©

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© 2017 EDIZIONI MINERVA MEDICA European Journal of Physical and Rehabilitation Medicine 2018 October;54(5):663-70
Online version at http://www.minervamedica.it DOI: 10.23736/S1973-9087.17.04876-6

ORIGINAL ARTICLE

Muscle stretching exercises and resistance

training in fibromyalgia: which is better?
A three-arm randomized controlled trial
Ana ASSUMPÇÃO 1, Luciana A. MATSUTANI 1, 2, Susan L. YUAN 1,
Adriana S. SANTO 1, Juliana SAUER 1, Pamela MANGO 1, Amelia P. MARQUES 1 *

1Department of Physical Therapy, Speech Therapy and Occupational Therapy, Faculty of Medicine, University of São Paulo, São Paulo,

Brazil; 2Department of Biological and Health Sciences, Institute of Education for Osasco Foundation, Osasco, Brazil
*Corresponding author: Amelia P. Marques, Department of Physical Therapy, Speech Therapy and Occupational Therapy, Faculty of Medicine, University
of São Paulo. Rua Cipotânea 51, Cidade Universitária, 05360-160 São Paulo (SP), Brazil. E-mail: pasqual@usp.br

ABSTRACT
BACKGROUND: Exercise therapy is an effective component of fibromyalgia (FM) treatment. However, it is important to know the effects and
specificities of the different types of exercise: muscle stretching and resistance training.
AIM: To verify and compare the effectiveness of muscle stretching exercise and resistance training for symptoms and quality of life in FM
patients.
DESIGN: Randomized controlled trial.
SETTING: Physical therapy service, FM outpatient clinic.
POPULATION: Forty-four women with FM (79 screened).
METHODS: Patients were randomly allocated into a stretching group (N.=14), resistance group (N.=16), and control group (N.=14). Pain was
assessed using the visual analog scale, pain threshold using a Fischer dolorimeter, FM symptoms using the Fibromyalgia Impact Questionnaire
(FIQ), and quality of life using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The three intervention groups contin-
ued with usual medical treatment. In addition, the stretching and resistance groups performed two different exercise programs twice a week for
12 weeks.
RESULTS: After treatment, the stretching group showed the highest SF-36 physical functioning score (P=0.01) and the lowest bodily pain score
(P=0.01). The resistance group had the lowest FIQ depression score (P=0.02). The control group had the highest score for FIQ morning tiredness
and stiffness, and the lowest score for SF-36 vitality. In clinical analyses, the stretching group had significant improvement in quality of life for
all SF-36 domains, and the resistance group had significant improvement in FM symptoms and in quality of life for SF-36 domains of physical
functioning, vitality, social function, emotional role, and mental health.
CONCLUSIONS: Muscle stretching exercise was the most effective modality in improving quality of life, especially with regard to physical
functioning and pain, and resistance training was the most effective modality in reducing depression.
CLINICAL REHABILITATION IMPACT: The trial included a control group and two intervention groups, both of which received exercise pro-
grams created specifically for patients with FM. In clinical practice, we suggest including both modalities in an exercise therapy program for FM.
(Cite this article as: Assumpção A, Matsutani LA, Yuan SL, Santo AS, Sauer J, Mango P, et al. Muscle stretching exercises and resistance train-
ing in fibromyalgia: which is better? A three-arm randomized controlled trial. Eur J Phys Rehabil Med 2018;54:663-70. DOI: 10.23736/S1973-
9087.17.04876-6)
Key words: Fibromyalgia - Physical therapy modalities - Randomized controlled trial - Muscle stretching exercises - Resistance training.

