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Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study

Authors:
  • University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology

Abstract and Figures

To evaluate the effects of 6 months of pool exercise combined with a 6 session education program for patients with fibromyalgia syndrome (FM). The study population comprised 58 patients, randomized to a treatment or a control group. Patients were instructed to match the pool exercises to their threshold of pain and fatigue. The education focused on strategies for coping with symptoms and encouragement of physical activity. The primary outcome measurements were the total score of the Fibromyalgia Impact Questionnaire (FIQ) and the 6 min walk test, recorded at study start and after 6 mo. Several other tests and instruments assessing functional limitations, severity of symptoms, disabilities, and quality of life were also applied. Significant differences between the treatment group and the control group were found for the FIQ total score (p = 0.017) and the 6 min walk test (p < 0.0001). Significant differences were also found for physical function, grip strength, pain severity, social functioning, psychological distress, and quality of life. The results suggest that a 6 month program of exercises in a temperate pool combined with education will improve the consequences of FM.
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ORIGINAL REPORT
J Rehabil Med 2009; 41: 751–760
J Rehabil Med 41
© 2009 The Authors. doi: 10.2340/16501977-0409
Journal Compilation © 2009 Foundation of Rehabilitation Information. ISSN 1650-1977
Objective: To evaluate the effects of pool exercise in patients
with bromyalgia and chronic widespread pain and to deter-
mine characteristics inuencing the effects of treatment.
Methods: A total of 134 women with bromyalgia and 32 with
chronic widespread pain were randomized to a 20-session pool
exercise and a 6-session education programme or to a control
group undertaking the same education programme. The pri-
mary outcomes were the Fibromyalgia Impact Questionnaire
(FIQ) total score and the 6-minute walk test (6MWT). FIQ
Pain and other health variables were included.
Results: The FIQ total (p = 0.04) improved in the interven-
tion group, with an effect size of 0.32. Patients who had par-
ticipated in at least 60% of the exercise sessions improved
in the FIQ total (effect size 0.44), the 6MWT (effect size
0.43) and FIQ Pain (effect size 0.69) compared with controls
(p < 0.05). Long-term follow-up revealed lasting, but small,
improvement (effect size < 0.29) in the 6MWT among the
active participants (p < 0.05). Analyses within the subgroups
showed that patients with milder stress, pain or depression
improved most by treatment on the FIQ total (effect size
> 0.50, p < 0.05) compared with controls.
Conclusion: The exercise-education programme showed sig-
nicant, but small, improvement in health status in patients
with bromyalgia and chronic widespread pain, compared
with education only. Patients with milder symptoms im-
proved most with this treatment.
Key words: pain measurement, bromyalgia, exercise therapy,
stress, psychological, outcome assessment (health care).
J Rehabil Med 2009; 41: 751–760
Correspondence address: Kaisa Mannerkorpi, University of
Gothenburg, Sahlgrenska Academy, Department of Rheumatol-
ogy, Guldhedsgatan 10, SE-413 46 Göteborg, Sweden. E-mail:
kaisa.mannerkorpi@rheuma.gu.se
Submitted September 9, 2008; accepted April 28, 2009
INTRODUCTION
Fibromyalgia (FM) is characterized by long-lasting, wide-
spread pain and generalized allodynia, often accompanied by
fatigue, stiffness, non-restorative sleep, distress (1), activity
limitations (2) and impaired body functions (3). Aberrations in
physiological pain-processing mechanisms (4), together with
psychological and environmental factors, are thought to interact
in the deve lopment and maintenance of FM (4). Criteria for FM
include a history of long-lasting widespread pain and pain at
11 of a total of 18 tender points examined by manual palpation
(1), while patients with widespread pain who do not full the
tender-point criteria are classied as having chronic widespread
pain (CWP) (1). The prevalence of FM in the general population
ranges from 1% to 3%, while that of CWP is approximately 10%
(5, 6), and it has been suggested that CWP and FM represent
overlapping disorders rather than discrete diseases (7).
The biopsychosocial model of health acknowledges that
the individual’s own beliefs and actions can inuence health.
Educational programmes have been developed to enhance self-
efcacy for the management of FM (8, 9), and when combined
with exercise, positive effects have also been found in physical
function and symptoms (813).
More knowledge is needed about the effects of education
and physical exercise, respectively, to develop guidelines for
treatments of patients with FM or CWP. Two earlier studies
reported improved self-efcacy in patients participating in
education or education-exercise programmes (8, 9), while pa-
tients in the combined treatments improved most (8). A recent
study showed that patients participating in an education plus
exercise programme improved more than those randomized to
an education programme (13).
It has been found previously that patients with more severe
pain and physical impairments obtain the best effects from
operant- and cognitive-behavioural treatment programmes
(14), while, to the best of our knowledge, there are no stud-
ies reporting which patients with FM or chronic pain benet
most from physical exercise. Exercise is troublesome for some
patients due to the activity-induced pain, while others appear
to manage it (15, 16). A high level of distress or stress may
also impact on the ability to exercise (17).
The aim of the present study was therefore to investigate
the effects of supervised physical exercise on health status and
body functions in patients with FM or CWP, and to analyse
whether the level of pain, distress, stress and activity limita-
tions might inuence the outcomes. As pool exercise has been
found to be suitable also for patients with FM, presenting se-
POOL EXERCISE FOR PATIENTS WITH FIBROMYALGIA OR CHRONIC
WIDESPREAD PAIN: A RANDOMIZED CONTROLLED TRIAL AND SUBGROUP
ANALYSES
Kaisa Mannerkorpi, PhD
1,2,3
, Lena Nordeman, MSc
4,5
, Anna Ericsson, MSc
2,6
, Maudh Arndorw,
MSc
7
and the GAU Study Group
From the
1
Institute of Neuroscience/Physiotherapy,
2
Institute of Medicine/Rheumatology, Sahlgrenska Academy,
University of Gothenburg,
3
Sahlgrenska University Hospital / Physiotherapy,
4
Institute of Medicine/Public Health,
Sahlgrenska Academy, University of Gothenburg, Göteborg,
5
Primary Health Care, Alingsås,
6
Primary Health Care,
Uddevalla and
7
Primary Health Care, Göteborg, Sweden
752
K. Mannerkorpi et al.
vere impairments (18) it was chosen as a mode of exercise for
this study. The intervention group was compared with an active
control group, participating in the same education programme
as the patients in the intervention group.
METHODS
Study design
A randomized controlled trial (RCT) aiming to compare the effects of a
20-session exercise programme combined with a standardized 6-session
education programme based on self-efcacy principles with an active
control group, which undertook the same education programme. The
primary outcome measures were health status using the Fibromyalgia
Impact Questionnaire (FIQ) total score and body functions using the
6-minute walk test (6MWT). The secondary outcomes included pain
(the FIQ Pain), fatigue (the FIQ Fatigue), depression (the Hospital
Anxiety and Depression Scale (HADS-D)), health-related quality of life
(the 36-item Short Form Health Survey (SF36)) and amount of leisure
time physical activity (the Leisure Time Physical Activity Instrument
(LTPAI)). The exploratory outcomes included clinical manifestations
of stress (the Stress ans Crisis Inventory (SCI)), multiple dimensions
of fatigue (the Multidimensional Fatigue Inventory (MFI-20)) and
experience of physical activity. Outcomes were evaluated using both
an intention-to-treat (ITT) and a per-protocol (PP) design, which was
dened as attendance at least 60% of the sessions. Per-protocol analyses
were conducted to study changes in patients who completed most of
the protocol they were randomized to, as several studies have reported
poor compliance with exercise protocols in FM (19). The outcomes were
assessed at the study start and after 20 weeks. Follow-up was conducted
11–12 months after the baseline. The subgroups were created using rating
scales assessing aspects of health that were hypothesized to inuence the
primary outcomes. The following variables were selected for subgroup
analyses: pain (the FIQ Pain), distress (the HADS-D), stress (the SCI)
and activity limitations (the SF36 Physical Function). To study clinical
relevance of treatment effects, effect sizes were calculated.
Recruitment
A total of 166 patients were recruited. This number enabled a subgroup
analysis. The patients were recruited from primary healthcare centres
in western Sweden by searching patient journals for the diagnoses of
FM and CWP (between 1995 and 2004) and by consecutive recruitment
(in 2004 and 2005). A systematic search of patient journals, found 818
subjects who were potentially eligible, but when the journals were
scrutinized, 520 individuals did not full the inclusion criteria for
FM or CWP, or they fullled exclusion criteria. The remaining 298
individuals were contacted by post (n = 55) or telephone (n = 243) for
further screening. Forty-eight persons could not be contacted, 35 did
not meet inclusion criteria, and 61 declined to participate in the study,
while 154 agreed to participate in an examination. Twenty-two of them
did not meet inclusion criteria, and 12 were excluded due to treatment
in progress (n = 3) or severe disorders (n = 9) and 18 declined to par-
ticipate. A nal total of 102 patients was referred to the intervention
study, but one was excluded for not fullling the inclusion criteria,
leaving a total of 101 patients. At the same time, 93 individuals were
consecutively recruited to the study. Sixty-ve of them fullled the
criteria and agreed to participate in the study. The study population
therefore comprised 166 patients, 134 of whom fullled the criteria
for FM and 32 for CWP (see ow-chart in Fig. 1).
The inclusion criteria were: women with FM or CWP, in the age
range 18–60 years. Patients who had a history of widespread pain
for at least 3 months and pain at manual palpation at 11 out of a total
of 18 examined tender-point localizations were classied as FM (1).
Widespread pain was dened as pain above and below the waist, on
Fig. 1. Flow-chart for the study population.
J Rehabil Med 41
753
Exercise for patients with FM or CWP
the right and left side and at the axial localization (1). Patients with
widespread pain for at least 3 months who did not full the tender-
point criteria were classied as CWP.
The exclusion criteria were: other severe somatic or psychiatric dis-
orders, such as stroke or schizophrenia, inability to understand Swedish,
allergy to chlorine, ongoing exercise therapy supervised by a physical
therapist, or plans to start such therapy during the study period.
