# Exercise as it relates to Disease/Resistance exercise improves physical fatigue in women with fibromyalgia

Resistance exercise improves physical fatigue in women with fibromyalgia: a randomized controlled trial. Critiqued as an assignment in the unit "Health, Disease and Exercise" at the University of Canberra, 2021.

## What is the background to this research?

Affecting 1-3% of adults, fibromyalgia causes widespread pain, fatigue, stiffness, cognitive impairment and disturbed sleep. More prevalent in women than men, fibromyalgia contributes to absences from work, social isolation, and reduction in ability to perform daily activities. Numerous studiesdetail positive effects of exercise on fibromyalgia symptoms. However, exercise type, duration and intensity is often poorly recorded, and progression and long-term follow up are rarely reported. This makes the practical application of research findings challenging.
This study is part of a multi-centre study looking at progressive resistance training (PRT) delivered in a person-centred program. It provides evidence that PRT contributes to improvement in multiple dimensions of fatigue in women with fibromyalgia.

## Where is the research from?

Researchers from universities and medical facilities across Sweden collaborated on this study; reflecting the complex nature of fibromyalgia, and the breadth of the trial. The lead author, Anna Ericsson, conducted data analysis and interpreted statistics while Annete Larsson and Annie Palstam, designed the main study.
The Swedish Rheumatism Association, Swedish Research Council, and a range of Institutes and Centres supported the research. The authors declared no conflicts of interest.

## What kind of research was this?

The study was an assessor-blinded randomised controlled trial (RCT) reported following CONSORT guidelines. 402 women were recruited through newspaper advertising and screened for suitability.
Inclusion criteria:
· Women aged 25 – 60 years with fibromyalgia
Exclusion criteria
· Severe somatic or psychiatric disorders
· Participation in a program of rehabilitation over the last year
· Inability to understand Swedish
By dividing the cohort randomly, concealing the actual variable from the participants and assessors, and ensuring research assessors did not know to which condition the participants were assigned, the researchers collected evidence unlikely to be biased or return false data. Alternative research designs such as observational or cross-sectional trials are unlikely to provide the same level of evidence as they tend to show correlations between variables rather than causal realtionships.

## What did the research involve?

Following initial screening, candidates underwent medical assessments, reducing the number of candidates to 130.
Baseline examinations included an interview, self-report questionnaires and physical capacity testing (Fig. 1).

###### Figure 1 - Tools for assessing baseline

| Assessment tool | Description |
| Multidimensional Fatigue Inventory (MFI) | Score /100, comprised of five sub-scores (4-20): General, physical and/or mental fatigue; reduced motivation and/or activity. |
| Fibromyalgia Impact Questionnaire (FIQ) - fatigue | Visual analogue scale (VAS) 0mm (no tiredness) -100mm (very tired) |
| Fibromyalgia Impact Questionnaire (FIQ) - pain | VAS 0mm (no pain) - 100mm (worst pain imaginable) |
| Pittsburgh Sleep Quality Index (PSQI) | Sleep quality/disturbances over one month. Score/21 from seven subscales (1-3): Sleep quality, latency, duration, efficiency and disturbances; needs medication to sleep; daytime dysfunction. |
| Pain Catastrophising Scale (PCS) | Assesses catastrophic thinking in response to pain. Includes rumination, magnification and helplessness subscales. |
| Hospital Anxiety/Depression Scale (HADS) | Scored against 14 statements identifying anxiety and/or depression |
| Leisure Time Physical Activity Instrument (LTPAI) | Self-reported activity over past week. |
| The 6-minute Walk Test (6MWT) | Distance (m) covered walking six minutes. |
Using a random computer-generated sequence distributed by a person not involved in the research treatments or examinations, participants were divided into active control (AC) or resistance exercise (RE) group. Both groups undertook two treatments per week for 15 weeks; were guided by physiotherapists at a physiotherapy centre or gym; worked in small groups (5 -8); and undertook individualised programs developed using a person-centred approach as follows:

###### Active Control Group

* autosuggestion and relaxation exercise 25 minutes
* discussion of experiences
* stretching exercises

###### Resistance Exercise Group

* 10 minute warm up
* 50 minutes resistance exercises - large muscle groups
* Commenced at 40% of one repetition maximum (1RM)
* Evaluation to progress loads each 3-4 weeks - up to 80% 1RM
Post-intervention, and at 13-18 months, participants were re-assessed using the same test regime.

