# Exercise as it relates to Disease/Is a combination of strength and endurance training effective for postmenopausal females suffering from fibromyalgia?

This page is a critique of the research article: 'Effects of Concurrent Strength and Endurance Training on Physical Fitness and Symptoms in Postmenopausal Women With Fibromyalgia: A Randomized Controlled Trial' by Valkeinen H, Alén M, Häkkinen A, Hannonen P, Kukkonen-Harjula K, Häkkinen K.
Critique was undertaken as an assignment for the unit Health, Disease, and Exercise (8340) at the University of Canberra, during Semester 2 of 2022.

## What is the background to this research?

Fibromyalgia syndrome (FMS) is a chronic rheumatic condition that causes individuals to experience widespread pain, fatigue, mental distress and often abnormal processing of pain. It impacts 2% to 5% of the population (the majority are females) and has no known cause or cure. American College of Rheumatology (ACR) published an article investigating the quality of life of fibromyalgia patients. ACR concluded that quality of life decreased from 8.6 out of 10 to 4.8 out of 10, through questionaries conducted by FMS patients. The European Alliance of Associations for Rheumatology (EULAR) reviewed management recommendations for FMS in 2016. EULAR concluded that aerobic and strength training are effective non-pharmacological methods for managing FMS symptoms. Current guidelines for exercise prescribe include:
* Highly individualised program.
* Low-intensity training.
* Progressive overload is slow and aims toward a moderate intensity level.
However, there is insufficient evidence on which forms of exercise are best and whether a combination of exercise types would be a more effective management method.The ‘Effects of Concurrent Strength and Endurance Training on Physical Fitness and Symptoms in Postmenopausal Women with Fibromyalgia: A Randomised Controlled Trial’ investigates the effectiveness of concurrent strength and endurance training as an exercise intervention to improve FMS patients’ symptoms and overall physical fitness. This knowledge would advance the understanding of exercise prescriptions for FMS patients and the extent of the impact.

## Where is the research from?

This peer-reviewed article was published in the Archives of Physical Medicine and Rehabilitation volume 89, issue 9, owned by the American congress of rehabilitation medicine (ACRM). ACRM is a private organisation that aims to share updated, accurate research in rehabilitation. Therefore, articles must be credible and limited bias to be published. ACRM is sponsored by numerous reputable organisations, including the American Stroke Association, decreasing the bias. All authors have been involved in several peer-reviewed projects. This experience increased the reliability of the study.
The small specific sample group reduces the ability to generalise the study to FMS patients with other health issues such as obesity, which is typical for FMS patients. Furthermore, the lab environment increases the difficulty of applying to hospital settings, decreasing generalising capacity.
Table 1: Author details. :
| Name | Employment | Publications |
| Heli Valkeinen | Finnish Institute for health and welfare | 48 |
| Markku Alén | Professor at University of Oulu | 176 |
| Arja Häkkinen | Professor at University of Jyväskylä | 359 |
| Pekka Hannonen | Central Hospital Central Finland | 244 |
| Katriina Kukkonen-Harjula | Professor at Tampere University | 125 |
| Keijo Häkkinen | Researcher at University of Jyväskylä | 843 |

## What kind of research was this?

This study is a randomised control trial (RCT), excellent for identifying a significant difference between using concurrent endurance and strength training or no exercise prescription for managing symptoms relating to FMS. Limitations in how concurrent exercise interventions are practical occur to due this RCT format. The size of this RCT have created a level two of evidence. The level of evidence can be improved through numerous RCTs or increased sample size. The 26 participants in this study were all females above 50 years old without any other chronic illnesses that could impact results, such as cardiovascular disease and diabetes. All participants had not been involved in an exercise intervention already. Participants were separated randomly into the training or control group.

## What did the research involve?

Participants in the training group had to complete a 21-week training program (table 2) that alternated two strength training and one aerobic training, followed by one strength training and two aerobic training. Sufficient rest periods between sessions were vital not to aggravate FMS patients' symptoms. Strength sessions were all supervised, and endurance sessions were supervised once a week. Physical fitness and perceived wellbeing were tested before the study and on weeks 7, 14 and 21. Aerobic testing was completed first, and strength testing seven days after. These tests include:
* Grip
* Isometric leg extension
* Concentric leg extension
* Elbow flexionTrunk flexion and extension
* Perceived symptoms during aerobic exercise testing
* Heart rate
* VO2Walking pace for 10 minutes
* Time to climb ten steps without support
* Stanford HAQ
Table 2: Exercise intervention program used in critiquing study. :
| Strength training | | | | |
| | Week | Intensity (%) | Sets | Reps |
| | 1-4 | 40-60 | 2-4 | 10-20 |
| | 5-7 | 50-70 | 2-4 | 8-15 |
| | 8-11 | 60-70 | 2-6 | 8-12 |
| | 12-14 | 60-80 | 2-6 | 5-12 |
| | 15-18 | 60-80 | 2-6 | 5-12 |
| | 19-21 | 70-80 | 2-6 | 5-10 |
| Aerobic training ||||||
| | Week | Intensity | Duration (minutes) | |
| | 1-7 | Low intensity | 30 | |
| | 8-14 | Intervals of low and high intensity | 45 | |
| | 15-21 | Intervals of low and high intensity | 60 | |
The methodology for this study has excellent measures to reduce bias, appropriate tests for physical fitness and reliable perceived pain questionnaire. The structure is similar to articles reviewed in Current Pain and Headache Reports review 'Exercise Therapy for Fibromyalgia', which are high standard meta-analyses or RCT. Increasing rest time during muscular strength tests would improve reliability of results as fatigue would decrease performance in tests.

