Top 10 Principles for Prescribing Exercise in Fibromyalgia
Kim Jones PhD

Most people with fibromyalgia (FM) have been advised to exercise. However, most have also experienced the symptom flare that accompanies exercise that is not tailored for FM. To make matters worse, many health care providers and even exercise instructors may not know how best to help.    

This article describes the top 10 principles for successful exercise in FM. Share this article with your health care provider and exercise instructor to achieve maximum success in your exercise attempts. Some of our advice can only be carried out by a health care provider, such as prescribing medications and ordering tests. Use this document as a way to have a conversation with your health care provider. Trying to discuss all 10 principles in a single office visit may not be as effective as choosing the two or three principles that apply most to you. Then talk about other principles at future visits. Applying these principles to your exercise routine should result in increased strength, flexibility, aerobic fitness and a gradual decline in many fibromyalgia symptoms.

 1)     Treat peripheral pain generators to minimize central sensitization

People with FM have an enhanced awareness of pain arising from skin, muscle, and joint structures, due to central sensitization, which has been found to be an important component in the pathophysiology of FM. It is critical to identify peripheral pain generators such as osteoarthritis, spine pathology, bursitis, tendonitis, plantar fasciitis, and myofascial trigger points. Treatments of peripheral pain generators with medications, injections, manual therapies, and lidocaine or capsacin patches as appropriate can increase the likelihood of exercise success.

Exercise should also be modified to minimize aggravation of the peripheral pain generators. It is important to choose a type of exercise that does not exacerbate these peripheral pain generators. For example, if you have significant knee osteoarthritis and stiffness you may do better with water-based aerobics than land-based aerobics. If you have significant gluteal and trochanteric (hip) trigger points, they will be have less aggravated by using an elliptical trainer rather than a stationary bike. If joints you have hypermobile joints, you may benefit from seeing a  physical therapist who can teach you to rest and exercise with your joints within the normal joint line, thereby reducing another source of peripheral pain generation.

Stretching can also aid in the release of peripheral pain generators, especially trigger points. Specifically tightened muscle bands and contraction knots within muscle are lessened as the Golgi tendon apparatus signals the muscle fibers to relax. The dose of stretching is key - you cannot stretch too often, but you can stretch too far. Stretches should not produce immediate muscle burning and should be static, rather than ballistic (avoid bouncing). If you experience too much pain to stretch, you may find relief with fluromethasone spray and stretch techniques. This technique requires a prescription spray from the provider usually given in concert with a referral to physical therapy who teaches you how to use spray and stretch at home. Alternatively, you can stretch in a warm bath or shower.

2)     Recognize the importance of restorative sleep

It is important for your provider to evaluate and treat for obstructive sleep apnea and restless legs syndrome, both of which are more common in FM. This may involve questions or an overnight sleep study. People with FM generally report sleep problems (difficulty falling asleep, staying asleep, or non-refreshing sleep). Minimal time in stages three and four sleep, alpha intrusion into delta sleep, and reduced sleep efficiency are well documented in sleep studies of FM patients. In fact, minimal time in stages three and four sleep may be responsible, in part, for disordered hypothalamic pituitary growth hormone axis, as 80% of GH is made during deep sleep. This dysfunction manifests itself as low insulin-like growth hormone levels in at least 30 percent of persons with FM and low growth hormone secretion in response to acute exercise in 90 percent of persons with FM. Growth hormone in adults has the critical function in adulthood is to repair muscle microtrauma after activity. A combination of medications and sleep hygiene will generally improve sleep quality, fatigue, and ability to exercise. A provider who finds it uncomfortable to prescribe long-term sleep medications may find it beneficial to refer sleep management to a sleep specialist, psychiatrist, or a psychiatric mental health nurse practitioner.

The exercise modification may be to choose a class that is during the your optimal hours of function (often 10 a.m.–3 p.m.) rather than at the end of the day. Additionally, many patients report an increased ability to tolerate exercise after a short nap. Dysfunctional breathing patterns are common in persons with chronic sleep deprivation and pain postures. In appreciation of this, the instructor should spend ample time in warm-up/cool-down and breathing practices at the beginning and end of class. Common unhealthy breathing practices include reverse breathing, chest breathing, collapsed breathing, or frozen/shallow breathing. Correcting these patterns in class provides patients with a skill set they can apply throughout their day.

