For the S & C professional, it is important to recognize that the client’s symptoms may fluctuate in intensity and region day to day and they may report multiple areas of pain that affect their overall function. This will have to be considered when designing an exercise program. These clients will be susceptible to overexercising especially if they have been inconsistent with their exercise program or have not been physically active because of their pain levels.
The primary concern for the S & C professional is the appropriate volume of aerobic exercise. A recent systematic review by Hauser et al. (23) provided further guidelines for aerobic exercise. Based upon their analysis of the literature (28 studies) through 2009, they developed the following exercise recommendations: (a) aerobic exercise should consist of land-based or aquatic exercises, (b) exercise should last for 20–30 minutes, (c) intensity should be light to moderate, and (d) the frequency of exercise should be 2–3 times per week for at least 4 weeks (23). These recommendations may provide a starting point when designing an individualized program for the client with fibromyalgia.
The available evidence supporting the efficacy of strength training is comparable to aerobic training. Bircan et al. (6) compared both an 8-week aerobic walking program (e.g., 20–30 minutes at 60–70% maximum heart rate) and a progressive strengthening program for the upper- and lower-body using free weights and machines (4–12 repetitions [reps] for 30 minutes) in 30 female participants. They found that both aerobic walking and strengthening produced similar effects by improving symptoms, tender point count, fitness, mood, and quality of life (6). This is supported by systematic reviews that have shown favorable results of strength training but point out that it has be underevaluated and could only conclude that it may have a favorable influence (8,12).
These preliminary findings are promising, but there is still a need to further research the specific effects of strength training and to develop exercise guidelines. Future research should focus on developing guidelines that match the client with the appropriate resistance level.
More recently, researchers have used a multimodal approach by combining various types of exercise such as aerobic, strengthening, and flexibility. Sanudo et al. (39) found improvements in self-reported quality of life, physical function, depression, and aerobic capacity in a group of female participants with fibromyalgia over a 3-year period. The authors trained the subjects with a combined exercise program for 6 months and detrained (no activity) them for 6 months over a 3-year period. They found positive effects after the training periods when compared with a matched control group (39). Carbonell-Baeza et al. (9) found similar effects of a 3-month multimodal program consisting of low- to moderate-intensity pool and land-based activity and psychological sessions 3 times per week. The authors found significant results with the Fibromyalgia Impact Questionnaire and 36-Item Short-Form Health Survey. Reported improvements from these measures included less fatigue, stiffness, anxiety, depression, and pain. Improved social function and vitality were also reported by subjects (9). Other authors have found similar results 6 months to 1 year after a multimodal program (33,37). The comparison of multimodal versus single mode programs has not been investigated. The current evidence suggests that multimodal programs may be beneficial for individuals who begin to lose motivation or require a choice of exercise that will help manage their symptoms. Further research is needed that compares multimodal programs with single mode programs.
Another intervention that has been recently studied is the effects of lifestyle physical activity. Lifestyle physical activity is a self-selected form of physical activity for individuals who cannot participate or have difficulty participating in conventional exercise. The goal is to work toward meeting the US Surgeon General’s 1996 recommendations for physical activity of accumulating at least 30 minutes of moderate-intensity physical activity 5–7 days a week (17). This is accomplished by integrating short bouts of activity such as walking or gardening throughout the day that is above the individual’s usual activity.
Other authors have found positive results such as less fatigue, depression, and improved pain and physical function scores on the 36-Item Short-Form Health Survey when exercise is combined with self- and Internet-enhanced programs (37,49). Lifestyle physical activity programs may offer an effective alternative for clients who suffer from more severe symptoms and cannot participate in conventional exercise.
Researchers have also looked at the effects of tai chi on the pain, function, and quality of life in individuals with fibromyalgia. Authors have found improved function and quality of life after a 12-week period (2 times a week for 60–90 minutes) in both men and women, improved lower body flexibility in men after a 4-month program (3 times a week for 60 minutes), and improvements in pain, function, and symptoms in women after a 7-month program (3 times per week for 60 minutes) (10,36,48). The interventions described in these studies consisted of a general warm-up, cooldown, and an 8- or 10-form classical Yang tai chi sequence that contained minor modification for individuals with fibromyalgia.
