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Chronic Pain Assessment and Management
with an Emphasis on Fibromyalgia
Mindfulness-based and Cognitive
Treatment Strategies
Combined Sections Meeting 2006
San Diego, CA
February 1-5, 2006
Carolyn McManus, PT, MS, MA
Swedish Medical Center
Seattle, WA
The International Association for the study of
pain defines pain as “an unpleasant sensory
and emotional experience associated with
actual or potential tissue damage, or described
in terms of such damage.”
Pain is more than sensation. The relationship
between reported pain intensity and the evoking
peripheral stimulus depends on many factors,
including level of arousal, anxiety, depression,
attention and expectation.
Brooks J, Tracey I J Anat. (2005) 207, 19-23.
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• Insula
• Somatosensory Cortices
• Anterior, Middle and
Posterior Cingulate
• Basal Ganglia
• Posterior Parietal Cortex
• Amygdala
• Hypothalamus
• Prefrontal Cortex
• Conscious perception of
event being painful created
by central processing of
incoming signals
• Brain and spinal cord can
modulate, but also create
pain perception
Thalamus
Spinal Cord
Brainstem
Peripheral input from pain
sensing nociceptors
‘C’
‘A’
Brooks J, Tracey I J Anat. (2005) 207, 19-23.
FM subjects exhibited greater activity than controls
over multiple brain regions in response to both
nonpainful and painful stimuli.
Cook DB, Lange G, et al. Functional imaging of pain in
patients with primary fibromyalgia. J Rheumatol 2004
Feb;31(2):364-78.
Application of mild pressure produced subjective
pain reports and cerebral responses in FM subjects
that were qualitatively and quantitatively similar to
the effects produced by applying at least twice the
pressures in control subjects.
Gracely RH, Petzke F, et al. Functional magnetic
resonance imaging evidence of augmented pain
processing in fibromyalgia. Arthritis Rheum 2002 May;
46(5):1333-43.
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Pain catastrophizing is significantly associated with
increased activity in brain areas related to the
anticipation of pain, attention to pain, the emotional
aspects of pain in subjects with FM.
Gracely RH, Geisser ME, et al. Pain catastrophizing
and neural responses to pain among persons with
fibromyalgia. Brain 2004 Apr;127(Pt 4):835-43.
In summary, people with FM appear to have
maladaptive increased activity in brain areas
associated with pain processing in response to
nonpainful and painful peripheral stimuli.
As clinicians, our treatment choices will be
enhanced by employing strategies that engage the
whole process of pain perception.
Chronic pain patients were able to learn control of
activity in the rostral anterior cingulate cortex, a brain
region involved in pain perception and regulation.
The ability to decrease activation in the rostral
anterior cingulate cortex was associated with a
decrease in perceived pain intensity.
deCharms RC, Maeda F, Glover GH, et al. Control over brain
activation and pain learned by using real-time functional MRI.
PNAS 2005;102(5);18626-31.
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It appears that a combination of interventions, in a
multimodal approach (eg. exercises combined with
education and psychologically-based interventions)
is the most promising means of managing patients
with fibromyalgia.
Adams N, Sim J. Rehabilitation approaches in
fibromyalgia. Disabil Rehabil 2005 Jun 17;27(12):
711-23. Review.
In the treatment of fibromyalgia, current evidence
suggests efficacy of low dose tricyclic
antidepressants, cardiovascular exercise, cognitive
behavioral therapy and patient education.
Goldenberg D, Burckhardt C, Crofford L.
Management of fibromyalgia syndrome. JAMA 2004
Nov;292(19): 2388-95. Review.
Mindful Awareness
Present moment
Kind, compassionate, friendly
Accepting
Non-striving
Curious
Beginner’s mind
Steady, unwavering
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Mindfulness meditation is the deliberate
training in mindful awareness through formal
and informal practices.
Formal
Sitting meditation
Walking meditation
Mindful body scan
Informal
Integration onto activities of daily life
Applications of mindful awareness include:
Injury prevention
Reconditioning, exercise
Preventing symptom exacerbation
Undergoing medical procedures
Quality of life
Pain management
Pain = Sensation + Our Reaction
Physical
Cognitive
Emotional
We may have no control over the onset of
an unpleasant sensation, but we do have
control of our response to the sensation.
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Pain = Sensation + Our Reaction
Physical
Cognitive
Emotional
The first step in a developing skillful response
to pain is awareness.
Mindful awareness of the sensation and our
reaction to that sensation is, in itself, a skillful
choice.
Mindful awareness of the breath
Diaphragmatic breathing
Breathe into your waistband
Key word or phrase
In breath Out breath
In Out
Arriving Home
Present moment Only moment
May I Be peaceful
Let go Let God
In the kingdom of God I dwell
Awareness of the breath assists in steadying the
mind and calming the body.
The mind is like the surface of a pond. When the
surface of the pond is turbulent it distorts the
reflection of the surrounding terrain. When the
surface is still, the surrounding terrain is seen clearly.
From this stable mind, the unpleasant sensation and
the reaction to that sensation can be observed.
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Pain = Sensation + Our Reaction
Physical
Cognitive
Emotional
Sensations are observed as sensations, thoughts
are observed as thoughts, emotions are observed
as emotions.
No deliberate effort is made to change, improve or
strive toward anything.
Acceptance of pain. Viane I, Crombez G, et al. Pain
2004 Dec;112(3):282-8.