3)     Minimize eccentric muscle work

Because most people with FM can not make adequate GH to repair their muscles during exercise, it is important to minimize eccentric muscle use. Eccentric muscle use is muscle lengthening against resistance. Exercise tailoring to minimize muscle work can be done in classes, with gym equipment or even in activities of daily living. For example while walking downhill load is placed on elongated muscles, and creating greater eccentric muscle work. If you prefer treadmill walking, choose to walk on a flat, not downward sloping grade to minimize eccentric muscle use.  Use small steps and limited arm extension when walking, mopping or vacuuming to minimize eccentric work in the hips and thighs. Also keep movements near the midline of the body and minimize overhead work and repetitive motion, particularly of small muscle groups. For example, in a water aerobics class you may chose to lift your bent elbows to your shoulder level (like a chicken) rather than reach your extended arm toward to sky.

Most gym equipment for aerobic training relies on repetitive movements. To minimize eccentric muscle work on machines such as elliptical trainers, stair steppers and Nordic tracks, use the lowest hand grip available or let the arms rest on the support bars. A better approach to these types of equipment is to move between machines every 10 minutes or less based on fitness level. Care should be taken with recumbent bikes to avoid knee hyper-extension. When using machine or free weights, spend more time in concentric contraction compared to eccentric contraction. For example, bicep contraction could be up 1-2-3-4-5-6, down 1-2-3, rest 1-2-3 to allow the muscle to return to full baseline resting state. Strength training movements should be kept on a parallel plane and near the midline of the body when possible.

Consider using lighter weight than age predicted norms, often less than 50% than recommended on standard age charts. Training should begin with single sets of 6 repetitions, increasing slowly. Soft, elastic bands have the advantage of providing resistance without requiring heavy lifting, a tight grip or sustained contraction. These are helpful if you have wrist pain or carpal tunnel syndrome. If you who wish to use free weights, consider employing a personal trainer to assure proper positioning. Trainers can also aid in counting repetitions and limiting time spent in eccentric contraction. A trainer also allows you to conserve your energy for specific exercise rather than spending your energy return weights to a rack and determining the next exercise from an often overwhelming number of machines. Lastly, a clinician can write a prescription for exercise, as can a personal trainer, and often the cost may be reimbursed through an employer-sponsored health-care flexible spending account.

4)     Program low-intensity, non-repetitive exercise

Early exercise interventions in FM offered trials that were more similar in dose to those recommended by the American College of Sports Medicine, whose original audience was elite athletes. People with FM, who could tolerate the interventions, demonstrated improvements in physical fitness, but results were mixed in terms of symptom reduction. One way to conceptualize the dose of exercise needed in FM is to realize that the therapeutic window is narrow: too much exercise results in symptom exacerbation; too little exercise is inadequate to obtain results. Just like 1/8th of an aspirin is probably too low a dose to help your headache, but 8 aspirin will most likely give you a stomach ache.

Aerobic activity in FM is best accomplished by moving the large muscle groups of the legs and hips, with lesser involvement of the upper extremities.  The program should avoid repetitive movements by alternating limbs, building in rest periods that are individualized by the participant, and change movement patterns frequently. These recommendations are difficult for instructors who use “add-on” routines in which patients learn eight-count dance-type moves, adding more complexity and a greater number of patterns. Many people with FM have difficulty remembering complex movement patterns, perhaps in part due to documented cognitive difficulties.

Effective exercise can be done on land or in the water, individually or in a group. The type of exercise is largely determined by your preference and access to group classes and warm water pools. Pool exercise classes should not be confused with swimming. Swimming may induce a flare if done too aggressively as it is an intense upper body exercise that relies heavily on overhead eccentric strokes.