F ibromyalgia (FM) is a rheumatologic syndrome char-

acterized by a plethora of symptoms such as chronic
and diffuse musculoskeletal pain, fatigue, and sleep dis-
orders.1, 2 Studies on FM are increasingly performed, due
to its high prevalence,3 impact on the health care sys-
tem,4, 5 and effect on quality of life,6 as well as the associ-
ated physical7 and psychological burdens.8
Considering the great complexity of the syndrome, the
scientific community has been dedicated to finding effec-
tive treatment alternatives capable of reducing the impair-

Vol. 54 - No. 5 European Journal of Physical and Rehabilitation Medicine 663

 ©
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ASSUMPÇÃO MUSCLE STRETCHING EXERCISES IN FIBROMYALGIA
ment caused by the syndrome, both in the personal sphere
by improving the quality of life, and in the socioeconomic
context by reducing the use of health system resources and
enabling the patient to perform productive activity.
Since FM is a pleomorphic condition, most patients re-
quire integrated and multidisciplinary approaches. In this
regard, exercise therapy seems to be an effective compo-
nent of treatment, yielding improvement in pain and other
symptoms, as well as decreasing the burden of FM on the
quality of life.9-11
Clinical practice and studies show that pain can be ex-
acerbated by movement, leading patients to become sed-
entary and inactive, with possible reduction of physical
capacity12-14 and development of kinesiophobia.15 Thus,
it becomes evident that the cycle of inactivity and pain
should be stopped cautiously, to minimize physical trauma
and emotional stress.
Although exercise therapy in the treatment of FM has
been studied since the 1970s,16 patient associations and
scientific societies address current issues on treatment that
remain unanswered in the literature; there is uncertainty
regarding what type, intensity, and frequency of exercise
is best for people with FM.17 Hence, this is a clinically
relevant research priority. In this regard, detailed clinical
trials can provide answers.
It is therefore important to know the effects and speci-
ficities of different types of exercise. In this work, the
choice of the type of exercise was based on two factors: 1)
stretching exercise allows the muscle to reach its functional
length, allowing amplitude and freedom of movement,18
and is important in prevention of kinesiophobia; 2) there is
a decrease in muscle strength of about 20% to 30% in FM.19
Accordingly, we conducted a three-arm randomized
controlled study to verify and compare the effectiveness
of muscle stretching exercise and resistance training for
symptoms and quality of life in FM patients.
Materials and methods
Patients
The sample consisted of women aged 30 to 55 years who
were referred to the physical therapy service, FM outpa-
tient clinic, Hospital das Clinicas HCFMUSP, Faculdade
de Medicina, Universidade de São Paulo during a period
of 18 months. FM was diagnosed by rheumatologists in
the FM outpatient clinic, according to the 1990 American
College of Rheumatology (ACR) classification criteria.1
Seventy-nine eligible subjects were identified.
Exclusion criteria were: non-controlled systemic dis-
664 European Journal of Physical and Rehabilitation Medicine October 2018
orders (diabetes, hypertension), neurological and muscu-
loskeletal conditions that could compromise assessments,
impaired alertness or comprehension, relevant joint disor-
ders (severe arthritis, arthroplasty of the hip or knee, rheu-
matoid arthritis), recent changes in physical activity, and
recent changes in therapy for FM (medication, educational
programs, alternative medicine, psychotherapy).
The sample size was calculated to detect a 15% im-
provement in the total score of the Fibromyalgia Impact
Questionnaire (FIQ) before and after intervention (paired
t-test), with a standard deviation of 15 points, a power of
0.90, and a significance level of 0.05, using Sigmastat (Sy-
stat Software Inc., Chicago, IL, USA). A minimum of 13
subjects were required for each group.
For randomization, each subject drew a paper numbered
one, two, or three from an urn (one = stretching, two =
resistance and three = control). A physical therapist with
expertise in FM treatment performed the assessments and
interventions.
The Research Ethics Committee of the Hospital das
Clinicas, Faculdade de Medicina, Universidade de Sao
Paulo approved this study (No. 0337/07). All patients
signed an informed consent form. This trial was registered
at ClinicalTrials.gov (Protocol Registration System num-
ber NCT01029041).
Procedures
Demographic data and pain history were obtained at base-
line assessment. The following outcome measures were
examined.
Pain at the time of assessment was measured using the
visual analog scale (VAS). Patients were asked to rate
their pain on a 10-cm line anchored by two descriptors:
“no pain” and “unbearable pain.” The VAS is reliable and
highly correlated with other forms of assessment of pain.20
FM symptoms over the prior week were assessed us-
ing the FIQ.21 This questionnaire was translated into
Portuguese and validated for the Brazilian population by
Marques et al.22 The FIQ measures physical functioning,
well-being, work status (missed days of work and job dif-
ficulty), pain, fatigue, morning tiredness, stiffness, anxi-
ety, and depression. This questionnaire has been widely
used in research, with good sensitivity, validity, and reli-
ability for each item and the total score.23, 24 Total score
ranges from 0 to 100, and higher scores are associated with
greater impact. According to Bennett, FM patients score
on average about 50, and severely affected patients score
70 or more.23