Randomization
The patients were allocated to one of the 2 treatment programmes us-
ing stratied randomization for the disorder, FM or CWP (20). Sealed
envelopes were prepared by the statistician, who created the allocation
sequence. When the patient examination had been conducted, the
numbered envelope was opened by a person who was not involved in
the examination, and who also informed the patient about the treatment
group to which she had been randomized.
Ethics
The study was approved by the ethics committee at Göteborg Uni-
versity. Written and oral information was given to all the patients and
written consent was obtained from all the patients.
Background data
The trained examiners were blinded to the patients’ group assignments.
Demographic data, and data on employment and pharmacological treat-
ment, were gathered using a standardized interview (see Table I). Pain
localizations (0–18) were recorded by the patient on a self-administered
sheet (6). Tender points were examined by manual palpation (1). Mus-
cle tenderness was examined using a Somedic algometer (Somedic
Production AB, Sollentuna, Sweden) (21) (Table I).
Self-administered questionnaires
Fibromyalgia Impact Questionnaire (FIQ). This is a self-administered
questionnaire, comprising 10 subscales of disabilities and symptoms,
ranging from 0 to 100, and validated for a Swedish FM population
(22). A higher score indicates lower health status. The total score, being
the mean of the 10 subscales, and the subscales for Pain and Fatigue
were applied in the study.
Short-Form 36 (SF36). This is a generic instrument assessing health-
related quality of life, comprising 8 subscales ranging from 0 to 100.
The subscales building 2 composite scores, the Physical Component
(PCS) and the Mental Component (MCS) (23), were included in the
study, together with the subscales building the PCS. A higher score
indicates better quality of life.
Hospital Anxiety and Depression Scale (HADS). This contains 14 state-
ments, ranging from 0 to 3, in which a higher score indicates a higher
degree of distress. The scores build 2 subscales: HADS-A for anxiety
(0–21) and HADS-D (0–21) for depression. The cut-off score of 8 is
suggested to indicate possible anxiety and depression (24).
Leisure Time Physical Activity Instrument (LTPAI). This instrument
assesses the amount of physical activity during a typical week, di-
vided into light and moderate exercise. The total score is the sum of
the activities (25).
Stress and Crisis Inventory (SCI). The SCI comprises 35 items (0–4),
assessing clinical manifestations of stress on a scale ranging from
0 “not at allto 4 very much”. The questions include physical and
mental sensations. The total score ranges from 0 to 140 and a higher
score indicates more stress (26). The SCI has been used in a previous
study of chronic pain (27).
Multidimensional Fatigue Inventory (MFI-20).The MFI-20 contains
20 statements that build 5 subscales. Each subscale ranges from 4 to
20 and a higher score indicates a higher degree of fatigue (28, 29).
Experience of physical activity. This scale comprises 22 items ranging
from 0 to 7 and assessing the following aspects related to physical
activity: Activity-related Physical relaxation (AR), Activity-related
Well-being (AW), Activity beliefs (AB), Activity-related symptoms
(AS) and Activity habits (AH). A higher score indicates more dis-
satisfaction (30).
Physical test of body function
Six-minute walk test (6MWT). The patient was instructed to walk as
quickly as she could without running. The test has shown satisfactory
test-retest reliability in a Swedish FM population (31).
Procedure
Examinations. The trained examiners were blinded to the patients’
group assignments. The examination for the American College of
Rheumatology criteria for FM and CWP included a pain localization
sheet (6), a standardized interview and an examination of tender points
(1). The patients completed a battery of questionnaires and performed
the 6MWT. The FIQ, the SF36, the HADS, the LTPAI and the SCI
were completed at baseline, post-test and follow-up. The MFI-20 and
the Experience of activity scale were completed at baseline and post-
test. The patients were instructed to continue their baseline medical
treatment with no change throughout the 20-week study period, and
their medical treatment was monitored at post-test.
Table I. Demographic data of the patients randomized to the Exercise-
Education and Education programmes, n = 166. p-values for the differences
between the 2 groups are given
Exercise-Education
n = 81
Education
n = 85
p-valueMean (SD) Mean (SD)
Age, years 44.6 (9.26) 46.5 (8.30) 0.235
Symptom duration, years 10.3 (6.85) 10.6 (7.46) 0.925
Tender points, n
13.4 (3.68) 13.6 (3.41) 0.796
Algometer, kPa/sec 180 (72.94) 187 (75.17) 0.702
Pain localization, 0–18 12.5 (3.42) 13.3 (3.42) 0.105
n (%) n (%)
Living with an adult 59 (73) 64 (75) 0.854
Born outside Sweden 9 (11) 18 (21) 0.120
Education
9 years 18 (22) 20 (24)
10–12 years 44 (54) 45 (53)
> 12 years 19 (24) 19 (22) 0.819
Employment
Not working 45 (55) 53 (62)
Working part-time 28 (35) 23 (27)
Working full-time 8 (10) 9 (11) 0.562
Sick leave
0% 61 (75) 68 (80)
25–75% 7 (9) 9 (11)
100% 13 (16) 8 (9 ) 0.294
Sick pension of limited duration
0% 61 (75) 61 (72)
25–75% 10 (13) 9 (11)
100% 10 (12) 15 (18) 0.501
Disability pension
0% 51 (63) 49 (58)
25–75% 14 (17) 15 (18)
100% 16 (20) 21 (25) 0.433
Pharmacological treatment
Analgesics 57 (70) 61 (72) 0.978
Psychotropic drugs
1
36 (44) 38 (45) 0.110
1
Antidepressants, sedatives.
SD: standard deviation.
J Rehabil Med 41
754
K. Mannerkorpi et al.
Intervention. The education programme, which was designed to in-
troduce strategies to cope with the FM symptoms, consisted of 6 1-h
sessions, conducted once a week for 6 weeks. The programme was
led by a physiotherapist. The pedagogical approach was based on the
active participation of the patients through discussions and practical
exercises. The topics were theories for long-lasting pain, pain allevia-
tion, physical activity, stress, relaxation and modications of lifestyle
to enhance health. At each session, the patients drew up a plan (a
contract) for physical activity for the next week and performed a short
relaxation exercise. The control group received the same education
programme. Details of the programme are shown in Appendix I.
The exercise programme comprised 20 sessions of 45-min pool exer-
cise once a week for 20 weeks in temperate (33°C) water, supervised by a
physiotherapist. The exercise was planned to permit individual progress,
aiming to improve overall function and to motivate regular physical ac-
tivity. The median value for exertion (6–20), measured by the Borg scale
for rating perceived exertion (BRPE) (32), ranged from 9 (“very light”)
to 11 (“light”) during exibility, co-ordination and stretching exercises,
while it was 13 (“somewhat hard”) during aerobic exercise. Heart rate
(HR) was monitored with a Polar S610i HR monitor (Kempele, Finland)
and expressed in values for age-adjusted maximum HR, 220 minus age
(HR
max
). The mean value for HR during the programme ranged from
48% to 65% HR
max
, which corresponds with light to moderate intensity
(33). Details of the programme are shown in Appendix II.
Statistics
Descriptive data are presented as the mean and standard deviation (SD)
or the number and percentage. For comparisons between 2 groups,
Mann-Whitney U test was used for continuous variables, Fishers exact
test for dichotomous variables and Mantel-Haenszel χ
2
test for trend in
contingency tables for ordinal categorical variables. For comparisons
within groups, Wilcoxon’s signed-rank test was used for continuous
variables, while McNemars test was used for dichotomous variables.
Effect size was calculated for variables showing a signicant change.
Effect size for between-group analyses was calculated by dividing the
mean difference between the post-test score and baseline score in the
intervention group and in the control group by the pooled SD. Effect
size for the 11–12 months follow-up was calculated as the mean dif-
ference between the follow-up score and baseline score divided by the
SD at baseline. Effect sizes from 0.20 to < 0.50 were regarded as small,
while effect sizes from 0.50 to < 0.80 were regarded as moderate (19).
To control possible Type I errors, the upper limit of expected number
of false signicances for the secondary and exploratory variables was
calculated by the following formula: α/1– α × number of tests number
of signicant tests), where α is the signicance level.
Pre-specied subgroups were created by dichotomized values for
the SCI, the FIQ Pain, the HADS-D and the SF36 PF. The SCI, the
FIQ Pain and the SF36 PF were dichotomized by the median value, as
there are no known cut-off points for these variables indicating more
or less pathology in a pain population, while the HADS-D was dichot-
omized by a score of 8, which indicates possible depression (24). The
heterogeneity, an interaction between the independent variable, group
membership and the change score for the primary outcome measure
(the FIQ total and the 6MWT), was analysed using a generalized linear
model for subgroup analyses. A signicant heterogeneity implies dif-
ferent effects of the intervention for 2 subgroups. Differences in the
change scores were analysed by Fisher’s non-parametric permutation
test, and mean differences with 95% condence intervals within each
subgroup are presented in the graph. All signicance tests were 2-tailed
and values of p < 0.05 were concidered signicant.
RESULTS
Study population
No signicant baseline differences in demographic data were
found between the patients (n = 166) randomized to either the
intervention group (n = 81) or the control group (n = 85) (see
Table I). Baseline pharmacological treatment is shown in Table I.
Use of analgesics at post-test was reported by 67% of the patients
in the exercise-education group and by 65% in the control group.
Use of antidepressants and/or sedatives was reported by 45%
of the patients in the exercise-education group and by 44% in
the control group. No signicant change in pharmacological
treatment over time was found for either of the 2 groups.
Intention-to-treat analyses (Table II)
Primary outcomes. Signicantly higher improvement (p = 0.040,
z = –2.049) was found for change in the FIQ Total in the exercise-
education programme (–4.8, SD 13.2) compared with change in
the control programme (–0.7, SD 12.2) after the 20-week study
period. The effect size of the FIQ total for the intervention group
compared with the control group was 0.32.
Change in the 6MWT in the exercise-education programme
(7.5, SD 53.5) was not statistically signicant (p = 0.067,
z = –1.830) compared with change in the control group (–2.0,
SD 63.2) after the 20-week study period.
Secondary outcomes. Signicant improvement (p = 0.018,
z = –2.370) was found for change in the FIQ Pain in the exer-
cise-education group (–7.8, SD 22.6) compared with change in
the control group (1.7, SD 19.5) after the 20-week treatment.
