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Am Fam Physician. 2002;66(11):2154

Approximately one percent of the adult population suffers from fibromyalgia, severe chronic musculoskeletal pain associated with multiple tender points. Treatment based on analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs), and antidepressants is relatively ineffective, but some patients have responded well to exercise programs. The exercise programs studied are not generaliz-able to community situations, and studies have frequently had design flaws and other issues that limit their applicability to practice. Richards and Scott compared a cardiovascular exercise program with one focusing on flexibility and relaxation for ability to improve symptoms in patients with fibromyalgia.

They recruited more than 100 patients who met American College of Rheumatology criteria for fibromyalgia from referrals to a London teaching hospital's rheumatology clinic. Patients were randomly assigned to either cardiovascular or relaxation and flexibility exercises, and each group met twice weekly for 12 weeks. The exercise programs were held in community facilities, and the instructors were unaware of the purpose of the study. Each patient in the cardiovascular group followed an individualized program based on use of treadmills and exercise bicycles as tolerated. The program of relaxation and flexibility exercises gradually extended to include various techniques of relaxation. The primary outcome was patient-rated global impression of change in symptoms. Patients also were assessed by evaluation of the 18 specific tender points in the fibromyalgia criteria, and by three standardized questionnaires addressing different aspects of mental and physical fatigue and the impact of fibromyalgia on ability to function. Patients were followed for up to one year after the program, and the assessors did not know the patients' assignment to the different exercise programs.

The two groups of patients were comparable in all important respects, and all were severely affected by fibromyalgia at entry to the study. Compliance was difficult to sustain, and only one half of all patients attended more than one third of the classes. Based on intention to treat, 24 (35 percent) of the 69 patients randomized to cardiovascular exercise were much better or very much better after three months, compared with 12 (18 percent) of those randomized to relaxation. These statistically significant differences were sustained at one year. The count of tender points also fell significantly in both groups, but by one year, the difference between groups was significantly in favor of the cardiovascular exercise group. No significant differences were found between the two groups on the other outcome measures.

The authors conclude that a three-month program of graded aerobic fitness exercise significantly benefitted patients with severe fibromyalgia and that the benefits persisted for at least one year. The program was conducted in community facilities and could be reproduced easily in most communities. Although compliance was a significant issue, they recommend the prescription of graded aerobic exercise for all patients with fibromyalgia.

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