## What were the basic results?

The training group had significant improvements in the aerobic workload (p=0.001), work duration (p=0.001), concentric leg extension (p=0.034 and pain perceived decreased (p=0.038). Other aspects of physical fitness had positive trends of improvement. However, they were not significant. Other elements of well-being reported through the HAQ had no significant progress. Researchers of this study interpreted the results with a more positive perspective, typically explaining positive changes in areas tested, but the p-value indicated was not significant. Researchers are implying there is potential for concurrent training to be a management treatment for FMS patients, but it needs more research. The small sample size decreases the accuracy, producing more inconclusive results.

## What conclusions can we take from this research?

This investigation indicated that with concurrent training, FMS patients could improve physical fitness in aspects of workload, work time and some parts of muscular strength. Symptoms of FMS did not worsen. Fatigue and pain changed in a positive direction. Throughout the study, numerous tests had insignificant results leading to inconclusive results. Therefore, there is a potential that concurrent training may not be beneficial management of FMS symptoms. Strength training in other RCTs has found more promising improvements in overall well-being. For example, Current Pain and Headache Reports review 'Exercise Therapy for Fibromyalgia', indicated high positive impact on physical function and mental wellbeing. Whereas, concurrent training had positive impacts in these aspects. Potentially strength training may be more effective in treatment management than a combination of training formats at one time. Comparison of different exercise interventions is required to further understand the most effective method and further research into concurrent training to produce more conclusive evidence. The methodology of this investigation is effective but the small sample size decreases the ability to generalise study.

## Practical advice

* Exercise interventions have a positive impact on individuals suffering from FMS.
* Concurrent training significantly improves fatigue, pain, concentric leg extension strength and aerobic capacity.
* Strength training improves the well-being of patients to a greater extent than contemporary training interventions, but aerobic fitness is not impacted.
* A trained physiotherapist or physiologist should supervise the exercise. Exercise should be low intensity to avoid injury or worsening of symptoms.
* Tailoring of the program should consider all diseases with the FMS, such as cardiovascular disease.

## Further information/resources

* American College of Rheumatology: https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia
* National Institute of Arthritis and musculoskeletal and Skin Diseases: https://www.niams.nih.gov/health-topics/fibromyalgia
* Arthritis Australia: https://arthritisaustralia.com.au/managing-arthritis/living-with-arthritis/physical-activity-and-exercise/exercise-and-fibromyalgia/

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Valkeinen H, Alén M, Häkkinen A, Hannonen P, Kukkonen-Harjula K, Häkkinen K. Effects of concurrent strength and endurance training on physical fitness and symptoms in postmenopausal women with fibromyalgia: a randomized controlled trial. Archives of physical medicine and rehabilitation. 2008 Sep 1;89(9):1660-6.
* 1 2 Centers for Disease Control and Prevenetion (CDC). Fibromyalgia [Internet]. Online: CDC; 2020 [cited 2022 Sep 10]. Available from: https://www.cdc.gov/arthritis/basics/fibromyalgia.htm
* 1 2 Clauw DJ. Fibromyalgia: a clinical review. Jama. 2014 Apr 16;311(15):1547-55.
* 1 2 Bernard AL, Prince A, Edsall P. Quality of life issues for fibromyalgia patients. Arthritis Care & Research. 2000 Feb;13(1):42-50.
* 1 2 3 Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, Choy E, Kosek E, Amris K, Branco J, Dincer Fİ. EULAR revised recommendations for the management of fibromyalgia. Annals of the rheumatic diseases. 2017 Feb 1;76(2):318-28.
* 1 2 Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, Casimiro L, Robinson VA, McGowan J, Busch A, Poitras S. Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Physical therapy. 2008 Jul 1;88(7):857-71.
* 1 2 Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, Casimiro L, Robinson VA, McGowan J, Busch A, Poitras S. Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2. Physical therapy. 2008 Jul 1;88(7):873-86.
* 1 2 3 American congress of rehabilitation medicine (ACRM). Archives of Physical Medicine and Rehabilitation [Internet]. America: ACRM; 2008 [cited 2022 Sep 10]. Available from: https://www.archives-pmr.org/
* ↑ ResearchGate. Profiles [Internet]. Online: ResearchGate; 2020 [cited 2022 Sep 10]. Available from: https://www.researchgate.net/
* ↑ Sanson-Fisher RW, Bonevski B, Green LW, D’Este C. Limitations of the randomized controlled trial in evaluating population-based health interventions. American journal of preventive medicine. 2007 Aug 1;33(2):155-61.
* 1 2 Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plastic and reconstructive surgery. 2011 Jul;128(1):305.
* ↑ Winnick JP, Short FX. The Brockport physical fitness test manual. Human Kinetics; 1999.
* ↑ Reza R, Samira R, Youssef S, Hossein M, Ali E, Ahmad J. Validation of the Persian version of the Stanford health assessment questionnaire [HAQ] in patients with rheumatoid arthritis.
* 1 2 3 4 Busch AJ, Webber SC, Brachaniec M, Bidonde J, Bello-Haas VD, Danyliw AD, Overend TJ, Richards RS, Sawant A, Schachter CL. Exercise therapy for fibromyalgia. Current pain and headache reports. 2011 Oct;15(5):358-67.
* ↑ Trossman PB, Li PW. The effect of the duration of intertrial rest periods on isometric grip strength performance in young adults. The Occupational Therapy Journal of Research. 1989 Nov;9(6):362-78.