Walking is well supported in the aerobic literature as well as the FM literature. It is touted as having the greatest chance of becoming a maintained exercise program. In addition to aerobic fitness, walking promotes core strength and thereby may reduce back pain. When walking, take small steps on flat, even surfaces, minimize eccentric muscle work, and reduce fall risk. Adding ankle or wrist weights to a walking routine is not recommended in FM as aerobic gains are made largely by maximizing the use of large muscles like the hips and thighs. Additionally, ankle weights may contribute to falls.

5)      Stretch the anterior chest and strengthen the upper back

Many people with chronic pain develop “pain postures”. These often include pulling the head and neck forward, raising the shoulders toward the ears and rounding the shoulders and upper back forward (picture a boiled shrimp). Pain postures may contribute to back and neck pain, headaches and shallow breathing. Reversing pain postures can be done by taking frequent work breaks from the computer, or while sitting or driving. During those breaks attempt to stand with the spine against a wall, heels touching the wall. If possible, gently pull the chin in toward the neck and lift the top of the head. If this is not too difficult, the next step is to position arms, elbows bent, at 90 degrees with palms facing the room, not the wall. Hold this stretch for 10 seconds initially. Slowly work up to holding this position for 2 minutes. To strengthen the upper back consider lying over a large exercise ball with your weight supported by your belly. Rest your heels against a wall so that the ball doesn’t roll away from you. Gently rest your folded hands behind your neck, without pulling on your neck. Use the muscle of your mid and upper back to lift up 1-2 inches and hold for 10 seconds if possible. Eventually, work up to lifting 10 times, holding each for 20 seconds. If you do not have an exercise ball, you can position yourself on hands and knees (on a pillow). Extend one arm in front of your and the opposite leg lifts behind you no higher than your back. The goal is to eventually become strong enough to make a straight line between your extended arm, leg and back. Keep your gaze slightly down and forward to remind yourself not to strain your neck.

6)     Screen for and treat autonomic dysfunction

Autonomic dysfunction is widely recognized as another component of FM. In particular, this can manifest as severe fatigue, near syncopal episodes, orthostatic hypotension and chronic low blood pressure. The clinician can screen for neurally mediated hypotension and postural orthostatic tachycardia syndrome, ordering a tilt table test when appropriate. If persistent low blood pressure is an issue, ask your provider if you should drink very dilute salt-water (1 tsp per gallon) and wear compression stockings. In severe cases, prescription of fludrocortisone (Florinef) may be necessary to allow patients to tolerate exercise. The exercise instructor should know if patients are taking medications that may worsen orthostatic hypotension or be associated with dizziness.

The exercise modification for autonomic dysfunction includes avoiding prolonged motionless standing. You may will prefer to exercise from a chair. Transitions from lying to standing positions during exercise should be slow, often up to 60 seconds. Lastly, instructors should avoid movements that require pivots or fast turns. Temperature dysregulation associated with dysautonomia and sleep deprivation may be bypassed by dressing in layers for exercise.

7)     Evaluate for poor balance and fall risks

People with FM often have poor balance and are more prone to falls and accidents. Balance has been shown to improve with exercise training in FM. Referral to a physical therapist may be beneficial in patients with very poor balance. They can teach you to use lightweight aluminum canes, even during exercise. The canes can be adjusted up or down a notch each day. The patient should also learn to alternate arms when using a cane. Both of these techniques reduce shoulder girdle stress and resultant regional pain.

The exercise instructor can design routines with movements near a wall or with a partner to promote stabilization. Multi-tasking during exercise and rapid turning should be reduced to decrease risk of falls. Gentle exercises in bare feet may increase kinesthetic awareness, thereby promoting balance. With regards to exercise equipment wear wearing supportive shoes are a must, a larger treadmill with a color difference between the moving treadmill and the side bar may minimize falls.