## What were the basic results?

The researchers reported 75% program adherence in the RE intervention and 68% program adherence in the AC intervention, and identified:
* improvements in test scores in general fatigue within the entire cohort;
* reduction in need-for-medications-to-sleep subscale in the AC group;
* and significant improvement in physical fatigue and sleep quality in the RE group.
Following extensive statistical analysis, and adjustments for baseline differences, researchers concluded that along with sleep and aspects of work, person-centred PRT contributes to an improving physical fatigue in women with FM. They state the limitations of their recruitment method, methodically explaining confounding factors, small effect sizes and differences in baseline characteristics. In their diligence they may have understated the benefits of RE for women with FM, given that poor sleep can amplify FM symptoms. They also found that individual factors such as age, level of psychological distress, and physical capacity were unlikely to impact the effects of RE on fatigue.

## What conclusions can we take from this research?

Other trials have demonstrated that RE can reduce symptoms of pain, low self-efficacy, poor balance and reduced functional capacity yet problems with the research, such as small study size, lack of a control group and limited follow up have limited the applicability of findings about fatigue. Researchers in this trial used several tools to isolate the impact of RE on multiple dimensions of fatigue, adding to evidence for RE as a vital component of any rehabilitation/treatment program for women with FM.
Researchers mentioned the high level of adherence and suggested it was due to the person-centred approach of the intervention. These levels are better than those reported in other interventions with sedentary and overweight or obese adults and three times the number of Australians reported to undertake regular muscle-strengthening exercises. Further research has demonstrated that health professionals prescribing exercise should work with the participant to choose a suitable program of RE with adherence in mind, and that many women with FM prefer RE to other forms of exercise.
Building confidence, reducing symptoms and fear of pain, and promoting social interaction through formal RE programs could assist FM patients in improving overall quality of life. The impact of improving fatigue and sleep quality should not be discounted, even with a small effect size.

## Practical advice
###### Pre-screening

* A pre-exercise screening must be undertaken.

###### Planning

* FM patients do best when they take an active role in managing the condition. Any small gain can trigger an improvement in the factors contributing to their symptoms. Starting an exercise program can be daunting, as the fear of triggering additional pain, fatigue and stiffness can be overwhelming. Working with an exercise professional such as an exercise physiologist or physiotherapist could provide assurance of an understanding of their condition.

###### Programming

* A program of RE twice weekly based on a sub-maximal assessment of 1RM, starting at 40% of 1RM with progressions up to 80% of 1RM, should assist in reducing fatigue. This should be coupled with the accumulation of moderate aerobic activity (such as walking, swimming or cycling) for at least 30 minutes per day on days when fatigue levels permit and building to daily, to prevent stiffness.

## Further information/resources

https://arthritisaustralia.com.au/types-of-arthritis/fibromyalgia/
https://exerciseright.com.au/mental-health/
https://www.nhs.uk/conditions/fibromyalgia/self-help/
https://www.healthdirect.gov.au/fibromyalgia

