In a recent article on PTontheNet.com, my husband Dr. Barry Brown discussed the symptoms, theories and possible causes of fibromyalgia (FM). (Click here to view.) This article is a follow up article focusing exclusively on exercise prescription for FM.
This population of 10 to 15 million Americans (mostly women between the ages of 25 to 50) who suffer from FM offers a unique opportunity for fitness and health professionals like yourself to expand your clientele base. An added benefit is that you have the wonderful opportunity of helping fibro clients have a better quality of life that is healthier and happier.
In research, several scientific studies have been conducted exploring the effects of exercise training and especially aerobic exercise on the symptoms associated with FM. Many of the leading authorities strongly recommend aerobic exercise as the key component of any intervention program to relieve symptomatic effects of FM.
An overwhelming number of scientific studies have shown that exercise is one of the best things you can do for FM. In fact, Dr. Robert Bennett, a prolific author and researcher in FM, has pointed out that FM patients cannot afford NOT to exercise.
If we know that exercise is beneficial, then how, when and what type of exercise should you as a trainer prescribe to an individual whose constant companions are pain and overwhelming fatigue?
Because fibros have varying degrees of pain and fatigue and what seems an unlimited number of symptoms, I have designed four different phases of FM. From this model, we will be able to prescribe an exercise program more effectively on an individual basis.
The Phases of Fibromyalgia
- Phase 1. This is the onset, diagnosis or initial flare up, usually accompanied with no restorative deep sleep and daytime exhaustion. Some type of trauma, stress, injury, emotional upset, virus or infection may have triggered the onset.
- Phase 2. Following the initial diagnosis, your client experiences an endless cycle of no restorative deep sleep, daytime exhaustion, daily chronic fatigue and tension headaches, and in this state, the immune system is vulnerable. Once in this phase, it feels hopeless as though there is no end to the cycle. But this cycle can be broken (depending on the individual) with sleep and stress management, proper nutrition and exercise. An essential ingredient in your arsenal is a positive attitude; without it, change is nearly impossible.
- Phase 3. The client experiences some restorative deep sleep, and chronic fatigue is not constant.
- Phase 4. The client experiences restorative deep sleep, which may suggest a type of remission. Chronic fatigue has dissipated, and symptoms of tiredness are occasional. I call this the "feeling human again" stage.
Unfortunately, a person can progress or regress from phase to phase, depending on their encounter and perception of life’s stresses. In any stage, a flare up can be triggered. A client can also experience cyclic phases where they waver from one phase to another. However, with the proper tools, fibros usually progress towards phase 4.
We have found that exercise prescription is more effective when it is based upon one of these four phases. Ask your client what phase they would consider themselves in. The category they find themselves in will determine which exercises to prescribe.
For phases 1 and 2, exercises such as stretching, relaxation techniques, yoga, walking, range of motion and water therapy are best. A slow progression is essential for both intensity and duration. It is not unusual for fibros to “talk more than they walk” in the beginning.
For phase 3, include everything in phase 1 and 2 plus Dynabands, chair exercises, hydraulic weight machines, balls, aerobics, bikes, treadmills and light work on weight machines or dumbbells.
If your client attends an entire 60 minute aerobics class, you may never see them again because of the pain and exhaustion it may incur. An aerobic class may be too repetitious for a fibro’s muscles, joints and ligaments; therefore, wait until they become accustomed to the exercise. Lead them in uncomplicated low impact steps at a pace they can tolerate and add a large amount of variety to avoid repetition and ultimately avoid soreness and exhaustion. Also alternate muscle groups and upper and lower body.
In phase 4, you can do about anything you recommend to your normal clients or recommended by the American College of Sports Medicine.
If the individual has a flare up in any of these stages, regress to phase 1 exercises and take it very slowly. When having a flare up or when a fibro exercises excessively (for several hours, according to their fitness level), symptoms of FM will be aggravated. But done properly, exercise can greatly improve a lot of the symptoms and provide a much better quality of life.
Sometimes day-to-day changes may not be readily apparent. In fact, exercise may exacerbate the pain response initially. Again, you must make time your ally and continuously reinforce the notion that long term adaptations to exercise training will result in reduced pain and alleviate a lot of the symptoms of FM.
