|
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.
|
