Exercise for treating fibromyalgia syndrome

78 Pages·2013·0.73 MB·English

Exercise for treating fibromyalgia syndrome (Review)
Busch AJ, Barber KA, Overend TJ, Peloso PMJ, SchachterCL
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2007,Issue4
http://www.thecochranelibrary.com
Exercisefortreatingfibromyalgiasyndrome(Review)
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Analysis1.1.Comparison1*AerobicOnly-ModeratetoHighQualitybyACSM(restrictedtountreatedcontrolgroups),
Outcome1Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Analysis1.2.Comparison1*AerobicOnly-ModeratetoHighQualitybyACSM(restrictedtountreatedcontrolgroups),
Outcome2Global. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Analysis1.3.Comparison1*AerobicOnly-ModeratetoHighQualitybyACSM(restrictedtountreatedcontrolgroups),
Outcome3PhysicalFunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Analysis1.4.Comparison1*AerobicOnly-ModeratetoHighQualitybyACSM(restrictedtountreatedcontrolgroups),
Outcome4Tenderpoints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Analysis1.5.Comparison1*AerobicOnly-ModeratetoHighQualitybyACSM(restrictedtountreatedcontrolgroups),
Outcome5Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Analysis2.1.Comparison2*StrengthTrainingversusControl,Outcome1Pain. . . . . . . . . . . . . . 48
Analysis2.2.Comparison2*StrengthTrainingversusControl,Outcome2GlobalWellBeing. . . . . . . . . 48
Analysis2.3.Comparison2*StrengthTrainingversusControl,Outcome3PhysicalFunction. . . . . . . . . 49
Analysis2.4.Comparison2*StrengthTrainingversusControl,Outcome4TenderPoints. . . . . . . . . . 49
Analysis2.5.Comparison2*StrengthTrainingversusControl,Outcome5Depression. . . . . . . . . . . 50
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Exercisefortreatingfibromyalgiasyndrome(Review) i
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Exercise for treating fibromyalgia syndrome
AngelaJBusch1,KarenA.R.Barber2,TomJOverend3,PaulMichaelJPeloso4,CandiceLSchachter5
1SchoolofPhysicalTherapy,UniversityofSaskatchewan,Saskatoon,Canada.2ContinuingPhysicalTherapyEducation,University
ofSaskatchewan,Saskatoon,Canada.3SchoolofPhysicalTherapy,UniversityofWesternOntario,London,Canada.4BaskingRidge,
NJ,USA.5Windsor,Canada
Contactaddress:AngelaJBusch,SchoolofPhysicalTherapy,UniversityofSaskatchewan,1121CollegeDrive,Saskatoon,Saskatchewan,
S7N0W3,[email protected].
Editorialgroup:CochraneMusculoskeletalGroup.
Publicationstatusanddate:Edited(nochangetoconclusions),publishedinIssue4,2008.
Reviewcontentassessedasup-to-date: 16August2007.
Citation: Busch AJ, Barber KA, Overend TJ, Peloso PMJ, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane
DatabaseofSystematicReviews2007,Issue4.Art.No.:CD003786.DOI:10.1002/14651858.CD003786.pub2.
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Fibromyalgia(FM)isasyndromeexpressedbychronicwidespreadbodypainwhichleadstoreducedphysicalfunctionandfrequent
useofhealthcareservices.Exercisetrainingiscommonlyrecommendedasatreatment.ThisisanupdateofareviewpublishedinIssue
2,2002.
Objectives
Theprimaryobjectiveofthissystematicreviewwastoevaluatetheeffectsofexercisetrainingincludingcardiorespiratory (aerobic),
musclestrengthening,and/orflexibilityexerciseonglobalwell-being,selectedsignsandsymptoms,andphysicalfunctioninindividuals
withFM.
Searchmethods
We searchedMEDLINE, EMBASE, CINAHL, SportDiscus, PubMed, PEDro, and the Cochrane Central Register for Controlled
Trials(CENTRAL,Issue3,2005)uptoandincludingJuly2005.Wealsoreviewedreferencelistsfromreviewsandmeta-analysesof
treatmentstudies.
Selectioncriteria
Randomizedtrialsthatwereselectedfocusedoncardiorespiratoryendurance,musclestrengthand/orflexibilityastreatmentforFM.
Datacollectionandanalysis
Twooffourreviewersindependentlyextracteddataforeachstudy.Alldiscrepancieswererecheckedandconsensuswasachievedby
discussion.Methodologicalqualitywasassessedbytwoinstruments:thevanTulderandtheJadadmethodologicalqualitycriteria.We
usedtheAmericanCollegeofSportMedicine(ACSM)guidelinestoevaluatewhetherinterventionshadprovidedatrainingstimulus
thatwouldeffectchangesinphysicalfitness.Duetosignificantclinicalheterogeneityamongthestudieswewereonlyabletometa-
analyzesixaerobic-onlystudiesandtwostrength-onlystudies.
