# Exercise as it relates to Disease/Exercise Therapy in Women With Fibromyalgia

The following is a critical appraisal of a journal article examining the effectiveness of exercise therapy on women with fibromyalgia. This appraisal has been written for a university assignment at the University of Canberra for the unit: Health, Disease and Exercise.
The Paper: Sañudo, B., Galiano, D., Carrasco, L., Blagojevic, M., de Hoyo, M., & Saxton, J. (2010). Aerobic Exercise Versus Combined Exercise Therapy in Women With Fibromyalgia Syndrome: A Randomized Controlled Trial. Archives Of Physical Medicine And Rehabilitation, 91(12), 1838-1843.

## What is the background to this research?

Fibromyalgia syndrome (FMS) is a chronic pain condition characterized by long-term, widespread musculoskeletal pain and tenderness and additional systemic symptoms such as alterations in psychological health status, chronic fatigue and nonrestorative sleep. With a complex diagnostic process and no current cure, exercise therapy is regularly prescribed for the management of symptoms. The current body of evidence surrounding FMS labels exercise therapy as a beneficial intervention, but it is unclear as to what forms of exercise provide the greatest benefits. Therefore, the purpose of this research was to investigate the effects of aerobic exercise (AE) and combined exercise (CE) on important health outcomes in women with FMS.
Prevalence:
Due to FMS being classified under the ‘chronic pain’ umbrella term in Australia, the population data would be underrepresented; therefore, the closest comparable statistics come from America.
* 2%-4% of the U.S.A population are diagnosed with FMS.
* FMS is the third most prevalent rheumatic disorder in the U.S.A.
* 80% of those affected are women.

## Where is this research from?

This study was undertaken by the following Universities:
* Department of Physical Education and Sport, University of Seville, Spain
* Department of Computer and Sports, University of Pablo de Olavide, Spain.
* Department of Primary Care Sciences, Keele University, UK.
* School of Allied Health Professionals, University of East Anglia, UK.
The study was published in the Archives of Physical Medicine and Rehabilitation (APMR), the official journal of the American Congress of Rehabilitation Medicine (ACRM). APMR It is the most highly cited journal in the Rehabilitation category of the Thomson Reuters Journal Citation Reports, has the highest Eigenfactor Score™ in the field (rating of total importance for a scientific journal), and has an Impact Factor that has increased annually since 2002.

## What kind of research was this?

This study is a non-crossover, randomised controlled trial (RCT) consisting of two intervention groups (aerobic exercise only and combined exercise) and one control group (usual-care). According to the National Health and Medical Research Council, a randomised controlled trial is classified as a level two research method, and is a well suited design for clinical trials. Therefore, this study has a strong basis to support the relationship between physical activity and fibromyalgia.

## What did the research involve?

64 women diagnosed with fibromyalgia were enrolled in the study by local physician practices and support groups. The subjects were then randomly assigned via a computer-generated random number sequence method to one of three groups:
Aerobic exercise (AE):
* 2 aerobic exercise sessions a week of 45 – 60 minutes’ duration.
* Steady state and interval training at varying intensities.
Combined exercise (CE):
* 2 combined exercise sessions a week of 45 – 60 minutes’ duration.
* Aerobic exercise, strength training and flexibility exercise.
Control:
* Usual medical treatment and continuation of normal daily activities, not including structured exercise.
Subjects initially underwent baseline assessments before commencing the 24-week program. Over the course of the study, researchers looked for changes in both primary and secondary outcomes. The primary outcome detailed a change in the Fibromyalgia Impact Questionnaire (FIQ) from baseline to completion of the 24-week program. The secondary outcomes included changes in the; Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), Beck Depression Inventory (BDI), 6-minute walk test, hand grip strength and range of motion (ROM) in the shoulders and hips.

## What were the basic results?

Primary outcome results:
* Both exercise groups showed an improvement of 9 points (14%-15%) from baseline FIG scores at 24 weeks.
* There was no change from baseline FIQ score for the control group.
Secondary outcome results:
* BDI scores decreased by 8.58 and 6.44 points in the AE and CE groups, respectively.
* Both exercise groups showed an improvement of 8 points from baseline Global SF-36 scores.
* AE group showed a 1% increase in the 6-minute walk test when compared to the CE group.
* Both left and right grip strength scores were higher in the CE group.
* The CE group showed increase in both shoulders and hips ROM.

