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Exercise
Protocols for Fitness Professionals - by Janice H
Hoffman, Clinical Exercise Specialist
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
micro trauma 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 damage5,6.
-
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.
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.
SEE A CLASS OUTLINE
HERE
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 micro trauma.
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 input10,11. 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.
SEE A CLASS OUTLINE
HERE
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 FM13,14. They further advise taking
a day off between endurance workouts gives muscles adequate time
to repair.
SEE A CLASS OUTLINE
HERE
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.
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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