Exercise Protocols for Fitness Professionals

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Beneficial Exercise for Fibromyalgia
Exercise Protocols for Fitness Professionals - Janice H Hoffman, CES

Introduction to Exercise for Fibromyalgia
Advances in research within the last ten years have provided many new clues regarding ways to help those with Fibromyalgia (FM). Where once patients with this condition were advised to limit their physical activity, we now understand that movement is essential for this population, to minimize loss of function and enhance quality of life. Consequently, physicians who once told their patients to rest now advise them to get some exercise.

This article provides guidelines based on clinical research, which physicians can use when advising patients to increase physical activity. It will also provide sample exercise programs that will minimize post-exertion pain while still providing an increase in overall fitness and well-being.

The benefits of consistent exercise for every one of us include maintaining muscle and bone mass, maintaining normal range-of-motion, and gaining overall endurance. The ultimate goal for FM patients is to create a conditioned body capable of moving through the activities of daily living without increased pain levels.

However, too often patients experience painful flares after attempting a standard fitness regime, and so they become reluctant to follow the advice of their primary care providers. This is understandable. Typical fitness workouts that might cause a small amount of post-workout soreness in a healthy beginner can produce delayed onset muscle soreness (DOMS) in FM patients. It is thought this quick advance into muscle microtrauma derives from the loss of quality sleep and/or low levels of IGF-1, a growth hormone, often present in those with FM¹.

Motivating Change in Activity Level
Two personality types stand out and are worth mentioning when discussing exercise willingness in FM. We could label them All-outs and Avoiders.

All-outs are patients who enjoyed an athletic lifestyle before their FM symptoms took hold. They try to make up for lost time whenever their pain symptoms start to improve. This leads to an ongoing cycle of exertion, flare, recovery, exertion, and flare that will frustrate their best efforts. These patients must learn to do less than they believe they can during any given exercise session. Success will occur when the focus is on long-term instead of short-term gains.

On the other hand, Avoiders are patients who have experienced severe flares from exercise, or who were inactive before disease onset. If they were inactive, they may never have felt the effect of endorphins, and have no expectation of any sense of well-being occurring after exercising. Moving more than necessary seems counterintuitive to them. This exercise avoidance leads to deconditioning via a cycle of exertion-based flare, fear of exertion, less movement, a decrease in fitness, followed by exertional flares that happen at ever-reduced exertion levels.

If both of these cycles of lessened well-being and physical ability are explained, patients can begin to adjust their expectations and focus on exercising smarter. They can be convinced that physical activity is a prescription worth filling. In addition, the sense of success that happens when exercise begins in very gradual, achievable workout sessions will bolster self-efficacy and can lead to continued motivation and exercise adherence^2,3.

Patients Need Knowledge for Adherence and Success
Overall, to encourage consistent and well-paced fitness training, FM Patients need to know that:

Exercise does not automatically increase pain or fatigue. When FM-specific modifications are in place, gradual improvement is quite possible.
Workouts modified for FM can release tight muscles and produce increased mobility, better posture, and less pain near joints.
Exercise can gradually reduce overall fatigue and improve sleep in FM, although it does not necessarily improve pain levels. However, over time, exercise may help control pain in some individuals⁴.
Exercising painful muscles does not mean there is damage taking place in those muscles. Fortunately, research as shown that strengthening muscles, including the muscles that hurt in FM patients, causes no structural damage^5,6.
If a symptom flare is present, patients should wait to exercise vigorously until after the symptoms subside, performing only ROM and flexibility work as tolerated. Once symptoms recede, they can begin a gradual entry (or reentry) into exercise⁷.

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EXAMPLE BEGINNER CLASS - Breath, POSTURE, Flexibility & Relaxation

Frequency:    3-x per week
Intensity:       Mild
Time:            45-minute class sessions

Why these forms of exercise help FM
Many muscles surrounding FM tenderpoints become tight and shortened due to lack of movement. When muscles stay short, the body may shift into abnormal 'pain postures'. Over time, these accommodation postures can produce pain that is not generated by FM at all; instead, the pain stems from general positional imbalances.