The effect size of the FIQ Pain was 0.45 for the intervention
group compared with the control group.
Exploratory outcomes. Change in the MFI-20 Reduced Motiva-
tion in the exercise-education group (–0.8, SD 3.3) was signi-
cantly improved (0.046, z = 1.994) compared with change in
the control group (0.3, SD 3.2). Change in the Activity-related
Relaxation in the exercise-education group (–0.4, SD 1.2) was
also signicantly improved (p = 0.017, z = –2.396) compared
with change in the control group (0.2, SD 1.4). The effect
size of the MFI-20 Reduced Motivation was 0.34, while the
effect size of the Activity-related Relaxation was 0.45 for the
intervention group compared with the control group.
Type I error. The secondary and exploratory between-group
analyses comprised a total of 23 statistical analyses, and the
upper level of number of false signicances was 1.05, which
indicates that one of the signicances found might be false.
Per-protocol analysis (Table III)
Forty-seven of 81 patients (58%) randomized to the exercise-
education programme and 56 (66%) of 85 patients randomized
to education were dened as active participants.
Primary outcomes. Significant improvement (p = 0.013,
z = –2.486) was found for change in the FIQ total in the
exercise-education programme (–6.3, SD 14.4) compared with
change in the control programme (–0.6, SD 12.5) at the 20-
week post-test. The effect size of the FIQ total for the interven-
tion group compared with the control group was 0.44.
Signicant improvement (p = 0.013, z = –2.497) was found for
change in the 6MWT in the exercise-education programme (14.5,
SD 35.8) compared with change in the control programme (–6.4,
SD 58.3) after 20 weeks. The effect size of the 6MWT for the
intervention group compared with the control group was 0.43.
J Rehabil Med 41
755
Exercise for patients with FM or CWP
Secondary outcomes. Signicant improvement (p = 0.002,
z = 3.073) was found for change in the FIQ Pain (–10.0, SD
18.8) in the exercise-education programme compared with
change in the control programme (3.0, SD 18.9). The effect
size of the FIQ Pain for the intervention group compared with
the control group was 0.69.
Change in the LTPAI Total activity (1.0, SD 3.7) was
signicantly increased (p = 0.026, z = –2.220) in the exercise-
education group compared with change in the control group
(–0.1, SD 5.06). Most part of the increase was at a moderate
level, shown by signicant (p = 0.048, z = –1.976) change in the
LTPAI Moderate activity (1.3, SD 2.7), among the exercisers
compared with change among the controls (0.2, SD 2.9). The
effect size of the LTPAI total activity was 0.25, while the effect
size of the LTPAI Moderate activity was 0.39 in the interven-
tion group compared with the control group.
Exploratory outcomes. Signicant improvement (p = 0.005,
z = –2.789) was found for change in the MFI Reduced Motivation
among the exercisers (–1.1, SD 3.1), compared with the controls
(–0.7, SD 3.0), effect size being 0.13. Signicant improvement
(p = 0.002, z = –3.027) was also found for change in the Activity-
related Physical relaxation among the exercisers (–0.6, SD 1.2),
compared with the controls (0.4, SD 1.5), as well as for the
Activity-related Well-being (p = 0.021, z = –2.312) in the exercise
group (–0.7, SD 1.4) compared with the controls (–0.1, SD 1.4).
The effect size of Activity-related relaxation was 0.72, while
the effect size of Activity-related Well-being was 0.43 when the
intervention group was compared with the controls.
Type I error. A total of 23 between-group analyses were con-
ducted, and the upper level of number of false signicances
was 0.89, which indicates that one of the signicances found
might be false.
11–12-month follow-up in the intention-to-treat population
(Table II)
A total of 125 patients (75%) randomized to the study completed
the follow-up at the 11–12-month examination. Within the
exercise-education group, signicant improvement was found
Table II. Intention-to-treat analysis. Baseline values, change from baseline in outcome variables, within-group and between-group differences for
the Exercise-Education group and the Education group
Exercise–Education group Education group
Ex–Edu
vs Edu
Baseline
n = 81
Mean (SD)
20 w
n = 69
Mean (SD) p
11–12 mo
n = 63
Mean (SD) p
Baseline
n = 85
Mean (SD)
20 w
n = 64
Mean (SD) p
11–12 mo
n = 62
Mean (SD) p
20 w
p
Primary outcomes
FIQ Total 61.6 (16.42) –4.8 (13.19)
0.006
3.9 (15.45) 0.077 66.6 (15.30) –0.7 (12.22) 0.952 –4.5 (14.32)
0.024 0.040
6MWT 511 (79.7) 7.5 (53.51)
0.047
14.1 (57.59)
0.013
517 (77.2) –2.0 (63.18) 0.591 3.9 (66.27) 0.800 0.067
Secondary outcomes
FIQ Pain 67.7 (16.79) –7.8 (22.57)
0.007
–6.5 (23.68) 0.119 70.4 (20.05) 1.7 (19.47) 0.674 –2.5 (19.85) 0.252
0.018
FIQ Fatigue 76.3 (22.49) –5.0 (25.50) 0.103 –2.7 (24.35) 0.486 81.7 (17.64) –3.8 (19.05) 0.035 –5.5 (21.88) 0.134 0.980
SF36 PCS 30.8 (8.09) 3.1 (7.70)
0.006
2.86 (8.64)
0.006
29.4 (8.03) 0.6 (8.32) 0.776 1.3 (7.93) 0.234 0.129
SF36 MCS 40.9 (13.77) 0.4 (10.64) 0.864 0.51 (13.93) 0.561 36.6 (12.29) 2.2 (12.02)
0.040
1.3 (11.26) 0.197 0.146
SF36 PF 56.6 (19.00) 0.7 (11.98) 0.614 2.19 (14.46) 0.252 50.9 (18.30) 0.7 (16.79) 0.839 1.3 (16.93) 0.761 0.702
SF36 RP 22.8 (32.16) 14.8 (44.26)
0.008
12.1 (40.68) 0.035 15.2 (26.04) 7.6 (33.34) 0.099 9.3 (43.62) 0.056 0.719
SF36 BP 28.6 (14.32) 5.1 (16.72)
0.014
5.0 (21.13) 0.084 25.7 (16.09) 0.4 (17.07) 0.650 3.6 (18.22) 0.129 0.236
SF36 VT 28.4 (21.09) 6.6 (20.67)
0.009
4.2 (23.03) 0.130 24.2 (16.72) 3.9 (21.57) 0.132 2.3 (21.02) 0.713 0.377
HADS Anx 8.1 (5.53) –0.7 (3.01) 0.117 –0.7 (3.30) 0.112 9.1 (4.82) 0.4 (3.39) 0.429 0.4 (3.79) 0.369 0.148
HADS Dep 6.4 (4.01) –0.2 (2.98) 0.508 –0.4 (3.26) 0.555 7.8 (3.64) –0.1 (2.77) 0.748 0.0 (3.15) 0.673 0.993
LTPAI, total 5.4 (4.06) 1.0 (4.26)
0.036
0.6 (4.09) 0.309 5.0 (4.23) 0.3 (4.64) 0.861 –0.4 (5.72) 0.811 0.117
LTPAI, mod 2.0 (2.14) 1.2 (2.91)
0.000
0.2 (2.85) 0.677 2.1 (2.72) 0.3 (2.69) 0.413 –0.5 (3.68) 0.530 0.068
Exploratory outcomes
SCI 73.3 (23.43) –2.8 (11.97) 0.094 –3.9 (13.23)
0.011
79.4 (26.09) –0.8 (12.14) 0.650 –2.6 (12.36) 0.339 0.436
MFI GF 16.9 (2.65) –0.4 (2.75) 0.394 17.8 (2.30) –0.8 (3.07)
0.037
0.368
MFI PF 16.6 (3.06) –0.6 (2.89) 0.083 17.6 (2.42) –1.0 (3.80)
0.010
0.544
MFI RA 15.0 (3.38) –0.6 (3.09) 0.075 16.0 (3.46) –1.1 (3.25)
0.008
0.436
MFI RM 10.2 (3.89) –0.8 (3.26)
0.040
10.8 (3.75) 0.3 (3.22) 0.451
0.046
MFI MF 14.4 (4.15) –0.2 (3.34) 0.585 14.2 (3.86) 0.3 (2.79) 0.408 0.390
A-Relaxation 4.6 (1.50) –0.4 (1.22)
0.008
4.6 (1.24) 0.2 (1.44) 0.439
0.017
A-Wellbeing 2.8 (1.46) –0.4 (1.41)
0.023
2.9 (1.31) –0.0 (1.41) 0.486 0.284
A-Beliefs 2.3 (1.35) 0.1 (1.39) 0.870
2.2 (1.25) –0.2 (1.02) 0.838 0.983
A-Symptoms 3.4 (1.23) –0.1 (1.42) 0.472 3.2 (1.23) –0.1 (1.59) 0.518 0.993
A-Habits 3.4 (1.59) 0.2 (1.58) 0.500 4.0 (1.55) –0.1 (1.85) 0.768 0.437
Signicant values are shown in bold.
A: activity; FIQ: Fibromyalgia Impact Questionnaire; HADS: Hospital Anxiety And Depression Scale; LTPAI: leisure time physical activity instrument;
MCS: mental component score; MFI: multidimensional fatigue inventory; MFI GF: MFI general fatigue; MFI MF: MFI mental fatigue; MFI PF: MFI
physical fatigue; MFI RA: MFI reduced activity; MFI RM: MFI reduced motivation; PCS: physical component score; SCI: stress and crisis inventory;
SD: standard deviation; SF36: 36-item short form health survey; SF36 BP: SF36 bodily pain; SF36 PF: SF36 physical functioning; SF36 RP: SF36
role-physical; SF36 VT: SF36 vitality; 6MWT: 6-minute walk-test.
J Rehabil Med 41
756
K. Mannerkorpi et al.
for change in the 6MWT (14.1, SD 57.6, p = 0.013, z = –2.472),
as well as for change in the SF36 Physical Component (2.86,
SD 8.6, p = 0.006, z = 2.731), the SF36 Role Physical (12.1, SD
40.7, p = 0.035, z = –2.108) and the SCI (–3.9, SD 13.2, p = 0.011,
z = –2.552). The effect size of the 6MWT was 0.18. The effect
size of the SF36 Physical Component was 0.35 and of the SF36
Role Physical 0.38. The effect size of the SCI was 0.17.
