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Physical therapy in treating fibromyalgia syndrome: a brief review/Fibromiyalji tedavisinde fizik tedavi: kisa derleme.


Fibromyalgia (FM) is characterized by chronic widespread pain and reduced pain threshold, with hyperalgesia and allodynia (1). Associated features include non-restorative sleep, fatigue, psychological distress, depression, anxiety, cognitive dysfunction, headache, paresthesias and bowel dysfunction (1,2). All these symptoms can have a prominent impact on patient's emotional and physical function and overall health-related quality of life. The current hypotheses of the aetiology of FM include an inflammatory disorder accompanied by changes in the neuroendocrine-immune system and central nervous system pain processing abnormalities containing central sensitization and inadequate pain inhibition (2,3).

Despite the investigations of a wide range of managements, optimal treatment of FM is still unknown. Management of the FM syndrome includes both pharmacologic and non-pharmacologic therapies, but currently, non-pharmacological management strategies cannot replace pharmacological ones. Non-pharmacologic strategies include physiotherapy, exercise, massage, mind-body cognitive/cognitive-behavioral, complementary and alternative therapies (4,5).

Multidisciplinary treatment has proven to be the best therapeutic option to FM syndrome and physiotherapy has an important role in this approach (6). Exercise is recognized as one part of the management of FM (7). Exercise improves psychological distress, physical function, and other quality of life parameters in FM (8). However, the mechanisms through which exercise benefits FM symptoms and all of the clinically relevant and practically important aspects of an exercise prescription need to be elucidated. One hypothesis is that while there are abnormalities in central sensitization and inadequate pain inhibition in individuals with FM, muscle microtrauma or metabolic disturbances in peripheral tissues may contribute to chronic pain through maintaining or even initiating central sensitization (8-10). Thus, exercise may contribute to pain improvement through the process of tissue repair and metabolic adaptations (8,11,12). Another hypothesis is that the benefits of exercise on FM symptoms are mediated by regulation of the cytokine-hypothalamic-pituitary-adrenal (HPA) axis feedback and its anti-inflammatory effects (7,8).

Exercise therapy has been used successfully to alleviate a number of conditions that are also commonly experienced by FM patients. Strength training and aerobic exercises have been found to improve depression in subjects with clinical depression and/or anxiety (13,14). Exercise can also improve sleep in subjects with sleep disturbances (15,16). Exercise training may also improve fatigue, because as one's maximal aerobic capacity improves.

The primary objective of this review was to evaluate the effects of physiotherapy and exercise training including aerobic (cardiorespiratory), muscle strengthening, flexibility exercises on global health related quality of life, fibromyalgia related signs and symptoms, and physical function in subjects with FM. Alternative treatments such as chiropractic, Thai-chi and acupuncture treatments are out of the objective of this review.

1. Exercises

1.1. Aerobic Exercise

AE includes land-based and water based exercises such as walking, cycling, games, dance, rhythmic or boxing movements and aquatic jogging (17,18). Most of the studies showed a positive effect of AE in FM patients. However, in some studies the sample size is very small, assessments and outcomes are not fully comparable. Although studies results are less clear for sleep and overall pain, AE generally was found efficacious for improvement in physical fitness, fatigue, depressed mood, tender points count, and FIQ score (17,18).

Recently, in a systematic review, Hauser et al (18) evaluated the efficacy of different types and volumes of AE in FM syndrome. They concluded that an AE programme for FM patients should consist of regular land-based or water-based exercises with slight to moderate intensity two to three times a week for at least 4 weeks. The patient should be motivated to continue AE after participating in an AE programme.

1.2. Muscle Strengthening Exercises

In a SE exercise program, free weights and/or body weight are used for strengthening of upper, lower limb and trunk muscles (19,20). Individuals begin with frequency of 2-3 days per week, and a minimum of one set of 8-12 repetitions at an intensity of the 8 to 12 Repetition Maximum of each SE. We found only a few studies in the literature evaluating SE in patients with FM. In these studies, fibromyalgia patients were randomized to either an aerobic AE program, a flexibility or a SE program. At outcome measures, AE, flexibility and SE are similarly effective at improving symptoms, tender point count, fitness, depression, and quality of life in fibromyalgia (19-22).

1.3. Flexibility Exercises

Flexibility exercises (FE) include controlled static stretching in which an individual assumes a position and holds it for a certain duration. Properties of a FE program are 3 to 4 repetitions for each stretch held for a duration of 20-30 seconds, intensity to a position of mild discomfort, and frequency of FE equal to or greater than two days per week (23,24).

The FE studies in FM are sparse. In these studies flexibility-only exercises compared to strength exercises have large positive effects on flexibility, but no effect on tender points or depression. Thus more studies, preferably of high quality, are needed to confirm and extend the effects of FE in FM syndrome.

2. Hydrotherapy Without Exercises

The mechanisms of action of hydrotherapy are not completely known, but most probably the benefits could be derived from mechanical, physical and chemical factors (25). Muscle tone and pain intensity can be positively influenced. There is moderate evidence that hydrotherapy has beneficial effects on pain and HRQOL in FM (26). Balneotherapy and Spa therapy without exercises were also reported as an effective, safe, possible alternative treatment for FM syndrome that could improve patients' HRQOL (25-27).