Exercisefortreatingfibromyalgiasyndrome(Review) 1
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Therewereatotalof2276subjectsacrossthe34includedstudies;1264subjectswereassignedtoexerciseinterventions.The34studies
comprised47interventionsthatincludedexercise.Effectsofseveraldisparateinterventionsonglobalwell-being,selectedFMsigns
andsymptoms,andphysicalfunctioninindividualswithFMweresummarizedusingstandardizedmeandifferences(SMD).There
ismoderatequalityevidencethataerobic-onlyexercisetrainingatrecommendedintensitylevelshaspositiveeffectsglobalwell-being
(SMD0.49,95%CI:0.23to0.75)andphysicalfunction(SMD0.66,95%CI:0.41to0.92)andpossiblyonpain(SMD0.65,95%
CI:-0.09to1.39)andtenderpoints(SMD0.23,95%CI:-0.18to0.65).Strengthandflexibilityremainunder-evaluated.
Authors’conclusions
Thereis’gold’levelevidence(www.cochranemsk.org)thatsupervisedaerobicexercisetraininghasbeneficialeffectsonphysicalcapacity
andFMsymptoms.StrengthtrainingmayalsohavebenefitsonsomeFMsymptoms.Furtherstudiesonmusclestrengtheningand
flexibilityareneeded.Researchonthelong-termbenefitofexerciseforFMisneeded.
PLAIN LANGUAGE SUMMARY
Exerciseforfibromyalgia
ThissummaryofaCochranereviewpresentswhatweknowfromresearchabouttheeffectofexerciseforfibromyalgia.Thereview
showsthatinpeoplewithfibromyalgia:
-moderateintensityaerobictrainingfor12weeksmayimproveoverallwell-beingandphysicalfunction;moderateintensityaerobic
exerciseprobablyleadstolittleornodifferenceinpainortenderpoints.
-strengthtrainingfor12weeksmayresultinlargereductionsinpain,tenderpointsanddepression,andlargeimprovementinoverall
well-beingbutmaynotleadtoanydifferenceinphysicalfunction.
-theexerciseprogramsthatwerestudiedweresafeformost.Theintensityofaerobicexercisetrainingshouldbeincreasedslowlyaiming
foramoderatelevel.Ifexercisersexperienceincreasedsymptoms,theyshouldcutbackuntilsymptomsimprove.Ifindoubtabout
adverseeffects,theyshouldcheckwithahealthcareprofessional.
-itisnotknownwhetherexercisetrainingformorethan12weeksimprovesothersymptomssuchasfatigue,stiffnessorpoorsleep.
Many people with FM do havedifficulty staying on an exercise program. Strategies tohelpindividuals exerciseregularly were not
measuredinthesestudies.
-itisnotknownwhetherflexibilitytraining,programscombiningtypesofexercise,andprogramscombiningexercisewithnon-exercise
strategiesimprovethesymptomsoffibromyalgia.
Whatisfibromyalgiaandwhatarethedifferenttypesofexercise?
Fibromyalgia is a syndrome of persistent widespread pain and tenderness. Individuals may also experience a wide range of other
symptomssuchasdifficultysleeping,fatigue,stiffness,anddepression.Symptomsmayputpeopleoffexercisingbutstudiesshowthat
the majority are able toexercise. Exercise training can include aerobics such as stepping and walking; strengthening exercisessuch
asliftingweightsorusingresistancemachines;andstretchingforflexibility.Althoughexerciseispartoftheoverallmanagementof
fibromyalgia,thisreviewexaminedtheeffectsofexercisewhenusedseparatelyorcombinedwithotherstrategiessuchaseducation
programs,biofeedbackandmedications.
Bestestimateofwhathappenstopeoplewithfibromyalgiawhotakepartinaerobicexercise:
Inthestudies,aerobicexercisesweredoneforatleast20minutesonceaday(ortwiceforatleast10minutes),2to3daysaweek.
Strengthtrainingwasdone2to3timesaweekandwithatleast8to12repetitionsperexercise.Theexerciseprogramslastedbetween
2½to24weeks.
Exercisefortreatingfibromyalgiasyndrome(Review) 2
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Whencomparedtonoexercising,aerobicexercisetrainingmay:
-improveoverallwell-beingby7pointsonascaleof0to100.
-improveabilitytoperformaerobicexercise;byusing2.8ml/kg/minutemoreoxygenwhenwalkingonatreadmill.
-increasetheamountofpressurethatcanbeappliedtoatenderpointby0.23kgs/cm2beforetheonsetofpain.
-reducepainby1.3onascaleof0to10.
-haveunknowneffectsonfatigue,depressionorstiffness.
Theseresultsarebasedonmoderatequalityevidence.
Bestestimateofwhathappenstopeoplewithfibromyalgiawhotakepartinstrengthtraining:
Whencomparedtonoexercise,strengthtrainingmay:
-reducepainby49fewerpointsonscaleof0to100.
-improveoverallwell-beingby41pointsonascaleof0to100.
-leadto2feweractivetenderpointsonascaleof0-18.
Theseresultsarebasedonlowqualityevidence.
Thenumbersgivenareourbestestimate.Whenpossible,wehavealsopresentedarangebecausethereisa95percentchancethatthe
trueeffectofthetreatmentliessomewherewithinthatrange.
BACKGROUND a substantial impact on an individual’s physical and emotional
functionandoverallhealth-relatedqualityoflife.