I designed an exercise program in 1997 called Fibromyalgia Lifestyle Intervention Program (FLIP). During each of three semesters, we conducted ongoing 10 week studies designed to investigate the effects of different types of exercise intervention on the quality of life of fibro clients.
In our last research study, we compared the effects of aerobic versus weight training. To see how each person responded to different types of exercise, I divided them up into two groups: one group using aerobic activity and the other strength training.
Our study demonstrated that 10 weeks of strength training did not exacerbate muscle tender point response and could be tolerated by most participants. Even though weight training for FM is controversial, I have found that with slow progression it is extremely beneficial.
In my class, I divided clients into beginner (phases 1 and 2), moderate (phases 2 and 3) and advanced (phases 3 and 4), depending on their fitness levels and amount of exercise experience. We administered a fitness test to determine what level of intensity to put each client. This included a VO2 max test in which most could not make it beyond a slow walk on the treadmill.
The cause of FM has not been pinpointed, but what has been found to be true is that the fitness or aerobic capacity of fibros is half to two thirds that of normal individuals. Also, strength levels are significantly less in fibros compared to age and sex matched normal individuals. Since these people in general are less fit, they may not all be able to tolerate normal progressions of exercise. I divided the exercise guidelines into three categories (beginner, moderate and advanced) since each individual is unique and will not be able to tolerate normal progressions in a one-size-fits-all exercise prescription. You will need to determine if your client is a beginner, moderate or advanced from the following descriptions.
- Beginner Level. An individual who has never exercised or has been sedentary for several years. Previous exercisers who quit exercising because of the pain and fatigue from FM would fit into this stage.
- Moderate Level. Those individuals who are engaging in some consistent activity over the last several months. This includes fibros who have been walking consistently or are engaged in other kinds of light to moderate activity such as water aerobics or light calisthenics. To qualify, they must be able to sustain a minimum of 20 to 30 minutes of aerobic activity.
- Advanced Level. When individuals can use their body weight resistance for lower body and at least 60 to 70 percent for upper body resistive exercise and can complete 30 to 40 minutes of aerobic activity at 80 percent of max heart rate, they are ready for the advanced level. The client should not experience chronic fatigue or exhaustion for up to two days after the exercise. Initially, it will be rare if you find a fibro that meets the advanced standards without coming up through the ranks.
Exercise Prescription for Beginner Level
The beginner stage is designed for people who have never exercised or who have been sedentary for several years. The purpose of this pre-conditioning phase is to accustom muscles and joints to ROM and minimize soreness. It is also needed to prepare clients physiologically and psychologically for the aerobic and strength training portion of the program.
After beginning clients feel comfortable with the routine, gradually increase aerobic activity starting at five minutes and increase by no more than two minutes per week so that at the end of one month of aerobic training, they will have accomplished 10 minutes of aerobic activity. The total time commitment at the end of one month of aerobic conditioning (including warm up, flexibility, aerobic exercise and cool down) will be about 30 to 40 minutes.
The first two weeks are preconditioning weeks, and weeks three through six represent the initial stage of aerobic conditioning. Beginning the seventh week, you may initiate strength training routines. Begin by using the resistance of the weight of the moving limb first to see how your client tolerates their body weight for each muscle group (i.e., use no weights when performing triceps extension, etc.) If your client does not experience pain and fatigue by the eight week, start using Dynabands, hydraulic machines and minimal weight pulley and CAM assisted machines. Start your beginning client with a slow progression while alternating body parts so that muscle exhaustion does not occur. The resistance should be minimal during the first two weeks and repetition should be kept to no more than four to six repetitions using one or two sets per muscle group. Rest intervals between sets should be longer than normal (two to three minutes) to allow adequate ATP recovery. Keep in mind that fibros need a longer recovery time between sets. Two to three minutes might seem like a long time, but that's how long it takes to recover 70 percent of the ATP that the muscle used. While resting, it would be helpful to stretch the muscle you are working.