Typical FM pain postures include shoulders held high and rounded forward, constricting the chest and leading to restricted breathing patterns⁸. Likewise, a forward head posture puts great pressure on posterior neck muscles and radiates down to the upper back, increasing trapezius tenderpoint pain. Other postural imbalances can cause pain in knees, hips and back. Examples include unconsciously resting on one foot, and locking out the knees when standing.

Class Flow

EXAMPLE

Modifications Specific to FM

Full Body Warm Up: 5 minutes

Purpose: A gradual progression of gentle rhythmic movement, designed to stimulate the neuromuscular system and metabolic pathways, and elevate core body temperature.

Begin Standing:

--March in place--Add close-to-body alternating arm swings--Change to small step touches side to side--Add alternating backward shoulder rolls--Change to two small steps right, two left--Add low dual arm side lifts--March in place--Add close-to-body alternating arm swings--Change to alternating heels front--Add dual biceps curls--Change to alternating front knee lifts--Add alternating forward arm lifts--Change to march in place--Add close-to-body alternating arm swings--Change to alternating curl backs--Add low, dual arm bent elbow press-backs

If the room temperature is set at about 70 degrees, warmer than a typical fitness studio, this will be ideal for this workout.

Avoid overhead arm work and movements that keep the limbs away from the body's centerline for extended periods.

Allow participants to modify the movements to accommodate their areas of pain on any given day.

Alignment Work: 5-minutes

Purpose: Retrain the body to become aware of the feeling of good body alignment.

Begin Standing:

--To center weight evenly between the heels and balls of the feet, rock forward and back from toes to heels. End with weight evenly distributed across the bottoms of the feet.--To align legs, bend and straighten the knees. End by gently softening knees. --To align the pelvis, move the tailbone to the front and then the back. End with a release from a forward-tucked tailbone. --To align the torso, lower and lift the ribcage away from the floor. End with a lift toward the ceiling and then let the ribcage relax. --To align the shoulders, move them forward and backward, End with shoulders back and down.--To align head over shoulders, pull the chin back so the entire head moves toward the back wall. End by releasing and relaxing.

For those experiencing hip and leg pain, the alignment work can be modified by sitting tall in a chair, beginning at torso alignment instruction.

Participants may express surprise that good alignment feels so uncomfortable at the beginning. The analogy of learning to ride a bike might help: Although awkward at first, learning to coordinate each motion is necessary for success and will eventually feel natural.

Have participants maintain their corrected alignment throughout the breathing section that follows.

Breath Work: 5 minutes

Purpose: Retraining breathing patterns will be a key success factor when beginning endurance activities that require increased oxygen.

Seated on a chair or standing:

Touch the abdomen below the navel --Breathe in and have the abdominal wall relax and rise --Breathe out and feel the abdominal wall move back, toward the spinal column.

Place hands on each side of the ribcage--Breathe in and have the chest wall move toward the right and left walls--Breathe out and let the chest move back to the center.

Place hands over the collarbones--Breathe in and have the collarbones and shoulder blades lift upward-- Breathe out and return to the starting point.

Advise class members to practice proper breathing techniques outside of class, several times per day, until it feels natural.

A take-home handout with the directions at left will be helpful for participants with "Fibro-Fog" cognitive issues.

Flexibility Work: 20 minutes

Purpose: Adding ROM and improved flexibility to tight muscles works in conjunction with alignment awareness to decrease abnormal postures.

Seated on a chair or working on a comfortable mat, stretch the following muscles while maintaining good postural alignment:

the splenius and mastoids
the anterior deltoids
the trapezius
the pectorals
the IT band and piriformis
the iliopsoas and quadriceps
the hamstrings
the gastrocnemius and soleus
the plantar fascia

NOTE: For major pain and stiffness, an appointment with a physical or occupational therapist may be needed to help stretch specific muscle groups. For example, the "Spray and Stretch" technique may be needed to unlock certain areas. This specific work is beyond the scope of what can be provided in a group setting.

Do not hold flexibility poses longer than 10-seconds. Instead, alternate limbs when possible, and perform several shorter poses.