Descriptionofthecondition
Wolfe 1995 reported the prevalence of FM (all ages) to be 2%
The 1990 American College of Rheumatology (ACR) criteria
(females3.4%,males0.5%).Arecentlarge-scaleCanadianstudy
for classification of fibromyalgia (FM) syndrome define it as
(McNalley2006)describesself-reportedprevalenceofFMas1.1%
widespreadpainforlongerthanthreemonthsduration,withpain
forallages(1.83%infemales,0.33%inmales)withafemaleto
onpalpationofatleast11of18specifiedtenderpointsonthebody
maleratioofsixtoone.Limitationsinactivitiesassociatedwith
(Wolfe1990).WhiletheACRcriteriaaremostfrequentlyused
dailylivinghavebeenreportedtobeashighinFMpatientsasin
inresearchstudies,cliniciansmayalsoemploytheAmericanPain
patientswithrheumatoidarthritis(Hawley1991).Inindividuals
SocietycriteriaforaclinicaldiagnosisofFM(Burckhardt2005),
who seek medical attention, the condition is chronic and non-
thatincludethepresenceofwidespreadpain(allfourquadrants
remitting,withsymptomsaffectingeveryaspectoflife,including
ofthebodyandalongthemidlineaxial)foratleastthreeconsec-
work,familylifeandleisure(Henriksson1994).Researchershave
utivemonthsandpainonpalpationof9of11bilateralsiteson
reportedasubstantialimpactofFMonabilitytoworkandpro-
thebody.A1996consensusreportoffersabroaderpictureofFM,
ductivity.Twentyto50%ofpersonswithFMcouldworkfewor
describing itasa“syndromeofwidespreadpain, decreasedpain
nodays(Ledingham1993,Wolfe1997),36%hadanaverageof
threshold,andcharacteristicsymptomsthatincludenon-restora-
twoormoreabsencesfromworkpermonth(Martinez1995),and
tivesleep,fatigue,stiffness,mooddisturbance,irritablebowelsyn-
26.5%to55%hadreceiveddisabilityorsocialsecuritypayments
drome,headache,paresthesias,andotherlesscommonfeatures”
(Martinez1995,Wolfe1997).
(Wolfe 1996, page 534). The AmericanPain Society Guideline
forManagementofFibromyalgiaSyndromeinAdultsandChil- ManyindividualswithFMhavebeenshowntobesedentary(Clark
dren(Burckhardt2005)also acknowledge thatothersymptoms 1993)andwithlevelsofcardiorespiratoryfitnesswellbelowaver-
includingfatigue,headache,poorsleep,psychologicaldistressand age(Bennett1989,Burckhardt1989,Clark1993,Clark1994).
cognitivedysfunctionoftenarepartofthesyndromeandcanhave While the underlying pain, fatigue and depression are likely to
Exercisefortreatingfibromyalgiasyndrome(Review) 3
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
contribute to sedentary lifestylesand therefore low levelsof fit- performingactivitiesofdailylivingatlowerabsolutepercentages
ness, the studies being evaluated indicate that individuals with ofmaximalcapacity.
FM are able to perform maximal tests cardiorespiratory fitness,
Whyitisimportanttodothisreview?
lowandmoderateintensityaerobicexercise,flexibilityandmuscle
strengtheningexercise. Incorporatingexerciseintoone’sweeklyroutineisnotasmallen-
deavour. It is the responsibility of clinicians and researchers to
Descriptionoftheintervention
identifyforclientswithFMboththeeffectsthattheycanexpectin
Despiteexaminationofawiderangeoftreatments,optimalman- termsofFMsignsandsymptomsandthemostefficaciousmeth-
agementofFMisstillunknown.Currentreviews(Bellamy1998, odsofachievingthoseeffects.Thisreviewisnecessarytodeter-
Berman1999,Burckhardt2002,Hadhazy2000,Holdcraft2003, mine the effectiveness of various types and training volumes of
Mannerkorpi 2003, Sim 2002) and evidence-based guidelines exerciseforimprovementofFMsignsandsymptoms.Thereview
(Goldenberg2004)haveexaminedarangeoftreatmentoptions shouldalsoexaminewhatoutcomesaremostimpactedbyexercise
dividedintopharmacologicandnon-pharmacologic. Non-phar- inthispopulation.Thereviewisalsoneededtoguideclinicians
macologicstrategiesincludeinterventionsclassifiedasmind-body andindividualswithFMthroughthemazeofstudiestowardsthe
cognitive/cognitive-behavioral, exercise, complementary and al- currentlyknownbestprescriptionsfor,andwaystoperformexer-
ternative therapies. Goldenberg 2004 concluded that “despite cisebyindividualswithFM.
thechronicityandcomplexityofFM,therearepharmacological
and non-pharmacological interventions available thathave clin-
icalbenefit.Basedoncurrentevidence,astepwiseprogramem-
OBJECTIVES
phasizingeducation,certainmedications,exercise,cognitivether-
apy,orall4shouldberecommended”(page2388).Goldenberg
Theprimaryobjectiveofthissystematicreviewwastoevaluatethe
2004goesontoadvisethatoptimalmanagementis“bestarrived
effectsof exercise training including cardiorespiratory (aerobic),
at when patients and health care professionals work as a team”
muscle strengthening, and/or flexibility exercise on global well-
(page 2394). However, while exercise is recognized as one part
being,selectedsignsandsymptoms,andphysicalfunctioninin-
ofthemanagementofFM,notalloftheclinicallyrelevantand
dividualswithFM.
practicallyimportantaspectsofanexerciseprescriptionhavebeen
elucidated.
