Exploring Fibromyalgia: The Puzzling Pain-Fatigue Syndrome
Those who have it suffer terribly. Exercise can ease the pain, but the program must match the client’s tolerance.
They’re usually in pain, typically tired and often depressed. There’s no cure for their condition, but science has proven that exercise can be a huge help.
They suffer from fibromyalgia, also called fibromyalgia syndrome (FMS), a multisystem disorder that affects up to 4% of the population aged 20–60; 80% of those diagnosed with the syndrome are women (Smith & Barkin 2010). Fibromyalgia is characterized by persistent, wide-ranging pain along with fatigue, disrupted sleep and depression, say Smith & Barkin. Other symptoms include headaches, temporomandibular (jaw joint) disorder, and sensitivity in various “tender points” (trigger points on the body that are especially sensitive to slight touch) (Lawrence et al. 2008; Smith & Barkin 2010) (see Figure 1 for all symptoms of FMS).
Scientists have observed FMS in families, suggesting links to multiple genes. While there is no cure for FMS, a patient-specific, multidisciplinary approach involving exercise, education, cognitive behavioral therapy (changing how a person thinks about fibromyalgia) and drug therapies has been shown to improve symptoms and function (Smith & Barkin 2010).
It’s important for exercise professionals to understand how deeply life-altering FMS can be. People can lose their jobs, their spouses and the ability to enjoy life. While exercise can ease the strain, it has to match the realities of how much activity someone with FMS can handle. A deeper understanding of fibromyalgia will help exercise professionals design appropriate exercise and lifestyle programs for FMS clients.
Historical Roots of Fibromyalgia
Inanici & Yunus (2004) note that in the 16th century, European medical literature mentioned people suffering from musculoskeletal aches and pains that may have been what we now call fibromyalgia. For several centuries, fibromyalgia-like muscular pain was identified as rheumatism (medical problems in the joints and connective tissue) and muscular rheumatism. Inanici & Yunus affirm that in 1904, British neurologist Sir William Gowers introduced the term fibrositis, which described several of the characteristic conditions now associated with FMS.
In 1976, the name fibrositis was changed to fibromyalgia (from the Latin fibro [fibrous tissue] and the Greek myo [muscle] and algia [pain]), and fibrositis became the definition for an inflammation of fibroconnective tissue. Hugh A. Smythe, MD, was the first to describe FMS as the generalized pain syndrome it is known as today and the first to identify specific tender points affected by FMS (Inanici & Yunus 2004). In 1990, the American College of Rheumatology established medical criteria for assessing FMS; these were revised in 2010 (see the forthcoming section on “How Fibromyalgia Is Assessed”).
Pathophysiology of Fibromyalgia and Its Toll on Sufferers
The underlying medical cause of FMS is still being figured out. At one time it was thought that FMS was psychosomatic, a physical illness caused by mental factors like stress. It is now believed to be a pathological disorder that affects how the nervous system processes pain (Smith & Barkin 2010). Evidence suggests it may be a consequence of genetic variations to specific neurotransmitters in the nervous system (Smith & Barkin 2010). The result is a heightened state of physical sensitivity to pain (called hyperalgesia) and the experience of pain from stimuli that are not normally painful, such as light touch.
Fibromyalgia is not a disease of the joints, so it cannot be related to arthritis, and it does not inflame or damage joints, muscles or other tissues. Fibromyalgia is considered a syndrome rather than a disease because it is a cluster of signs, symptoms and medical problems that tend to occur together with no identifiable cause (see Figure 1). A disease has a specific cause or causes and identifiable signs and symptoms.
The full array of fibromyalgia symptoms can take a severe toll on sufferers in several ways. Many feel unable to carry out their daily routines. For example, among FMS patients who were surveyed,
- 35% reported having difficulty performing normal activities of daily living;
- 55% had difficulty walking two blocks;
- 62% had trouble climbing stairs; and
- two-thirds or more had difficulty with the minor tasks of shopping (66%), light household chores (68%) and carrying 10 pounds (70%) (Bennett et al. 2007).
Aspects of life like careers and personal relationships have succumbed to the debilitating effects of fibromyalgia. A survey conducted by Bernard, Prince & Edsall (2000) revealed that 94% of divorced or separated FMS patients attributed their status to the syndrome. Furthermore, 30% of those surveyed reported quitting their jobs after diagnosis, owing to FMS symptoms. Finally, the condition can be quite costly: 74% of FMS patients surveyed said they spent between $100 and $500 a month on over-the-counter products to treat symptoms. Common purchases included acetaminophen, ibuprofen, naproxen (for pain), cyclobenzaprine (for muscle relaxation), amitriptyline (for depression) and aspirin (Bennett et al. 2007).