This beginning stage will last from three to six months for the typical beginning fibro client. The point at which your beginning client is ready to advance to the next stage is based upon several factors.:
- Your client should not experience residual fatigue or exhaustion the following day (muscle soreness is okay). How to distinguish between muscle soreness and FM symptoms will be discussed later.
- Your client should be able to comfortably accomplish the entire aerobic and strength training routine along with warm up and cool down for at least 45 minutes.
- Although the intensity of the aerobic activity and strength training will vary among individuals, in general your client should be able to work at an intensity of 70 to 75 percent of their maximum heart rate, which is 50 to 55 percent of their max oxygen consumption or aerobic capacity and between half to two thirds of their body weight for resistive exercise. When your client has achieved these goals, she is now ready to progress to the moderate phase.
Summary of the Beginner Level
- Weeks one and two are the preconditioning stage.
- Start aerobic activity at five minutes and increase no more than two minutes per week.
- Weeks three through six are the initial stage of aerobic conditioning.
- Week seven, initiate strength training routines using the weight of the moving limb. If tolerated well, progress to equipment.
The beginner level may take three to six months or longer. They can progress to the next level when:
- Residual fatigue or exhaustion is not experienced the following day.
- They are capable of performing aerobic and strength training routines (warm up and cool down) for at least 45 minutes.
- They are capable of working at an intensity of 70 to 75 percent of max heart rate and between half to two thirds of their body weight for resistive exercise.
Exercise Prescription for Moderate Level
The moderate group is comprised of two groups of people: those who have progressed from the beginning level as previously described as well as those who have been engaging in some consistent activity over the last several months, such as walking consistently or other kinds of light to moderate activity such as water aerobics or light calisthenics.
To qualify for this group, individuals should be able to sustain a minimum of 20 to 30 minutes of light to moderate aerobic activity. They need not have been involved in a weight training program. It is always wise to drop back one to two levels when you initiate any new program, therefore begin the moderate level of training as though they were advanced beginners. The initial workout should consist of warm up and flexibility routines lasting 20 minutes or more, followed by aerobic activity of 20 minutes and strength training routines lasting 15 to 20 minutes. During strength training, start with two to three sets of six to eight repetitions per muscle group. When they feel comfortable, increase the intensity and weight (not more than once a week).
Workout should be finished with a cool down to prevent muscle cramping and blood pooling. Total workout time during normal workout sessions should last about 55 minutes to one hour.
The strategies of a moderate program are to:
- Gradually increase the intensity for both aerobic and strength training sessions. Aerobic levels should be gradually increased to 80 percent max heart rate or roughly 65 to 70 percent of their aerobic capacity, and the intensity of resistive exercise increased to two thirds or more of body weight, depending upon the size of the specific muscle group used.
- Introduce variety into the program. Concepts of cross training can reduce boredom and adapt muscles to different kinds of activities. This includes varieties of activities for aerobics and strength training. You can and should begin to use eccentric exercise that your client can tolerate. However, concentric work should still make up a bulk of the routines. Let their fatigue and pain level the day following exercise be a guide to the progression you should use with your client. As a trainer, be wary of progressing too quickly, especially in terms of increased intensity. The steps you take to increase intensity will be smaller and take a longer time to achieve. It is to be expected that this stage may last six months.
- When your client is comfortable with handling body weight resistance for lower body and at least 60 to 70 percent for upper body resistive exercise and can complete 30 to 40 minutes of aerobic activity at 80 percent of max heart rate, they are ready for the advanced stage.
Summary of the Moderate Level
- To qualify, clients should sustain a minimum of 20 to 30 minutes of aerobic activity.
- Warm up and flexibility routines lasting 20 minutes or longer.
- Strength training will last about 15 to 20 minutes of two to three sets of six to eight repetitions per muscle group.
- An adequate cool down is recommended.
- Total workout time should be 55 minutes to one hour.
- Increase aerobic levels to 80 percent max HR or 65 to 70 percent of their aerobic capacity and the intensity of resistive exercise to two thirds or more of their body weight
- Incorporate variety and cross training
- Incorporate eccentric exercise
Progress to advanced level when your client can use body weight resistance for lower body and at least 60 to 70 percent for upper body resistive exercise and can complete 30 to 40 minutes of aerobic activity at 80 percent of max heart rate.