Within the control group, change in the FIQ Total (–4.5, SD
14.3) signicantly improved (p = 0.024, z = 2.254) over time,
effect size being 0.29. The change scores for the control group
have been omitted from Table II.
Type I error. A total of 15 analyses were conducted, and the upper
level of number of false signicances was calculated to 0.78, which
indicates that one of the signicances found might be false.
11–12- month follow-up in the pre-protocol population (Table III)
The follow-up outcomes were analysed separately for the PP
population. Signicant improvements over time were found for
the 6MWT (21.5, SD 48.2; p = 0.007, z = –2.707), the FIQ Pain
(–9.1, SD 20.9; p = 0.019, z = –2.336); the SF36 Physical Com-
ponent (3.0, SD 6.7; p = 0.002, z = 3.057); the SF36 Physical
function (4.2, SD11.1; p = 0.024, z = –2.250); the SF36 Bodily
Pain (8.3, SD 32.5; p = 0.014, z = –2.454); the LTPAI Moderate
Activity (0.8, SD 2.7; p = 0.045, z = –2.009); and the SCI (4.5,
SD 10.2; p = 0.010, z = –2.569). The effect size was 0.29 for
the 6MWT; 0.54 for the FIQ Pain; 0.35 for the SF36 Physical
Component; 0.43 for SF36 Bodily Pain; 0.12 for SF36 Vitality;
0.41 for the LTPAI moderate activity, and 0.18 for the SCI.
No signicant improvements over time were found within
the control group, and the change scores have been omitted
from Table III.
Type I error. A total of 15 analyses were conducted, and the
upper level of number of false signicances was 0.42, which
indicates that 0–1 signicances found might be false.
Subgroup analysis (Fig. 2)
FIQ Total. No signicant heterogeneity was found for the
subgroups created by level of pain, distress, stress and activity
Table III. Per-protocol analysis. Baseline values, change from baseline in outcome variables, within-group and between-group differences for the
active participants in the Exercise-Education group and the Education group
Exercise-Education group Education group
Ex–Edu
vs Edu
Baseline
n = 47
Mean (SD)
20 w
n = 46
Mean (SD) p
11-12 mo
n = 42
Mean (SD) p
Baseline
n = 56
Mean (SD)
20 w
n = 50
Mean (SD)
Baseline
p
11-12 mo
n = 40
Mean (SD) p
20 w
p
Primary outcomes
FIQ Total 61.2 (17.73) –6.3 (14.41)
0.003
–4.7 (13.45) 0.063 65.9 (15.98) –4.4 (15.53) 0.881 –0.6 (12.47) 0.121
0.013
6MWT 507 (75.05) 14.5 (35.79)
0.024
21.5 (48.18)
0.007
511 (71.07) –6.4 (58.34) 0.287 3.7 (59.53) 0.856
0.013
Secondary outcomes
FIQ Pain 68.8 (16.73) –10.0 (18.83)
0.002
9.1 (20.89)
0.019
68.3 (19.87) 3.0 (18.92) 0.512 –2.3 (19.69) 0.595
0.002
FIQ Fatigue 75.1 (23.74) –7.6 (27.12) 0.063 –4.0 (25.31) 0.473 82.3 (17.76) –4.7 (19.59)
0.042
–5.6 (21.33) 0.534 0.732
SF36 PCS 30.4 (8.65) 2.9 (6.28)
0.007
3.0 (6.69)
0.002
29.3 (8.24) –0.3 (8.73) 0.942 1.4 (8.44) 0.412 0.104
SF36 MCS 41.9 (14.17) 0.1 (10.21) 0.562 0.0 (11.94) 0.856 36.2 (12.80) 3.8 (12.38)
0.008
1.8 (12.39) 0.162 0.085
SF36 PF 53.6 (19.64) 1.5 (11.22) 0.346 4.2 (11.08) 0.024 50.6 (16.90) 0.2 (16.42) 0.856 1.3 (17.31) 0.724 0.583
SF36 RP 26.2 (33.95) 11.4 (40.15) 0.074 8.3 (32.51) 0.134 15.2 (26.83) 9.9 (36.24) 0.079 10.2 (37.06) 0.067 0.697
SF36 BP 27.9 (15.44) 6.1 (15.07)
0.006
6.7 (15.76) 0.014 25.1 (14.83) 0.7 (16.01) 0.782 4.1 (19.28) 0.207 0.183
SF36 VT 30.3 (22.15) 6.1 (15.07)
0.021
2.6 (17.47) 0.192 23.0 (16.20) 4.9 (21.09) 0.154 3.3 (22.20) 0.659 0.329
HADS Anx 8.16 (5.48) –0.9 (2.74) 0.055 –0.8 (2.76) 0.071 9.15 (5.03) 0.4 (3.38) 0.471 –0.4 (3.87) 0.352 0.099
HADS Dep 6.21 (4.18) –0.2 (2.77) 0.327 – 0.5 (2.56) 0.418 7.82 (3.41) –0.3 (2.78) 0.472 –0.0 (3.18) 0.611 0.865
LTPAI, total 5.6 (4.43) 1.0 (3.68)
0.017
0.0 (3.37) 0.823 5.3 (4.15) –0.1 (5.06) 0.678 –0.2 (4.99) 0.420 0.026
LTPAI, mod 1.9 (1.96) 1.3 (2.74)
0.001 0.8 (2.67) 0.045
2.1 (2.90) 0.2 (2.90) 0.654 –0.5 (3.93) 0.802
0.048
Exploratory outcomes
SCI 72.3 (24.56) –3.1 (9.53) 0.053 –4.5 (10.19)
0.010
81.4 (25.24) –1.1 (9.83) 0.512 –3.2 (12.13) 0.168 0.382
MFI GF 17.0 (2.76) –0.5 (2.68) 0.238 18.0 (2.73) –0.6 (2.93) 0.217 0.819
MFI PF 16.7 (2.76) –0.9 (2.71)
0.036
18.0 (2.11) –0.7 (2.60) 0.074 0.738
MFI RA 15.3 (3.47) –1.1 (2.78)
0.010
16.3 (3.02) –1.0 (3.30)
0.034
0.868
MFI RM 10.0 (4.05) –1.1 (3.13)
0.031
10.8 (3.68) –0.7 (3.02) 0.089
0.005
MFI MF 14.6 (4.56) 0.1 (3.09) 0.978 14.3 (3.87) 0.5 (2.75) 0.101 0.379
A-Relaxation 4.8 (1.49) –0.6 (1.21)
0.001
4.6 (1.31) 0.4 (1.54) 0.198
0.002
A-Wellbeing 3.0 (1.57) –0.7 (1.36)
0.001
2.9 (1.35) –0.1 (1.44) 0.943
0.021
A-Beliefs 2.5 (1.31) –0.3 (1.14) 0.102 2.2 (1.36) 0.0 (1.00) 0.984 0.262
A-Symptoms 3.0 (1.08) 0.3 (1.16) 0.070 3.2 (1.27) –0.0 (1.62) 0.723 0.294
A-Habits 3.4 (1.58) –0.0 (1.66) 0.624 4.0 (1.63) –0.2 (1.85) 0.603 0.960
Signicant values are shown in bold.
A: activity; FIQ: Fibromyalgia Impact Questionnaire; HADS: Hospital Anxiety And Depression Scale; LTPAI: leisure time physical activity instrument;
MCS: mental component score; MFI: multidimensional fatigue inventory; MFI GF: MFI general fatigue; MFI MF: MFI mental fatigue; MFI PF: MFI
physical fatigue; MFI RA: MFI reduced activity; MFI RM: MFI reduced motivation; PCS: physical component score; SCI: stress and crisis inventory;
SD: standard deviation; SF36: 36-item short form health survey; SF36 BP: SF36 bodily pain; SF36 PF: SF36 physical functioning; SF36 RP: SF36
role-physical; SF36 VT: SF36 vitality; 6MWT: 6-minute walk-test.
J Rehabil Med 41
757
Exercise for patients with FM or CWP
limitations, implying that these aspects did not have any sig-
nicant inuence on change in the FIQ total score. However, a
non-signicant tendency towards heterogeneity (p = 0.073) was
found for the subgroup created by the SCI (< 78/
78), implying
that the improvement in the FIQ total tended to be inuenced
by stress, in favour of those with lower stress scores.
Analysis within the subgroup characterized by lower degree
of the stress (< 78 on the SCI) relieved a signicant (p = 0.013)
improvement in the FIQ Total in the exercise-education group
(–6.0, SD 15.2) compared with change in the control group
(2.9, SD 11.4), effect size for the intervention group compared
with the control group being 0.64. A signicant improvement
(p = 0.042) was also found for change in the FIQ total (–4.7, SD
15.1) in the exercise-education group characterized by lower
ratings on the FIQ Pain (< 70), compared with change in the
control group (2.8, SD 12.2), effect size for the intervention
group compared with the control group being 0.54. Signicant
improvement (p = 0.025) was also found for change in the FIQ
total (–5.0, SD 13.8) in the patients in the exercise-education
group reporting lower level of distress (< 8 on the HADS-D),
compared with change in the control group (2.2, SD 13.3), effect
size for the intervention group compared with the control group
being 0.53. No signicant change in the FIQ total was found in
the patients reporting more severe scores on the SCI (p = 0.723),
the FIQ Pain (p = 0.530) or HADS-D (p = 0.911) (see Fig. 2).
6MWT. No signicant heterogeneity was found for the subgroups
created by the level of pain, distress, stress and activity limitations
implying their inuence on the change score of the 6MWT.
DISCUSSION
The present RCT showed that a 20-week supervised exercise-
education programme improved health status (the FIQ total
score) in patients with FM and CWP, which is in line with previ-
ous studies of exercise and education (8–13). The intervention
group was compared with a control group that undertook the
same 6-week education programme, including planning weekly
exercise in their own environment. The effect size of the FIQ
total was small (0.31) in the intervention group compared with
the controls in the ITT-population, but it increased to 0.45 in the
active participants in the intervention group compared with the
controls (the PP-population). These results are comparable to the
effect sizes found in pharmacological and non-pharmacological
studies of patients with FM in primary healthcare (34).