How Fibromyalgia Is Assessed
In 1990, the College of Rheumatology established classification criteria for FMS that included a history of chronic, widespread pain, along with moderate pain or tenderness in at least 11 of 18 tender points. “Widespread pain” is defined as pain in the axial skeleton of the body (cervical spine, anterior chest, thoracic spine and low back), pain in the left side of the body, pain in the right side of the body, pain above the waist and pain below the waist (Wolfe & Hauser 2011).
In 2010, the American College of Rheumatology revised the criteria. Instead of assessing tender points, the new criteria rely on a detailed interview and examination to evaluate total body pain using a widespread–pain index scale (0–19) that takes into account 19 locations on the body. Locations include areas of the jaws, abdomen, chest, arms, legs, hips, shoulders, neck and back (Wolfe & Hauser 2011). The 2010 criteria also include a Symptom Severity Score, which measures fatigue, cognitive symptoms and the experience of waking unrefreshed. Scoring is based on the following scale:
- 0 = no problem
- 1 = slight or mild problems; generally mild or intermittent
- 2 = moderate or considerable problems; present at a moderate level
- 3 = severe problems; continuous and life disturbing (Wolfe & Hauser 2011).
Treatments for Fibromyalgia
Smith & Barkin (2010) conclude that a patient-specific, multidisciplinary approach is the best way to help FMS patients keep their symptoms under control and significantly increase their quality of life. Sim (2012) adds that since the causes of fibromyalgia are complex, a multifactorial treatment plan is recommended and has proved to be the most helpful method (see Figure 2). Rossy et al. (1999) propose, on the basis of their meta-analysis of 49 studies, that drug-free treatments are more effective than drug treatments for the symptoms of fibromyalgia, and assert that exercise is central to the treatment of fibromyalgia.
Occupational therapists usually aim to improve functional tasks and manage pain and fatigue (Sim 2012). Physical therapists, meanwhile, focus on increasing exercise tolerance and fitness levels, reducing pain and improving functional ability, says Sim. Both kinds of therapists prefer FMS interventions that include endurance exercise, fatigue management, functional movement reeducation, strengthening exercise, postural education, relaxation and aqua therapy (Sim 2012).
Why Aerobic Exercise Helps in Treating Fibromyalgia
FMS-related pain can be debilitating, so we can be grateful for the strong evidence that exercise can reduce pain. Chronic stress seen in FMS patients can reduce vasodilatation, capillary permeability and capillary density, thereby restricting blood flow to the skin and muscles at rest; this cluster of problems is referred to as cardiovascular dysregulation (Vierck 2012).
Body areas affected by this compromised blood flow may become hypersensitive to pain, and tissues affected may be easily impaired or harmed. Temperature regulation may also be weakened, creating even more discomfort. Additionally, lack of circulation can lead to a buildup of acidic metabolites, which contributes to discomfort and/or pain. Cardiovascular dysregulation is more prominent in women than men, which is likely the reason more women suffer from FMS (Vierck 2012). Regular aerobic exercise has been shown to minimize (or attenuate) cardiovascular dysregulation.
Long-term exercise studies show that exercise can reduce chronic stress and improve microcirculation (Vierck 2012). Chronic stress often leads to elevated blood pressure, or hypertension, whereas consistent aerobic exercise has been shown to lower elevated resting blood pressure. Regular exercise promotes angiogenesis (new blood vessel formation) and helps to lessen symptoms of claudication (cramping pain in the legs, typically caused by obstruction of blood flow) and ischemic muscle pain (from shortage of oxygen).
Furthermore, muscle contraction during exercise elicits an increase in endothelial growth factor (the endothelium is the thin layer of cells lining the interior surface of blood vessels). This increase in EGF—an essential contributor to capillary growth—results in better blood supply to skeletal muscle. And improved blood supply to muscle from exercise enhances the removal of metabolic byproducts and thus minimizes the associated discomfort of acidosis.
Why Exercise Is So Hard for FMS Sufferers
Even though the benefits of consistent long-term exercise are all-embracing for FMS clients, many people with the syndrome cannot keep up an exercise regime. It is important to remember that FMS is a multisymptom disorder that includes widespread pain, sleep disruption, chronic fatigue, depression and stress.
With these conditions affecting people with FMS so profoundly, exercise professionals need to recognize that engaging in exercise is very difficult for these clients. Acutely, the buildup of metabolic byproducts from exercise may cause an increase in pain and discomfort during and after exercise. Thus it is vital for exercise professionals to design mild workouts with gradual progressions and to avoid intense, fatiguing exercises that enhance the buildup of metabolic byproducts.