Anyone can teach a simple 5 - 10 minute mindful
breathing exercise and encourage the informal
practice of mindfulness. I recommend any health
care practitioner introduce these practices.
Teaching mindfulness meditation requires years of
personal practice. As the instructor, you embody
mindfulness and teach it, not as a brief exercise or
technique, but as a way of life.
Physical
Breathe
Relax
Progressive Relaxation
Autogenic Training
Relaxation Body Scan
Guided Imagery
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Cognitive
Life happens. Then we tell ourselves a story about
what has happened.
The story begins to take on a life of its own.
We can get so caught in the story that it becomes a
lens that distorts our perception.
We begin to selectively see things that reinforce our
viewpoint.
We can believe and make choices based on the
story, even if it has no basis in fact.
1. You are not your pain.
You are not your diagnosis.
You are a whole human being, with a multitude
of dimensions, and you have a medical
condition, but that medical condition is not you.
There is more right with you, functioning in a
wondrous and miraculous manner, than is
problematic.
2. Camera lens metaphor. Choose a wide angle
lens.
The mind is like the sky, pain is like a cloud.
Think of someone you love dearly. Feel that
energy of love in your heart. You carry a capacity
for love that is boundless and immeasurable. By
comparison the pain is small.
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3. Label pain as sensation.
4. If your best friend were experiencing this, how
would you talk with or comfort your best friend?
We often carry an inner wisdom that can help us
navigate difficult situations. We sometimes more
easily access it for others. We need to access this
inner wisdom for ourselves.
Talk to yourself in the same manner as you would
talk to your best friend.
5. Anticipation and catastrophic thinking
Anticipation, catastrophic thinking and fear are often
about the future, what is going to happen next.
The truth is, no one knows what is going to happen
next.
It is easy to feel overwhelmed when you add the
unknowns of tomorrow on to the challenges you face
today.
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Plan for the future, but do not spend your life there.
The present moment is the foundation for the next
moment. Today is the foundation for tomorrow.
Today is where your power resides.Taking care of
yourself as best you can today is your foundation for
tomorrow.
The present moment is the only moment we
have for living. This is it.
6. Ask yourself:
If I keep talking to myself in this way, what kind of
future is it contributing to? Is this the future I want?
Is this a story I want to give my life energy to?
What would be a healing or comforting story?
7. Water the weeds or water the flowers
If you think of life is like a big garden, we all have
plants in our gardens that are not doing well.
You can spend all of your energy focusing on the
plant that isn’t doing well, or you can spend
sometime in other parts of your garden.
This not only gives you a more accurate
experience of life, it also provides a better
perspective and can help strengthen you.
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Emotional
Compassion
Life is a bumpy road with unexpected twists, turns
and unforeseen weather conditions.
The price of being on this road is a human body
that is vulnerable to sickness, aging and death.
You can travel that road with a mean and harsh
critic, and truly have a miserable experience.
You can travel that same road with someone kind
and compassionate, friendly and understanding, and
the experience would be much more manageable.
The voice that travels this road with us is our
own. The choice is always ours.
Loving kindness meditation
May I be peaceful and joyful
May I be free of distress and the causes of distress
May I care for myself with love and compassion
May I awaken to my wholeness and be free
Loving kindness is extended to oneself, a loved one,
a neutral person, a difficult person and to all beings.
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Exploring Pain with Cognitive Restructuring
Identify your thoughts, feelings and subsequent
behaviors in response to pain.
Thoughts:
Feelings:
Behavior:
Identify automatic thoughts that are distorted,
negative or exaggerated:
If you are caught in unrealistically negative or
distorted thinking, identify alternative ways of thinking
about your symptoms that reduce your distress:
Identify how changing your thoughts can impact your
feelings and behavior:
Exploring a Difficult Situation with Mindfulness
Identify the difficult situation:
How have you reacted to this situation?
Thoughts
Emotions
Physical reaction
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Observe your reaction with generous acceptance,
openness, curiosity, with basic kindness and
compassion and no need to criticize, judge or
blame. Observe your reaction with a “beginner’s
mind.” This alone is a healing practice.
Has this reaction contributed to your distress?
If yes, how?
Is there a component of your reaction that you can
change that would decrease your distress?
Are there unavoidable elements of this situation
that are not in your power to change?
What is life teaching you? Is there something of
value here?
CarolynMcmanus.com
Carolyn.McManus@swedish.org
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Case Example
Patient is a 40 year old woman, married with 2
young children
Diagnosed at age 34 with FM and Lupus
At 39 she changed MDs, and was dx’d with
Undifferentiated Connective Tissue Disease
c/o chronic pain neck, shoulders, back, hips,
both joint and muscular pain
Pain intensity 5 - 8/10
Office Visits
Before 6 mos After
Rheumatologist 1-2 x/mo 1x/3 mos
Psychiatrist 2x/mo 1x/6-8 wks
Physical Therapist 2-4x/mo 1x/2 mos
Bibliography

