Exercise Blog Series, Part 4: Exercise Fights Fibromyalgia Symptoms with You!

By: Michelle Zong and Zachary Zenko, PhD

This is the fourth post in a series designed to review some of the many benefits of exercise in an accessible manner. Previous posts can be found here, here, and here. Some academic research will be reviewed, synthesized, and summarized so that people without a background in research methods and statistics can appreciate the findings. The evidence in these posts is by no means comprehensive. Instead, only a glimpse of the available evidence is shared. If you have suggestions for future topics in this series, please e-mail Zachary Zenko at zachary.zenko@duke.edu.

Exercise fights Fibromyalgia (FM) symptoms with you!

Have you ever seen an advertisement about fibromyalgia (FM) medicine and wondered what this disease is? FM is a complex musculoskeletal disorder with no known cure. The 1990 American College of Rheumatology classified FM as a combination of “widespread pain” and “tenderness at 11 or more of the 18 specific tender point sites” (Wolfe et al., 1990). Tender point sites are often areas around joints, but not in the joints themselves, as they have been described as pain just under the surface of the skin. Below is a diagram displaying common tender points (Langtree, 2011).

Figure 1: Location of the 18 tender points stated by the American College of Rheumatology criteria for FM (Langtree, 2011).

So with no known cure – how do the 2 to 6 percent of individuals (in Western countries) who suffer from this deal with their symptoms (Branco et al., 2010)? Lie down and accept their fate? Not a chance; most individuals realize that exercise is a tool they can use against their pain symptoms. However, just as every tool is designed to help with a certain action, specificity matters. The type of exercise, the intensity, as well as the frequency and duration are all contributing factors to the effectiveness of this exercise tool.

Please note that this is a review of only some of the academic research out there. This post should be treated as a glimpse into how researchers have obtained the evidence that individuals with FM may be able to exercise their way to reduced symptoms of pain.

Research studies tell us what kind of exercise is the right tool for FM:

Munguía-Izquierdo and Legaz-Arrese (2008) created a four-month exercise program, consisting of 40-60 minute aquatic exercise sessions carried out three times per week in a warm (32°C, 89.6°F) chest-high pool. The program began with a 10-minute warm up of slow walking, moving to a 10-20 minute strength exercise using water and aquatic materials as resistance, and ended with a 20-30 minute aerobic exercise followed by a 10-minute cool down.

Munguía-Izquierdo and Legaz-Arrese (2008) demonstrated that this exercise program could significantly decrease the number of tender points, and significantly increase the health status and physical fitness of FM patients. They performed a randomized control trial (RCT) where they randomly assigned half of their female participants to the exercise program and the other half to a non-exercise control group that did no exercise during the 4 months. Compared to the non-exercise control group, the exercise group experienced small-to-medium reductions in tender-point counts (Munguía-Izquierdo & Legaz-Arrese, 2008).

Health status was measured by the Fibromyalgia Impact Questionnaire (FIQ). This questionnaire measures the overall well-being of a patient with FM through questions that ask about various aspects of their lives, from physical functioning to their work status. The FIQ used in this study consisted of 10 questions either answered by choosing a number on a numerical scale or by marking a position on a bipolar visual analog scale. For example, to indicate their responses, participants would mark a position on a line ranging from “no problem with work” to “great difficulty with work”. The questionnaire is scored from 0 to 100; the higher the score, the more the individual is impacted by FM symptoms. Impact of fibromyalgia decreased significantly more in the exercise group (-5.1) compared to the control group (-0.9) (Munguía-Izquierdo & Legaz-Arrese, 2008).

So aquatic exercise works, but how effective is it compared to land exercise?

Another randomized controlled trial, which also required 60-minute workouts three times a week, found results consistent with Munguía-Izquierdo and Legaz-Arrese (2008). Assis and colleagues (2006) randomly assigned 26 participants to a deep-water running group (DWR) and 25 participants to an aerobic land-based exercise group (LBE). The major differences from the former study are that Assis and colleagues (2006) had a slightly different aquatic exercise program; they compared this aquatic program with a group that exercised on land (rather than no exercise at all), and they used slightly different outcome measures to assess the effects of their exercise programs (Assis et al., 2006).