Exercise Prescription for Advanced Level
Individuals who have successfully completed the moderate stage can now progress to the advanced stage. You will have very few clients who will enter the advanced stage without coming up through the ranks of your program. If they claim to be ready, it is advisable to run them through a battery of tests before admitting them into this more intensified stage.
For testing you can use: the Max Heart Rate method, the Karvonen method (heart rate reserve method) or Rate of Perceived Exertion. (For more on these tests, please click here.)
Stretching and warm up should be about 15 to 20 minutes. You can lead clients in a warm up doing low impact aerobics or on a piece of equipment.
Aerobic time should start out at 30 to 40 minutes if desired and eventually build intensity up to 85 percent of max HR and duration to 50 to 60 minutes. Gradually increase strength training time to 30 to 40 minutes, incorporating three sets of eight to 10 repetitions per muscle group. When they feel comfortable, increase the intensity (not more than once a week).
Total workout time should last from one to two hours. Don’t forget to cool down to prevent muscle cramping and blood pooling.
The strategies of an advanced program are to:
- To increase volume and duration of activity
- To develop extensive variety of different exercise and cross training into their repertoire
- To graduate clients into self sufficiency so they may continue the life-long process of fitness on their own, with only periodic re-evaluations or motivation on your part
Intensity levels for aerobics need not exceed 85 percent of max heart rate. This includes daily variability in combining intensity and duration of activities. Your client in this stage may wish to alternate 30 minutes of aerobic activity at a moderately high percentage of max heart rate with activities at a lower intensity for the remainder of the session. On alternate days, your client may wish to perform more moderate activity at 70 percent of max HR for 60 minutes.
This stage should be reserved only for those individuals who wish to achieve a high level of fitness and have the necessary time and commitment to devote the extra effort needed. It is important that you as a trainer emphasize to your clients that most of their symptoms associated with FM may be masked only if they are willing to achieve a moderate to advanced stage of fitness.
It is during this stage that significant weight loss and weight control will occur due to the high volume of training and sufficient energy expenditure. Fibros tend to have high body fat levels so if their goal is to lose weight, they may need to aim at the advanced stage. I myself lost a lot of weight at this level.
There is the danger that if a person progresses too quickly to this stage, they may experience a relapse and be more susceptible to respiratory diseases. Therefore, no one should be permitted to enter and progress through each stage unless they have fulfilled the criteria previously prescribed.
The goals of this stage may take one or more years to achieve but are well worth the effort. Do not be discouraged if no more than 10% of your clients achieve this advanced stage. After all, no more than 10% of normal clients reach this high level of fitness.
This advanced stage is the most controversial of all stages, and we have just begun doing research in this area. Many authorities would disagree that fibros should strive for such an advanced level of training; however, we are continuing to collect data that shows individuals who are motivated and capable of exercising at such high volumes after proper progression may truly mask the devastating symptoms of FM. Wigers found that after 4.5 years of aerobic exercise, former FM patients no longer fulfilled the American College of Rheumatology 1990 criteria for FM.
Summary of Advanced Level
- To sustain a minimum of 30 minutes of aerobic activity
- Warm up and flexibility routines lasting 15-20 minutes
- Followed by aerobic activity of 30-40 minutes and build up to 50-60 minutes if desired
- Strength training for 30-40 minutes, three sets of eight to 10 repetitions per muscle group
- Cool down
- Total workout time from one to two hours
- To increase volume and duration of activity
- To develop extensive variety of different exercises
- To graduate each client into self-sufficiency
Intensity levels need not be increased beyond 85% of max heart rate. You can combine high and low intensity and duration of activities.
Gradually build up the aerobic frequency to three to five days per week. Clients should participate in an aerobic and strength training program at least three days per week. Consistency is the key. Fatigued and beginner clients may benefit from two 10 to 20 minute sessions rather than one long session.
Also, beginners starting strength training programs may tolerate a mini session working one body part per day or each muscle group once a week, rather than exercising every body part three times per week. I found that even on days I didn’t feel like exercising, if I just went ahead and did it, I usually felt better.
