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MODEL

Journal of Bodywork & Movement Therapies (2014) xx, 1e7

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/jbmt

LITERATURE REVIEW

Muscle strengthening activities and

fibromyalgia: A review of pain and strength
outcomes
Nicole L. Nelson, MS, LMT*
4012 Alesbury Drive, Jacksonville, FL 32224, USA
Received 4 June 2014; received in revised form 8 August 2014; accepted 10 August 2014

KEYWORDS
Fibromyalgia;
Strengthening;
Pain;
Outcomes;
Randomized
controlled trial;
Exercise

Summary Objective: The primary aim of this review was to investigate whether fibromyalgia
(FM) patients can engage in sufficient muscle strengthening activity (MSA) to elicit positive
strength and functional outcomes, while not exacerbating pain. The second aim was to report
strength training recommendations based upon the findings of this review.
Methods: Studies published between January 1, 2000 and May 1, 2014 were located using the
electronic databases CINHAL, PubMed and Google Scholar. Studies were included if a strength
training component (e.g. resistance machines, bodyweight, exercise tubing, dumbbells) was
part of the intervention, and if the investigation reported pain and/or strength outcomes. A
total of eleven comparative controlled trials were included in this review.
Results: The majority of the studies demonstrated encouraging increases in strength, along
with significant reductions in pain.
Conclusions: MSA can be a safe and effective mode of exercise for FM patients, particularly
when progressed from low intensities.
2014 Elsevier Ltd. All rights reserved.

1. Introduction
Fibromyalgia (FM) is an idiopathic syndrome characterized by
chronic widespread pain, fatigue, sleep disturbances,
muscular strength loss, muscle stiffness and cognitive issues
(Wolfe et al., 1990). The prevalence of FM has been reported

* Tel.: 1 904 716 2972.

E-mail address: Nicolelnelson@att.net.

to be 2e5% among the general population (Pereira et al.,

2009). Fibromyalgia imposes a large socio-economic burden
largely due to loss of physical function, reductions of quality of
life, and missed work (Pereira et al., 2009). Case-control
studies have demonstrated than those with FM are less physically active, have significantly lower perceived functional
ability and demonstrate impaired physical performance
(McLoughlin et al., 2011; Jones et al., 2010). Furthermore,
epidemiologic data show that fibromyalgia patients have a
higher prevalence of obesity (40%) and overweight (30%) when
compared with healthy individuals (Ursini et al., 2011). The

http://dx.doi.org/10.1016/j.jbmt.2014.08.007
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Please cite this article in press as: Nelson, N.L., Muscle strengthening activities and fibromyalgia: A review of pain and strength outcomes,
Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/j.jbmt.2014.08.007

MODEL

2
pervasiveness of sedentary lifestyles and obesity among those
with FM, places this population at risk for several chronic diseases, thereby creating a demand for effective exercise recommendations. Although, many clinicians strongly encourage
physical activity (PA), there is little consensus as to which
modalities may be best suited for this population. Many studies
have investigated the efficacy of low intensity, aerobic modalities, with recent systematic reviews reporting moderate
quality evidence demonstrating that short-term programs of
supervised aerobic exercise produce important benefits
including improvements in physical function and reduction in
pain (Hauser et al., 2010a; Brosseau et al., 2008; Busch et al.,
2008). Until recently, few studies have investigated the effects
of muscle strengthening activity (MSA) on the signature
symptoms of FM. The reason for this may have been due to
early research contending that FM patients might have structural alterations within muscles fibers (Sprott et al., 2004;
Drewes et al., 1993), abnormalities in microcirculatory capillaries (Morf et al., 2005), and irregularities in muscle metabolism (McIver et al., 2006; Sprott et al., 2004; Park et al.,
1998). Collectively, these analyses prompted concerns that
MSA may augment muscle damage and widespread pain.
Muscular strength is one of the five health-related
components of physical fitness (ACSM, 2009). Strength is
needed to accomplish many activities of daily living and
functional tasks, such as walking, climbing stairs, and lifting and carrying objects. The development of strength
through MSA is also believed to assist in the prevention and
management of debilitating health conditions (e.g. sarcopenia and osteoporosis) and chronic diseases (e.g. cardiovascular disease, diabetes and obesity) (ACSM, 2009). For
these reasons, the American College of Sports Medicine
(ACSM) recommends that MSA be performed two to three
days per week and include every major muscle group.
The primary aim of this study was to investigate whether FM
patients can engage in sufficient MSA intensities to elicit positive strength and functional outcomes, without exacerbating
pain. Based on these findings, the second aim was to report
recommendations for strength training exercise prescription.
Comparative controlled trials published between January 1,
2000 and May 1, 2014 were considered for this review. Studies
reporting the outcomes of pain and/or strength, and having a
minimum sample of 10 participants in each group were
included. Studies involving participants with FM in an MSA
treatment group or a comparison group were included, as were
experimental studies comparing the effects of MSA in those
with FM to healthy subjects participating in MSA. A strengthening exercise was defined as an isometric, isokinetic, or
concentric/eccentric resistance exercise with the purpose of
increasing the maximal force generated by a specific muscle or
muscle group (Balady et al., 2000). Based on the inclusion
criteria, a total of eleven comparative controlled trials were
ultimately found relevant and included in this review.