In this study, both treatment groups performed aerobic exercises of different forms. The DWR group simulated running in a pool while maintaining their head above water with a flotation device, while the LBE group walked or jogged on a treadmill. Researchers monitored participant heart rates at 10-minute intervals and also asked them to reach and stay at their target heart rates, which was around their anaerobic threshold (Häuser, 2010). Both groups reported an average 36% reduction on pain intensity. They measured this pain reduction with a visual analog scale, where participants self-rated their pain on a sale from zero (no pain) to ten (the worst imaginable pain). The FIQ was also administered to measure fibromyalgia impact. Both the DWR and LBE groups improved in their FIQ scores, but these scores improved earlier on in time for the DWR group. Overall, it seems that both DWR and LBE forms of aerobic exercise helped in reducing FM symptoms (Assis et al., 2006).

Final consensus on this exercise tool?

These studies show that low- to moderate-intensity aerobic exercise in a pool or on land, with the frequency of two to three times per week can, among other benefits, reduce pain, physical and emotional limitations, and improve physical fitness of FM patients. Although it may be easier to pop a pain relief pill whenever symptoms arise, we recommend physical activity as a long-term strategy for reducing symptoms of FM.

*Note that this is still a growing area of study. The American Pain society and the Association of the Scientific Medical societies in Germany highly recommend aerobic exercise for combating FM symptoms. The European League Against Rheumatism believes that evidence is lacking (Wolfe et al., 1990).

Michelle Zong is an associate at the Center for Advanced Hindsight. She holds a Bachelor of Science degree in psychology and economics from the University of North Carolina – Chapel Hill. Michelle can be reached at michelle.zong@duke.edu.

Zachary Zenko is a postdoctoral associate at the Center for Advanced Hindsight. He has a PhD in Kinesiology from Iowa State University and a background in exercise science with research focuses in exercise psychology. Broadly, his research is aimed at promoting physical activity and exercise behavior by creating positive associations with exercise, making exercise experiences more pleasant, and using behavioral economics. He is also interested in the psychological predictors and consequences of exercise. Zachary can be reached at zachary.zenko@duke.edu and @zackzenko on Twitter.

References:

Assis, M. R., Silva, L. E., Alves, A. M. B., Pessanha, A. P., Valim, V., Feldman, D., … Natour, J. (2006). A randomized controlled trial of deep water running: Clinical effectiveness of aquatic exercise to treat fibromyalgia. WIley Online Library, 55(1), 57–65.

Branco, J. C., Bannwarth, B., Failde, I., Abello Carbonell, J., Blotman, F., Spaeth, M., … Matucci-Cerinic, M. (2010). Prevalence of fibromyalgia: A survey in five European countries. Seminars in Arthritis and Rheumatism, 39, 448-453. https://doi.org/10.1016/j.semarthrit.2008.12.003

Häuser, W., Klose, P., Langhorst, J., Moradi, B., Steinbach, M., Schiltenwolf, M., & Busch, A., (2010). Efficacy of different types of aerobic exercise in fibromyalgia syndrome: A systematic review and meta-analysis of randomised controlled trials. Arthritis Research & Therapy, 12, R79. DOI: https://doi-org.proxy.lib.duke.edu/10.1186/ar3002

Ian Langtree. (2011). Fibromyalgia pain and the weather. Disabled World Towards Tomorrow. Retrieved from https://www.disabled-world.com/health/fibromyalgia/weather-pain.php

Munguía-Izquierdo, D., & Legaz-Arrese, A. (2008). Assessment of the effects of aquatic therapy on global symptomatology in patients with fibromyalgia syndrome: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89(12), 2250–2257.

Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., … et al. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis & Rheumatology, 33(2), 160–172. DOI: https://doi.org/10.1002/art.1780330203