Medical Literature
Adams N, Sim J. Rehabilitation approaches in fibromyalgia. Disabil Rehabil 2005
Jun 17;27(12):711-23. Review.

Astin JA. Mind-body therapies for the management of pain. Clin J Pain 2004 Jan-
Feb;20(1):27-32. Review.

Astin JA, Berman BM, Bausell B, Lee WL, Hochberg M, Forys KL. The efficacy of
mindfulness meditation plus Qigong movement therapy in the treatment of
fibromyalgia: a randomized controlled trial. J Rheumatol 2003 Oct;30(10):2257-62.

Bantick SJ, Wise RG, et al. Imaging how attention modulates pain in humans
using functional MRI. Brain Feb;125:310-19.

Bradley L, McKendree-Smith NL. Central nervous system mechanisms of pain in
fibromyalgia and other musculoskeletal disorders: behavioral and psychologic
treatment approaches. Curr Opin Rheumatol 2002 Jan;14(1):45-51.

Brooks J, Tracey I. From nociception to pain perception: imaging the spinal and
supraspinal pathways. J Anat 2005 Jul;207(1):19-33.

Burckhardt CS. Nonpharmacologic management strategies in fibromyalgia.
Rheum Dis Clin North Am 2002 May;28(2):291-304. Review.

Cook DB, Lange G, et al. Functional imaging of pain in patients with primary
fibromyalgia. J Rheumatol 2004 Feb;31(2):364-78.

Crombez G, Eccleston C, et al. Hypervigilance to pain in fibromyalgia: the
mediating role of pain intensity and catastrophic thinking about pain. Clin J Pain
2004 Mar-Apr;20(2):98-102.

DeCharms RC, Maeda F, et al. Control over brain activation and pain learned by
using real-time functional MRI. PNAS 2005 Dec;102(51):18626-31.

Glass JM, Park DC. Cognitive dysfunction in fibromyalgia. Curr Rheumatol Rep
2001 Apr;3(2):123-7. Review.

Goldenberg D, Burckhardt C, Crofford L. Management of fibromyalgia syndrome.
JAMA 2004 Nov;292(19):2388-95.

Gracely RH, Geisser ME, et al. Pain catastrophizing and neural responses to pain
among persons with fibromyalgia. Brain. 2004 Apr;127(Pt 4):835-43. Epub 2004
Feb 11.

Gracely RH, Petzke F, et al. Functional magnetic resonance imaging evidence of
augmented pain processing in fibromyalgia. Arthritis Rheum 2002 May;46(5):1333-
43.

Grossman P, Niemann L, et al. Mindfulness-based stress reduction and health
benefits. A meta-analysis. J Psychosom Res 2004 Jul;57(1):35-43.

Kakigi R, Nakata H, et al. Intracerebral pain processing in a Yoga Master who
claims not to feel pain during meditation. Eur J Pain 2005 Oct;9(5):581-89.

Lazar SW, Bush G, et al. Functional brain mapping of the relaxation response and
meditation. Neuroreport 200 May;11(7):1581-85.

Lazar SW, Kerr CE, et al. Meditation experience is associated with increased
cortical thickness. Nueroreport 2005 Nov;16(17):1893-97.

Lemstra M, Olszynski WP. The effectiveness of multidisciplinary rehabilitation in
the treatment of fibromyalgia: a randomized controlled trial. Clin J Pain 2005 Mar-
Apr;21(2):166-74.

Lutz A, Greischar LL, et al. Long-term meditators self-induce high-amplitude
gamma synchrony during mental practice. PNAS 2004 Nov;101(46):16369-73.

Mackey SC, Maeda F. Functional imaging and the neural systems of chronic pain.
Neurosurg Clin N Am 2004 Jul;15(3):269-88. Review.