Eliminate overhead flexibility movements, whenever possible by positioning supine on mats for overhead stretches.

A percentage of persons with FM are hypermobile. If this is the case, they should model the leader for safe positioning instead of moving until a stretch is felt.

Mind Relaxation: 10 minutes

Purpose: There is increased sympathetic nervous system activity due to heightened pain levels in FM. Relaxation techniques are valuable for reducing the resulting stress response.

Seated on a chair or supine on a comfortable mat:

Without tightening muscles, call attention to the following body areas:

Toes--Tops and soles of feet--Heels--Ankles--Lower legs--Knees--Thighs--Backside--Hips--Lumbar spine--Thoracic spine--Cervical spine--Shoulders--Upper Arms--Elbows--Forearms-- Wrists--Tops and palms of hands--Fingers--Place hands over belly--Belly--Chest--Collarbones--Neck--Jaw--Lips--Cheekbones--Eyes--Forehead

Briefly remind participants to soften the belly and allow abdominals to rise gently with each inhale.

Ask participants to relax each body area that is mentioned, using exhalations as the relaxation trigger.

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example intermediate workout - Balance and strength Class

Frequency: Maximum 3-x per week.
Intensity: Low resistance; Rep/Pause/Rep format
Time: 45-minute class sessions

Why these forms of exercise help FM
Training the body for functional strength is an essential component in avoiding the deconditioning all too common in FM patients⁹. Resistance exercises will strengthen the muscles around sore joints and provide a bracing action that takes the load off bones and cartilage, thereby decreasing FM pain. Moreover, as stated previously, stronger muscles are less prone to DOMS muscle microtrauma.

Balance is another area of concern in FM. A lower body resistance program, utilizing standing balance techniques, can provide functional strengthening for lower body muscles; having strength in hips, knees and ankles will help reduce falls. Recent research has demonstrated that, compared to healthy controls, people with FM also have objective balance disorders not related to deconditioning. The hypothesis is that FM affects balance due to decreased somatosensory input^10,11. Because this is so, training the correctable strength deficiencies that affect balance can be vital.

The body has muscle pairings that work in concert with each other. When one muscle group grows stronger, the opposing muscle group needs to become relationally stronger as well, to prevent injury. Because of this, all major muscle groups will be worked in the following class scenario, not just those thought to be weakened by inactivity.

Class Flow

EXAMPLE

Modifications Specific to FM

Full Body Warm Up: 5 minutes

Purpose: A gradual progression of gentle rhythmic movement, designed to stimulate the neuromuscular system and metabolic pathways, and elevate core body temperature.

Begin Standing:

Avoid overhead moves and movements that keep the limbs away from the body's centerline for extended periods. Keep arms at shoulder height, no higher.

Allow participants to modify the movements to accommodate their areas of pain on any given day.

Upper Body Work: 15 minutes

Purpose: Building muscular endurance in the upper body with low resistance, high repetition training.

Training tools:

Light free-weight, latex-free dynabands, or exercise tubing

Seated on a chair or standing, strengthen the following muscles:

the deltoids
the rotator-cuff
the rhomboids
the latissimus dorsi
the pectorals
the erector spinae
the abdominals
the triceps
the biceps

Rep/pause/rep format: Alternate sides or pause between repetitions to create small rest periods whenever possible.

Minimize eccentric work.

Eliminate overhead training and any move that involves extended-time holds.

For a participant returning after a flare, use no resistance, and instead focus on ROM.

Progressions need to be much more gradual than advised for the general population.

Lower Body Work: 15 minutes

Purpose: By standing on stability trainers, the lower body is trained for both strength and balance.

Training tools:

Unstable surface foot pads such as Theraband stability trainers.

Standing on stability trainers:

Sway side to side--Shift to one side and lift alternate foot off the pad for a possible 10 seconds--Repeat on other side --Return to first leg--Perform one-legged bicycling motions--Repeat other side-- Return to first leg--Perform a side leg lift that includes a full body lean--Repeat other side-- Return to first leg--Perform a leg extension that includes a full body lean forward--Repeat other side--

Perform the progression again from the beginning, adding knee bends (short-lever squats) on the standing leg.