The quality of life was assessed using the validated Por-
 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
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MUSCLE STRETCHING EXERCISES IN FIBROMYALGIA ASSUMPÇÃO
tuguese version of the Medical Outcomes Study 36-item
Short-Form Health Survey (SF-36).25, 26 The SF-36 is a
multidimensional tool measuring eight domains: physi-
cal functioning, physical role, bodily pain, general health,
vitality, social functioning, emotional role, and mental
health. Domain scores range from 0 to 100, and higher
scores indicate a better quality of life. The SF-36 is widely
used in research, and excellent psychometric properties,
such as sensitivity, specificity, and reliability, have been
demonstrated for the eight domain scores.25, 27
Pain threshold and tender point count were assessed us-
ing a Fischer dolorimeter,28 according to the 1990 ACR
criteria1 and a report by Okifuji et al.29 The dolorimeter
measures the pressure applied to the skin in kg/cm2, from
1 kg/cm2 to 10 kg/cm2. Discomfort felt at values below
1 kg/cm2 are defined as 0.5 kg/cm2. The pain threshold
was defined as the mean of the pressure values obtained
from the 18 tender points. When a subject reported pain
at pressures of 2.6 kg/cm2 or lower, the tender point was
considered positive.30
All outcome measures were reassessed at the end of the
12-week exercise program for stretching and resistance
groups and at 12 weeks from baseline for the control group.
Interventions
Stretching group
The stretching group underwent a 12-week supervised exer-
cise program of 40-minute sessions performed twice a week,
as suggested by the American College of Sports Medicine.31
Patients performed segmental active muscle stretching
without therapist assistance. Large muscles were chosen
for their role in the muscular chains of the global postural
reeducation method. The triceps surae, gluteus, ischiotibi-
al, paravertebral, latissimus dorsi, hip adductor, and pecto-
ralis muscles were targeted. At early stages of the program,
patients performed three repetitions; from the fifth week,
four repetitions; and from the ninth week, five. The stretch
intensity was increased gradually to the point of moderate
discomfort, and the position was held for 30 seconds, ac-
cording to the recommendation of the American College of
Sports Medicine.31 The exercises are described in Table I.
Resistance group
The patients completed a 12-week supervised resistance
training program of 40-minute sessions performed twice
a week, with progressive overload. The equipment used
included dumbbells (upper limbs) and shin pads (lower
limbs). In the first two sessions, no load was used. Subse-
Vol. 54 - No. 5 European Journal of Physical and Rehabilitation Medicine 665
Table I.—Description of muscle stretching exercises.
The exercises are performed on a stable surface such as a mat or firm
mattress.
Exercise 1.—Paravertebral: In dorsal decubitus, support your head on a
folded sheet. Flex both hips and knees; bring them to your chest and
hold them with your hands.
Exercise 2.—Gluteus: In dorsal decubitus, flex only one hip; bring the
knee to the chest and hold it with your hands. Alternate limbs. Take care
that the lumbar segment and head remain supported.
Exercise 3.—Ischiotibial: In dorsal decubitus, flex hips and knees, with
feet resting on the mattress. Extend one knee, holding it with your
hands. Be careful with knee alignment. Alternate limbs.
Exercise 4.—Hip adductor: In dorsal decubitus, flex hips and knees, join
the soles of the feet and abduct the thighs. Take care that the lumbar
segment remains in physiological and relaxed lordosis.
Exercise 5.—Latissimus dorsi: In dorsal decubitus, flex hips and knees,
with feet supported on the mattress and lumbar segment in physiological
lordosis. Flex your arms to the maximum, keep your elbows extended
and your palms open.
Exercise 6.—Pectoralis: In dorsal decubitus, flex hips and knees, with
feet resting on the mattress. Position the arms at approximately 45°
abduction, keep the shoulders away from the ears, with the medial
epicondyles resting on the mattress and hands open.
Exercise 7.—Paravertebral, gluteus, ischiotibial, triceps surae: Sitting on
the ischial tuberosities, keep trunk and head resting against the wall and
upright, extend the knees and do the dorsiflex the ankles. Be careful of
the alignment of the knees.
quently, 0.5 kg was added each week if the patient identified
the effort as slightly intense on the Borg scale (score = 13).32
The patients were instructed to perform a series of eight
repetitions of resistance exercises for the following mus-
cles:33 triceps surae, quadriceps, hip adductors and abduc-
tors, hip flexors, elbow flexors and extensors, pectoralis
major, and rhomboids (Table II). These muscles partici-
pate in functions such as gait and upper limb activities, and
stabilize the pelvic and scapular girdles.
Control group
The control group continued with usual medical treatment.
After 12 weeks, the patients were reassessed, and invited
to receive physical therapy treatment based on muscle
stretching exercises and resistance training.
Data analysis
Data were analyzed using descriptive and inferential sta-
tistics. Significance level was set at P<0.05. Data were
analyzed using Excel for Windows (Microsoft) and Sigma
Plot 12.3 (Systat Software Inc.). Variables were tested for
normality using the Shapiro-Wilk Test.
At baseline, one-way analysis of variance (ANOVA),
Kruskal-Wallis, and χ2 tests were performed to test for dif-
ferences in the variables between groups.
 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
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ASSUMPÇÃO MUSCLE STRETCHING EXERCISES IN FIBROMYALGIA