The 6MWT, the primary outcome at the level of body
function, did not signicantly improve in the between-group
analysis of the ITT population. In the active participants (PP-
population), the 6MWT improved in the intervention group,
compared with the controls, but the change was smaller than
expected. A contributory reason for this poor improvement
might be the fairly good baseline walking capacity in the pa-
tients (> 500 m, SD > 70 m), which possibly resulted in ceiling
effects for several patients. It is probable that patients today
are more physically active than in previous years, as the mean
baseline walking distance in the present study appears to be
higher than in our previous study (467 m) published in 2002
(12). Increased public knowledge of the benets of exercise
may have contributed to a higher activity level.
Improvement in the FIQ total in the intervention group was sup-
ported by improvement in several components related to health.
The FIQ Pain showed signicant improvement in the intervention
group compared with the control group. Effect size of the FIQ
Pain score was 0.45 in the ITT-population, increasing to 0.69 in
the active participants in the exercise-education group compared
with the controls. Signicantly enhanced activity-related relaxa-
tion among the exercisers, being in line with previous studies
(35–37), might also have contributed to the improved health
status. No signicant changes were found for pharmacological
treatment during the study period, indicating that a reduction in
pain intensity cannot be explained by pharmacology.
MFI-20 Reduced motivation signicantly improved in the
intervention group compared with the control group. Other
fatigue dimensions showed conicting results, as some of them
improved within the control group, while others improved
Fig. 2. Subgroup inuences on change in the primary outcomes. (a)
Fibromyalgia Impact Questionnaire (FIQ) total. (b) Six-minute walk test
(6MWT). The subgroups were created by dichotomized values of the
stress and crisis inventory (SCI), the FIQ Pain, the Hospital Anxiety and
Depression Scale (HADS), and the 36-item Short-Form Health Survey
(SF36) Physical Function. Mean differences for the change score and
95% condence intervals (CI) are presented in the graphs, followed
by p-value, separately for each subgroup. p-value for heterogeneity
(interaction between the randomized group and the change score of the
primary outcome) is given in the right-hand column. ITT: intention to
treat.*Fishers Non-Parametic Parmulation test.
J Rehabil Med 41
758
K. Mannerkorpi et al.
within the intervention group. Improvement in fatigue within
the education group is supposedly related to the programme,
designed to introduce strategies to cope with the symptoms.
Symptoms in the study population ranged from mild to very
severe. The median value of the FIQ Pain was 70 on the 0–100
scale, which indicates severe pain. Distress was also common
in the study population, as shown by the HADS scores. The
median SCI score in the patient population was 78, which
indicates a high level of stress, but it corresponds with the
ndings in a previous Swedish study of stress in FM, where
the SCI score was 75 (26).
The second aim of the present study was to investigate the
inuence of stress, pain, distress and activity limitations on
changes in the primary outcomes. No signicant heterogeneity
was found, but stress tended (p = 0.07) to inuence change in
the FIQ total. This implies that exercisers presenting with lower
scores for stress might improve more in their health status as
a consequence of the treatment than those with higher scores.
A slight tendency towards heterogeneity (p = 0.137) was also
found in the HADS-D.
Separate within-group analyses of patients presenting with
lower ratings for stress, pain and distress revealed a signicant
improvement in the FIQ total (p < 0.05) among the exercisers,
compared with the control group (effect size > 0.50).
No signicant heterogeneity was found for change in the
6MWT, which may be related to the small improvement in the
intervention group discussed earlier. However, the HADS-D
showed a slight tendency (p = 0.109) towards heterogeneity, in
favour of exercisers not perceiving distress (< 8). This result
was supported by a non-signicant (p = 0.069) improvement
in the 6MWT (10.9, SD 46.3) among the exercisers with low
HADS-D scores, compared with change among the controls
(–14.1, SD 68.5). A non-signicant improvement (p = 0.077) in
the 6MWT (26.1, SD 43.2) was also found among the exercis-
ers characterized by better SF36 Physical Function compared
with the control group (–1.1, SD 61.9).
Subgroups based on symptom severity and physical impair-
ments among patients with FM have been described previously
(14, 38, 39). To the best of our knowledge, this is the rst study
to demonstrate subgroup differences in outcomes of exercise
in patients with FM, suggesting that patients with milder
symptoms gain the best effects from exercise.
The long-term follow-up, conducted 11–12 months after the
baseline, revealed lasting, but small, improvement in the 6MWT
in the exercise-education group, in both the ITT and PP popula-
tions. The FIQ Pain and the SF36 Bodily Pain revealed signicant
long-term improvements in the active participants, indicating that
regular exercise may contribute to control of pain in FM. An al-
ternative explanation might be the signicantly shorter symptom
duration (9.7, SD 7.19) in the PP-population compared with the
non-active participants (11.7, SD 6.95). Also, a previous study
has suggested that shorter symptom duration is associated with
higher improvement in FM (34). No signicant baseline differ-
ences for age, education, work status or main outcomes were
found between the active and non-active participants.
The pool exercise programme provided an opportunity
for individual adjustments of exercise to perceived pain and
fatigue. Perceived exertion (BRPE) ranged fromvery light
to “somewhat hard” (32), reecting the content of the pro-
gramme that included exercises with and without resistance.
The patients exercised in the pool only once a week, which is a
limitation of the exercise protocol studied. Increased frequency
might have improved the effects of exercise.
Another limitation of the present study was the choice of the
control group. Education is regarded as a treatment modality;
therefore the control group was not totally without interven-
tion, which would have been the ideal situation. Comparison
between 2 treatment protocols may have minimized the
differences indicating improvement in the intervention pro-
gramme. Signicant improvements within the education group
were, however, few in number. One reason might be the long
symptom duration of the patients, as many of them reported
that they had already participated in education to help them
manage their symptoms.
Several outcomes were included in the study, as we were in-
terested in different aspects of health. The 2 primary outcomes
were analysed rst and the FIQ Pain was regarded as the most
important secondary outcome. Due to multiple comparisons,
the signicance levels found should be interpreted with caution,
and the upper limit of expected number of false signicances
is presented after each analysis.
The recruitment process began with a systematic search of
patient journals with codes associated with myalgia. A total
of 818 journals were found and scrutinized. Most of these did
not meet the inclusion criteria for CWP. A total of 109 patients
could not be assessed for eligibility, while 30 patients who
fullled the criteria declined to participate or were excluded
from the study. Thus, all together, 17% of the total number of
potentially eligible patients was not included in the study; this
proportion is, however, not regarded as a threat to the external
validity of the study.
Twenty percent of the patients (n = 33) included in the study
did not complete the post-test, despite attempts to motivate them
to participate. Half of these patients (n = 17) did not start the
treatment programme, mainly due to time limitations associ-
ated with changes in work schedules or family commitments or
concomitant disorders. Other reasons for dropping out were dis-
satisfaction with the group to which they had been randomized,
increase in pain and other reasons not reported. Drop-out rates
of approximately 20% are not rare in exercise studies enrolling
patients with FM, as highlighted in several reviews (40).
In conclusion, an exercise-education programme improved
health status in FM and CWP. No signicant heterogeneity was
found for the subgroups created by level of pain, distress, stress
and activity limitations, but patients with milder stress, pain
or depression improved most by treatment, gaining moderate
improvements in their health status,
ACKNOWLEDGEMENTS
The GAU Study Group: Mona Lind, Eva Melin, Anne Fredrikson,
Marianne Hjerpe and Åsa Holmestrand in Primary Health Care, Alingsås;
Mattias Hjelm and Elisabeth Enhörning in Primary Health Care, Ud-
devalla; Ann-Kristine Neuman in Primary Health Care in Göteborg. The
statistical adviser was Nils-Gunnar Pehrsson.
J Rehabil Med 41
759
Exercise for patients with FM or CWP
Financial support was provided by The Swedish Research Council, The
Health and Medical Care Executive Board of Västra Götaland Region,
The Swedish Rheumatism Association, The Länsförsäkringsbolagens
Research Foundation, The Rheumatic Pain Society in Göteborg/RiG,
The Göteborg Region Foundation for Rheumatology Research/GSFR
and ALF at Sahlgrenska University Hospital.
REFERENCES
Wolfe F, Smythe H, Yunus M, Bennet R, Bombardier C, Golden-1.
berg D, et al. The American College of Rheumatology 1990 criteria
for the classication of bromyalgia. Report of the Multicenter
Criteria Committee. Arthritis Rheum 1990; 33: 160–172.
Henriksson C, Gundmark I, Bengtsson A, Ek A. Living with 2.
bromyalgia. Consequences for everyday life. Clin J Pain 1992;
8: 138–144.
Mannerkorpi K, Burckhardt C, Bjelle A. Physical performance 3.
characteristics of women with bromyalgia. Arthritis Care Res
1994; 7: 123–129.
Clauw D, Crofford L. Chronic widespread pain and bromyalgia: 4.
what we know and what we need to know. Best Pract & Res Clin
Rheumatol 2003; 17: 685–701.
Gran T. The epidemiology of chronic generalized musculoskeletal 5.
pain. Best Pract Res Clin Rheumatol 2003; 17: 547–561.
Bergman S, Herrström P, gström K, Peterson I, Svensson B, 6.
Jacobsson L. Chronic musculoskeletal pain, prevalence rates, and
sociodemographic associations in Swedish population study. J
Rheumatol 2001; 28: 1369–1377.
Croft P, Schollum J, Silman A. Population study of tender point 7.
counts and pain as evidence of bromyalgia. Br Med J 1994;
309: 696–699.
Burckhardt C, Mannerkorpi K, Hedenberg L, Bjelle A. A rand-8.
omized, controlled clinical trial of education and physical training
for women with bromyalgia. J Rheumatol 1994; 21: 714–720.
King S, Wessel J, Bhambhani Y, Sholter D, Maksymowych W. 9.
The effect of exercise and education, individually or combined, in
women with bromyalgia. J Rheumatol 2002; 29: 2620–2627.