## How did the researchers interpret the results?

Researchers determined that both exercise groups produced similar improvements in FIQ, SF-36 and BDI, however, the CE group did elicit additional health benefits when compared to AE alone. These include:
* Improvements in physical functioning, bodily pain, vitality and mental health dimensions in the SF-36.
* Increased grip strength.
* Increased flexibility and joint mobility.
These results coincide with a recent review in 2011 which assessed all RCT’s in relation to exercise and FMS from 2008 to 2011 This review identified a combined exercise program as one of the most beneficial treatments for women suffering from FMS. In addition, according to The American College of Sports Medicine (ACSM), FMS sufferers should be exercising at a low intensity to prevent symptom exacerbation. In this study, participants were performing at up to 80% of their HRmax, which is classified as borderline ‘high intensity exercise’. The researchers believed that working at high intensities evoked greater improvements within subjects in primary and secondary outcomes; with this ideology being supported by current research on chronic pain conditions. As the study implements conflicting exercise recommendations to the ACSM guidelines, further research is required to understand optimal exercise frequency, intensity and duration for FMS patients and which exercise modalities provide the greatest improvements in FMS symptoms.
Limitations:
Though adherence to the program was exceptional, this study does not provide insight into the benefits of AE and CE in women with FMS past 24 weeks. Another limitation is the restricted range of outcome measures assessed. When compared to current research, the present study provides limited understanding of exercise therapy effects in women with FMS. The study’s small sample size may also affect the study’s validity.

## What conclusions can we take away from this research and what are their implications in a real-world setting?

The research concludes that women with a diagnosis of FMS can gain additional health benefits by participating in an CE program, with more recent studies showing greater benefits, particularly in physical and psychological functioning, when such programs are individualised. However, further research to understand the most appropriate exercise methodology to reducing FMS symptoms is essential.

## Further reading

* Online FMS forum/support group: http://www.fibromyalgiaforums.org/forum/
* American College of Rheumatology FMS fact sheet: http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia

## References

* 1 2 3 4 5 6 7 8 Sañudo, B., Galiano, D., Carrasco, L., Blagojevic, M., de Hoyo, M., & Saxton, J. (2010). Aerobic Exercise Versus Combined Exercise Therapy in Women With Fibromyalgia Syndrome: A Randomized Controlled Trial. Archives Of Physical Medicine And Rehabilitation, 91(12), 1838-1843. http://dx.doi.org/10.1016/j.apmr.2010.09.006
* 1 2 3 4 5 Moore, G., Durstine, J., & Painter, P. (2016). Exercise Management for Persons with Chronic Diseases and Disabilities (4th ed., pp. 221-225). Champaign, IL: Human Kinetics.
* ↑ Archives of Physical Medicine and Rehabilitation. (2016). Archives-pmr.org. Retrieved 18 September 2016, from http://www.archives-pmr.org/content/about
* ↑ National Health and Medical Research Council,. (2016). NHMRC additional levels of evidence and grades for recommendations for developers of guidelines (p. 15). Adelaide: National Health and Medical Research Council. Retrieved from https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf
* 1 2 Busch, A.J., Webber, S.C., Brachaniec, M. et al. (2011). Exercise Therapy for Fibromyalgia. Current Pain Headache Rep 15: 358. http://dx.doi.org/10.1007/s11916-011-0214-2
* ↑ Assis, M., Silva, L., Alves, A., Pessanha, A., Valim, V., & Feldman, D. et al. (2006). A randomized controlled trial of deep water running: Clinical effectiveness of aquatic exercise to treat fibromyalgia. Arthritis Rheum, 55(1), 57-65. http://dx.doi.org/10.1002/art.21693
* ↑ Altan, L., Bing, U., Ayka, M., Koc Z., & Yurtkuran, M. (2003). Investigation of the effects of pool-based exercise on fibromyalgia syndrome. Rheumatol Int, 24(5). http://dx.doi.org/10.1007/s00296-003-0371-7
* ↑ van Koulil, S., van Lankveld, W., Kraaimaat, F., van Helmond, T., Vedder, A., & van Hoorn, H. et al. (2010). Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia. Arthritis Care Res, 62(10), 1377-1385. http://dx.doi.org/10.1002/acr.20268