Table II.—Description of resistance training.

Exercise 1.—Quadriceps: Sitting on a stretcher (or raised surface), keep one of the feet supported and the other suspended, with the trunk straight and
hands resting on the thighs. Extend the suspended knee and return to the starting position. Be careful with the lumbar segment.
Exercise 2.—Elbow flexors: Sitting on a stretcher, with feet supported, erect trunk, and upper limbs beside the body, perform flexion and extension of
elbows.
Exercise 3.—Elbow extensors: In dorsal decubitus, with flexed hips and knees, feet supported on the mattress, shoulders flexed at 90°, perform elbow
flexion and extension, one side at a time.
Exercise 4.—Pectoralis major: In dorsal decubitus, with flexed hips and knees, feet supported on the mattress, shoulders and elbows flexed at 90º,
perform horizontal adduction and abduction of shoulders.
Exercise 5.—Hip flexors: In dorsal decubitus, flex one hip and knee, with foot supported on the mattress. Raise the other leg, with the knee extended, to
the height of the other knee. Be careful with the lumbar segment. Keep the abdominal muscles contracted. Return to starting position.
Exercise 6.—Hip adductors: In lateral decubitus, flex the hip and knee to about 90º, place the leg on a pillow, being careful to keep the pelvis aligned.
Raise the lower limb from below, keeping the knee extended. Return to starting position.
Exercise 7.—Hip abductors: In lateral decubitus, flex the hip and knee. Abduct the hip from the top toward the ceiling, keeping the knee extended. Do
not flex the hip. Keep the pelvis aligned. Return to starting position.
Exercise 8.—Rhomboids: Standing, with anterior trunk flexion, rest one forearm and hand on a wall (or on the stretcher), with the other elbow flexed at
90º, and perform shoulder extension and scapular adduction. The physiotherapist will help with scapular movement. Return to starting position.
Exercise 9.—Triceps surae: Standing with hands lightly supported on a wall perform ankle extension. Return to starting position.