Cedraschi C, Desmeules J, Rapiti E, Baumgarther E, Cohen P, 10.
Finckh A, et al. Fibromyalgia: a randomised, controlled trial of
a treatment programme based on self-management. Ann Rheum
Dis 2004; 63: 290–296.
Gowans S, deHueck A, Voss S, Richardson M. A randomised 11.
controlled trial of exercise and education for individuals with
bromyalgia. Arthritis Care Res 1999; 12: 120–128.
Mannerkorpi K, Nyberg B, Ahlmén M, Ekdahl C. Pool exercise 12.
combined with an education program for patients with bromyalgia
syndrome. J Rheumatol 2000; 27: 2473–2481.
Rooks D, Gautam S, Romeling M, Cross M, Stratiqakis D, Evans 13.
B, et al. Group exercise, education, and combined self-management
in women with bromyalgia: a randomized trial. Arch Intern Med
2007; 12: 2192–2200.
Thieme K, Turk D, Flor H. Responder criteria for operant and 14.
cognitive-behavioral treatment of bromyalgia syndrome. Arthritis
Care Res 2007; 57: 830–836.
Mannerkorpi K, Kroksmark T, Ekdahl C. How patients with bro-15.
myalgia experience their symptoms in everyday life. Physiother
Res Int 1999; 4: 110–122.
van Santen M, Bolwijn P, Verstappen F, Bakker C, Hidding A, 16.
Houben H, et al. A randomized clinical trial comparing tness
and biofeedback training versus basic treatment in patients with
bromyalgia. J Rheumatol 2002; 29: 575–581.
Kurtze N, Gundersen K, Svebak S. Quality of life, functional dis-17.
ability and lifestyle among subgroups of bromyalgia patients:
the signicance of anxiety and depression. Br J Med Psychol
1999; 72: 471–484.
Mannerkorpi K, Iversen M. Physical exercise in bromyalgia and relat-18.
ed syndromes. Best Pract & Res Clin Rheumatol 2003; 17: 629–647.
Fayers PM, Machin D. Quality of life. Assessment, analysis and 19.
interpretation. Eastbourne: John Wiley sons, Ltd; 2001.
Pocock SJ, Simon R. Sequential treatment assignment with balanc-20.
ing for prognostic factors in the controlled clinical trial. Biometrics
1975; 31: 103–115.
Kosek E, Ekholm J, Hansson P. Sensory dysfunction in bromy-21.
algia patients with implications for pathogenic mechanisms. Pain
1996; 68: 375–383.
Hedin P, Hamne M, Burckhardt C, Engström-Laurent A. The Fi-22.
bromyalgia Impact Questionnaire, a Swedish translation of a new
tool for evaluation of the bromyalgia patient. Scand J Rheumatol
1995; 24: 69–75.
Ware JJ, Sherbourne C. The MOS 36-item short-form health survey 23.
(SF36). I. Conceptual framework and item selection. Med Care
1992; 30: 473–483.
Herrmann C. International experiences with the hospital anxiety 24.
and depression scale a review of validation data and clinical
results. J Psychosom Res 1996; 42: 17–41.
Mannerkorpi K, Hernelid C. Leisure time physical activity in-25.
strument and Physical Activity at Home and Work instrument.
Development, face validity, construct validity and test-retest
reliability for subjects with bromyalgia. Disabil Rehabil 2005;
27: 695–701.
Krafft B, Nystm C. High level of stress and immature defenses 26.
make for a vicious circle in chronic pain. Läkartidningen 2002;
99: 4040–4043.
Tyni-Lenne R, Stryjan S, Eriksson B, Berglund M, Sylven C. 27.
Benecial therapeutic effects of physical training and relaxation
therapy in women with coronary syndrome X. Physiother Res Int
2002; 7: 35–43.
Smets E, Garssen B, Bonke B, De Haes J. The Multidimensional 28.
Fatigue Inventory (MFI). Psychometric qualities of an instrument
to assess fatigue. J Psychosom Res 1995; 39: 15–25.
Ericsson A, Mannerkorpi K. Assessment of fatigue in patients 29.
with bromyalgia and chronic widespread pain. Reliability and
validity of the Swedish version of the MFI-20. Disabil Rehabil
2007; 30: 1665–1670.
Mannerkorpi K, Rivano-Fischer M, Ericsson A, Nordeman L, Gard 30.
G. Experience of physical activity in patients with bromyalgia and
chronic widespread pain. Disabil Rehabil 2008; 30: 213–221.
Mannerkorpi K, Svantesson U, Carlsson J, Ekdahl C. Tests of 31.
functional limitations in bromyalgia syndrome: a reliability study.
Arthritis Care Res 1999; 12: 193–199.
Borg G. Psychophysical bases of perceived exertion. Med Sci 32.
Sport Exerc 1982; 14: 377–381.
Fletcher G, Balady G, Amsterdam E, Chaitman B, Eckel R, Fleg 33.
J, et al. Exercise standards for testing and training. A statement
for healthcare professionals from the American Heart Association.
Circulation 2001; 2001: 1694–1740.
Garcia-Campayo J, Magdalena J, Magallon R, Fernandez-Garcia 34.
E, Salas M, Andres E. A meta-analysis of the efcacy of bro-
myalgia treatment according to level of care. Arthritis Res Ther
2008; 10: R81.
Mannerkorpi K, Gard G. Physiotherapy group treatment for pa-35.
tients with bromyalgia an embodied learning process. Disabil
Rehabil 2003; 25: 1372–1380.
Altan L, Bingol U, Aykae M. Investigation of the effects of pool-36.
based exercise on bromyalgia syndrome. Rheumatol Int 2003;
24: 272–277.
Gowans S, deHueck A, Voss S, Richardson M. Effect of a randomized 37.
controlled trial of exercise on mood and physical function in individu-
als with bromyalgia. Arthritis Care Res 2001; 45: 519–529.
Giesecke T, Williams D, Harris R, Cupps T, Tian X, Tian T, et al. 38.
Subgrouping of bromyalgia patients on the basis of pressure-pain
thresholds and psychological factors. Arthritis Rheum 2004; 48:
2916–2922.
Turk D, Okifuji A, Sinclair J, Starz T. Pain, disability and physical 39.
functioning in subgroups of patients with bromyalgia. J Rheu-
matol 1996; 23: 1255–1262.
Mannerkorpi K, Henriksson C. Non-pharmacological treatment 40.
of chronic widespread musculoskeletal pain. Best Pract Res Clin
Rheumatol 2007; 21: 513–534.
J Rehabil Med 41
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K. Mannerkorpi et al.
APPENDIX I. Education programme
The education programme consisted of 6 1-h sessions, once a week, based on self-efcacy principles requiring active participation of the patients.
The aim was to introduce strategies to cope with bromyalgia symptoms and to encourage regular physical activity.
The topics were:
1. Symptoms and explanatory theories for long-lasting pain. The session started by listing the patients’ symptoms on a ip chart, followed by a
discussion of these symptoms. A short presentation of theories for long-lasting pain was given, followed by a discussion of the participants’ own
theories and beliefs. A short relaxation exercise was performed while seated.
2. Pain and pain alleviation. Physical activity and exercise. A short presentation of the local (gate theory) and central (central nervous system) levels
of pain modulation and strategies for pain alleviation was given, followed by a discussion of the participants’ experience. The participants were
encouraged to use different techniques, including physical activity and relaxation. A contract for physical activity for the forthcoming week was
written. A short relaxation exercise was performed while seated.
3. Stress, pain and depression. Feedback for physical activity during the past week was given and a new contract for activity for the forthcoming
week was written. A short presentation of theories about stress was given, followed by the participants’ own experience of what makes them
stressed and how they prevent and alleviate stress. A short relaxation exercise was performed while seated.
4. Physical relaxation and body awareness. Feedback for physical activity during the past week was given and a new contract for activity for the
forthcoming week was written. Continuation of discussion about stress. Methods for active and passive relaxation and body awareness were
presented and practiced.
5. Lifestyle. Feedback for physical activity during the past week was given and a new contract for activity for the forthcoming week was written.
Identication of possible causes of increases in pain and stress and opportunities to do something about them were discussed. The participants
were asked to write down their own plans for changes, according to a model that was presented.
6. Lifestyle. Feedback for physical activity during the past week was given and a new contract for activity for the forthcoming week was written.
Continuation of the topic introduced at session 5.
APPENDIX II. Pool exercise programme
Pool exercise was designed for patients with chronic widespread pain or bromyalgia. Each session lasted for 45 min in temperate (33°C) water.
The aim was to enable the participants (i) to perform movements with awareness and to nd their own rhythm and harmony when exercising and
to learn the limits and potential of their bodies, (ii) to understand how to modify the exercises individually, (iii) to be condent about their ability to
choose optimal resistance and control pain while exercising, (iv) to increase their motivation for physical activity, and (v) to improve function.
At the start of each pool group, the physiotherapist demonstrated all the movements at a slow and smooth pace, emphasizing that everyone should
adjust the exercise individually with respect to their threshold of pain and fatigue. When the participants had learnt the movements and performed
them correctly, the pace was increased for those who were able to accept it. Individual instructions were given whenever needed. A oating device
(FD) that provides stability, assistance and/or progression when exercising was used in different parts of the programme.
Warming up
Walking or jogging forwards, backwards and to the side with increasing speed either paddling with the arms in order to achieve resistance, or
smoothly stroking the arms in the water.
Two programme sets of co-ordination and exibility exercises
The participants were instructed to select the pace and resistance by positioning their hand during the movement with respect to their current
threshold of pain.
Arm movements combined with transferring weight from side to side while standing.
Reciprocal shoulder exion and extension with paddles combined with knee bending while standing.
Bilateral elbow extension and exion with the upper arms held towards the thorax.
Bilateral shoulder internal and external rotation with the upper arms held towards the thorax.
Swimming strokes with the arms.
Arm movements with bilateral elbow exion and extension holding the FD at the surface in front of the body with progression, for those who
were able to manage this, pushing the FD in the direction of the bottom and close to the body.
Arm movements holding the FD at the surface in front of the body while rotating from side to side.
When standing, unilateral hip extension and exion.
Reciprocal diagonal movement with the hand touching the knee.
