shown that patients with FM benefit from physical exercise as they achieved improved physical functions, reduced the severity of symptoms, increased mood and wellbeing (4-9).
The physical activity should be planned individually according to the patient's current level of function and tolerance to pain. The purpose of physical activity and exercise in people with FM is primarily to maintain and / or improve physical function, not to "give away" the pain (3). A summary of all review and research articles (3-9) about the recommendation of physical activity or exercise for the people with FM has been given below:

Exercise prescription for the patients with fibromyalgia (FM):

Low intensity exercise: Patients with FM whose have a low activity level, are often depressed or frightened of experiencing increased pain due to physical activity or exercise. The exercise should start at a low level and carefully increase at the rate well tolerated. It may be important for the motivation to continue exercise and to experience the exercise as useful or pleasant. Regularity is more important than exercise intensity. Exercise at low or medium intensity level (based on the individual input parameters) has been shown to provide improved physical function and reduce the severity of symptoms and depression. Basic physical activity or exercise for 30 minutes per day can be divided into several sessions. Body image therapy and education in self-care may be good for the patients who need to get to know about their bodies and physical limitations.

Medium-or high-intensity exercise: Those patients who are able to train conditioning 2-3 times a week for at least 20 minutes at an intensity of 55-90% of maximum heart rate, have improved fitness and pain. Exercise forms consisted of cycling combined with cardiovascular fitness, strengthening and stretching exercises. Because of the pain problem many patients cannot achieve a relatively moderate to high intensity exercise level. However, the most untrained patients are able to achieve moderate-intensity exercise level reached simply by walking on ground.

Strengthening exercise: Patients who perform weight strengthening exercise at 40-60% of their maximum capacity and progressively increases resistance to 60-80%, have been shown improve muscular strength.

In summary, fitness, walking, pool exercise or swimming and strengthening exercise can improve physical functions, symptoms and depression in patients with FM. All exercises at the appropriate level seem to lead to increased confidence and a more positive view of the body. Exercise in group is beneficial for many because the group can provide a social support needed to to continue exercising regularly.

References:

1. Wolfe F, Clauw DJ, Fitzcharles MA, 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):600-10.
2. Kosek E. Fibromyalgi – Den osynliga sjukdomen. Sveriges fibromyalgiförbund.2006.
3. Börjesso
M, Mannerkorpi K, Knardahl S. Physical activity in the prevention and treatment of disease (FYSS), 2012. Pain, chapter 39
4. Carville SF, Arendt-Nielsen S, Bliddal H et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. A

Rheum Dis.
2008 Apr; 67(4):536-41.
5. Dupree Jones K, Adams D, Winters-Stone K, Burckhardt CS. A comprehensive review of 46 exercise treatment studies in fibromyalgia (1988-2005). Helth and Quality of Life Outcomes 2006; 4:67-73.
6. van Wigen CP, Bloten H, Oeseburg B. Results of a multidiciplinary program for patients with fibromyalgia implemented in the primary care. Disability and Rehabilitation 2007; 29(15):1207-1213.
7. Hävermark A-M, Langius-Eklöf A. Long-term follow up of a physical therapy programme for patients with fibromyalgia syndrome. Scandinavian journal of Caring Science 2006; 20: 315-322.
8. Busch AJ, Barber KAR, Overend TJ, Peloso PMJ, Schachter CL. Exercise in fibromyalgia. Cochrane Database of Systematic Reviews 2008; 2.
9. Mannerkorpi K. Exercise in fibromyalgia. Current Opinion in Rheumatology 2005; 17:190-194.