McManus C. Group Wellness Programs for Chronic Pain and Disease
Management. Philadelphia, PA: Butterworth-Heinemann/Elsevier, 2003.

Montoya P, Larbig W, et al. Influence of social support and emotional context on
pain processing and magnetic brain responses in fibromyalgia. Arthritis Rheum
2004 Dec;50(4): 4035-44.

Montoya P, Sitges C, et al. Abnormal affective modulation of somatosensory brain
processing among patients with fibromyalgia. Psychosom Med 2005 Nov-Dec;
67(6):957-63.

Ploghaus A, Narain C, et al. Exacerbation of pain by anxiety is associated with
activity in a hippocampal network. J Neurosci 2001 Dec 15;21(24):9896-903.

Ploghaus A, Tracey I, et al.Dissociating pain from its anticipation in the human
brain. Science 1999 Jun 18;284(5422):1979-81.

Sim J, Adams N. Systematic review of randomized controlled trials of
nonpharmacological interventions for fibromyalgia. Clin J Pain 2002 Sep-
Oct;18(5):324-36.

Singh BB, Berman BM, et al. A pilot study of cognitive behavioral therapy in
fibromyalgia. Altern Ther Health Med 1998 Mar;4(2):67-70.

Taylor RR. Cognitive Behavioral Therapy for Chronic Illness and Disability. New
York: Springer, 2005.

Tracey I, Ploghaus A, et al. Imaging attentional modulation of pain in the
periaqueductal gray in humans. J Neurosci 2002 Apr 1;22(7):2748-52.

Viane I, Crombez G, et al. Acceptance of the unpleasant reality of chronic pain:
effects upon attention to pain and engagement with daily activities. Pain 2004
Dec;112(3):282-8.

Williams DA. Psychological and behavioral therapies in fibromyalgia and related
syndromes. Best Pract Res Clin Rheumatol 2003 Aug;17(4):649-65. Review.

Meditation
Chodron, Pema. The Places that Scare You: A Guide to Fearlessness in Difficult
Times. Boston, MA: Shambhala Publications, 2001.

Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind
to Face Stress, Pain and Illness. New York, NY: Dell Publishing, 1990.

Kabat-Zinn, J. Where Ever You Go, There You Are: Mindfulness Meditation in
Everyday Life. New York, NY. Hyperion, 1994.

Nhat Hanh, T. Peace is Every Step: The Path of Mindfulness in Everyday Life.
New York, NY. Bantam Books, 1991. *Thich Nhat Hanh has multiple titles on the
topics of mindfulness meditation and transforming suffering.

Packer, T. The Wonder of Presence and the Way of Meditative Inquiry. Boston,
MA: Shambhala Publications, 2002.

Wallace, A. Genuine Happiness: Meditation as a Path to Fulfillment. New Jersey:
Wiley& Sons, 2005.

Living Well with Chronic Pain and Illness (Recommendations for your patients)
Caudill, M. Managing Pain Before It Manages You. New York: Guilford Press,
1995.

Fennell P. The Chronic Illness Workbook: Strategies and Solutions for Taking
Back Your Life. Oakland, CA: New Harbinger Publications, Inc. 2001.

Greenberger D, Padesky C: Mind Over Mood. New York: Guilford Publications,
1995.

Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind
to Face Stress, Pain and Illness. New York: Del Publishing Co, 1991.

Spero D. The Art of Getting Well: A Five-Step Plan for Maximizing Health When
You Have a Chronic Illness. Berkeley, CA: Hunter House Publishers 2002.


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Evidence-Based Treatment of Fibromyalgia
Nancy C. Rich, Ph.D.,PT,FACSM

Etiology
• Morphological, histochemical, ultrastructural changes in
muscles?
• Differences in amounts of high energy phosphate metabolite
concentrations (ATP, ADP, Pi, lactate)?
• Differences in muscle blood flow?
• Weaker muscles?
• Decreased motor unit activity?
Etiology
• “… although muscular pain has been a central feature of FMS
syndrome, controlled studies of muscle fail to support a
convincing role for muscle in the pathophysiology of the
condition. Muscle tenderness in fibromyalgia cannot be
explained on the basis of primary muscle abnormalities, either
structural or functional.” (Simms, 1996)
Etiology
“…these results and previous investigations support the hypothesis
that hyperalgesia in these patients with FM is due to an
upregulation in the central nociceptive system.”