Paired t-tests were used to detect differences before
and after the intervention within groups for outcome
measures with normal distribution; the Wilcoxon test was
used for outcome measures that were not normally dis-
tributed.
At baseline and after the intervention, intergroup com-
parisons were carried out using one-way ANOVA and
Kruskal-Wallis tests; post-hoc analysis was conducted us-
ing Holm-Sidak and Dunn’s tests.
We also evaluated clinical improvement, defined as:34
the mean change of the variable in the treatment group
minus the mean change of the variable in the control
group, divided by the pooled mean of the baseline scores
for the variable. Minimal clinically important differences
were defined as 30% for pain,35, 36 14% for the FIQ total
score35, 37 and 15% for the SF-36 domain scores, according
to the Philadelphia Panel for back pain, cervical pain, and
pain in knees and shoulders.35, 38

Table III.—Baseline characteristics.

Stretching group Resistance group Control group
Variables P
(N.=14) (N.=16) (N.=14)
Age (years) 47.9 (5.3) 45.7 (7.7) 46.9 (6.5) 0.65
BMI (kg/m2) 28.9 (4.2) 28.1 (4.7) 29.4 (4.8) 0.74
Years of education 11 [8; 11] 9 [7; 11] 11 [4; 11] 0.86
Occupation
Have a job outdoors 7 (50%) 7 (44%) 8 (57%) 0.76
Housewife or insurance security 7 (50%) 9 (56%) 6 (43%)
Do regular physical activities 4 (29%) 7 (44%) 7 (50%) 0.49
Use medication for FM
Antidepressant 5 (36%) 7 (44%) 5 (36%) 0.89
Analgesic 2 (14%) 0 (0%) 2 (14%)
Anti-inflammatory 3 (21%) 2 (13%) 2 (14%)
Psychotropic 1 (7%) 2 (13%) 1 (7%)
None 6 (43%) 6 (38%) 8 (57%)
Comorbidities
Depression 2 (14%) 1 (6%) 2 (14%) 0.83
Thyroid dysfunction 1 (7%) 3 (19%) 3 (21%)
Systemic arterial hypertension 3 (21%) 4 (25%) 3 (21%)
Diabetes mellitus 1 (7%) 5 (31%) 1 (7%)
Osteoarthritis 3 (21%) 5 (31%) 5 (36%)
Tendinitis 1 (7%) 5 (31%) 1 (7%)
Herniated disc 1 (7%) 2 (13%) 3 (21%)
Mean (SD)/ median [25-75%] /N. (%).
BMI: Body Mass Index.