End with alternating toe lifts, to strengthen tibialis anterior muscle.

Participants who are fearful of falling can be placed near a wall to reduce anxiety and for safety.

Switch to the alternate leg before the standing leg becomes fatigued.

Progressions include changing to less stable footpads, adding dual arm motions, adding single arm motions, tilting the head back (visual balance challenge), and closing eyes (vestibular balance challenge)

Post Strength Stretching: 10 minutes

Purpose: To reduce tightness in the muscles previously worked in this session.

Seated, stretch the following muscles just worked:

Anterior and Posterior deltoids--Rhomboids and Latissimus dorsi--Pectorals--Lumbar erector spinae--Hip Abductors and Adductors--Quadriceps, Iliopsoas, Hamstrings--Gastrocnemius, Soleus and Tibialis Anterior

Do not hold a flexibility pose longer than 10-seconds.

Eliminate overhead flexibility movements.

If a participant is hypermobile, they should model the leader for safe positioning instead of moving until a stretch is felt.

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EXAMPLE advanced workout - cardio endurance Class

Frequency: Maximum 3-x per week
Intensity: Mild to moderate
Time: 45-minute class sessions

Why this form of exercise helps FM
Endurance training builds a strong heart, which then increases blood flow to muscles, helping muscles manage longer workloads.

Those with FM need to avoid impact-loading work such as jogging, basketball, or high impact aerobic dance. There are many forms of suitable lower-impact endurance workouts outside of a class setting. Walking, cycling, and non-impact gym trainers are good examples.

Water-based workouts are frequently mentioned as a good starting point, although this form of exercise does not typically provide enough contact impact to help increase bone density. Because of this, changing to land-based endurance work should be seen an eventual part of the progression process.

Robert Bennett, MD, FRCP, and Sharon Clark, PhD are leading FM researchers who state that an acceptable starting point for deconditioned patients is two or three daily exercise sessions of 3 to 5 minutes duration. The duration is gradually increased to two daily 10-minute sessions, then one daily 15-minute session. At this point, the goal of one 20 to 30-minute session 3 or 4 times per week can be realized¹². The class described below would then be useful.

Bennett and Clark's research has also shown that endurance workouts lasting longer than 30 minutes will increase delayed onset muscle soreness in FM^13,14. They further advise taking a day off between endurance workouts gives muscles adequate time to repair.

Class Flow

EXAMPLE

Modifications Specific to FM

Full Body Warm Up: 5 minutes

Purpose: A gradual progression of gentle rhythmic movement, designed to stimulate the neuromuscular system and metabolic pathways, and elevate core body temperature.

Music BPM: 130-135

Begin Standing:

Avoid overhead moves and movements that keep the limbs away from the body's centerline for extended periods. Keep arms at shoulder height, no higher.

Allow participants to modify the movements to accommodate their areas of pain on any given day.

Pre-Cardio Work: 5 minutes

Purpose: A gradual assent to the upcoming steady state endurance work.

Music BPM: 140-145

Sample aerobic dance routine performed at tempo:

Two steps right and left x2--step-touch right and left x4--Step touch right and left x4--March right lead x16--Alternating tap toe front, right and left x4--alternating tap toe side, right and left x4

Avoid quick direction turns.

Continue avoiding overhead moves and movements that keep the limbs away from the body's centerline for extended periods.

Cardio Work: 20 minutes

Purpose: A steady-state aerobic workout designed to increase cardio endurance.

Music BPM: 140-145

Sample aerobic dance choreography performed at tempo (Each number is a 32-count block):

Moving diagonally toward the front right corner two steps right, and move diagonally toward the front left corner two steps left-- Move diagonally toward the back, two steps right and two steps left-- Repeat from the top x1

Alternating step curl-backs x4--Alternating step knee-lifts x4--Repeat

Step-touch forward x4--March backward x16--Repeat

Step knee lift to the right corner x4--Step-touch left right x4--Step knee-lift to the left corner x4-- Step-touch right left x4

Repeat all from the top, reducing all 32 count blocks by half.