Sorensen et al., 1998
Etiology
• “Patients with FMS have lowered mechanical and thermal pain
thresholds, high pain ratings for noxious stimuli, and altered
temporal summation of pain stimuli”

Goldenberg et al. Management of Fibromyalgia Syndrome.
JAMA, 2004;292:2388-2395

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Etiology
• Hyperalgesia and Allodynia
– Based on changes in nociception
– Hyperalgesia = an increased response to noxious stimuli
– Allodynia = a reduction in pain threshold
Etiology
• Robert Bennett, 1999
– Dorsal horn cells become more sensitive

– Original receptive fields increase in size

– New receptive fields in muscle and skin become active
Etiology
• Central sensitization = hyperexcitability of CNS neurons
• Pillemer et al (1999) instructed that the hyperexcitability of the CNS is
controlled by activation of N-methyl-D-aspartate (NMDA) receptors.
• Substance P reacts with neurokinin (NK
1
) receptor sites which causes
release of excitatory amino acids which activates NMDA receptors
Etiology
• Substance P can travel long distances in the spinal cord and
sensitize neurons away from the site of an injury

• Russell et al, 1994: Cerebrospinal fluid of patients with FMS
was approximately 3 times that found in controls.
Etiology
• Sleep disturbance
– People with FMS demonstrate abnormalities of stages 1-4
– People with FMS demonstrate an average of 60% of Non-REM sleep
with alpha waves intruding, versus 25% normals

Etiology
• Somatomedin C – also called insulin-like growth factor 1 (IGF-
1)
– Mediates the amount of growth hormone that is secreted
– Growth hormone necessary for muscle healing
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– Decreased in people with FMS
– 80% of a 24 hour production of growth hormone is secreted during
stages 3 & 4 of sleep
Etiology
• Bennett et al.
– Somatomedin C levels in patients with FMS were 124.7+ 47 ng/ml
– Somatomedin C levels in persons without FMS were 175.2 + 60 ng/ml
Etiology
• Psychological Disturbances
– “ … fibromyalgia might share a genetic abnormality with disorders
such as migraine and major depression, but different genetic or
environmental factors, such as susceptibility or exposure to certain
viral antigens, may be necessary for the development of fibromyalgia.”
(Hudson et al, 1985)
Etiology
“The majority (65% to 80% of patients with fibromyalgia do not have an
active psychiatric disorder.” (Goldenberg, 1989)

“…it is not clear that psychological disturbance can predict a specific
chronic pain syndrome such as FS or whether psychological disturbance is
the general result of experiencing chronic pain.”
Patient Presentation
• Pain… “all over”
• Stiffness
• Swelling
• Overwhelming fatigue
• Tender points
• Muscle spasms or nodules
• Impaired memory and concentration
• Irritable bowel syndrome
• Headaches
• Interstitial cystitis


Patient Presentation
• Paresthesias
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• Chest wall pain
• Sensitivity to cold & humidity
• TMJ
• Non-restorative sleep
• Urinary urgency
• Anxiety

Trigger Point vs Tender Point
• Tender Points: distinct and localized areas of soft tissue that are painful
when 4 kg of pressure is applied by pressure or a dolorimeter. Also called
‘Mechanical hyperalgesia’
• Trigger Points: local points of tenderness in a nodule or in a taut band of
muscle fibers. Trigger point pain can refer away from the point.
Patient Presentation
• It is important to evaluate for musculoskeletal problems
– Rotator cuff
– Epicondylitis
– Carpal tunnel
– Plantar faciitis
– Etc.
Intervention
“Despite improved recognition and understanding of FMS,
treatment remains challenging.”


Goldenberg et al. JAMA, 2004
Intervention
“Nonpharmacologic treatments that target pain, stress, and
physical and psychological dysfunction using a variety of
physical, cognitive, behavioral, and educational strategies are
essential components of comprehensive treatment.”

Burckhardt CS. Rheum Dis Clin, 2002
Intervention
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• Patient education
• Cognitive-behavioral strategies
• Physical Training
• Multicomponent strategies
• Complementary and alternative medicine strategies
Intervention
“There is strong evidence that intensive patient education is an
effective treatment in FMS.”


Goldenberg et al. JAMA, 2004
Education
“planned, organized learning experiences designed to facilitate
voluntary adoption of behaviors or beliefs conducive to health”
(Health Professional Association, 1994)
• One-to-one provider-patient
• Organized programs
• Fibromyalgia-specific self help course (Arthritis Foundation)
Education
“Basic information on fibromyalgia, treatment options, self-
efficacy theory, and self-management strategies should be
considered the standard of clinical care in fibromyalgia.”

Burckhardt, 2002
Cognitive-behavioral Strategies
• Role of thoughts, beliefs, expectations, and behaviors on
symptoms
• How to prioritize time and activities
• How to balance work, leisure, and ADL
Intervention
• Self-efficacy
– Sense of control
• Mastery experiences
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• Modeling
• Social persuasion
• Physiological feedback
Intervention
“There is strong evidence that cardiovascular exercise is effective
treatment in FMS.”