Howtheinterventionmightwork METHODS
WhilepaininindividualswithFMmayberelatedtocentralner-
vous system pain processing abnormalities that include central
sensitizationandinadequatepaininhibition,peripheraltissuesin- Criteriaforconsideringstudiesforthisreview
cluding muscle may contribute to chronicpain throughinitiat-
ingand/ormaintaining centralsensitization (Staud2005,Staud
2006).Exercisemaythuscontributetopainthroughtheprocessof
musclemicrotrauma,repairandadaptationassociatedwithnormal Typesofstudies
acuteexerciseandexercisetraining.Severalstudieshavedescribed Weselectedrandomizedclinicaltrials(RCT)thatcomparedanin-
metabolic findings in muscle tissue that are consistent with de- terventionthatincludedanexercisecomponentwithanuntreated
conditioning(Bennett1989,Elvin2006,Lund1986,Park1998, controloranon-exerciseintervention.Studieswereincludedifthe
Bengtsson1986a,Bengtsson1986b,Jubrias1994).Themetabolic authorsusedwordssuchasrandomly,randomorrandomization,
adaptationsinducedbyaerobicandbystrengthtrainingmaynor- todescribethemethodofassignmentofsubjectstogroups.
malizesomeofthesefindings,thuscontributingtoimprovements
inpain(Costill1979,Deschenes2002,Holloszy1984).
Typesofparticipants
Exercisetraininghasbeenusedsuccessfullytoaddressanumber
of conditions that are also commonly experienced by individu- The studies used a variety of published criteria for the diagno-
alswithFM.Aerobicandstrengthtraininghavebeenshownto sisofFM:Smythe1981,Wolfe1990,Yunus1981,Yunus1982,
improvedepressioninindividualswithclinicaldepression(Brosse Yunus 1984.Althoughsome differencesexistbetweenthediag-
2002,Dunn 2001).Moderate exercisecan improvesleepinin- nosticcriteria,forthepurposeofthisreviewallwereconsidered
dividuals with sleepcomplaints (King 1997, Singh 1997). One tobeacceptableandcomparable.Whileexclusioncriteriavaried
can also reflecton training-induced improvementsin cardiores- amongstudies,allallowedforexclusionofindividualswithmed-
piratoryfitnesstosuggestthatfatiguemayalsoimprovebecause icalconditionsforwhichexercisecouldbeeithercontraindicated
asone’smaximalaerobiccapacityimproves,theindividualwillbe orunsafeunderunmonitoredconditions.
Exercisefortreatingfibromyalgiasyndrome(Review) 4
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Typesofinterventions Searchmethodsforidentificationofstudies
Exercise was defined as the “planned, structured and repetitive IntheoriginalreviewwesearchedMEDLINE(1966-12/2000),
bodilymovementdonetoimproveormaintainoneormorecom- CINAHL(1982-12/2000),HealthSTAR(1990-12/2000),Sport-
ponentsofphysicalfitness”(ACSM2001).Inclassifyingexercise Discus(1975-12/2000),EMBASE(1974to12/2000),andthe
interventions, we recognized two types of interventions. Com- CochraneControlledTrialsRegister(CCTR,Issue4,2000).
posite interventions included both an exercise and non-exercise Electronicsearches
component(s) delivered simultaneously. Exercise-only interven- Thesearchtermsandparameterofourearlierreviewareprovided
tionsdidnotincludeanon-exercisecomponentandwereclassi- inTable1.Forthisupdate,wesearchedthefollowingdatabases
fiedbythepredominant typeexercise.Inclassifyingthetypeof from1/2000 to 5/2005: MEDLINE (Ovid), EMBASE (Ovid),
exercise,theexerciseperformedinwarm-upandcool-downwere CINAHL(Ovid),SportDiscus(Ovid),PubMed,PEDro,andthe
notconsidered.Exercise-onlyinterventionsincludedaerobic-only Cochrane Central Register of ControlledTrials Register (CEN-
training,strength-onlytraining,flexibility-onlytraining,ormixed TRAL,Issue3,2005).Theprimarysearchtermswere:
exercise-onlyinterventions.Norestrictionsonfrequency,intensity 1.expFIBROMYALGIA/
or duration weremade beyondrequiring thattheexercise com- 2.fibromyalgia.tw.
ponent of composite interventions be a substantial part of that 3.fibrositis.tw.
treatment. 4.or/1-3
5.expexercise/
6.expEXERTION/
7.expPhysicalFitness/
Typesofoutcomemeasures
8.expExerciseTest/
Outcomemeasuresdidnotformpartoftheinclusioncriteriafor 9.expExerciseTolerance/
thisreview.Wegroupedtheoutcomemeasuresintosixconstructs 10.expSPORTS/
representingglobalwell-being,commonlyexperiencedsignsand 11.expPLIABILITY/
symptomsofFMandobserver-measuredphysicalfunction. 12.expPhysicalEndurance/
Primaryoutcomes 13.exertion$.tw.
Primaryoutcomesrepresentedfourconstructs. 14.exercis$.tw.
1.Pain(e.g.,visualanaloguescale(VAS)or10pointordinalscale) 15.sport$.tw.
2.Globalwell-being(overallfeelingofwell-being)orperceivedim- 16.((physicalormotion)adj5(fitnessortherapyortherapies)).tw.
provementinFMsymptoms(outcomessuchastheFibromyalgia 17.(physical$adj2endur$).tw.