2. Key findings (see Table 1 for a summary of

pain and strength outcomes)
2.1. Pain
Table 1 Pain outcomes were commonly measured by the
pain visual analog scale (VAS), the number of tender points,

N.L. Nelson
or by tender point sensitivity. Eight studies compared pain
outcomes among FM patients performing MSA to FM patients
randomized to a comparison group. Among the eight investigations, seven found either between-group or withingroup reductions in pain (Gavi et al., 2014; Hooten et al.,
2012; Kayo et al., 2012; Valkeinen et al., 2008; Bircan
et al., 2008; Jones et al., 2002; Alen et al., 2001).
Kingsley et al. (2005), the only study within in this collection to not report significant reductions in pain, randomized
15 FM patients to a strength-training program, while 14 FM
patients served as a non-exercising control group. Intervention subjects performed MSA two times per week,
including one set of eight to twelve repetitions at 40%e60%
of their one repetition max (1RM) and progressing to 60%e
80% 1RM by the end of the 12-week trial. Though there were
no indications of reductions in pain scores (tender point
sensitivity), no increases were reported. Moreover, significant increases in upper and lower body strength (p < 0.05)
were discovered. Remarkably, seven (47%) of the strengthtraining group dropped out of the study after the first four
weeks. Of the seven, only one cited pain as the reason for
leaving the study. The researchers also mentioned that this
subject was experiencing a flare up prior to the beginning
of the intervention. Among other studies, Hakkinen et al.
(2001) investigated the effects of a 21-week progressive
MSA program on neuromuscular function and pain in premenopausal women with FM. Neck pain improved significantly, with no significant changes in general pain or
number of tender points. Jones et al. (2002) conducted a
study investigating the effects of a 12-week MSA program
compared to a stretching program of equal length. The
researchers reported statistically significant improvements
in total myalgic scores, and VAS for pain in the MSA group.
Although no significant between-group differences in pain
scores were found, effect sizes indicated that the magnitude of change was greater in the MSA group.
Three studies compared the effects of an aerobic intervention to a strength intervention in participants with FM.
Each of these studies indicated similar between-group reductions in pain scores along with concomitant improvements in functionality (Kayo et al., 2012; Hooten et al., 2012;
Bircan et al., 2008). Kayo et al. (2012) recruited 90 FM patients to participate in a 12-week RCT, involving an MSA
group, a walking (WA) group and a non-exercising control
group. The researchers noted no significant differences in
pain (VAS) scores between the WA and MSA groups (p Z 0.19),
but did note significantly higher pain scores in the control
group compared to both the MSA group (p Z 0.03) and WA
group (p Z 0.01). Pain medication use of the non-exercising
control group at the end of the 12-week trial was 80%,
compared to 46.7% in the MSA group and 41.4% in the WA
group. In as few as three weeks, Hooten et al. (2012) found
significant within-group reductions in pain (p < 0.001), as
measured by the Multidimensional Pain Inventory, among FM
subjects performing a progressive MSA program consisting of
one set of ten exercises performed five days per week.
Gavi et al. (2014) compared the effects of a 16-week
MSA intervention to 16-weeks of flexibility training in individuals with FM. Though both groups demonstrated
reduced pain at the end of the trial (p < 0.05), the
strength-training group showed greater and more rapid
reductions in pain (p < 0.05).