Goldenberg et al. JAMA, 2004
Intervention
“This review reports moderate to strong evidence that exercise
programs that meet ACSM guidelines for aerobic training
produce short-term improvements in cardiorespiratory fitness,
and pain pressure threshold of FMS tender points.”

Busch et al. Cochrane Database, 2003
Intervention
• Bennett et al., (2002) found in their study that 80% of persons
with FMS had a below average level of aerobic fitness
Intervention
“Aerobic exercise should be regarded as a legitimate and useful
treatment component in the management of FMS. Improvement
can be expected in aerobic performance, tender points, and
global well-being.”

Busch et al., 2003


Intervention
“This review reports moderate to strong evidence that exercise
programs that meet ACSM guidelines for aerobic training
produce short-term improvements in cardiorespiratory fitness,
and pain pressure threshold of FMS tenderpoints.”
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Busch et al. Cochrane Database, 2003
Exercise Training
American College of Sports Medicine. The recommended quantity
and quality of exercise for developing and maintaining
cardiorespiratory and muscular fitness, and flexibility in older
adults. Med Sci Sports Exer. 1998;30:975-991.
Cardiovascular Training
• Document physician permission
• Guidelines from American College of Sports Medicine
– Minimal training intensity is approximately 40-50% of Heart Rate
Reserve
Cardiovascular Training
• Heart Rate Reserve (Karvonen formula)
– HRR = maximum heart rate minus resting heart
rate
– Maximum heart rate = 220 – age
– Calculate % HRR (e.g. 50-80% HRR) - *may have to start much lower
for patients with FMS
– Add resting HR to each value

Karvonen Formula


Target HR range =
([HR
max
– HR
rest
] x 0.40 ? - 0.50) +HR
rest


Cardiovascular Training
Age = 40
Max HR = 220 – 40 = 180
Resting HR = 60 bpm
180-60 = 120
120 x .40 = 48; 120 x .50 = 60
48 + 60 = 108; 60 + 60 = 120
Target HR = 108 - 120
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* HR attained in water will be 16 bpm less than on land

Cardiovascular Training
Intensity %HRR RPE
Very Light <20 <10
Light 20-39 10-11
Moderate 40-59 12-13
Hard 60-84 14-16
Very hard >85 17-19
Maximal 100 20

Cardiovascular Training
• Goal is 20-60 minutes of continuous or intermittent (minimum of
10 minute bouts) of aerobic activity

• May take a year to get there!!!
Intervention
Moldofsky (1976)
• One group of patients performed cardiovascular exercise and had
a 29.1% increase in peak work capacity

