# Exercise as it relates to Disease/Resistance exercise improves muscle strength, health status and pain intensity in fibromyalgia
## What kind of research was this?

Fibromyalgia (FM) is a chronic pain condition that affects all four quadrants of the body(1-3,5-7). FM’s prevalence rate is approximately 1-3% of the population and commonly affects women more than men (1,5-6). Some characteristics associated with FM include; persistent widespread pain, heightened pain sensitivity and muscular tenderness (1,6,7). The heightened pain within the FM population is caused by an increase in nociceptive input due to central sensitization and an impairment of central pain inhibition (1). Furthermore, FM individuals experience strength deficits of up to 39% and are most commonly highly distressed due to the associated characteristics (1, 3).
The authors of this study concluded that there was a lack of high quality evidence for resistance exercise in FM. Therefore, it was unknown what effects resistance training may have on FM individuals.
This lack of evidence provided grounds for research to be conducted and allow the evaluation of the effects of resistance exercise in a female fibromyalgia population. With specific focus on improving muscular strength, decreasing pain intensity (desensitisation) and improving individuals health and wellbeing.

## Where is the research from?

There are three locations where this research was conducted, all of which were located in Sweden. Anette Larsson and her colleagues have quite profound research knowledge within the FM population. With some research focussing on fear avoidance following resistance exercise, pro-inflammatory cytokine levels post resistance exercise and resistance exercise to decrease overall fatigue levels in FM populations. ‘Karolinska Institutet’ in Sweden sponsored this study and no conflict of interest was reported.

## What kind of research was this?

This study was an assessor blinded randomised controlled trial (RCT). Subjects were assigned to either a resistance exercise group or relaxation therapy group (control). As an assessor blinded RCT this study was deemed to be moderate quality evidence as it clearly documents all sources of bias within the research and follows the hypothesised study design.
The quality of evidence does differ depending on the type of trial undertaken, for example an RCT is of superior quality to an observational study or a case series study. These are examples of unfiltered information, whereas a meta-analysis and systematic review are filtered information from many research articles. Meta-analysis and systematic reviews are the best form of literature as they interpret all qualities of evidence and present a final statement.

## What did the research involve?

Within this study, females aged between 20–65 years and clinically diagnosed with FM were included. Subjects with high blood pressure (160/90mmhg), osteoarthritis of the hip or knee, any severe somatic or psychiatric disorders and high alcohol consumption subjects were excluded. 134 subjects were selected and informed written consent was obtained from all participants.
The program ran for 15 weeks and each participant was randomised into one of two groups via a concealed opaque envelope. The intervention group included patient specific exercises created by a trained physiotherapist. These exercises were chosen based on patient testing and previous exercise experience. From this information, an exercise protocol was created for each subject which was to be performed twice weekly under supervision at a selected physiotherapy premise. Progressions with exercises by either implementing a harder exercise or progressively loading were encouraged. The relaxation therapy group was required to attend a selected physiotherapy premise twice weekly for fifteen weeks. The relaxation therapy was a group class who performed physiotherapy-guided movements to allow each body part to fully relax.
The set up and recruitment of the methods within this article was performed to a high level, although did present some flaws. Specifically the low participant number was a limitations which reflects on the extensive exclusion criteria during pre-screening. Also, to improve the quality of evidence reported, a double-blinded RCT could have been undertaken to decrease in experimental bias or any subject related placebo effects. Further limitations include the lack of information provided regarding ‘testing for patient specific exercises’, which doesn’t allow any repeatability of exercise selection within this trial.

## What were the basic results?

Outcomes were assessed at baseline and after 15 weeks. The primary outcomes included isometric knee extension force using a standard protocol and maximal isometric elbow flexion to test strength of the extremities. Further testing included; fibromyalgia impact questionnaire (FIQ) and a visual analogue scale (VAS) for pain intensity, also a 6 minute walk test (6MWT), and the short form health survey (SF-36) which was a quality of life measure.
Improvements were reported through all primary measures stated above compared to the control group. As this study did incorporate an extensive amount of measures, below are some of measures recorded:
* An improvement of greater than 20% for all of the intervention group was reported in isometric knee extension compared to no change in the control group.
* A reduction of 11.5 points on the VAS was reported in the intervention group compared to a decline of 1.5 points within the control group.
* A large improvement in the SF-36 (+3.3 points) scores within the exercise group compared to the control (+0.8 points). A long-term follow up (13-18months) was conducted and concluded that there was no significant difference between the resistance exercise and relaxation (control) group.

## What conclusions can we take from this research?

This studies objective measurements showed that patient specific exercise interventions are beneficial within a FM population for improving health status, quality of life, strength and pain intensity compared to a relaxation therapy control method. These benefits are only gained when a long term exercise protocol is being undertaken. This study was only performed in females that were diagnosed with fibromyalgia, therefore carry-over to males can not be assumed.

## Practical advice?

Throughout this research, it was evident that resistance exercise played an important role in decreasing female FM individual’s pain intensity, muscular strength and health status. Although a patient specific exercise protocol is beneficial over a 15-week period, the research suggests that this protocol has to be consistently maintained to provide long-term benefits. Further evidence supports a moderate to high intensity resistance exercise program to improve pain intensity, muscle strength, tenderness, and overall health status within a female population (6,7).

## Further information

1. Online FM forum/support group: http://www.fibromyalgiaforums.org/forum/
2. Fibromyalgia Professional Resource Center from the National Fibromyalgia Association
3. American College of Rheumatology FMS fact sheet: http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia

## References

1. Larsson A, Palstam A, Löfgren M, Ernberg M, Bjersing J, Bileviciute-Ljungar I, Gerdle B, Kosek E, Mannerkorpi K. Resistance exercise improves muscle strength, health status and pain intensity in fibromyalgia—a randomized controlled trial. Arthritis research & therapy. 2015 Jun 18;17(1):1.
2. Busch A, Barber K, Overend T, Peloso P, Schachter C. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev 2007;4(4).
3. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, Fam AG. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis & Rheumatism. 1990 Feb 1;33(2):160-72. 4. https://commons.wikimedia.org/wiki/File:Fibromyalgia.jpg
5. Geel SE, Robergs RA. The effect of graded resistance exercise on fibromyalgia symptoms and muscle bioenergetics: A pilot study. Arthritis Care & Research. 2002 Feb 1;47(1):82-6.
6. Busch AJ, Schachter CL, Overend TJ, Peloso PM, Barber KA. Exercise for fibromyalgia: a systematic review. The Journal of rheumatology. 2008 Jun 1;35(6):1130-44.
7. Busch AJ, Webber SC, Richards RS, Bidonde J, Schachter CL, Schafer LA, Danyliw A, Sawant A, Dal Bello‐Haas V, Rader T, Overend TJ. Resistance exercise training for fibromyalgia. The Cochrane Library. 2013 Jan 1.
8. https://commons.wikimedia.org/wiki/File:Regional-symptoms-of-fibromyalgia.png