ImpactQuestionnaire (FIQ)total score, study participant-rated 18.manipulat$.tw.
change in FM symptoms, observer-rated change in FM symp- 19.(skate$orskating).tw.
toms).(Note:TheFIQisaself-reportquestionnairedevelopedto 20.jog$.tw.
evaluateoverallimpactofFM.TheindividualwithFMratescom- 21.swim$.tw.
monlyexperiencedFMsymptoms,including(butnotrestricted 22.bicycl$.tw.
to)pain,fatigue,depression,anxiety,levelofrestednessaftersleep, 23.(cycle$orcycling).tw.
and effectof FM on work. The scores for each item can be re- 24.walk$.tw.
portedindividuallyorsummedtoreporttheFIQtotalscore.In 25.(roworrowsorrowing).tw.
thisreviewwehaveusedtheFIQtotalscoretorepresentoverall 26.weighttrain$.tw.
orglobalwellbeing.) 27.musclestrength$.tw.
3.Physicalfunction 28.or/5-27
a. Physical performance -aerobic (e.g., submaximal or maximal 29.4and28
treadmillorcycleergometertests,6minutewalk) 30.limit29toyr=2000-2005
b.Physicalperformance-musculoskeletal(e.g.,gripstrength,hip Othersources
andkneeextensionstrength) Referencelistsfromidentifiedarticles,meta-analysesandreviews
c.Physicalperformance-flexibility(e.g.,sitandreachtest) ofalltypesoftreatmentforFMwerereviewedindependentlyby
4.Tender points(e.g.,painthresholdoftenderpointsusing do- tworeviewersandallpromisingreferenceswerescrutinized.
lorimetryortendernesstothumbpressure)
Secondaryoutcomes
Secondaryoutcomesrepresentedtwoconstructs.
Datacollectionandanalysis
5.Depression(e.g.,BeckDepressionInventory,FIQsubscalefor
depression). Selectionofstudies
6.Fatigueandsleep(e.g.,FIQfatiguesubscale,sleepVAS) Tworeviewers(AJB,CLS)independentlyscannedthetitlesand
Exercisefortreatingfibromyalgiasyndrome(Review) 5
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
reviewedabstractsofstudiesgeneratedfromsearches.Therefer- Inthisupdateweconsiderthe11itemsofthevanTuldermethod-
encelistsfrombibliographiesofreviewarticleswerealsoexamined ologicalcriteriathatreflectinternalvalidity(vanTulder2003).We
andabstractswereretrievedforallpromisingtitles.Weretrieved arbitrarilyclassifiedstudiesintohigh,moderateandlowquality
allcompletepublicationsforthepromisingabstracts.Thefulltext studiesbased onscoresontheseelevenitems. Studiesachieving
articleswerethenexaminedindependentlybytworeviewerstode- a score of 8-11 were classified as being of high quality; studies
termineiftheymettheselectioncriteria.Disagreementsbetween scoring5-7wereclassifiedasbeingofmoderatequalityandthose
thetworeviewerswereresolvedinconsensusmeetingsofthefull scoring 1-4wereclassifiedaslowquality studies.Inthisreview,
team. Foreign language studies were translated and included in weplacegreaterweightonmoderatetohighqualitystudies(i.e.,
thereview.Inouropinion,noimportantpapersweremissed. thosewithascoreof5orgreater).Inactuality,thisrepresenteda
Dataextractionandmanagement scoreof50%orgreaterbecauseoneofthe11items(theblinding
Forthepreparationofthefirstreview(16studies,Busch2002), ofthecareprovider)isseldomachievedinexercisestudies.
two reviewers (AJB, CLS) independently extracted data (study Evaluationofcongruenceofexercise/physicalactivitywithrec-
characteristics,studyresults).Pointestimatesforselectedvariables ognizedguidelines
were extracted by one of the reviewers and a research assistant, WeusedtheAmericanCollegeofSportMedicine(ACSM)guide-
and checked by a pair of reviewers. For the preparation of this lines(ACSM2001;ACSM2006),toevaluatewhetherinterven-
major update, two of four reviewers (AJB, CLS, KARB, TJO) tionshadprovidedatrainingstimulusthatwouldeffectchanges
independentlyextracteddataforeachstudy.Alldiscrepancieswere in physical fitness. The ACSM recommendations for achieving
recheckedandconsensusachievedbydiscussion. improvementsinphysicalfitnessrepresentwidelyacceptedcrite-
Assessmentofmethodologicalqualityofincludedstudies ria. Since exercise guidelines have not been developedfor those
Twoinstrumentsforassessingmethodologicalqualitywereapplied withFM,theACSMguidelines(developedforhealthyindividu-
in this review: the van Tulder Methodological Quality Criteria als)wereused.