666 European Journal of Physical and Rehabilitation Medicine October 2018

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

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MUSCLE STRETCHING EXERCISES IN FIBROMYALGIA ASSUMPÇÃO

Results after the intervention. The resistance group had the low-
est FIQ depression score (P=0.02). The control group had
Of the 79 eligible subjects, 26 were excluded for reasons the highest score for FIQ morning tiredness and stiffness
described in Figure 1. Fifty-three patients started therapy, (P=0.01), and the lowest score for SF-36 vitality (P=0.01).
and the data of 44 patients were analyzed. In the evaluation of clinical improvement, the stretching
Table III shows baseline characteristics. group had important improvements in quality of life for
The groups were similar at baseline for all variables, all SF-36 domains, and the resistance group had important
except for FIQ well-being (P=0.02). improvements in the FM symptoms impact measured by
The before-after comparison in the stretching group the FIQ total score and in quality of life for SF-36 domains
showed significant improvements in pain threshold of physical functioning, vitality, social function, emotional
(P<0.01), impact on FM symptoms measured by the FIQ role, and mental health.
total score (P=0.04), and quality of life measured by SF-36
physical function, bodily pain, vitality, and mental health
(P<0.05). After the intervention, the resistance group had Discussion
significant improvements in pain threshold (P=0.01), num-
ber of tender points (P=0.03), impact on FM symptoms The objective of this study was to verify and compare the
(P=0.01), and quality of life measured by SF-36 physical effectiveness of muscle stretching exercises and resistance
function, vitality, and mental health (P<0.05), compared training for the improvement of symptoms and quality of
with baseline. No differences were seen for the control life in FM patients.
group in the before-after comparison, except for the im- In the present study, both types of exercises programs
provement in FIQ well-being (P<0.01). provided benefit for women with FM. Resistance train-
Between-group comparison (Table IV) showed that the ing significantly improved FM symptoms, especially de-
stretching group had the highest SF-36 physical functioning pression, possibly due to an increase in activity with a
score (P=0.01) and the lowest bodily pain score (P=0.01) well-conducted proactive exercise program. The muscle
stretching exercise program improved the quality of life,
especially physical functioning and bodily pain. Well-
Assessed for eligibility being and quality of life may be considered similar con-
(N.=79)
cepts,39 and are associated in practice with muscle stretch-
ing, possibly due to its characteristics of reducing muscle
Excluded (N.=26)
• Not meeting inclusion criteria (N.=5) tension, increasing flexibility, and focusing on respiration
• Refused to participate (N.=17)
• Severe rheumatologic problems (N.=4)
and posture.40 Therefore, well-being would be related to
the perception and belief that life had greater quality.
Randomized Regarding the pain data, it is important to note that VAS
(N.=53) measures the intensity or severity of pain at the time of
evaluation. The SF-36 addresses the aspects of pain in the
prior month, according to intensity or severity and interfer-
Stretching Resistance Control ence with work. These differences may explain the results.
group group group We observed that the FIQ functional capacity was the
(N.=18) (N.=19) (N.=16)
only outcome that showed a decrease in both groups. We
believe that this did not represent an actual negative im-
Lost to Lost to Lost to pact, considering that the patients tended to overdo activi-
reassessment reassessment reassessment
(N.=1) (N.=1) (N.=2) ties of daily living due to their “perfectionistic and over-
Discontinued Discontinued worked” personality traits.41 The reduction in the frequen-
intervention intervention
(N.=3) (N.=2) cy of performance of certain tasks could mean that they
learned to pace themselves; such a behavioral change is
Analyzed Analyzed Analyzed favorable to the improvement of symptoms.
(N.=14) (N.=16) (N.=14) Guidelines recommend resistance training, progressing
Figure 1.—Flow chart for inclusion procedure and allocation of subjects from low intensity, at a frequency of twice a week, in the
into groups. treatment of FM.42-45 The muscle stretching exercises still