The preliminary research on these complimentary interventions shows promise for individuals with fibromyalgia. These interventions may fit well into a multidisciplinary program that encompasses the conventional aerobic and strengthening activity.
Several authors have found that whole body vibration with traditional strengthening is effective in improving pain, fatigue, and balance in women after a 6-week program (2-day strengthening, 3 days of whole body vibration) and a 12-week program (1,2,40). The whole body vibration interventions used in these studies consisted of bilateral and unilateral static and dynamic lower extremity exercises (range, 15–45 seconds, repeated 3–6 times, 3-minute rest period in between bouts) using a vibration frequency range of 12.5–30 Hz with a 2- to 3-mm amplitude.
Previous studies have found that a 30-Hz vibration frequency induces maximum muscular electrical activity and higher frequencies such as 50 Hz may induce postexercise soreness in untrained individuals (11,35). The range of frequencies and amplitudes varied, which may be because of the lack of consensus among researchers due to the novelty of this intervention for this population. Further research is needed to assess the effectiveness of whole body vibration on male participants and to establish more specific exercise guidelines for individuals with fibromyalgia.
The interventions discussed above cover the most current research on each topic. Many of the interventions need further study, but their preliminary outcomes are promising. Table 2 provides suggested exercise guidelines for each of the interventions and are based on what was recommended or used during the investigations. The S & C professional may want to use these guidelines as a starting point when designing an exercise program for individuals with fibromyalgia.
It is important for the S & C professional to understand which medications the client is taking and how they will influence physical activity. Pharmacological treatment is primarily used to address the client’s symptoms with a goal of decreasing pain and improving function. Common medications used in the treatment of fibromyalgia include pain relievers, opioids, antidepressants, sedatives, and muscle relaxants (41). The interaction of the client’s medication and physical activity will have to be considered when designing his/her exercise program. Certain medications could affect the client’s muscle performance (e.g., muscle relaxants), mask the client’s pain level (e.g., pain relievers), or make them drowsy (e.g., sedative). Table 3 lists common medications and their adverse reactions (34). The client’s level of pain and fatigue should be carefully monitored during and after exercise because the medications may mask symptoms and increase the risk of overexercising and worsening of symptoms.
Communicating with the client’s physician may be beneficial in finding out how the medication may interact with certain forms of physical activity, especially if the medication has certain side effects. Common side effects among the fibromyalgia medications include dizziness, drowsiness, dry mouth, headaches, constipation, and fatigue (34). This section provides a brief overview of common medications and their side effects. The S & C professional is encouraged to further study this topic to have a more complete understanding of how medications influence physical activity in this population.
It is important for the S & C professional to consider program modification in the presence of pain or exacerbated symptoms such as fatigue. Monitoring for changes during exercise is important for the client’s safety. For example, pain can be effectively monitored with the use of an 11-point numerical pain rating scale with 0 (no pain) to 10 (worst pain imaginable) or fatigue can be monitored using the Borg’s Scale of Perceived Exertion with these individuals (16,30). Alternative or modified activity may be necessary to reduce postexercise soreness. A graded exercise program will be necessary for clients of all levels to ensure a safe progression. These clients will be susceptible to overexercising especially if they have been inconsistent with their exercise program or have not been physically active because of their pain levels. This idea is supported by other authors who believe in the importance of assigning a workload that does not exacerbate the individual’s postexercise pain (12).
Also, understanding the client’s overall perception toward physical activity is important. More specifically, determining how the client learns, stays motivated, and his/her level of self-efficacy (e.g., ability to complete a task and reach goals) are important to a successful program. In fact, Oliver and Cronan (31) investigated predictors of exercise behaviors among individuals with fibromyalgia. They found that exercise self-efficacy and continued participation in regular exercise most strongly predicted present and future exercise behaviors (31). Other authors have found similar findings regarding the importance of self-efficacy for the success of the client’s exercise program (7,14).
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