Two programme sets of aerobic exercises
Jogging and walking while sitting on an FD, combined with arm movements.
Two programme sets of body awareness and breathing exercise
• Performed when standing, combined with pelvic movements.
Stretching
Stretching exercises for arm and leg muscles.
Relaxation
Performed either standing and leaning against a wall or in a supine position. FD such as air-lled tyres or neck collars were provided.
J Rehabil Med 41
... Thus, due to the nature of water, hydrotherapy can reduce swelling and relieve pain in TKRA patients. Its added benefit is that it allows for the safe reduction of body weight during exercise [12][13][14][15][16][17][18]. ...
... Although intensive rehabilitation treatment could be ideal for TKRA patients, the implementation of early intensive exercise may be difficult due to pain and swelling immediately after surgery. Aqua therapy has been used in various therapeutic fields to help manage conditions such as arthritis, neuromuscular diseases, and cerebral palsy [10,16,[30][31][32][33]. The main advantages of aqua exercise for the patients are the lifting force (buoyancy) and density, hydrostatic pressure, viscosity, and thermodynamics of water [34]. ...
Article
Full-text available
Background and Objectives: Early intensive exercise after total knee replacement arthroplasty (TKRA) has become increasingly popular due to its ability to enhance knee physical function and reduce pain. When implemented exclusively, aquatic exercise (AE) appears to be more advantageous than land exercise (LE), particularly in the early phase after TKRA. Our study aimed to compare the clinical efficacy of AE and LE with respect to their effects on pain and physical function after TKRA. Materials and Methods: Between February 2008 and January 2020, 100 female patients who underwent TKRA were enrolled in this retrospective study. We measured the range of motion (ROM) of the knee, the isokinetic strength of the knee joint (function), and pain both initially and one month after TKRA. Two weeks after TKRA, the participants were enrolled in either the AE or the LE program for a total of two weeks. Two 30 min sessions of intensive ROM and knee strengthening exercises and balance training were provided to the AE and LE groups for 10 days. The home exercise group (HE) only received information on ROM and strengthening exercises. There were 33, 21, and 46 patients allocated to the AE, LE, and HE groups, respectively. Results: The ROM of the side on which surgery was performed improved significantly in all groups, as did the pain scores. In the AE group, the knee flexor strength showed a tendency toward improvement. Contrastingly, there was no significant improvement in the knee extensor strength in the AE group. Conclusions: Overall, the AE and LE groups showed superior outcomes compared with HE. In addition, the AE group demonstrated some improvement in knee muscle strength even with a short hospital stay. Further study with long-term follow-up should be performed to better define the outcomes.
... The exclusion criteria were heterogeneous and included pregnancy [27,46,47,53,[59][60][61]63,71,74,82,83,86,88,98], neurological diseases [29,35,37,39,41,44,62,65,77,81,82,84,97], rheumatic diseases [29,32,33,39,[41][42][43][44]47,55,[57][58][59][60]65,74,77,79,80,83,88,91,94,98], psychological/psychiatric conditions [27,32,38,42,45,46,49,50,55,[59][60][61]63,64,66,69,70,[73][74][75][79][80][81][82][83]89,91,94], intake medication [32,35,41,44,49,54,57,58,64,66,75,95], diabetes mellitus [32,43,44,55,57,58,65,85], cancer [32,34,46,58,64,67,82,89], skin disorders [29,[50][51][52]92], trauma [59-61, 65,83,92], hypertension [32,[42][43][44]57,58,65,66,72], migraine [59][60][61]83], osteoarthritis [30,43,66,85,91], peripheral nerve entrapment [59][60][61]83], obesity [29,39,74], substance abuse [64,73,77], and hypotension [50,51,65]. It is important to mention that in 54.7% (n = 40/73) of clinical trials, people with cardiac, pulmonary or kidney diseases were excluded since these "visceral" conditions could limit the therapeutic intervention used in these trials (exercise). ...
... The exclusion criteria were heterogeneous and included pregnancy [27,46,47,53,[59][60][61]63,71,74,82,83,86,88,98], neurological diseases [29,35,37,39,41,44,62,65,77,81,82,84,97], rheumatic diseases [29,32,33,39,[41][42][43][44]47,55,[57][58][59][60]65,74,77,79,80,83,88,91,94,98], psychological/psychiatric conditions [27,32,38,42,45,46,49,50,55,[59][60][61]63,64,66,69,70,[73][74][75][79][80][81][82][83]89,91,94], intake medication [32,35,41,44,49,54,57,58,64,66,75,95], diabetes mellitus [32,43,44,55,57,58,65,85], cancer [32,34,46,58,64,67,82,89], skin disorders [29,[50][51][52]92], trauma [59-61, 65,83,92], hypertension [32,[42][43][44]57,58,65,66,72], migraine [59][60][61]83], osteoarthritis [30,43,66,85,91], peripheral nerve entrapment [59][60][61]83], obesity [29,39,74], substance abuse [64,73,77], and hypotension [50,51,65]. It is important to mention that in 54.7% (n = 40/73) of clinical trials, people with cardiac, pulmonary or kidney diseases were excluded since these "visceral" conditions could limit the therapeutic intervention used in these trials (exercise). ...
Article
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Evidence supports the presence of comorbid conditions, e.g., irritable bowel syndrome (IBS), in individuals with fibromyalgia (FM). Physical therapy plays an essential role in the treatment of FM; however, it is not currently known whether the IBS comorbidity is considered in the selection criteria for clinical trials evaluating physiotherapy in FM. Thus, the aim of the review was to identify whether the presence of IBS was considered in the selection criteria for study subjects for those clinical trials that have been highly cited or published in the high-impact journals investigating the effects of physical therapy in FM. A literature search in the Web of Science database for clinical trials that were highly cited or published in high-impact journals, i.e., first second quartile (Q1) of any category of the Journal Citation Report (JCR), investigating the effects of physical therapy in FM was conducted. The methodological quality of the selected trials was assessed with the Physiotherapy Evidence Database (PEDro) scale. Authors, affiliations, number of citations, objectives, sex/gender, age, and eligibility criteria of each article were extracted and analyzed independently by two authors. From a total of the 412 identified articles, 20 and 61 clinical trials were included according to the citation criterion or JCR criterion, respectively. The PEDro score ranged from 2 to 8 (mean: 5.9, SD: 0.1). The comorbidity between FM and IBS was not considered within the eligibility criteria of the participants in any of the clinical trials. The improvement of the eligibility criteria is required in clinical trials on physical therapy that include FM patients to avoid selection bias.
... Several studies reported the benefits of aerobic exercise for reducing the signs and symptoms presented by patients with fibromyalgia [27,67,68]. Six articles had the objective of evaluating the effects of an aerobic intervention protocol, but only four studies used instruments to assess cardiovascular parameters or performed analysis of aerobic capacity. ...
Article
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Physical exercise has been used as a form of treatment for fibromyalgia, however, the results indicate the need for further investigations on the effect of exercise on different symptoms. The aim of the study was to synthesize and analyse studies related to the effect of exercise in individuals with fibromyalgia and provide practical recommendations for practitioners and exercise professionals. A search was carried out in the Web of Science, PubMed, and Scopus databases in search of randomized clinical trials (RCT) written in English. A meta-analysis was performed to determine the effectiveness of different types of exercise on the fibromyalgia impact questionnaire (FIQ), and the protocol period and session duration on the pain outcome. Eighteen articles were eligible for a qualitative assessment and 16 were included in the meta-analysis. The exercise showed large evidence for the association with a reduction in the FIQ (SMD − 0.98; 95% CI − 1.49 to − 0.48). Protocols between 13 and 24 weeks (SMD − 1.02; 95% CI − 1.53 to − 0.50), with a session time of less than 30 min (SMD − 0.68 95% CI − 1.26 to − 0.11) or > 30 min and < 60 min (SMD − 1.06; 95% CI − 1.58 to − 0.53) presented better results. Better results were found after combined training protocols and aerobic exercises. It is suggested that exercise programs lasting 13–24 weeks should be used to reduce pain, and each session should last between 30 and 60 min. In addition, the intensity should always be carried out gradually and progressively. PROSPERO registration number CRD42020198151.
... Con respecto al tipo de programa de entrenamiento más conveniente, existe cierta evidencia de que la realización de ejercicio aeróbico y de fortalecimiento muscular serían los más adecuados para reducir el dolor y mejorar el bienestar en las personas con FM; que los ejercicios de estiramiento y aeróbicos mejorarían más la CVRS; y que los ejercicios combinados producirían las mayores mejoras en cuanto a la sintomatología depresiva (Sosa-Reina et al., 2017). Sin embargo, se necesitan estudios más robustos para confirmar cuál debería ser la prescripción de ejercicio (intensidad, duración, tipo de ejercicio o actividad y/ con qué otros medios de tratamiento podría ser combinado) más favorable para cada persona con FM (Andrade et al., 2018;Bidonde et al., 2014;Busch et al., 2009Busch et al., , 2013Gowans et al., 2001;Kim et al., 2019;Mannerkorpi et al., 2000). ...
Article
El objetivo de este estudio fue estudiar el efecto de un entrenamiento de Vibracio?n Meca?nica de Cuerpo Completo (VMCC) de 12 semanas en el dolor de espalda de personas sedentarias con Fibromialgia (FM). 41 mujeres diagnosticadas con FM de una media de 47 an?os (±10.5) fueron aleatorizadas en un grupo control (n= 20) y grupo de VMCC (n=21). La intervencio?n de VMCC consistio? en 6 repeticiones a 12,5 Hz repartidas en 3 sesiones por semana durante 12 semanas. Se midio? el dolor de espalda con el cuestionario Roland Morris y el grado de discapacidad con el Cuestionario de Impacto de FM. Tras la realizacio?n del programa VMCC no se han obtenido diferencias estadi?sticamente significativas en el dolor de espalda. Como conclusio?n, el programa propuesto no ha mejorado el dolor especi?fico de espalda en mujeres sedentarias con FM
... La mayoría de los estudios presentan calidad alta o media. Por último, se han identificado estudios que no cumplen criterios de inclusión, pero pueden aportar información adicional en otros aspectos del diagnóstico [24][25][26][27][28][29][30][31] . ...
