Exercise and Fibromylagia

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Exercise and Fibromylagia
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Exercise in Fibromyalgia

• Kaisa Mannerkorpi
• Current Opinion in Rheumatology 2005, 17190-194

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Mannerkorpi, K. et al. Physical exercise in
fibromyalgia and related syndromes. Best Pract
Res Clin Rheumatol 2003 17629-647.
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What is Fibromyalgia?

• A complex condition that causes persistent pain
  in muscles, ligaments, tendons, and joints (most
  commonly the neck, back shoulders, pelvic girdle
  and hands).
• It is usually accompanied by a primary or
  secondary chronic medical condition such as
  rheumatoid arthritis, hypothyroidism, and, most
  particularly, chronic fatigue syndrome

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How prevalent is it?

• 1-3 of the population world wide.
• 3-6 in the US.
• 3.4 of all women 0.5 of all men

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What causes it?

• A disorder of central processing with
  neuroendocrine/neurotransmitter dysregulation
  which is amplified due to abnormal sensory
  processing in the CNS
• Some abnormalities found in FM patients
• Increased levels of substance P in the spinal
  cord
• Low levels of blood to the thalamus region
• HPA axis hypofunction
• Low levels of serotonin and tryptophan
• Abnormalities in cytokine function

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What are symptoms of fibromyalgia

• Widespread pain with fatigue (reported by
  approximately 90 of people with FM), and
  disturbed sleep
• Irritable bowel and bladder, headaches, restless
  leg syndrome, impaired memory, skin sensitivity,
  dry eyes and mouth, anxiety, depression,
  dizziness, vision problems, etc.
• Symptoms can be made worse or triggered by
  anxiety, cold or drafty environments, depression,
  hormonal changes before menstrual periods or
  during menopause, physical overexertion, stress,
  and weather changes

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Diagnosis

• No laboratory test available
• My take 5 years for some patients to be diagnosed
  
• Criteria
• Widespread pain in all four quadrants of the body
  for a minimum of 3 months
• Tenderness or pain in at least 11 of the 18
  specified tender points when pressure is applied

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Specified Tender Points
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Treatment

• OTC pain medication
• Antidepressants (increase serotonin)
• Sleep management
• Psychological support
• Exercise

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Exercise and FM

• Muscle deconditioning occurs with FM when
  exercise is neglect in order to avoid pain.
• Deconditioned muscles use excess energy to
  accomplish tasks.
• This may contribute to more fatigue and make the
  muscles more susceptible to microtrauma, thus
  aggravating pain even at low intensity exertion.
• This cyclical process leads to atrophy and
  greater effort performing various activities.

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Exercise and FM

• Exercise can help to counteract this
  deconditioned state by improving oxygen delivery,
  increasing cellular metabolism, reducing muscle
  tightness, and eventually relieving pain to some
  degree.
• The main aims of exercise are to relieve and
  restore the effects of the prolonged
  deconditioning that may occur.

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Exercise and FM

• Exercise for FM should include a comprehensive
  exercise program that incorporates designating
  individual goals, a slow start, pain management,
  and specific exercises for aerobic benefits,
  flexibility, and, where possible, increasing
  strength.
• There is no "One Size Fits All" when it comes to
  designing the appropriate exercise program for
  people with FM.

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Exercise Benefits

• Increase in or prevention of a reduction in
  aerobic capacity
• Increase in or prevention of a reduction in
  muscular strength
• Relieving much, if not all, physical pain
• Reducing physical impairment and recovering
  function

• Improving flexibility
• Improving weight control
• Improving sleep
• Improving energy levels
• Reducing stress and depression
• Improving self-efficacy, some feeling of control
  over one's care, and overall feelings of
  well-being

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Exercise Concerns

• Many people report experiencing exercise-induced
  pain 1 to 3 days following exertion.
• Some days may be worse than others but one bad
  day shouldnt prevent future exercise

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General Exercise Suggestions

• Avoid high intensity, high impact exercises
• The exercise program should start out slowly and
  gradually which will reduce the risk of muscle
  pain or trauma
• Alternate cycles of moderate activity with cycles
  of rest.
• Aerobic exercise and stretching are most helpful
  strength training should be added later.
• Exercise is most helpful when done on a regular
  basis

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General Exercise

• Many FM patients describe themselves as "exercise
  intolerant," that is, they report no noticeable
  improvement in symptoms following exercise
• Some find that exercise greatly reduces their
  pain
• Improvement in or prevention of a reduction in
  aerobic capacity
• Similar results with short or long bouts of
  exercise with the same total time
• Some studies show no improvement in aerobic
  capacity
• Differences due to the various training programs
  and baseline levels of FM in the patients
• Increase pain threshold
• Reduce their symptoms

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Stretching

• Stretching can help remedy the general loss of
  flexibility inherent with FM
• Much of FM pain occurs in the muscles and tendons
  
• In most people tendons shorten with age and may
  become painful or discomforting when they are
  tight or when they are stretched--as they are in
  most exercise routines.

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Aerobic Exercise

• People with FM may need to begin at the low end
  of this heart rate range or even much lower.
• Aerobic activity may lead to self-efficacy and
  increased psychological well-being, as well as
  pain relief, due to the release of hormone-like
  substances--endogenous endorphins.
• Pain may occur 1 to 3 days after exercise so any
  changes should be made gradually
• High-impact exercise has been known to worsen FM
  symptoms.
• At least 10-15 minutes but 20 to 30 minutes of
  aerobic exercise is recommended.
• Gradually increase up to 40 or even 60 minutes of
  exercise, 3 times a week.

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Walking

• Results from walking are improved physical
  function, self-efficacy, tender point status,
  well-being, and quality of life with some lasting
  up to 7-11 months.
• As a minimum, start with 1 or 2 minutes and
  increase until walking for 30-60 minutes, 3-4
  times a week

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Jogging

• Recommended to be able to comfortably walk 3-4
  times a week before starting a jogging program.
• May still need or want to alternate walking with
  jogging

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Cycling

• Stationary bikes in an upright or recumbent
  position (not bent forward) may work best

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Pool Exercise

• Recommended due to low impact and warm water
  (88-90 F)
• Benefits include reduced stiffness and pain and
  improvements in aerobic fitness.
• Studies using control groups show pool exercise
  improved FM symptoms including less depression,
  pain, fatigue, and stiffness.

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Strength Training

• Not for all FM patients
• Muscular endurance program of low resistance and
  moderate reps
• Elastic bands may be a good option
• FM patients can increase or prevent a reduction
  in muscular strength through resistance exercise.

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Qigong Movement Therapy

• Aimed at improving the quality of movement,
  concentration, and peacefulness.
• One study found it was effective but not more so
  than an educational program while another study
  found it to be more effective in movement
  harmony but not reducing symptoms.

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Exercise Combined with Education

• Education helps with the ability to manage the
  disease and the difficulties encountered in daily
  life.
• Combining both are effective but no study has
  been conducted to determine if one is more
  effective than the other.
• FM patients who are informed about the risks and
  benefits of exercise are more likely to adhere to
  an exercise program.

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Exercise and Symptoms

• Inconsistent results from research studies.
• Some studies found improvements in tender point
  status while others did not.
• Most patients chose to exercise at lower
  intensity levels.

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Long-term Adherence

• Ability to deal with the increase in
  post-exercise pain (temporary)