(vanTulder1997,vanTulder2003)andtheJadadMethodologi- ACSMguidelines:(ACSM2006)
calQualityCriteria(Jadad1996)ThevanTulderMethodological 1. Cardiorespiratory Endurance (Aerobic Training) The dosage
QualityCriteriawereappliedwithtwodeviationsfromthoseof requiredisasfollows:a)frequencyofexerciseatleastthreedays
vanTulder1997.Weinterpreted’patientblinding’tomeanrigor- per week, b) intensity of exercise sufficient to achieve equal to
ousinformationcontrolbecauseitisnotpossibletoblindsubjects orgreaterthan40%ofheartratereserve(min-max:40-85%)or
toan exerciseintervention (itemh).We usedawithdrawal rate 64% of predicted maximum heart rate (min-max: 64-94%), c)
of20%(iteml)asacceptableandawardedpositivescoresifdata sessionsofatleast20minutesduration(min-max:20-60minutes),
fromatleast80%ofsubjectswereanalysedatcompletionofthe eitherascontinuousexerciseorspreadintermittentlythroughout
primaryshort-termendpointofthestudy,orifallsubjectswho thedayinblocksof10minutesormore,andusinganymodeof
enteredthestudywereanalysedatcompletion(i.e.,intention-to- aerobicexerciseinvolvinguseofmajormusclegroupsinrhythmic
treatanalysis). TheJadad Methodological QualityCriteriawere activities, d) for a total time period of at leastsix weeks. While
appliedexactlyasdescribedbyJadad1996. ACSMrecommendsanexercisefrequencyof3-5daysperweek,
Beforebeginningthemethodologicalevaluationforthe2002re- it acknowledges that “deconditioned persons may improve CR
view,threereviewers(AJB,CLS,PMP)independentlyevaluated fitness with only twice-weekly exercise, greater improvement is
asampleoftwostudiesandsubsequentlyagreeduponaconsis- achievedwithafrequencyof3-5sessionsperweek.”(ACSM2006)
tentinterpretationofcriteriaforeachofthetwoinstruments.The 2. Muscle Strengthening: The dosage requirements for strength
threereviewersthenindependentlyappliedthetwoinstruments, traininginterventionsare:a)frequencyof2-3daysperweek,b)
usingstandardizedformsforeach.Differencesinratingswerere- aminimum ofonesetof8-12repetitions atanintensity of the
solvedbyconsensus.Forthecurrentupdate,reviewers(AJB,CLS, 8to12RepetitionMaximumofeachexercise,usinganytypeof
KARB,TJO)workedinpairs,independentlyevaluatingasample strengtheningexercisethatcanbeprogressedovertime.
oftwostudiesandthenreviewing theestablishedinterpretation 3.FlexibilityTraining:Flexibilityprescriptionreferstocontrolled
ofcriteriafortheinstruments.Consensusonfurtherclarification staticstretchinginwhichasubjectassumesapositionandholds
oftheinterpretationwasachievedinameetingofthefourreview- itforagivenduration.Dosagerequirementsare:a)frequencyof
ers.Reviewersthenworkedinpairs,independentlyapplyingthe exerciseequaltoorgreaterthantwodaysperweek,b)intensityto
twoinstruments,usingstandardizedformsforeach.Differences apositionofmilddiscomfort,c)3to4repetitionsforeachstretch
inratingswereresolvedbyconsensus. Toavoidbias, oneof the heldforadurationof10-30seconds.
includedstudies(Schachter2003)whichwasauthoredbythree ThePhysicalActivityGuidelineoftheCentresforDiseaseCon-
ofthecurrentreviewerswasexaminedbythetworeviewersnot trolandPrevention(CDC)(CDC2001)representsarecommen-
involvedinthatstudy.Inter-raterreliabilitycalculatedfortheup- dationsupportedbyepidemiologicalstudiesaboutminimumin-
datedassessmentusingKappawasverygood(K=0.914,“almost tensitiesanddurationofphysicalactivitythatcanimprovehealth-
perfect”accordingtoLandis1977). related variables (such as blood pressure and lipid profile). The
Exercisefortreatingfibromyalgiasyndrome(Review) 6
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
recommendationthatmostadultsshouldperformatleast30min- provementasabenchmarkforclinicalimportancebasedonwork
utesofmoderateintensityphysicalactivity(inblocksofatleast10 byFarrar2001.Farrar2001 determinedthatareductionofap-
minutes)onfiveormoredaysoftheweekoratleast20minutesof proximately30%onthepainintensitynumericalratingscalerep-
vigorousintensityexerciseatleastthreedaysperweek,represents resentsaclinicallyimportantdifferenceforpatientswithchronic
apublichealthstatementtothegeneralpopulation.Weusedthe pain (Farrar 2001). This is also consistent with the findings of
CDCGuidelinetoevaluatewhetherinterventionshadprovided Dunkl2000whoexaminedresponsivenessofmeasuresofclinical
anexerciseorphysicalactivitystimulusthatcouldimprovehealth. improvementinFM.Relativepercentageimprovementwascalcu-
Tworeviewersindependentlyclassifiedstudieseitherasmeeting, latedasthemeanchangeinthetreatmentgroupminusthemean
or not meeting, the ACSM and CDC training guidelines, and changeinthecontrolgroupdividedbythepooledmeanforthe
thenreachedaconsensusbydiscussion. baselinescoresforthevariable.