Please cite this article in press as: Nelson, N.L., Muscle strengthening activities and fibromyalgia: A review of pain and strength outcomes,
Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/j.jbmt.2014.08.007

Summary of MSA randomized controlled trials and pain outcomes.

Length

MSA protocol

Comparison gp

Strength outcomes

Pain outcomes

Gavi et al. (2014)

MSA (n Z 36)
Stretching (n Z 36)

16 wks

Supervised, 2 d/wk, 12
exercises @ 45%1RM, 3  12
reps

Stretching, 2 d/wk 45 min

Handgrip dynomometry: sig

btwn-gp diff (p < 0.004)

Kayo et al. (2012)

MSA (n Z 30)
WA (n Z 30)
NE control (n Z 30)

16 wks

(i) WA group:3 d/week duration increased over 12 wks

to 60e70% HRR. 5 min
warmup/cool-down
(ii) Control gp: NE

No strength assessments
administered

Hooten et al. (2012)

MSA (n Z 35)
Aerobic (n Z 31)

3 wks

Supervised, 3 d/week, 11 free

wt body wt.
Wks 1e2:No load, 3  10 reps.
1 min rest btwn sets.
wks 3e16: 3  15 reps
After wk 5 load added. On
average, load increased every
2 wks.
Supervised, 5 d/wk,
alternating upper and lower
body.
1  10 reps, encouraged to
increase wt by 1 kg/wk 25
e30 min w/warmup-cooldown.

VAS: No btwn-gp diff in pain

reduction.
Both gps had sig reductions in
VAS (p < 0.05)
VAS: sig higher in NE control
gp vs. both WA (p < 0.01) and
MSA (p < 0.03).
No sig. differences between
MSA and WA gps (p Z 0.19).

Supervised, stationary cycling

5 d/wk @70-75%maxHR.
wk 1: 10 min
wk 2:15 min
wk 3:20e30 min

Valkeinen et al. (2008)

MSA aerobic (n Z 13)
Control (n Z 11)

21 wks

Isometric knee ext 60 : sig

within-gp improvement in
MSA gp (p < 0.001).
Isometric Knee Flex 60 : sig.
within-gp improvement in
MSA gp (P < 0.001)
Isokinetic knee ext: sig.
within-gp improvement in
MSA gp (p < 0.001)
Conc leg ext: Sig btwn-gp diff
(p Z 0.043)
10-step climb time: Sig btwngp diff (p < 0.001).
10-step climb fatique: Sig
btwn-gp diff (p Z 0.038).

Bircan et al. (2008)

MSA (n Z 13)
Aerobic (n Z 13)

8 wks

Kingsley et al. (2005)

MSA (n Z 14)
Control NE (n Z 14)

12 wks

NE

WA:3 d/wk treadmill initially

20 min, increasing to 30 min
per tolerance @ 60-70%
maxHR. 5 min warmup/
cooldown

No strength assessments
administered

NE

Chest Press: MSA gp sig

higher scores compared to NE
gp (p  0.05).
Leg ext: MSA gp sig higher
scores compared to NE gp

MODEL

Supervised, 2-3 d/wk,

MSA aerobics.
MSA:7e8 exercises
wk1-11:40e70% 1RM, 2-4sets.
wk12e21:60e80% 1RM, 2
e6sets.
Aerobic:wk 1e7:30 min
wk 8e14:45 min
wk 15e21:60 min
Supervised, 3 d/wk, free
wt body wt, initially 1  4
e5 reps of easy intensity,
progressing to 1  12 reps, wt
inc according to tolerance.
5 min warmup/cooldown
Supervised, 2 d/wk, 11
exercises, 1  8e12 rep@40
e60% 1RM, progressing to
1  60e80% 1RM.
5 min warm-up/cooldown

MPI: sig within-gp reductions

in both gps (p < 0.001). No
btwn-gp diff in mean change
severity.
PPT: sig within-gp increases
in both gps (p < 0.001)

Study/participants

Muscle strengthening activities and fibromyalgia

VAS: sig reduced within-gp in

MSA aerobic grp
(p < 0.039).