Patients who try to do too much exercise too soon or the wrong type usually will make themselves temporarily worse. I have my clients fill out a daily monitor of how they feel each day, what they ate, how much water they drank, what the weather was like, how well they slept the night before and what exercises they performed that day. This helps both of you to learn the difference between muscle soreness from exercise and pain associated with FM. Therefore, good communication with your client is essential so that you can track their progress.
In the beginning, there may be days when your client can’t exercise because of chronic fatigue or extreme pain. However, as they progress in their programs, they will find these days of inactivity becoming less and less. And you may be amazed at how quickly they improve!
Below are some guidelines to determine whether you need to alter duration and intensity of exercise:
- If your client only has tiredness or muscle soreness, encourage them to continue with the normal progression, increasing intensity and duration.
- If they complain of a shaky quivering muscle, stop the movement and continue the following day. A quivering muscle can mean that the firing circuits are overloaded, but in time, the muscle will adapt. A shaky muscle could mean a state of contracture. In order for the muscle to relax and stop contracting, you have to release calcium that’s bound to troponin and bring it back into the lateral sacs of the sarcoplasmic reticulum. This requires ATP and sarcoplasmic ATPase. If the ATP is used up (or the sarcoplasmic ATPase isn’t available), the muscle cannot relax because calcium remains bound to the troponin, and the myosin head remains attached to the active site on the actin myofilament.
- If the client experiences sharp pain during the workout, stop the movement and continue the following day.
- If your client feels nauseated while exercising, rest a few minutes and then continue. This may be due to a parasympathetic response, the sensory feedback through the CNS, digestive problems or a pain response.
- If your client experiences chronic fatigue, is not sleeping at night or has tension headaches that occur the same or the following day, this is a sign to regress or cut back to ROM and stretching until symptoms cease. These symptoms may or may not be accompanied by a flare up. Usually in this condition, the body is already maxed out or stressed to the limit and just responds to exercise as yet an added stressor. During a flare up, you should regress to only ROM, stretching, yoga, relaxation or slow walking. I can usually tell when I’m going to have a flare up because I develop a red rash on my face or chest and develop symptoms of chronic fatigue and tension headaches and I stop sleeping well at night. Since I’ve succeeded to the advanced level of fitness, I have only experienced a few flare ups.
Each FM client responds to exercise differently and will progress at his or her own rate. So you may have a beginner progress rapidly to the next level, or they may start out at a low level and progress very slowly and not seem to be making much progress. But encourage them to be patient. For the first several weeks, there are metabolical and enzymatic changes going on inside their bodies along with neurological changes. In time, your clients will learn the difference between muscle soreness and fibro pain and how to monitor themselves. And eventually, they will be able to tell when to push themselves and when to lighten up.
It is difficult for FM patients to get started on an exercise program because of the pain and fatigue experienced at first with repetitive movements. However, those who do exercise experience worthwhile improvement and are reluctant to give it up.
To prepare your clients, go slow and keep encouraging them every chance you get. One common complaint of fibros is that other people look at them and say, “Oh, you look fine.” But what they can’t see is that pain is invisibly written on every muscle in the body. For this reason, most fibros do not like to be touched because it hurts, anywhere and everywhere.
A little muscle soreness and fatigue should be expected the first week or two of exercise, and that is normal. Exercise may exacerbate the pain response initially. Even though they are hurting, it is essential to exercise. Normally pain is an indication that you need to stop exercising. But in the case of the FM client, it is the motivation they need to begin exercising. Have your client take responsibility for his/her health.
Begin exercising with a warm up. A warm up, stretching and cool down are of the utmost importance to fibros because it will help to eliminate stiffness, soreness, injuries and promote circulation, which may be contributing factors to the symptoms of FM. A good warm up is especially important in fibros because of contractile properties of the neuromuscular system. It may increase speed and efficiency of neuromuscular messages in fibros.
Also as part of the warm-up routine, you can incorporate strength training movements of each joint without any resistive weights. This prepares joints and muscles for the neuromuscular patterns they will encounter during strength training, and it provides minimal resistance to the weight of the moving limb.