Measuresoftreatmenteffect The Cochrane Musculoskeletal Group has recently adopted
Weplannedaprioritoconsiderseveralvariablesforoutcomemea- newguidelinesfordescribing andinterpretingclinical relevance
sures:pain,tendernessortenderpoints,globalassessmentsbyei- (Tugwell2004).Inthisreview,inadditiontousingacriterionof
therpatientorphysician,theFibromyalgiaImpactQuestionnaire 30%, we have applied the new guidelines. The guidelines were
(FIQ),anxietyanddepressionmeasures,andmeasuresofphysical usedtodeveloptheplainlanguagesummary.
performanceandself-efficacy.Theoutcomemeasuresofinterest Randomizedclinicaltrials(RCT)
were most often presented as continuous data with means and We included RCTs that compared the effectsof exercise to the
standarddeviations.Thus,weusedastandardizedmeandifference effectsofothertreatments(e.g.,relaxation,CognitiveBehaviour
(SMD),whichconvertsscalestoacommonmetric.Tocalculate Training)ortocontrolconditionsthatdidnotinvolveanyform
SMD,weusedmeansandstandardizeddeviationsofchangescores ofactivity ortreatment(e.g.,treatmentasusual,attentiononly,
foreachintervention.Whennotavailable,standarddeviationsof waitlistcontrols).Whenmultipleinterventionswerecomparedin
changescoreswerederiveddirectlyfromconfidenceintervalsof asinglestudy,weanalysedthecomparisonsthatarosefromeach
changescores,orestimatedfromthepretestandpostteststandard exerciseinterventionseparately.Inthemeta-analysis,weincluded
deviations(orstandarderrors)wherethesewereprovided.SMDs onlythestudieswhichcomparedexercisetoanuntreatedcontrol.
werecalculatedusingRevManAnalyses,astatisticalanalysistool We preferentially analysed intention to treat (ITT) data when-
incorporatedinRevMan. everavailable.Tocreateamorecompletedatasetforanalysis,we
Evaluationofclinicallyimportantdifferences contactedauthorsofstudieswithmissingdatarequestingdatare-
Recentliteraturesuggestsuseofrelativedifferenceinchangescores quiredforanalysis.Severalauthorsgenerouslyprovidedestimates
orpercentchangeasaguidefordeterminingclinicallyimportant ofcentraltendencyorvariability (means,standarddeviations of
difference.ThePhiladelphiaPanel,2001regardsa15%difference pretestandposttestdataorstandarddeviationsofchangescores)
betweengroupsasclinicallyimportantandtheAmericanCollege (Buckelew1998;Burckhardt1994;DaCosta2005;Gowans1999;
ofRheumatology(ACR)establishedadefinitionofimprovement Richards2002)andinformationneededforthequalitativeanal-
inrheumatoidarthritisclinicaltrialsthatis20%inselectedmea- ysis (Altan 2004; Cedraschi 2004; Hakkinen 2001; Mengshoel
sures(Felson1995).Areductionofapproximately30%inthe11- 1992;Redondo2004).Studiesthatonlyprovidedcategoricaldata
pointpainintensitynumerical ratingscale(PI-NRS)wasfound andthoseforwhichwewerenotabletoobtainmissingdatawere
to representaclinically important difference in clinical trials of excludedfrommeta-analysis(Genc2002).
chronicpaintherapies(Farrar2001).ThePI-NRSstudyreviewed Assessmentofheterogeneity
datafrom10placebo-controlledclinicaltrialsincluding2724sub- Wecreatedthedataextractiontablesandthendiscussedasateam
jects,529ofwhichhad(FM).Anadditional placebo-controlled whatissuesofclinicalheterogeneityshouldbeexamined.Impor-
studywith99subjects(Dunkl2000)foundthe11-pointPI-NRS, tantsourcesofheterogeneitywereconsideredtobe:variationsin
FM Impact Questionnaire (FIQ) and tender point counts were interventions(aerobictraining,flexibilitytraining,strengthtrain-
all able to distinguish among groups of patients with FM who ing or mixed/composite training) and dosage of exercise inter-
reportedimprovedclinicalstatusfromthosewhodidnot. vention(meetingASCMtrainingcriteria),disparatecomparators
Percentchangeresultsmustbeinterpretedwithcautionsinceesti- (e.g.,intervention versus acontrol group or intervention versus
matesofimportantchangehavebeenfoundtovarybymagnitude asecondintervention), andtimingofmeasurementofoutcome
ofbaselinemeasurementonagivenscale(Stratford1998).Dis- measuresandmethodologicalquality.
easestatusoractivitylevelatbaselineaffectsrelativeimprovement Heterogeneityamongthetrialswasnextassessedusingthehetero-
whenusingpercentchangeasamarkerforimprovement(vanRiel geneitystatistics(chisquared,I2).WeconsideredvaluesofP=0.1,
2000).Thescale’ssensitivity tochangeisalsodependentonthe orsmaller,tobeindicativeofsignificantheterogeneity.WhereP<
construct that is used as a comparison for determining clinical .1andorI2>50%,theresultswereexaminedforsourcesofclin-
importance(Riddle1998). icalheterogeneityandmethodologicaldifferences.Ifnomethod-
Weusedaconservative estimateof30% relativepercentageim- ologicalorclinicalreasonscouldbefoundtoexplainthestatisti-
Exercisefortreatingfibromyalgiasyndrome(Review) 7
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
calheterogeneity,weproceededwiththemeta-analysisusingthe refinementstometa-analysisasnewtrialscomeavailable;forex-
randomeffectsmodel. ample,wehopetoalsoexaminetheeffectsofmoderatetohigh
Assessmentofreportingbiases qualitystrengthtrainingandflexibilitytrainingassuchstudiesare
When appropriate, publication bias was assessed using a visual published.