8)     Modify exercise for common co-morbidities (central sensitivity syndromes)

The provider should look for common co-morbidities, such as irritable bowel syndrome, overactive bladder, chronic headaches, multiple chemical sensitivies and pelvic pain syndromes that accompany FM.. Along with maximizing medical management of these conditions, exercise can be modified for common co-morbidities. For irritable bowel/bladder, choose an exercise room within easy access of a restroom. If exercising at home, consider walking around the block several times rather than walking a mile away from the house and a mile back to maintain proximity to a bathroom. For pelvic pain syndromes such as endometriosis, vulvodynia, and vulvar vestibulitis, patients should avoid jarring/pounding standing exercises such as jumping jacks. They can use a reclined exercise bike rather than upright and use a pillow or donut during seated exercises. For chronic headaches and multiple chemical sensitivities, the instructor can institute the exercise studio as a “fragrance-free zone”, use a lower volume setting for music, and avoid glaring or flashing lighting. You can also wear silicone ear plugs if they find that noise precipitates a headache.

9)     Address obesity and deconditioning

The FM patient population is experiencing a steep rise in body mass index, much like the general United States population. Obese people with FM may face additional challenges when trying to maintain therapeutic exercise, and can feel self-conscious about participating in group exercise classes. Provider discussions about obesity should focus on functional improvements, not body-image. It can be helpful to refer patient to a dietician. If insurance doesn’t cover a visit to a registered dietician, the provider can write a prescription for dietary counseling for obesity and FM, which may be reimbursable through a flexible health care spending account.

To ease your concerns during a group exercise classes, look for instructors who avoid body image discussion during exercise. In otherwords, is isn’t helpful to hear the instructor say that “we working our abdominal muscles to get ready for swimsuit season”. Mirrors can be covered or classes can be oriented away from mirrors. When teaching positions, the instructor should allow for added abdominal girth instructing patients to separate their knees during seated positions or selected resting positions (e.g., child’s pose in yoga).

Aerobic and muscular deconditioning is common in FM regardless of body mass index. Both are essential to maintaining functional independence. Furthermore, muscle function in FM is retrainable. Multiple studies have demonstrated strength gains in people with FM that mirror strength gains seen in healthy controls. Maintaining strength and aerobic conditioning, therefore, is an essential and realistic component of the exercise prescription.  The critical element is understanding the limits of traditional aerobic and strength training given demonstrated deconditioning and the flare inducing potential of muscle microtrauma. You should attempt to increase the exercise intensity by approximately 10% only after you feel comfortable for two or more weeks at the previous level.

10)   Conserve energy in daily life in order to exercise

Unlike the standard exercise recommendations from the Surgeon General to increase lifestyle activity (e.g., take stairs instead of elevator, use manual garage door openers, park farther away), this type of activity has not shown to be effective in FM. Fontaine et al tested increasing lifestyle activity, such as walking, housework, yard work by 70 percent, as assessed by a pedometer, and found that it did not demonstrate statistical significance in FM symptoms and 6-minute walk times compared to an FM education control group. However, FM patients who are more fit may be able to increase activities of daily living (ADLs) as recommended by other FM exercise experts. For patients who have been sedentary for greater than three months, we recommend a fatigue reduction program that allows patients to save their energy for an actual exercise session. For example, in daily life patients can conserve energy in non-exercise activities (e.g., sit in shower, consider a hairstyle that doesn’t require morning shower/overhead blow drying/styling). The ultimate goal of exercise in FM is not elite athletic fitness, but a gradual move toward functional independence and fitness. A more fit body will allow patients to move through their ADLs without inducing a symptom flare. As aerobic conditioning improves, multiple physiologic adaptations occur that allow the body to work more efficiently without fatiguing. As strength and flexibility return, taut muscle bands are released creating longer more supple muscles that are less likely to pull the body into “pain postures” and dysfunctional breathing patterns. Physical therapists, occupational therapists, social workers, psychiatric mental health nurse practitioners, and psychologists are excellent resources in helping patients balance rest with exercise.

In summary, the FM literature supports the notion that tailored exercise reduces symptoms and improves fitness. A therapeutic alliance between provider and patient is enhanced if both understand the potential physiologic obstacles to exercise as well as the top 10 principles for prescribing exercise in FM. Such an alliance increases the likelihood that the patient will successfully integrate life-long exercise into his/her comprehensive FM treatment plan.