The aim of this commentary is to summarize the published Cochrane Review “Aerobic Exercise Training for Adults with Fibromyalgia” by Bidonde et al.,1 (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011336/full) which was developed by the Cochrane Musculoskeletal Group. This Cochrane Corner is produced in agreement with the AJPM&R by Cochrane Rehabilitation.
Almost all adults with fibromyalgia (FM) experience the core symptoms of chronic widespread pain, sleep disorders with nonrestorative sleep, and fatigue. In addition, many patients may develop stiffness, irritable bowel, depression, and headaches.2 Because of these symptoms, FM patients are often disabled in everyday life. Rehabilitation focuses on the main goals of optimizing functioning in activities of daily living and health-related quality of life (HRQOL). Aerobic exercise plays an important role in the treatment of FM to achieve these aims.3
AEROBIC EXERCISE TRAINING FOR ADULTS WITH FIBROMYALGIA
What Is the Aim of this Cochrane Review?
The aim of this Cochrane Review was to evaluate the benefits and harms of aerobic exercise training for adults with FM (Bidonde et al., 2017).1 From the rehabilitation perspective, this could be understood as follows: What is the role and what is the best mode of aerobic exercise in FM patients in the context of therapy and rehabilitation for best possible function and HRQOL?
What Was Studied in the Cochrane Review?
The population addressed were mainly women with FM (750/839 individuals) with an average age of 41 yrs (range, 32–56 yrs). Interventions included different types of aerobic exercise such as walking, cycling, running, low-impact aerobics, and aquatic exercise performed mostly two to three sessions per week and at different intensities, which increased as the study progressed. Almost all programs were supervised. Aerobic exercise was compared to either other modalities of aerobic exercise; nonexercise interventions such as self-management, education, or medications; or to standard care. Outcomes included HRQOL, pain, fatigue, stiffness, physical function, safety, and tolerability.
What Were the Main Results of the Cochrane Review?
The review included 13 studies (839 participants) that had been published up to June 2016.
Aerobic exercise versus standard care (eight studies, 456 participants):
- Moderate-quality evidence suggests that aerobic exercise results in improved HRQOL.
- Low-quality evidence suggests that aerobic exercise results in improved physical function and decreased pain, fatigue, and stiffness.
- Aerobic exercise resulted in gains in submaximal cardiorespiratory function as measured by the 6-min walk test (three studies) but no differences in maximal cardiorespiratory function as measured by peak VO2max (one study).
- Aerobic exercise was beneficial for pain and physical function in the long-term (24 to 208 wks) (four studies).
- Aerobic exercise seems to be well tolerable; uncertainty exists about its safety because of the lack or poor reporting of adverse events
Comparisons between different types of aerobic exercise (Nordic walking vs. low-intensity walking, long bout vs. short bout, group classes vs. individual sessions) (three studies involving 248 people):
- No significant differences were detected between different types of aerobic exercise.
Aerobic exercise vs. nonexercise interventions (five studies):
- Aerobic exercise was compared to self-management and education interventions in four studies and to medications (paroxetine) in one study. There were statistically significant differences favoring the aerobics program for HRQOL (one of three trials) and pain intensity (two of four studies).
What Were the Authors' Conclusions?
There is evidence to suggest that aerobic exercise may improve HRQOL, pain, stiffness, and physical function in people with FM. The quality of the evidence was low or moderate owing to the small sample size of participants in the available trials (range, 10 to 56 participants) and study design limitations.
What Are the Implications of the Cochrane Evidence for Practice in Rehabilitation?
Aerobic exercise could play an important role in the management of FM and could lead to improvements in HRQOL, pain, stiffness, and physical function probably without a higher risk for harm.
An advantage seems to be that aerobic exercise, for example, walking, could be easily started and adapted to the individual capacity without additional equipment or facilities for most of the FM patients.
The quality of the evidence, however, was low to moderate, pointing to the need for further research on this topic because it is highly likely that the results could change in case of low-quality evidence.
The main suggestions (among many others) of the review authors for future studies include a detailed description of the study population, exercise protocols and randomization, standardized outcome measures and standardized reporting of adverse events, evaluation of cardiorespiratory outcomes, and monitoring of compliance and long-term effects.
Because the studied population were predominantly white women aged 32 to 56 yrs, the importance of aerobic exercise in rehabilitation for all FM patients cannot be fully understood. It is important to assess how important aerobic exercise is compared with all other therapies and which mode of aerobic exercise serves best to FM patients. Pedometer or activity tracker could be used to measure activities for more precise information. In addition, it is noteworthy to include the rehabilitation-relevant outcomes of sick leave per year and return to work through aerobic exercise training in future research.
The author thanks the Cochrane Rehabilitation and Cochrane Musculoskeletal Group for reviewing the contents of the Cochrane Corner.
1. Bidonde J, Busch AJ, Schachter CL, et al: Aerobic exercise training for adults with fibromyalgia. Cochrane Database Syst Rev
2017;6:CD012700 . doi: 10.1002/14651858.CD012700
2. Wolfe F, Clauw DJ, Fitzcharles MA, et al: The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken)
3. Winkelmann A, Bork H, Brückle W, et al: Physiotherapy, occupational therapy and physical therapy in fibromyalgia syndrome: Updated guidelines 2017 and overview of systematic review articles. Schmerz