Exercise Recommendations From the Research
The benefits of aquatic exercise make it an attractive option for FMS patients. Buoyancy, controlled temperature and water viscosity can lead to a more comfortable exercise experience than land-based activity for people in chronic pain (Assis et al. 2006). With sedentary women, an 8-week deep-water running regimen of 45 minutes per day (at moderate intensity, as determined by blood lactate measurement) on 3 nonconsecutive days of the week improved physical function, general health and quality-of-life indicators; subjects also experienced reduced discomfort from FMS symptoms (Cuesta-Vargas & Adams 2011). Similarly, twice-weekly 30-minute sessions of instructor-led aerobics in warm water (30–31 degrees Celsius), along with sauna therapy, was shown to lessen pain by 31%–77% after 12 weeks, and by 28%–68% after 6 months of continual exercise (Matsumoto et al. 2011).
Cycling is another aerobic activity that has been successfully tested to reduce pain and symptoms in FMS patients. Riding at an intensity of 70%–75% of age-predicted maximum (220– age) heart rate, FMS patients meaningfully reduced their pain (Hooten et al. 2012). Interestingly, exercising at lower, self-selected intensities (about 45% of age-predicted heart rate maximum) may even be more effective than following prescriptive exercise intensities (Newcomb et al. 2011).
Potential of Resistance Training
Properly performed resistance training regimens are safe and have been shown to improve FMS patients’ pain tolerance (Hurley, Hanson & Sheaff 2011). Hurley and colleagues found that resistance training slowed losses in muscle mass, quality, power and strength—which are typically accelerated in FMS patients. A literature review by Busch et al. (2011) suggests that resistance training 2–3 days per week at intensities corresponding to 8–12 repetitions to fatigue can reduce pain by up to 49 points on a 0–100 scale and effectively reduce the number of active FMS tender points. Progression is clearly critical for the success of resistance training interventions with FMS clients.
Other Helpful Exercises
Jones et al. (2012) demonstrated that 12 weeks of tai chi (90-minute sessions, twice-weekly) notably reduced pain. Lifestyle physical activity like walking has also proved helpful for optimal physical functioning for FMS clients with pain (Busch et al. 2011). According to Busch and colleagues, mind-body approaches such as yoga, Pilates, breathing exercises, whole-body vibration training and Nordic walking (with poles) may also provide clinically relevant results for FMS clients.
It appears that a combination of cardiovascular exercise, resistance training and other exercise modes helps to manage FMS symptoms. Sixteen weeks of self-determined, moderate-intensity walking combined with twice-weekly strength training—progressing to 2 sets of 10–12 repetitions of multijoint resistance movements (chest press, seated row, leg press, for example)— and some stretching reduced fatigue in women with FMS (Rooks et al. 2007). In an 18-week intervention (with three sessions per week), 15 minutes of walking at an intensity of 55%–65% of heart rate reserve combined with low-intensity resistance circuit training (eight exercises) plus core stability work also reduced fatigue (Etnier et al. 2009).
In some of these interventions, researchers observed noteworthy improvement not only in pain management and fatigue but also in depression status and mood. It is always important for exercise professionals to recognize the mental health benefits that exercise can provide to clients with FMS.
Final FMS Recommendations
Although fatigue and pain may make exercise and movement activities challenging for FMS clients, it is critical for them to be physically active (Busch et al. 2011). Research has repeatedly shown that regular exercise is one of the most effective treatments for fibromyalgia (NIAMS 2011). In general, cardiovascular exercise performed 2–3 times weekly for 30–60 minutes at approximately 50% of age-predicted heart rate maximum or at a self-selected exercise intensity appears to noticeably lessen pain in FMS clients, improve mental health and reduce depression. However, the literature supports the notion that a wide variety of exercise modes—including aquatic, cardiovascular and resistance training, along with mind-body activities—can be useful in decreasing FMS symptoms (Busch et al. 2011). Clients should be introduced to a variety of exercises and then be free to decide which are the most comfortable.
Careful supervision of clients as they undergo an exercise regimen is recommended, as 70% of surveyed patients with the syndrome have reported that strenuous physical activity is a prime aggravator for their symptoms (Bennett et al. 2007). (See Figure 3 for tips on programming exercise for FMS clients.) Furthermore, home-based interventions are associated with poor compliance (Harden et al. 2012), which highlights the importance of personal trainers for this population. Personal trainers can help improve exercise adherence by regularly motivating and inspiring FMS clients to believe they can successfully complete regular exercise (Busch et al. 2011).
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