• One group performed flexibility exercises and had a 4.3%
decrease in peak work capacity
Intervention
• Gowans et al., 1999
– Therapeutic pool
– 20 mins walking/jogging/sidestepping/arm exercises
– 5 mins of stretching pre and post
– HR = 60%-70% age-adjusted max
– Educational sessions on topics of posture, ADLs, sleep, relaxation, medications,
nutrition, coping skills
*6 weeks of exercise (2x/week)
Outcome Measures
Gowans et al., 1999
6 minute walk
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Arthritis Self-efficacy scale
Fibromyalgia Impact Questionnaire
Knowledge questionnaire
Results
• Exercise groups improved in 6- minute walk, well-being, fatigue,
self-efficacy, knowledge
Intervention
Gowans et al., 2001
• Exercise group: 10 mins stretching, 20 mins aerobic exercise at
60-75% age-adjusted max HR (first 6 weeks in a therapeutic
pool, then walking and jogging in a gymnasium)
• Control Group
Outcome Measures
• Beck Depression Inventory
• 6-minute walk test
• State-Trait Anxiety Inventory (STAI)
• Mental Health Inventory (MHI)
• Tender point number
• FIQ
• Arthritis Self-Efficacy Scale
Results
• Exercise group improved in 6-minute walk distances, BDI,
STAI, FIQ, ASES, MHI
Intervention
• Schacter et al., 2003
– Group 1 = Long Bout of Exercise (10 mins week 1 to 30 mins by week
9) – 1x/day
– Group 2 = Short Bout of Exercise (5 mins week 1 to 15 mins week 9) –
2x/day
– Control
* home-based, low impact aerobics
* HR started at 40-50%, increased to 65-75% by week 12
Outcome measures
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• FIQ
• Pain Diagrams
• Arthritis Impact Scale
• Chronic Pain Self-Efficacy Scale
• Tender Point Number
• Treadmill Test – Peak Oxygen Uptake
Results
• Dropout of 14% (ctrl), 38% (SBE),
29% (LBE)
• No differences between exercise groups
• SBE and LBE improved in disease severity
“Out training stimulus may have been inadequate because participants found
the mode of exercise unsuitable or too difficult or because of the isolation
of a home-based program…”
Intervention
• Martin et al., 1996
– Group 1 exercised 20 mins walking at 60-80% max HR and 20 mins
flexibility and 20 mins strength training (3x/week for 6 weeks)
– Group 2 was a relaxation group – visualization, yoga, autogenic
relaxation (3x/week for 6 weeks)
Outcome Measures
• FIQ
• Illness Intrusiveness Questionnaire
• Self-Efficacy Questionnaire
• Visual Analog Scale
• Treadmill – time to volitional exhaustion
• Sit and Reach
• Isokinetic Strength
• Myalgic Score (sum of tender point scores)
• Tender point (0-4 tenderness at each site)
Results
• Tender point number decreased in exercise group
• Myalgic Score decreased for exercise group
• Aerobic fitness increased for exercise group
• Sit and Reach increased for exercise group
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Intervention
• Wigers et al., 1996
– Group 1 = Aerobic exercise: high intensity aerobic exercise (60-70% max HR) – 45
mins 3x/week for 14 weeks (warm-up +2 peaks of high intensity training of 3-4
mins followed by 15 minutes aerobic games (tag, ball games), ending with
stretching)
– Group 2 = Stress Management- 90 mins 2x/week for first 6 weeks and then
1x/week for 8 weeks
– Group 3 = Treatment as Usual (aquatic, psychomotor treatment, medications)
Outcome Measures
• Pain drawing
• VAS scales for pain, disturbed sleep, lack of energy, and
depression
• Pressure tenderness in 90 points
• Work capacity with cycle test
• Global subjective improvement – 4 step scale
Results
• Aerobic exercise group improved pain distribution, tenderness of
tender points, work capacity,
VAS pain, VAS lack of energy, global subjective improvement
• Stress management group improved tenderness of tender points,
VAS pain, VAS depression
Intervention
McCain et al., 1988
• Cardiovascular fitness group: 60 mins 3x/week for 20 weeks (10
min warm-up, cycling at >150 bpm,
• Flexibility group: 60 mins 3x/week for 20 weeks
Outcome Measures
• VAS pain
• Body diagram – pain
• Sleep quality questionnaire
• Pain threshold – total myalgic score
• Predicted peak work capacity
• Symptom checklist – 90 - Revised
12 12
Results
• Exercise group improved in pain threshold scores, global
assessment by patient and physician
Intervention
• Meyer & Lemley, 2000
– High Intensity Exercise: 40% HRR at week 1, increased 10% for the
first 4 weeks, 5% for weeks 5,6, and 10 to a max of 85%
– Low Intensity Exercise: 25% HRR at week 1, increased 5% per week
for first 6 weeks, to a max of 60% at week 10
– * Exercise duration began at 12 min to 30 min for the last 4 weeks
Outcome Measures
• Tender point number
• Resting Heart Rate
• Exercise Heart Rate
• Blood Lactate
• Rating of Perceived Exertion
• FIQ
• Beck Depression Inventory
• State Anxiety Inventory
• Pain Scale
• Health Assessment Questionnaire Disability Index
Results
• Only 8 subjects completed the study so groups were combined
for analysis
• Resting HR and HR decreased
• FIQ did show a trend to decrease more in the low-intensity group
Intervention
Ferraccioli et al., 1987
• True EMG – Biofeedback: 15 sessions 2x/week- progressive
relaxation training
• False EMG - biofeedback : no instruction
• control

Outcome Measures
• Number of tender points
• Grip strength
13 13
• Morning stiffness
• VAS – pain
• Clinical questionnaire
Results
• Only true group improved in all measures
Intervention
Rooks et al., 2002
• Phase I in a pool – AROM; Phase 2 on land treadmill, elliptical
device, walking on a track. Strength training on machines, hand
weights, and body weight
• No control group
*20 week program (60 min sessions, 3x/week)
Outcome Measures
• 1 Repetition max
• 6-minute walk
• FIQ

Results
• Improvements in strength, 6-minute walk distance, FIQ
Intervention
McCain, 1986
• Exercise group: 20 week program (3x/week) at HR >150 –
bicycling
• Flexibility group
Outcome Measures
• Myalgic Scale – dolorimetry (pain thresholds)
• VAS
• Pain diagram
• Predicted peak work capacity
• Psychologic profile