Experts on FM recommend that fibros stretch and perform ROM exercise every day (a routine that is gentle on the joints and does not require a lot of getting up and down off the floor). Stretching aids in pain relief by releasing and relaxing tightened contracted muscle fibers commonly associated with FM. Stretching may also serve to lubricate, reduce friction and cause greater exchange of fluids within the synovial fluid of a joint. Tight muscle fibers left unstretched may respond to exercise by aggravating a client's condition.
Most fibros are very tense in the neck and shoulder areas, so don’t forget to concentrate on stretching out that area during the stretching session. It would also help if your client could concentrate on relaxing while stretching. Muscles not accustomed to a normal stretch or tone respond negatively to the slightest tension. By gradually loosening muscles through stretching, they may be less inclined to proprioceptively contract at the slightest tension. Exercise may serve to gradually stretch ligaments to accustom them to increased range of motion (ROM) as well as invoke the Golgi tendon reflex, which inhibits muscles from contracting thereby increasing ROM.
Slow, continuous, maintained stretching prevents or inhibits the muscle spindle from firing, thereby preventing a reflex contraction of the muscle being stretched. In other words, the rate of firing is reduced from the motor nerve in the spinal cord to the muscle. This allows the muscle to remain in a stretched position without contracting back to its original position. Muscle groups that tend to be tighter, such as Achilles tendon, may require a longer stretch time. If your client is concerned about the time it takes to stretch, have them stretch at home or come early to the facility to stretch.
The beginner who has never exercised should start stretching five minutes a day and progressively increase the time by one minute per day until they are capable of stretching and engaging in ROM activity for 20 to 30 minutes. Dr. Sharon Clark, an exercise physiologist and coordinator of FM treatment program at Oregon Health Sciences University, advises holding the stretch up to 60 seconds. Have them hold the stretch as long as possible and build on time spent holding the stretch. The beginner will need to warm up and stretch longer than an advanced individual. Take precaution whenever stretching and never bounce a stretch. Bouncing stimulates sensory receptors to shorten the muscle, which may result in muscle tears or pulls.
AB and Lower Back Work
Most fibros tend to have weak abs. Therefore, ab work should be performed last since they need strong abs for support of the trunk and girdle for motion and movement during their workout. Strong abs can help prevent back pain by producing a posterior pelvic tilt. Abs weaken and tire quickly and may not give you the support needed if worked first.
A lot of tension seems to accumulate in the tender points of the neck and shoulder area on fibros, so ab movements should be gentle with no strain to the neck. Using a towel instead of your hands would be ideal to support the neck. More emphasis should be placed upon correct position and proper intensity to strengthen abs rather than through repetition. In general, muscles should be shortened to prevent hyperextension of the lower back. This can be accomplished by bending one's knees. In addition, avoid holding down the ankles of your client during a sit up to avoid over reliance on the hip flexors during the sit up motion.
There are many machines and devices for working the abs. However, since fibros tend to have weak abs, they may need to stick to floor work until their abs become stronger.
Fibros tend to be injury prone, so any precaution ahead of time is smart. Try not to have your client move backward or perform any complicated or quick moves. This is because some fibros can get lightheaded or dizzy, lose their balance and have coordination and cognitive problems. A possible explanation for this may be due to fibrofog. Research from the University of Alabama has shown that brain scans of fibros have shown decreased blood flow in three areas of the brain that are concerned with feelings and sensations. This may contribute to fibrofog, memory loss and loss of concentration.
Because one study suggested that microtears may occur during weight lifting, many health professionals have failed to incorporate strength training into the normal protocol for fibro clients. However, we have completed three studies that have included strength training and found that individuals who maintain strength training programs for an extended period of time may effectively mask symptoms of pain associated with FM.
Dr. Sharon Clark supports concentric contractions but recommends against eccentric contractions due to development of delayed onset muscle soreness (DOMS) the following day. However, normal individuals also experience DOMS following eccentric contractions during the early stages of training. Dr. Clark states that exercise induced pain of fibros can occur from one to three days following the exertion.