No of TP:No btwn-gp diff.

Sig within-gp reductions in
both groups (p < 0.05).
VAS: No btwn-gp diff.
Sig within-gp reductions in
both gps (p < 0.05).
No of TP:No sig btwn-gp or
within-gp diff.
TMS:No sig btwn-gp or withingp diff.
(continued on next page)

Please cite this article in press as: Nelson, N.L., Muscle strengthening activities and fibromyalgia: A review of pain and strength outcomes,
Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/j.jbmt.2014.08.007

Table 1

Length

MSA protocol

Comparison gp

Jones et al. (2002)

MSA (n Z 28)
Stretching (n Z 28)

12 wks

Supervised, 2 d/wk. 12
muscle groups. Hand
wts tubing. 1  4e5 reps
initially, progressing to 1  12
reps.
5 min warm-up, 10 min cooldown

Supervised, 2 d/wk 40 min

static stretching; 12 muscle
groups guided imagery,
5 min warm-up/cool-down.

Alen et al. (2001)

FM-MSA (n Z 11)
FM-NE (n Z 12)
HC-MSA (n Z 12)

21 wks

Supervised, 2 d/wk, 6e8

exercises
wk 1e4:NoMSA
wk 5e7:15e20 reps @40e60%
1RM
wk 8e14:8e12 reps @60e80%
1RM
wk 15e21:5e10 reps @70
e80% 1RM. After 7th wk
explosive leg exercises
performed @40e60% 1RM.
Warm-up/cooldown.

FM-NE
HC: same protocol as FM-MSA

Strength outcomes
(p  0.05)
Max isokinetic knee ext: sig
within-gp increases in both
gps (p < 0.001)
Max isokinetic knee flex: sig
within-gp increases in MSA
and stretching gps (p < 0.001
and p < 0.01, respectively)
Shoulder internal and
external rotation: sig withingp increases in both gps
(p < 0.001)
Isometric leg ext: sig withingp increases in FM-MSA and
HC-MSA (p < 0.001).
Among FM-MSA and FM-NE, sig
btwn-gp diff (p < 0.001).
Vertical squat jump ht: sig
within-gp increases in FM-MSA
and HC-MSA (p < 0.005 and
p < 0.007, respectively).
Among FM-MSA and FM-NE, sig
btwn-gp diff (p Z 0.003)

Pain outcomes
VAS: Sig within-gp reduction
in MSA gp (p < 0.001).
Total myalgic score: Sig
within-gp reduced in MSA gp
(p < 0.01).
No of TP: Within-gp
reductions in MSA (p < 0.01).
No sig within-gp changes in
stretching gp.

Neck pain: Sig within-gp

reductions in MSA gp
(p < 0.05).
No change in FM-NE gp.
VAS: no sig reduction in FMMSA or FM-NE gps.

MODEL

Study/participants

Conc: Concentric, d:days, diff: difference, Ext: extension, Flex: flexion, gp:group, HC:healthy control, HRR:heart rate reserve, ht: height, maxHR:age-adjusted maximum heart rate,
MSA:muscle strengthing activity, MPI:Multidimensional Pain Inventory, NE:no exercise, No:number, TP:tender point, PPT:pressure pain thresholds, RCT:randomized controlled trial,
rep:repetition, sig: significant, TMS:total myalgic score, VAS: Visual analog scale for pain, WA:walking, wk:week, Wt:weight.

N.L. Nelson

Please cite this article in press as: Nelson, N.L., Muscle strengthening activities and fibromyalgia: A review of pain and strength outcomes,
Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/j.jbmt.2014.08.007

Table 1 (continued )