## References

* 1 2 3 4 5 Ericsson, A., Palstam, A., Larsson, A. et al. Resistance exercise improves physical fatigue in women with fibromyalgia: a randomized controlled trial. Arthritis Res Ther 18, 176 (2016). https://doi.org/10.1186/s13075-016-1073-3
* ↑ Wolfe F, Clauw DJ, Fitzcharles M-A, Goldenberg DL, Häuser W, Katz RL, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminars in Arthritis and Rheumatism. 2016 2016/12/01/;46(3):319-29.
* ↑ Yunus MB. The role of gender in fibromyalgia syndrome. Current Rheumatology Reports. 2001;3(2):128-34.
* ↑ Mannerkorpi K, Burckhardt CS, Bjelle A. Physical performance characteristics of women with fibromyalgia. Arthritis & Rheumatism 1994;7(3):123–9.
* 1 2 Andrade A, Dominski FH, Sieczkowska SM. What we already know about the effects of exercise in patients with fibromyalgia: An umbrella review. Semin Arthritis Rheum. 2020 Dec;50(6):1465-80.
* 1 2 Juhlin S, Bergenheim A, Gjertsson I, Larsson A, Mannerkorpi K. Physical activity with person-centred guidance supported by a digital platform for persons with chronic widespread pain: A randomized controlled trial. Journal of rehabilitation medicine [serial on the Internet]. 2021; 53(4): Available from: http://europepmc.org/abstract/MED/33576434 https://doi.org/10.2340/16501977-2796 DOI:10.2340/16501977-2796
* 1 2 Jones KD, Burckhardt CS, Clark SR, Bennett RM, Potempa KM. A randomized controlled trial of muscle strengthening versus flexibility training in fibromyalgia. The Journal of Rheumatology. 2002;29(5):1041.
* 1 2 Kayo AH, Peccin MS, Sanches CM, Trevisani VFM. Effectiveness of physical activity in reducing pain in patients with fibromyalgia: a blinded randomized clinical trial. Rheumatology International. 2012;32(8):2285-92.
* 1 2 Hammond A, Freeman K. Community patient education and exercise for people with fibromyalgia: a parallel group randomized controlled trial. Clinical rehabilitation. 2006;20(10):835-46.
* 1 2 Valkeinen H, Alen M, Hannonen P, Häkkinen A, Airaksinen O, Häkkinen K. Changes in knee extension and flexion force, EMG and functional capacity during strength training in older females with fibromyalgia and healthy controls. Rheumatology. 2003;43(2):225-8.
* 1 2 3 4 5 Larsson A, Palstam A, Lofgren M, Ernberg M, Bjersing J, Bileviciute-Ljungar I, et al. Resistance exercise improves muscle strength, health status and pain intensity in fibromyalgia--a randomized controlled trial. Arthritis Res Ther. 2015 Jun 18;17:161.
* ↑ Kwakkenbos L, Imran M, McCall SJ, McCord KA, Fröbert O, Hemkens LG, et al. CONSORT extension for the reporting of randomised controlled trials conducted using cohorts and routinely collected data (CONSORT-ROUTINE): checklist with explanation and elaboration. BMJ : British Medical Journal (Online). 2021 2021 Apr 29 2021-05-10;373.
* ↑ Hariton E, Locascio JJ. Randomised controlled trials - the gold standard for effectiveness research. BJOG: An International Journal of Obstetrics & Gynaecology. 2018;125(13):1716-.
* ↑ Powers, S., Howley, E. ISE eBook Online Access for Exercise Physiology: Theory and Application to Fitness and Performance, 11th Edition. McGraw-Hill Higher Education (International); 20200901. Retrieved from vbk://978126058964120200901.
* ↑ Bigatti SM, Hernandez AM, Cronan TA, Rand KL. Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression. Arthritis and rheumatism. 2008;59(7):961-7.
* ↑ Kibar SMD, Yıldız HEMD, Ay SMD, Evcik DMD, Ergin ESMD. New Approach in Fibromyalgia Exercise Program: A Preliminary Study Regarding the Effectiveness of Balance Training. Archives of physical medicine and rehabilitation. 2015;96(9):1576-82.
* ↑ Góes SM, Leite N, Shay BL, Homann D, Stefanello JMF, Rodacki ALF. Functional capacity, muscle strength and falls in women with fibromyalgia. Clin Biomech. 2012;27:578–83
* 1 2 Andrade A, Dominski FH, Sieczkowska SM. What we already know about the effects of exercise in patients with fibromyalgia: An umbrella review. Semin Arthritis Rheum. 2020 Dec;50(6):1465-80.
* ↑ Perri MG, Anton SD, Durning PE, Ketterson TU, Sydeman SJ, Berlant NE, et al. Adherence to exercise prescriptions: Effects of prescribing moderate versus higher levels of intensity and frequency. Health Psychology. 2002;21(5):452-8.
* ↑ Australian Institute of Health and Welfare. Insufficient physical activity [Internet]. Canberra: Australian Institute of Health and Welfare, 2020 [cited 2021 Sep. 12]. Available from: https://www.aihw.gov.au/reports/risk-factors/insufficient-physical-activity
* ↑ Richards SCM. Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial. BMJ. 2002;325(7357):185-.
* ↑ Andersson UM, Aberg AC, von Koch L, Palstam A. Women with Fibromyalgia Prefer Resistance Exercise with Heavy Loads-A Randomized Crossover Pilot Study. Int J Environ Res Public Health. 2021 Jun 10;18(12).
* ↑ Andrade A, Steffens RAK, Vilarino GT, Miranda R, Benetti M, Coimbra DR. Preferred exercise and mental health of the patients with fibromyalgia syndrome. Complement Ther Clin Pract. 2020 Aug;40:101195.
* 1 2 Medicine, A. S. ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription, 7th Edition. Lippincott Williams & Wilkins; 2013. Retrieved from vbk://97814698284352013.