Avoid any impact loading exertion.

Break up overly repetitious patterns.

Due to commonly prescribed FM medications, in a group setting use the RPE scale as a guideline for appropriate aerobic intensity.

Continue avoiding fast direction turns.

Continue avoiding overhead arm moves.

Post-Cardio Work: 5 minutes

Purpose: A gradual drop from the above steady state endurance work.

Music BPM: 125-130

Sample routine performed at tempo:

Alternating heels front x8--Alternating double heels front x4-- Alternating heels front x4--Alternating double heels front x2--Step-together-step front x2--March backward right lead x16

Repeat.

Continue avoiding overhead moves and movements.

Cool-Down Stretches: 10 minutes

Gentle static stretches for the muscles used during the training session.

Standing, stretch the following muscle groups:

the gastrocnemius and soleus
the tibialis anterior
the iliopsoas and quadriceps
the hamstrings
the IT band and piriformis
the pectorals
the latissimus dorsi
the trapezius
the deltoids

Do not hold flexibility poses longer than 10-seconds. Alternate limbs and repeat poses twice instead.

Offer alternative poses to accommodate for obesity, tenderpoint pain and inflexibility.

Remind hypermobile participants to model the leader's poses rather than moving until they feel the stretch.

Final Thoughts
Exercise programs for those with FM are designed to promote health, not necessarily athleticism. A physician-guided fitness professional will know not to push these patients beyond this goal, and will be able to accept the training fluctuations of a disease that involves flares and remissions. The key is remembering that Fibromyalgia participants do not need to train hard, but they do need to train consistently in specific formats to achieve optimal results.

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References:

(1) Jones KD, Burckhardt CS, et al. Growth hormone response to acute exercise normalizes with long-term pyridostigmine but does not change IGF-1. Journal of Rheumatology. In Press 2007.

(2) Jones KD, Burckhardt CS, Clark SR, Bennett RM, Potempa KM. A randomized controlled trial of muscle strengthening versus flexibility training in fibromyalgia. Journal of Rheumatology. May 2002.

(3) Jones KD, Burckhardt CS, Bennett R. Motivational interviewing may encourage exercise in persons with fibromyalgia by enhancing self-efficacy. Arthritis & Rheumatism. Oct 2004

(4) Staud R. Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome. Arthritis Research & Therapy. Aug 2006.

(5) Jones KD, Clark SR, Bennett RM. Prescribing exercise for people with fibromyalgia. AACN Clinical Issues; May 2002.

(6) Clark SR, Jones KD, Burckhardt CS, Bennett R. Exercise for patients with fibromyalgia: risks versus benefits. Current Rheumatology Reports. Apr 2001.

(7) Bennett RM. Rational management of fibromyalgia. Rheumatic Disease Clinics of North America. May 2002.

(8) Farhi D. The Breathing Book: Good Health and Vitality Through Essential Breath Work. First Edition. Henry Holt & Co. New York 2007.

(9) Clark SR, Burckhardt CS, Campbell S, O'Reilly C, Bennett R. Fitness characteristics and Perceived Exertion in Women with Fibromyalgia. Musculoskeletal Pain: Myofascial Pain Syndrome and Fibromyalgia. Jul 1994.

(10) Jones KD, Horak FB, Winters K, Bennett RM. Fibromyalgia Impairs Balance Compared to Age and Gender Matched Controls. Arthritis & Rheumatism. 2005.

(11) Pierrynowski MR, Tiidus PM, Galea V. Women with fibromyalgia walk with an altered muscle synergy. Gait & Posture. Nov 2005.

(12) http://www.myalgia.com/Treatment/treatment_introduction.htm. Treatment Overview. Last visited 5/14/2007.

(13) Bennett RM. The contribution of muscle to the generation of fibromyalgia symptomatology. Journal of Musculoskeletal Pain. 1996.

(14) Clark SR, Jones KD, Burckhardt CS, Bennett R. Exercise for patients with fibromyalgia: risks versus benefits. Current Rheumatology Reports. Apr 2001.

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