Over the last 22 years, I have had many clients with fibromyalgia in my practice. I have a special interest in this condition, as well as chronic pain in general, so I have decided to dedicate a blog to this topic. Please note that many of the recommendations below apply to other chronic pain conditions as well.
Many of you may have heard of the chronic pain condition called fibromyalgia (FM). It is characterized by widespread body pain in muscles and tendons that is often felt from head to toe. It is considered a rhematological condition although its etiology is unknown. Statistics Canada reports that 343,000 Canadians have been diagnosed with FM, although the organization Fibromyalgia-Chronic Fatigue Syndrome Canada believes that this number is grossly underestimated – they state that upwards of 700,000 to 1.2 million Canadians are living with FM – or 3.5 to 5 percent of the Canadian population. Unfortunately, some physicians still do not believe that FM is a real disease and fail to diagnose it even when the diagnostic criteria are clearly present.
Diagnostic Criteria for Fibromyalgia As stated above, FM is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple tender points. “Tender points” refers to tenderness that occurs in precise, localized areas, particularly in the neck, spine, shoulders, and hips. People with FM may also experience sleep disturbances, morning stiffness, irritable bowel syndrome, anxiety, cognitive problems (“brain fog” and memory impairment), headaches, sleep disorders, muscle spasms, reduced coordination, multiple chemical sensitivity, and decreased physical endurance. The term "chronic neuroendoimmunological dysfunction" for FM and Chronic Fatigue Syndrome has been recommended by experts but is not generally accepted as yet. In order to be clinically diagnosed with FM, an individual must have
- Widespread pain in all four quadrants of the body for a minimum of 3 months
- At least 11 of the 18 specified tender points clustered around the neck, shoulder, chest, hip, knee, and elbow regions. Over 75 other tender points have been found to exist but are not utilized for diagnostic purposes.
The selection criteria have been shown to be 88% accurate in their ability to identify patients with FM.
Exercise and Fibromyalgia It is difficult to study the effect of exercise on fibromyalgia, as many participants drop out during the course of research studies, for various reasons. Often, the exercise protocols, modelled after the general guidelines of the American College of Sports Medicine (ACSM), are too challenging for these participants. This can exacerbate their level of pain and fatigue, as well as other symptoms.
That being said, there is moderate evidence that cardiovascular exercise is helpful for people with FM. On average, this population has a 58% reduction in cardiovascular capacity, compared to normal subjects the same age. A meta-analysis from 2008 of six studies deemed to be good quality found that regular cardiovascular exercise (following the ACSM guidelines) had a positive effect on global well-being, physical function, pain, and tender points. An interesting finding was that the positive effect of the exercise was unrelated to increases in actual aerobic capacity (VO2max). That is to say that, in these studies, people with FM experienced benefits from physical activity that did not necessarily result in actual increases in fitness level. Strength and flexibility training for FM are relatively unstudied at this time, so we do not know if these are beneficial for this condition. However, there is theoretical evidence that strength training may be helpful, as people with FM have selective weakening of what are called Type II muscle fibres – the type which are strengthened when you lift weights. Type II muscle fibres – also called fast twitch fibres - are crucial for dynamic joint stabilization, so their weakening will theoretically lead to unstable, painful joint structures. This characteristic of FM was discovered in a pivotal study from 1993 in the Journal of Rhematology. In FM patients, fast twitch fibres actually start to look more like slow twitch fibres – meaning that their contractile capacity slows down and joint stabilization, in effect, comes to a halt. In addition, the energy producing parts of the muscle fibre, called the mitochroncria (which can be thought of as the “furnace” of a muscle), are abnormal in number and shape in people with FM. An article in the journal Joint Bone Spine from 2006 stated that these abnormalities did not appear to be the result of muscle deconditioning.
Exercise Specialist Recommendations Unlike hypertension, cardiovascular disease and diabetes, I am unable to say unequivocally that exercise will help manage the symptoms of fibromyalgia. But it may, and results will vary from individual to individual.
- Learn how to breathe before learning how to exercise. Learning how to breathe without bracing for the pain is a critical skill to master before progressing to structured exercises. You can pair this with simple movements like gentle stretching or small pelvic tilts.
- Be realistic about goals. Expecting a drastic reduction in pain, especially in the short term, is not realistic. The best advice is to focus on functional capacity – the ease with which you can carry out activities of daily living. Pain management will hopefully come later on. If exercise is making pain worse, stop. If it has no impact on pain, or results in marginal improvement, continue.
- Focus on function, as opposed to pain. Pay attention to what you are able to do, not how much pain you are in. Keep a journal and so you can recognizae improvements in your ability to carry out activities of daily living (ADLs).
- Exercise at a very low intensity, with one to two days between workouts. Low intensity cardio reduces the risk of cardiovascular risk factors and diabetes. You can also use discontinuous exercise – small exercise segments lasting 2-10 minutes, broken up throughout the day.
- Do less than you feel capable of! People with FM are super-sensitive, and always must err on the side of caution when it comes to exercise volume and intensity. Do more on the days you feel better, but never overdo it.
- Use gradual progression! People with FM must take this concept in exercise physiology to the extreme. Whereas someone without the condition might spend three to six months working up to an ideal exercise intensity, those with FM will need at least six to twelve months to slowly build strength and endurance. Temporary flare-ups, as well, may require a person with FM to take a break before resuming the exercise routine.
- Start with one modality at a time. You will have a better idea of what is working or not working if you focus on one exercise modality at a time. Start with cardiovascular exercise because we know that this is the type that is most likely to provide benefit. Then move on to strength training (see below) and stretching.
- Try strength training. Anecdotally, I have seen clients present with generalized muscle pain which remediates after a few weeks of strength training – often in inactive women over the age of 40. In some individuals, a vicious cycle develops – inactivity due to chronic pain, then more pain due to muscle atrophy, and so forth. Strength training does not just strengthen muscles, it also strengthens connective tissues like tendons and ligaments - which enhances joint stability. Futhermore, loss of muscle mass also increases the risk of acute injuries like tendonitis and strained ligaments, and chronic problems like arthritis.
- Schedule rest. This should be considered part of the exercise program. People with FM may experience post exertional fatigue up to 48 hours after a workout, and adequate rest the day of your workouts may prevent his from happening. Soaking in a hot bath with Epsom salts can also be helpful.
- Safeguard sleep. Most people who suffer from FM also have disordered sleep, most commonly a lack of delta sleep – the deepest part of the sleep cycle. Go to bed at the same time every night. Make the hour before you plan to go to sleep relaxing – avoid the computer, phone, email, or upsetting conversations. Do not drink lots of liquid before bed. Avoid exposure to bright light before bed and during the night. Eat meals at regular times. Avoid afternoon naps – when you rest, try to avoid falling asleep. Consider naturopathic or pharmacological medication to help with sleep if nothing else proves to work. Do not exercise if you have had a particularly poor night’s sleep.
By following the above recommendations, people who suffer from fibromyalgia can have success with exercise, just like those without the condition.