Article
Full-text available
Objective To prevent the deterioration of patients with fibromyalgia due to potentially avoidable harmful actions in clinical practice. Methods A multidisciplinary panel of experts identified key areas, analysed the scientific evidence and formulated recommendations based on this evidence and qualitative techniques of “formal assessment” or “reasoned judgement”. Results Thirty-nine recommendations were made on diagnosis, ineffective and unsafe treatments, patient education and practitioner training. This part II shows the 12 recommendations, referring to the latter two areas. Conclusions Good knowledge of fibromyalgia on the part of patients improves their coping and acceptance of the disease and reduces the severity of some clinical manifestations. Healthcare professionals treating patients with fibromyalgia should be well trained in this disease to improve treatment outcomes and patient relationships.
... Accordingly, one previous investigation, after an 18-week physical training program, showed improvements in perceived pain, balance and ability to produce force (Latorre Roman et al., 2015). Other study obtained improvements in the MFI-20, specifically in reduced motivation and mental fatigue after a program of physical exercise in an active environment combined with educational activities (Mannerkorpi et al., 2000). While most programs focused on a specific type of effort (only an aerobic or strength training), several studies applied multicomponent training programs composed of endurance training, resistance training and relaxation (Munguía-Izquierdo & Legaz-Arrese, 2007). ...
Article
Full-text available
Fibromyalgia is a chronic and multifactorial disease, characterized by the presence of generalized pain that negatively influences the health-related quality of life of the affected person. Despite the severity and disabling effects that this disease causes in most cases, the physical and psychological symptoms can be alleviated through adequate physical fitness, with water-based exercise being one of the most recommended approaches for fibromyalgia patients. The objective of this case report was to verify the suitability and feasibility of a multicomponent aquatic training program carried out in a high temperature spa pool for a woman with fibromyalgia. For this purpose, a complete physical and psychological analysis in this patient with a history of lack of compliance and tolerance of physical activity is presented as a case report. A 62 year-old woman with fibromyalgia participated in 6-week program of strength, core, aerobic, and flexibility training developed in the aquatic environment, with analyses performed before and after intervention, where physical and psychological parameters were evaluated. The percentage of improvement showed an enhancement in all physical and psychological factors, with some test results over the reference values of minimal detectable change and minimal clinically significant difference for fibromyalgia patients and women of similar age. The presented case report provides a comprehensive examination of the physical and psychological status of a woman with fibromyalgia, prior to and proceeding a non-pharmacological intervention based on a multicomponent water-based training program. Results highlighted that a 6-week programme of water-based exercise program in a spa pool was suitable for reaching an enhancement in different physical and psychological parameters in this fibromyalgia patient, with her history of poor compliance and tolerance to conventional physical activity. If future studies with more sample size confirm our results, this approach could result interesting for fibromyalgia patients with low adherence and tolerance to land based training. Key Words: multicomponent training, aquatic exercise, quality of life, women health.
... physiotherapists). This also included exercise sessions in pools in a smaller number of studies [32,35,42,44,[47][48][49][50]. In one study the physical activity component comprised of Qigong, (a gentle movement system grounded in Traditional Chinese Medicine) [51]. ...
Article
Full-text available
Background Chronic widespread pain (CWP) including fibromyalgia has a prevalence of up to 15% and is associated with substantial morbidity. Supporting psychosocial and behavioural self-management is increasingly important for CWP, as pharmacological interventions show limited benefit. We systematically reviewed the effectiveness of interventions applying self-management principles for CWP including fibromyalgia. Methods MEDLINE, Embase, PsycINFO, The Cochrane Central Register of Controlled Trials and the WHO International Clinical Trials Registry were searched for studies reporting randomised controlled trials of interventions adhering to self-management principles for CWP including fibromyalgia. Primary outcomes included physical function and pain intensity. Where data were sufficient, meta-analysis was conducted using a random effects model. Studies were narratively reviewed where meta-analysis could not be conducted Evidence quality was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluations) (PROSPERO-CRD42018099212). Results Thirty-nine completed studies were included. Despite some variability in studies narratively reviewed, in studies meta-analysed self-management interventions improved physical function in the short-term, post-treatment to 3 months (SMD 0.42, 95% CI 0.20, 0.64) and long-term, post 6 months (SMD 0.36, 95% CI 0.20, 0.53), compared to no treatment/usual care controls. Studies reporting on pain narratively had greater variability, however, those studies meta-analysed showed self-management interventions reduced pain in the short-term (SMD -0.49, 95% CI -0.70, -0.27) and long-term (SMD -0.38, 95% CI -0.58, -0.19) compared to no treatment/usual care. There were few differences in physical function and pain when self-management interventions were compared to active interventions. The quality of the evidence was rated as low. Conclusion Reviewed studies suggest self-management interventions can be effective in improving physical function and reducing pain in the short and long-term for CWP including fibromyalgia. However, the quality of evidence was low. Future research should address quality issues whilst making greater use of theory and patient involvement to understand reported variability.
... La mayoría de los estudios presentan calidad alta o media. Por último, se han identificado estudios que no cumplen criterios de inclusión, pero pueden aportar información adicional en otros aspectos del diagnóstico [24][25][26][27][28][29][30][31] . ...
Article
Resumen Objetivo Evitar el deterioro de los pacientes con fibromialgia por actuaciones perjudiciales en la práctica clínica potencialmente evitables. Métodos Un panel multidisciplinar de expertos identificó las áreas clave, analizó la evidencia científica y formuló las recomendaciones a partir de esta evidencia y de técnicas cualitativas de «evaluación formal» o «juicio razonado». Resultados Se han elaborado 39 recomendaciones sobre diagnóstico, tratamientos no eficaces ni seguros, educación del paciente y formación del profesional. En esta parte II se reflejan las 12 recomendaciones, referidas a las dos últimas áreas. Conclusiones Un buen conocimiento de la fibromialgia por el paciente mejora el afrontamiento y la aceptación de la enfermedad reduciendo la gravedad de algunas manifestaciones clínicas. Los profesionales sanitarios que tratan a los pacientes con fibromialgia deben tener una buena formación sobre esta enfermedad para mejorar los resultados del tratamiento y la relación con el paciente.
... First of all, swelling in the lower extremities can be reduced by hydrostatic forces from immersion combined with exercise [11]. Secondly, immersion in water can relieve body-weight and allows patients to move their legs more easily, resulting in patients having a pleasurable experience when exercising in water [12]. Moreover, by varying the speed of movement in the water, different resistances can be obtained, which are beneficial in developing increased muscular strength [13]. ...
Article
Background Hydrotherapy or aquatic exercise has long been known as a source of postoperative rehabilitation proposed in routine clinical practice. However, the effect on clinical outcome as well as the optimal timing of hydrotherapy in patients undergoing total knee arthroplasty (TKA) remain unclear. The purpose of this review was to assess the influence of aquatic physiotherapy on clinical outcomes and evaluate the role of the timing of aquatic-therapy for clinical outcomes after undergoing TKA. Methods An extensive literature search was performed in Embase, PubMed, and the Cochrane Library for randomized controlled trials (RCTs) that evaluated the impact of hydrotherapy on patients after TKA. The methodological quality of the trials was evaluated based on the Cochrane Risk of Bias Tool. Results All available studies on postoperative hydrotherapy after TKA were included. The primary endpoint was to evaluate the effect of hydrotherapy on clinical outcomes. The secondary outcome was to explore the role of the timing of aquatic therapy for clinical outcomes following TKA. Conclusion Although definitive conclusions could not be reached due to insufficient data, most studies indicated that participants benefited from aquatic-therapy in muscle strength, rather than gait speed, after TKA. Currently available data demonstrated that early postoperative hydrotherapy possessed a greater potential to improve clinical outcomes in main clinical scores and quality-adjusted life years (QALYs).
... En el primero 149 , con la combinación de ejercicios (entrenamiento de fuerza, ejercicios aeróbicos y de flexibilidad) y educación, se muestra una mejora significativamente mayor en comparación con la educación o el ejercicio aplicados separadamente en los síntomas de la FM. Otros dos ensayos, que se centraron en la combinación del ejercicio en grupo y la educación, muestran también que el programa de ejercicio-educación obtenía una mejora significativa en el estado de salud, la calidad de vida y la satisfacción de esta población 150,151 . En otro ECA 152 , se encontraron mejoras significativas pre-post en todas las variables (escala de Beck, cuestionario FIQ, otras variables subjetivas mediante escala EVA) en el grupo de intervención educativa + ejercicio aeróbico suave, no siendo así en el grupo control que recibió solamente folletos. ...
Technical Report
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Durante los últimos años se ha producido un avance importante en el estudio de los mecanismos patogénicos involucrados en la fibromialgia (FM) con un conocimiento más profundo de la enfermedad. Ha habido también numerosos cambios en el diagnóstico y en el manejo terapéutico con la aprobación de varios fármacos y otras medidas terapéuticas eficaces para su control. Asimismo, se han publicado varias recomendaciones realizadas por importantes sociedades científicas que recogen los avances producidos en FM. Sin embargo, algunas actuaciones en la dinámica de la atención sanitaria de los pacientes con FM perjudican notablemente su manejo y también el pronóstico. La elaboración de estas Recomendaciones se ha centrado en detectar aquellas actuaciones comunes en la práctica clínica que pueden resultar perjudiciales para el paciente con FM y, así se han podido establecer una serie recomendaciones cuyo objeto es el de evitar un deterioro de la situación de estos pacientes. Pretenden ser una herramienta que facilite la actuación adecuada de todos los posibles especialistas implicados en el control de la actividad de la enfermedad. Esto permitirá disminuir la variabilidad clínica sin detrimento de la calidad de vida de los pacientes. El documento de Recomendaciones se ha elaborado teniendo en cuenta una metodología rigurosa. También ha sido sometido a un proceso de revisión externa y exposición pública para asegurar su transparencia y no ha recibido alegación alguna Se creó un panel formado por cinco reumatólogos, una médica de fami-lia, un psicólogo, una psiquiatra, una enfermera y una paciente con FM, previamente seleccionados mediante una convocatoria abierta o por méritos profesionales. https://www.ser.es/recomendaciones-sobre-fibromialgia-fm/
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