Vol. 54 - No. 5 European Journal of Physical and Rehabilitation Medicine 667

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ASSUMPÇÃO MUSCLE STRETCHING EXERCISES IN FIBROMYALGIA

Table IV.—Pain, symptoms by FIQ and quality of life by SF-36 in stretching, resistance and control groups.
Stretching (N.=14)
Variables Before After Clinical improvement (%)
Pain
VAS pain (cm) 5.6 (1.8) 4.6 (2.6) 26
Pain threshold (kg/cm2) 1.8 (0.5) 2.1 (0.5) 38
Number of tender points 17 [12; 18] 15 [13; 17] 9
FIQ
Physical Functioning 6.5 (5.5) 9.5 (5.2) -26
Well-being (days) 2.0 [0.0; 5.0] 4.0 [3.0; 5.0] 24
Work missed (days) 0.0 [0.0; 1.0] 0.0 [0.0; 1.0] 0
Job ability (cm) 7.0 [6.5; 8.7] 6.5 [5.1; 7.3] 10
Pain (cm) 8.1 [7.0; 9.2] 7.4 [4.7; 8.4] 11
Fatigue (cm) 8.6 [7.3; 9.5] 7.8 [4.8; 8.9] 17
Morning tiredness (cm) 7.8 [7.0; 9.5] 6.6 [5.8; 7.8] 23
Stiffness (cm) 8.3 [7.1; 9.2] 5.8 [2.9; 7.4] 41
Anxiety (cm) 7.9 [6.5; 9.6] 7.7 [5.7; 8.2] 7
Depression (cm) 8.7 [5.0; 9.6] 7.9 [4.5; 8.7] 10
Total score 66.3 [49.9; 75.3] 57.4 [40.9; 71.5] 8
SF-36
Physical functioning 40.0 [20.0; 60.0] 52.5 [45.0; 65.0]# 28
Role-physical 25.0 [00.0; 50.0] 37.5 [00.0; 100.0] 51
Bodily pain 31.0 [22.0; 41.0] 41.5 [41.0; 52.0]# 46
General health 48.5 [22.0; 77.0] 52.0 [40.0; 72.0] 17
Vitality 27.5 [15.0; 40.0] 45.0 [40.0; 60.0] 74
Social function 50.0 [25.0; 75.0] 62.5 [50.0; 75.0] 27
Role-emotional 33.3 [00.0; 66.7] 33.3 [00.0; 100.0] 35
Mental health 60.0 [28.0; 76.0] 72.0 [48.0; 80.0] 21
Mean (SD)/median [25-75%]/N. (%).
#Group statistically different from the others at the post-hoc tests.

have an open recommendation because of the low method-
ological quality of the studies; their advantage is minimal
risk and high practicability.42, 45, 46 There is an open scien-
tific question about whether aerobic exercise or resistance
training would be most effective in FM, since both are
strongly recommended.47 This scientific question could
be answered by clinical trials, such as this work. Which
therapeutic exercise would act more effectively on which
specific symptoms? The revised European League Against
Rheumatism recommendations for FM treatment suggest
the importance of clarifying who will specifically benefit
from each intervention.47 Thus, resistance training could
be emphasized for a patient with depressive symptoms.
In a synthesis of systematic reviews of exercise therapy
for adults with FM, the authors recommend that future sys-
tematic reviews more accurately assess clinical heteroge-
neity, such as specific details of interventions, to clarify
what makes exercise beneficial for individuals with FM.39
A detailed description of the exercise programs in this
work allows future systematic reviews to have sufficient
resources to compare interventions.
In this study, both stretching and resistance groups un-
derwent low-cost exercise programs, which can be imple-
mented in any environment.
The facilitation of body awareness and the correct exe-
cution of movements cannot be neglected. One subject in
the resistance group interrupted participation in the study
because of worsening pain. In general, dropout due to ad-
verse effects is more common with high-intensity exer-
cise.34 The modulation of resistance training intensity was
not based on a percentage of one-repetition maximum
(RM), as suggested by the American College of Sports
Medicine.31, 33 There was the concern that the one-RM
test could cause physical overload and trigger a flare-up
of symptoms. Hence, the modulation of exercise intensity
was based on the self-perception of effort. The relation-
ship between the effort perception scale and the amount
of weight lifted was described by Lagally et al.48 and Day
et al.49 According to these authors, there is an associa-
tion between the perception assessed by the Borg scale
and the percentage of one-RM. The Lagally group later
described the validity of this scale for the prescription of
resistance training, particularly for “mildly intense” and
“very heavy,” and suggested its use instead of one-RM.48

668 European Journal of Physical and Rehabilitation Medicine October 2018

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MUSCLE STRETCHING EXERCISES IN FIBROMYALGIA ASSUMPÇÃO

Resistance (N.=16) Control (N.=14) Among groups

Before After Clinical improvement (%) Before After After (P value)