Results
14 14
• Exercise group improved in VAS, total myalgic score,
percentage total body area of pain, psychologic profile
Intervention
Mannerkorpi et al., 2000
• Exercise group: temperate pool – 1x/week for 35 mins – also 6
one hour education sessions
• Control group
Outcome Measures
• FIQ
• Short-Form 36
• Multidimensional Pain Inventory
• Arthritis Self-Efficacy Scale
• Arthritis Impact Measurement Scale
• Quality of Life Questionnaire
• 6-minute walk test
• ROM
• Strength
Results
• Exercise group improved in FIQ, 6-minute walk, physical
function, grip strength, pain severity, social functioning,
psychological distress, quality of life
Intervention
Richards and Scott, 2002
• Aerobic exercise (treadmills & bicycles)
• Relaxation & Flexibility
*each group met 2x/week for 12 weeks
*exercise increased from two 6-minute sessions to two 25-minute
sessions per class
Outcome Measures
• Self-rated change in global impression scale
• Tender point number
• FIQ
• Chandler fatigue scale
• McGill pain questionnaire (short form)
15 15
• SF-36
Results
• 35% of the exercise group and 18% of the control group
improved in the global impression scale
• Exercise group had decreased tender point counts at one year
post
Why does exercise result in improvements in FMS?
“Exercise whether administered short-term to unfit persons or long-term to
fit persons leads to significant alterations in opioid and non-opioid as well
as neural and hormonal intrinsic pain regulatory systems. For example,
strenuous exercise leads to predictable increases in serum levels of beta-
endorphin-like immunoreactivity, ACTH, prolactin, and growth
hormone…”
McCain, 1986
Why?
“Other hypotheses suggest that exercise may improve circulation
within the muscles, improve sense of control over the body, and
increase the resistance of trained muscle to microtrauma.”

Sandstrom & Keefe, 1998
Multidisciplinary
“There is strong evidence that
multidisciplinary treatment is effective in treating FMS.”

Goldenberg et al, 2004
Multidisciplinary
• Doctors (rheumatologists)
• Psychologists/Psychiatrists
• Physical Therapist (exercise physiologist)
• Social workers
• Occupational therapists
• Sleep specialists
• Headache specialists
• Massage therapists
• Acupuncturists
• endocrinologists

16 16
Exercise
“The results of the present study indicate that engaging in regular exercise
and having higher exercise self-efficacy significantly predict continued
engagement in exercise behavior in people with FMS. Factors such as
age, employment status, depression, education level, self-efficacy for
managing FMS, and the size of one’s social network also demonstrate
predictive qualities.”
Oliver & Cronan, 2002
Physical Therapy Treatments
• Validate the symptoms
• Education
• Cardiovascular Training (non-impact)
• Patient needs to be sleeping well
• Energy conservation
• Active participation
• MUST NOT increase pain or fatigue
• Initially, no eccentric exercise
Physical Therapy Treatments
• Musculoskeletal System
• Posture correction
• Ergonomics
• Body mechanics
• Modalities???
• AQUATIC THERAPY
• Diary of flare-ups
Exercise Prescription
• Minimize Muscle Microtrauma
- no/little eccentric exercise
• Minimize Central Sensitization
- must not cause a flare-up
• Emphasize low-intensity exercise
• Individualized exercise
• Maximize self-efficacy
Jones & Clark, 2002


17 17
Exercise Prescription
• 12 week exercise program
- 4 supervised visits 1
st
90 min session and follow-up at 1,3,
& 9 weeks
- at home pts performed 60-120 mins/week
of aerobic exercise at 60-85% max HR
- weekly exercise logs
- examined exercise adherence 3 months post
Exercise Prescription
• High in-treatment adherence predicted maintenance of exercise
• Higher baseline disability predicted worse maintenance
• Increased barriers to exercise predicted less exercise
• Inclusion of Cognitive Behavioral Therapy produces better results (self-
efficacy)
Dobkin et al., 2005
Outcome Measures
• Fibromyalgia Impact Questionnaire

Burckhardt CS, Clark SR, Bennett RM. The Fibromyalgia Impact
Questionnaire: development and validation. J Rheumatology,
1991;18:728-734.
Resources
• American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345-4300
Phone: (404)633-3777
http://www.rheumatology.org
Resources
• The Arthritis Foundation
PO Box 7669
Atlanta, GA 30309-0669
1-800-283-7800
http://www.arthritis.org
18 18
Resources
• Fibromyalgia Network
PO Box 31750
Tucson, AZ 85751-1750
1-800-853-2929
http://www.fmnetnews.com
Resources
• National Fibromyalgia Research Association
2200 N. Glassell St.
Suite A
Orange, CA 92865
1-800-544-2345, ext 265
Thank You For Attending


Any Questions ?

ncrich@gwi.net
Intellectual Property
This information is the property of Nancy C. Rich, Ph.D.,PT, and
should not be copied or otherwise used without express written
permission of the author

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