Since many FM patients do not wish to experience additional pain, it is probably wise to delay incorporation of eccentric exercise until your client has reached phase three or is sufficiently accustomed to the exercise. Since normal life activities such as stooping, housecleaning and walking down steps involve eccentric contractions, it can be strongly and logically argued that eccentric training will strengthen those muscles involved in normal daily tasks.
If you are concerned about DOMS, hydraulic resistance equipment is ideal because it helps eliminate this soreness. In the initial stage, this equipment is strongly recommended for fibros because you use all positive movements or concentric contractions. This would be a great advantage for fibros if indeed their muscles are de-conditioned.
Provide a variety of choices for your client like relaxation, breathing, stretching, ROM, yoga, isometrics, chair exercises, Dynabands, balls and hydraulic weight machines. Also water aquatics (if the temperature is mid 80 to low 90 degrees F) is an excellent choice, especially if your client has orthopedic or joint immobility. Exercise equipment, weight machines and dumbbells can still be used but at a slow progressive rate with constant monitoring to see how much your client can handle each progression.
Exercises Not Recommended
Because tender points tend to be aggravated by certain exercises, we recommended that you limit the use of the following exercises. Since there is individual variability in response to various exercises, some clients may be able to tolerate these exercises, but they are not recommended for most.
- Knee extension - Cause shin splints in some people (pressure on knee cap, above knee cap tender point area).
- Smith machine - Squats may be for advanced group only because of tender points on the neck and shoulder area.
- Upright row - Puts tension on the tender point of the scapula.
- Chin ups
- Pull-ups (or any hanging exercises)
- Roman chair for lower back. More injuries have occurred on this machine in clubs than any other piece of equipment.
- Cables - Because of the eccentric contractions, this is suggested for advanced groups.
- Rowers - Questionable even for advanced level since a lot of the tender points are around the neck and shoulder area, and the high repetitions may cause potential injury.
Equipment with repetitive motion to the shoulders like rowers, skiers and ergometers should be monitored to see if it aggravates the shoulder/neck area. The Nordic Track is okay, but be aware of hip-related problems due to moderate resistance and high repetitions. Keep in mind, this exercise takes a lot of coordination and causes problems for some fibros. Kickboxing or movements that jolt or have an impact to the joint or muscle should be avoided.
Back to the Beginning
I would like to end where you should begin, and that is by evaluating your client’s musculature. This procedure may greatly improve your client’s performance. Fibros tend to get extremely tired, and as the day wears on, their shoulders slump, their head becomes too heavy to hold up and tension builds up in the tender points of the neck and shoulder area.
Maintaining a good posture is critical. When fibros experience pain, the muscle around the pain site tightens guarding the hurt area. The working muscle is in a constant state of tension. This constant state of holding your muscles tight in a stress response changes your body’s posture patterns. In an attempt to alleviate discomfort, some fibros develop rounded shoulders, swayback and a tendency to lean forward. Walking in this hunched over rigid way can constrict breathing and puts a lot of strain on your lower back. To add to this, fibros may have trouble holding their heads up. For each inch that you bend your head forward, the muscle force required to maintain your head in an erect position significantly increases.
If your client exhibits poor posture, he or she may be more injury prone because of induced strain and stress on muscle, tendons and ligaments. You may need to work on strengthening the lower abdominal muscles, the middle and lower trapezius muscles, and the pectoral muscles while keeping the spine stabilized. Also, incorporate supine shoulder flexion exercises and internal shoulder rotation. Keep in mind a posterior pelvic tilt while performing appropriate exercises will help take a lot of the weight off the lumbar spine.
For fibros exercise is not an option, it’s a requirement. The symptoms of FM can be devastating, but with your help, fibro clients can experience a better quality of life. Exercise can help mask their pain and start them on the journey towards better health and better living!
- Clark SR. Prescribing exercise for fibromyalgia patients. Arthritis Care Res. 1994;7: 221-225.
- Wigers SH, Stiles TC, Vogal PA. Effects of aerobic exercise versus stress management treatment in fibromyalgia: a 4.5 year prospective study. Scan J Rheumatol. 1996; 25:77-86.
- Wolfe F, Smyth H, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the Multicenter Criteria Committee. Arthritis Rheum. 1990; 33:160 –172.