5.3 (2.5) 4.4 (3.0) 25 6.0 (2.6) 6.4 (2.7) 0.11

1.6 (0.7) 2.0 (1.0) 48 1.6 (0.5) 2.1 (1.2) 0.14
18 [15; 18] 17 [10; 18] 16 18 [14; 18] 18 [16; 18] 0.22

10.9 (6.3) 14.5 (5.0)# -28 9.6 (3.8) 10.5 (5.3) 0.03
2.0 [0.0; 4.0] 3.0 [3.0; 5.0] 11 0.0 [0.0; 1.0] 2.0 [0.0; 4.0] 0.05
0.0 [0.0; 3.0] 0.0 [0.0; 3.0] 0 2.0 [0.0; 6.0] 2.0 [0.0; 3.0] 0.96
8.5 [7.8; 9.5] 6.7 [3.6; 9.1] 18 7.9 [7.0; 9.5] 8.4 [6.9; 8.7] 0.19
8.6 [8.0; 9.5] 5.4 [3.1; 9.2] 21 8.0 [7.1; 9.4] 8.4 [7.0; 9.1] 0.27
8.5 [7.9; 9.4] 5.7 [2.4; 8.8] 20 9.2 [7.5; 9.6] 8.4 [7.3; 9.7] 0.07
8.4 [6.9; 9.6] 5.9 [4.4; 7.7] 26 8.6 [6.6; 9.5] 9.4 [7.1; 9.5]# 0.01
8.3 [6.7; 9.5] 5.8 [3.1; 8.9] 26 9.2 [6.5; 9.7] 9.0 [6.7; 9.5]# 0.01
9.1 [3.5; 9.7] 5.6 [2.3; 9.1] 27 8.8 [7.4; 9.6] 8.0 [6.7; 9.6] 0.14
8.2 [6.9; 9.3] 1.9 [0.9; 7.2]# 53 8.0 [6.3; 9.2] 7.9 [6.2; 9.6] 0.02
72.0 [64.4; 76.7] 48.3 [33.6; 66.8] 18 73.6 [69.3; 78.7] 72.2 [60.5; 81.7] 0.06

25.0 [20.0; 37.5] 35.0 [25.0; 60.0] 27 27.5 [15.0; 40.0] 30.0 [20.0; 45.0] 0.01
00.0 [0.0; 0.0] 00.0 [0.0; 0.0] 5 00.0 [0.0; 50.0] 00.0 [0.0; 50.0] 0.17
22.0 [22.0; 31.0] 31.0 [16.0; 42.0] 2 22.0 [10.0; 42.0] 26.5 [22.0; 41.0] 0.01
36.0 [22.5; 56.0] 41.0 [27.5; 52.0] 13 40.0 [30.0; 52.0] 33.5 [20.0; 57.0] 0.24
30.0 [20.0; 42.5] 47.5 [27.5; 55.0] 53 27.5 [25.0; 50.0] 30.0 [15.0; 40.0]# 0.04
43.8 [25.0; 62.5] 62.5 [50.0; 75.0] 43 43.8 [25.0; 62.5] 31.3 [25.0; 50.0] 0.07
00.0 [00.0; 66.7] 33.3 [00.0; 83.3] 69 16.7 [00.0; 66.7] 00.0 [0.0; 66.6] 0.62
46.0 [26.0; 62.0] 62.0 [54.0; 74.0] 30 48.0 [24.0; 64.0] 42.0 [32.0; 64.0] 0.11

Limitations of the study
The limitations of this work are the lack of follow-up after
treatment and the restriction of results to the immediate
postintervention period. Moreover, the evaluator was not
blinded to the intervention.
Conclusions
The muscle stretching exercise program was the most ef-
fective modality in improving quality of life, especially
physical functioning and pain, and resistance training was
the most effective modality in reducing depression. In
clinical practice, we suggest including both modalities in
programs of exercise therapy for FM.
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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
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cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
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Funding.—The authors thank the financial support from Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP).
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