Fibromyalgia and Activity

Physical Activity

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.

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.

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. 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.

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.

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. 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.

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.

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. 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.

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).

Social Activity

Supportive social contact is a huge buffer against a chronic illness like fibromyalgia, says Connie O’Reilly, Ph.D., of Beaverton, OR. But couples may have to rethink and recreate a social life based on new realities. On an individual basis, patients may need to consider new passtimes that are fun but don’t drain their energy bank or overwork sore muscles (see the article on New Hobbies).

"Develop new mutual interests," O’Reilly suggests to help couples maintain a social life. "The kind of socializing may be different than it was before the illness." It’s important to continue to make plans, but be sure to have contingency plans for those inevitable disruptions because of pain or fatigue. Be prepared to be flexible with a time or date, or take a rain check.

“You need to try to let go of this idea that you can or should try to prevent someone else from being upset or disappointed,” O’Reilly says. Pushing yourself to meet social commitments will only make your fibromyalgia worse. And it’s also important to let your partner do what he needs to do to achieve his social needs.

“Your job is to engage in good self-care so that you don’t feel jealous or resentful when your partner does choose to go out without you. Your partner’s job is to decide what he needs to do to make certain he takes care of himself,” she says.

“Needs for the couple to socialize together shouldn’t be relegated to the trash heap,” says Don Uslan, M.A., M.B.A., L.M.H.C., a therapist in Seattle, WA. “Couples who are not used to individual socializing may have a very difficult time with this concept. But there aren’t a lot of choices. Either the well spouse learns to do certain things alone or with her own group of friends, so she can meet some social needs and lessen any possible resentment. Or the couple will have to learn to enjoy and accept a less active form of socializing together.”

There are challenges in living with a chronic illness that “good will and good intentions cannot solve on their own,” says Uslan. This is when couples therapy or professional counseling may be needed.

Barbara Suter, Ph.D., a therapist in New York City, says, in addition, an outside support group could act as psychological support for the well spouse to let-off steam or even be a social outlet. And "if time is too limited, perhaps an online group could be an option."

"A couple may be fortunate enough to go for many years before a major challenge strikes. Or it may be early in the relationship," Uslan says. “If you didn’t come down with fibromyalgia, it might have been something else, cardiac problems or severe back pain. The end result is the same. Either both parties are in it for the long haul, or one partner will try to find some way out, usually by blaming the person with the illness for some failure of not living up to the relationship contract. So, if it’s clear that both parties are in it for the long haul, they just need tools and techniques to figure out how to cope."