MODEL

Muscle strengthening activities and fibromyalgia

Trials progressing FM participants from low intensity
(40e50% 1 RM) to higher intensity (70e80% 1RM) MSA protocols, demonstrated significant improvement in a variety
of strength outcomes, with most reporting concomitant
reductions in pain (Valkeinen et al., 2008; Kingsley et al.,
2005; Valkeinen et al., 2004; Alen et al., 2001). For
example, during the final nine weeks of a 21-week trial,
Valkeinen et al. (2004) had participants perform three to
five sets of five to ten repetitions at an intensity of 70e80%
1RM. Participants showed significant improvements in leg
extension strength (p < 0.001), leg flexion strength
(p < 0.05), and time to climb ten stairs (p < 0.01), while
experiencing a significant reduction in the number of tender points (p < 0.05). The researchers also reported a nonsignificant trend of reduced perceived pain measured by
the VAS scale compared to non-exercising FM controls. At
the end of the 21-week trial, the non-exercising control
subjects with FM demonstrated no change in the number of
tender points and had increased VAS pain scores.

2.2. Strength outcomes

Strength outcomes appear to improve to significantly
among study participants with FM when compared to nonexercising controls with FM (Valkieinen et al., 2008; Alen
et al., 2001; Hakkinen et al., 2001). Likewise, individuals
with FM engaging in MSA show similar strength increases
when compared to healthy aged-matched individuals
participating in MSA (Kingsley et al., 2010; Valkeinen et al.,
2004; Hakkinen et al., 2002). Valkeinen et al. (2004)
compared the effects of MSA on 13 females with FM to 11
participants without FM. Mean increases in maximal
extension force during the training period increased in the
FM group and in the control group (33%) (p < 0.001) and
(12%) (p < 0.001), respectively. Explosive force of the extensors and EMG analysis of the quadriceps muscles also
demonstrated similar increases in both the FM group and
control group. These results are consistent with an investigation by Alen et al. (2001), which showed that after a 21week progressive strength-training program, females with
FM increased their maximal dynamic and isometric strength
to the same extent as healthy controls. Another study
compared the effects of MSA on strength, cross-sectional
area (CSA) and serum hormones in premenopausal women
with FM (Hakkinen et al., 2002). The researchers ultimately
concluded that the magnitude and time course of adaptations of the neuromuscular system to MSA in women with FM
were completely comparable to those occurring in healthy
controls. Figueroa et al. (2008) compared the responses of
a two-day per week MSA program among women with FM
(n Z 10) and healthy controls (n Z 9). The women performed one set of eight to twelve repetitions on nine
resistance machines. The subjects initially exercised at 50%
1RM and were slowly progressed throughout the 16-week
trial to 80% 1RM. The researchers found significant increases in muscle strength among the FM participants
(p < 0.05). After completion of an eight-week trial
comparing the effects of a MSA intervention to an aerobic
intervention in individuals with FM, Bircan et al. (2008)
discovered the aerobic group increased their six-minute
walk distance by 41 m, while the MSA group improved

5
their distance by 77 m. Sanudo et al. (2010) discovered
similar, though non-significant, improvements in 6-min walk
distances among study subjects that performed either a
combined intervention of strength, aerobic and flexibility
training, or an aerobic exercise only intervention. The results of these studies suggest that improvements in 6min walking distance may still occur when participants
engage in MSA, despite a decrease in volume of aerobic
exercise.

3. Discussion/general recommendations
One of the main findings of this review was that MSA
resulted in significant strength improvements in women
with fibromyalgia. Interestingly, women with FM had similar
strength improvements when compared with healthy controls participating in MSA. It is important to note, however,
that the participants in these studies were relatively
deconditioned, where very little stimulus might result in
initial strength gains. Future study is needed to investigate
the long-term effects of MSA in this population.
Consistent with other investigations of the effects of
exercise on FM, this review revealed that MSA results in the
reduction of pain (e.g. number of trigger points, pressure
point threshold, VAS for general pain) (Busch et al., 2008).
Most likely, the pathogenesis of FM must be established in
order to fully understand why strength training ameliorates
the pain associated with FM. Newer, yet controversial,
theories postulate that PA may reduce sympathetic hyperactivity and abnormal vagal balance commonly seen in FM
(Gavi et al., 2014; Kingsley et al., 2010; Solano et al., 2009;
Figueroa et al., 2008). It is also plausible that exercise, of
any type, improves sleep quality, psychological well-being
and health related quality of life, which may lead to the
reduction of pain perception (Bircan et al., 2008). Causal
mechanisms notwithstanding, strong evidence does indicate that multi-faceted approaches including pharmacological intervention, cognitive behavioral therapy and
exercise offer greater relief to FM patients when compared
to any singular intervention (Hauser et al., 2010b). Further
study is needed to clarify which doses and which combinations of these treatments are most effective at managing
the symptoms of FM.
When possible, participation in aerobic, strength and
flexibility exercise should be encouraged, as each confers
specific health benefits. Certain individuals, however, may
be deconditioned to the extent that multi-modal exercise
imposes too great of a stimulus, ultimately eliciting a flareup of symptoms. In this case, therapists and exercise professionals should make a determination, based upon the
health history and results of physical assessments, as to
which modalities or combination of modalities are most
essential for the immediate needs of the client or patient.
For example, if an individual presents with limited cardiorespiratory endurance and a family history of cardiovascular disease, a greater focus on aerobic fitness may be
warranted. Conversely, if a client demonstrates significant
deficiencies in strength, and is unable to complete
everyday tasks of lifting or carrying light objects, an
emphasis on MSA might be appropriate.