assessmentofthefunnelplot(RevManAnalyses). Sensitivityanalysis
Datasynthesis(meta-analysis) Except for the aerobic-only exercise studies, there were too few
UsingRevManAnalysessoftware,meanchangescoreswerecom- studiesinanyothergroupingtoperformsensitivityanalysis.We
paredandweightedandcombinedusingarandomeffectsmodel. assessedthebiasrelatedtolowmethodologicalqualityusingvisual
Wheremeta-analysiswasinappropriate,weusedRevManAnaly- inspection of the forest plots of poor quality studies versus the
sestoproduceeffectsizes(SMD)andeffectsizeconfidenceinter- moderatetohighqualityaerobic-onlystudies.
vals.WeusedCohen’scategoriesforeffectsize(Cohen1988)to
evaluatethemagnitudeoftheeffect(.2=smalleffect,.5=medium
effect,.8=largeeffect).Weusedthefollowinglevelsofevidence
descriptorsofvanTulder2003toclassifytheresultsofthemeta- RESULTS
analysis:
• Strong-consistentfindingsamongmultiplehighquality
(HQ)RCTs Descriptionofstudies
• Moderate-consistentfindingsamongmultiplelowquality
See:Characteristicsofincludedstudies;Characteristicsofexcluded
(LQ)RCTsand/orcontrolledclinicaltrials(CCTs)and/orone
studies.
HQRCT
• Limited-oneLQRCTand/orCCT Resultsofthesearch
• Conflicting-inconsistentfindingsamongfindingsamong Weinspected2226titlesgeneratedfromthesearchesconducted
in2002 and 2005 andfound 64citations offull-lengtharticles
multipletrials(RCTsand/orCCT)
• Noevidencefromtrials-noRCTsorCCTs describing experimentaltrials whichexamined theeffectsof in-
terventionsthatincludedanexercisecomponentinsubjectswith
Wedefinedinconsistentas: FM.
1.Intheabsenceofhighqualitystudies,atleastoneRCTclearly Includedstudies
favorscontrolwhileatleastoneRCT(s)clearlyfavorstreatment Thirty-four reports (Altan 2004; Buckelew 1998; Burckhardt
2.Ifmorethanonehighqualitystudiesisavailable,andatleast 1994;Cedraschi2004;DaCosta2005;Genc2002;Meyer2000;
oneHQRCTclearlyfavorscontrolwhileatleastoneHQRCT Gowans1999;Hakkinen2001;Hakkinen2002;Isomeri1993;
clearlyfavorstreatment Jentoft2001;Jones2002;Keel1998;King2002;Mannerkorpi
Wedefinedconsistentas: 2000; Martin 1996; McCain 1988; Mengshoel 1992; Meyer
1.Allstudiesclearlyfavortreatment 2000;Nichols1994;Norregaard1997;Ramsay2000;Redondo
2.Allstudiesclearlyfavorcontrol 2004;Richards2002;Schachter2003;Sencan2004;Valim2003;
3.Somestudiesclearlyfavortreatment,theremainderareincon- Valkeinen2004;vanSanten2002a;vanSanten2002b;Verstappen
clusive(donotexcludethenull) 1997;Wigers1996;Zijlstra2005)metourselectioncriteriaand
Wedefined“clearlyfavor”as:theconfidenceintervalexcludeszero. wereincludedforanalysis.Threepublicationswereaccompanied
Outcome Measures: When researchers reported more than one bysubsequentreportsdealingwiththesamesubjects.Hakkinen
measureforadependentvariable,weusedthefollowingorderof 2002 reportedonadditional variablesfromtheHakkinen2001
preferenceforentryintothemeta-analysis: studyandthuswascountedasonestudyforanalysis.Twopubli-
1.Pain:VAS,VASFIQ,OrdinalScale cationspresentedinformationonlongtermuncontrolledfollow-
2. Tender Points: dolorimetry, total myalgic score, tender point upofincludedRCTs:Gowans2004wasafollow-uptoGowans
count 2001;Mannerkorpi2002wasafollow-uptoMannerkorpi2000;
3. Global: FIQ Total, subject-rated VAS or ordinal scale, QOL datawerenotanalysedinthisreviewandthereportsweretreatedas
scale,SIPTotal. secondarystudies.Thebasiccharacteristicsoftheincludedstudies
4.Depression:BeckCognitive,BeckTotal,CES,FIQ-depression, aresummarizedinthe’CharacteristicsofIncludedStudies’Table.
AIMSDepression Participants
5.ObjectiveMeasuresofPhysicalFunction:selectedonacase-by- Therewereatotalof2276subjectswiththeconfirmeddiagnosis
casebasisdependingontheresearchers’statedobjectives ofFMacrossthestudies;1264subjectswereassignedtoexercise
Subgroupanalysis interventions.Theaveragesamplesizeforthesmallestexperimen-
Subgroup analyses were limited to aerobic-only interventions talgroupwas24.7(SD=16.4,min-max:5-80)forthe34original
(frommoderatetohighqualitystudies)andstrength-onlyinter- studies.Meanageinthestudiesrangedfrom27.5to60.2yearsin
ventions(frompoorqualitystudies).Futureupdatesmayinclude 34studies(unspecifiedinRamsay2000).Forthe2197subjectsfor
Exercisefortreatingfibromyalgiasyndrome(Review) 8
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.