Please cite this article in press as: Nelson, N.L., Muscle strengthening activities and fibromyalgia: A review of pain and strength outcomes,
Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/j.jbmt.2014.08.007

MODEL

6
Based upon the findings in this review, it appears that
individuals with FM can engage in higher intensity MSA,
provided progression is appropriately paced and sufficient
recovery time is allotted between exercise sessions. Prior
to beginning MSA, exercise and rehabilitation professionals
should perform a muscular assessment to define the individuals baseline fitness level, and to determine a training
stimulus that does not provoke pain. Testing procedures,
scores and normative data have been detailed elsewhere
(Heyward, 2010; ACSM, 2009).
The tenet of start low and go slow is strongly advised,
involving the gradual progression of low-intensity MSA to
higher intensity MSA (Kayo et al. 2012; Hooten et al., 2012;
Valkeinen et al., 2008; Bircan et al., 2008). Though not a
common reported finding in this review, it is important to
note that adverse reactions, such as post-exercise pain or
fatigue, are not uncommon within this population. As such,
it is recommended that exercise intensity be markedly
reduced until symptoms subside.

4. Limitations
There are a number of limitations to this review. Most
notably, many studies had small sample sizes, with relatively high attrition rates. These factors have the potential to reduce the statistical power and increase the
chances of a type II error. Second, detailed descriptions of
the types of exercise, duration, intensity, and frequency
were not offered in many studies, precluding the exact
duplication of a given protocol. Third, the lengths of trials
were widely variable, ranging from three to 24 weeks.
Likewise, the number of sessions per week and reported
intensities varied, as such, specific dose responses with
regard to amelioration of FM symptoms and improvements
in strength remain elusive. Multiple investigations, however, did demonstrate encouraging improvements in
strength and reductions in pain when MSA was performed
at least two days per week. Fourth, only a few studies
used multiple measurement points to evaluate pain
throughout the respective investigation. A major challenge to evaluating exercise in FM populations is due to
the wax and wane nature of symptoms. For this reason,
it may be prudent for studies to evaluate pain outcomes
across a range of time periods rather than simply at the
conclusion of a trial. Finally, this review only investigated
indices of strength and pain. Fibromyalgia involves a
number of symptoms including sleep disturbances and
alterations in psychological health status, which are
worthy of further study.

5. Conclusions
Strength training is beneficial for the improvement in
strength and functional outcomes and may contribute to
the reduction of pain associated with FM. Traditionally, it
has been assumed that those with FM can only engage in
low intensity activities. This collection of studies demonstrates that appropriately progressed MSA is safe and
effective for individuals with FM, and should be considered
as part of a multi-faceted treatment plan. Future studies
must provide explicit details with regard to frequency,

N.L. Nelson
intensity, duration and type of MSA in order to draw more
robust conclusions about exercise prescription.

Acknowledgements
I would like to thank Dr. James Churilla for his valuable
comments and advice.

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Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/j.jbmt.2014.08.007

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Please cite this article in press as: Nelson, N.L., Muscle strengthening activities and fibromyalgia: A review of pain and strength outcomes,
Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/j.jbmt.2014.08.007