3. Massage

Massage therapy (MT) may be helpful in improving pain, sleep and reducing depression and anxiety symptoms in FM syndome. It is suggested that the release of ,-endorphins is linked with the pain relief and feeling of warmth and well-being associated with MT (28,29). MT is substantially requested by patients with FM seeking symptoms relief (30). MT may promote the restorative sleep in FM (30-32) and in other patients (33,34), alleviate anxiety and depression symptoms (35,36), and relieve acute and chronic pain (37-39).

Painless MT to cervical, thoracal and lumbar spine and paravertebral muscles as well as around tender point sites is more appropriate for treating patients with FM. The sessions should be performed at least 1-2 times a week for 1 to 3 months. In MT of FM patients, in accordance with patient's symptoms it is suggested that intensity of MT should be increased gradually from session to session. However, there is weak evidence of efficacy for MT in the treatment of FM (40).

4. Electrotherapeutic Interventions

It is crucial to mention that all electrotherapeutic interventions should be performed by a trained physiotherapist to avoid life threatening misusage and side effects of these modalities.

4.1. Transcutaneous Electrical Nerve Stimulation (TENS)

TENS has been used successfully for pain relief in acute and chronic pain conditions. TENS can be used for pain relief at varying frequencies (most commonly between 50 and 120 Hz.

Although not fully understood, it is thought that TENS alleviate pain through activating supraspinal and spinal mechanisms. TENS has resulted in increased levels of Y-amino-butyric acid (GABA), endorphin, encephalin and dynorphin in spinal cord (41,42). Self-administered TENS yielded comparable temporary pain reduction in patients with FM (43).

4.2. Pulsed Electromagnetic Fields, Repetitive Transcranial Magnetic Stimulation

Low-frequency pulsed electromagnetic fields (PEMF, 1000 Hz or less), comprise a potentially new modality of therapy for chronic pain conditions such as FM. Exposure to PEMF of low strength (200 head surface to 35 deep brain) has been shown to produce ana lgesic (antinociceptive) effects in humans. This modality can be administered by means of cranial exposure (44,45).

Repetitive transcranial magnetic stimulation (rTMS) is another safe non-invasive technique for electromagnetic stimulating the cerebral cortex. rTMS is also effective in reducing pain in patients with refractory central pain (46). The rTMS parameters for treating FM syndrome in the previous studies were 25 series of eight-second pulses, with 52 s interval between series, at a stimulation frequency of 10 Hz, giving a total of 2000 pulses per session. rTMS was also found to induce a long-lasting decrease in pain and improved quality of life in patients with FM, without affecting mood or anxiety levels (47-49).

The mechanisms by which electromagnetic forces cause pain reduction are not fully understood. However, there is evidence that electromagnetic forces increase the release of endogenous opioids via the brain's limbic system and a direct effect on thalamic function by changing brain wave activity. In previous studies, PEMF was found effective to improve function, pain, fatigue, and global status in patients with FM (49,50).

4.3. Transcranial Direct Current Stimulation

Transcranial direct current stimulation (tDCS) is among the techniques of noninvasive brain stimulation. Low amplitude direct current is applicated to the scalp via two relatively large anode and cathode electrodes in this thecnique. Consecutive 5 or 10 daily sessions of 2 mA, 20 min tDCS of the left primary motor (M1) or dorsolateral prefrontal cortex (DLPFC) could be applicated. In the previous studies, tDCS was found effective to improve pain, and sleep in patients with FM. A longer treatment protocol involving consecutive 10 daily sessions offer additional, more long-lasting clinical benefits in the management of pain from FM (51,52).

4.4. Low Level Laser Therapy (LLLT)

The efficacy of this treatment method is controversial in FM syndrome (53,54). It is suggested that prolonged laser exposure may produce photochemical reactions which alter neuronal activity resulting in pain relief. Patients with FM may be treated for 3 min at each tender point daily for consecutive 10 to 15 d ays at each point with approximately 2 to 10 J/cm2.

4.5. Ultrasound Therapy and Interferential Current

Ultrasound (US) therapy is used for the physiological effects on tissues derived from its mechanical and thermal action. The mechanical action increases cell permeability, decreases inflammatory responses consequently reduces pain by decreasing nerve conduction velocity. As well as US has a thermal action that contributes to local vasodilatation leading to an improvement in muscle spasm and pain (55,56). The pulse parameters of US therapy for FM treatment could be 1MHz and 2.5 W/[cm.sup.2] (57).

Interferential current is a type of medium frequency currents which is able to reach deep muscles and nerves. It enhances peripheral blood flow, stimulates active contraction, and promotes analgesia in painful areas. The parameters for interferential current treatment could be 4000-4100Hz, and Amplitude-Modulated Frequency 100Hz. US therapy combined with massage or interferential current might be an effective therapeutic approach for pain and sleep manifestations in FM (57).

In conclusion; At present, use of selected electrotherapeutic intervention or hydrotherapy with aerobic exercises or other exercises programs and massage are indicated. At this time, in the light of literature, none of the currently used physical therapy agents can be refuted in the treatment of FM.


(1.) Smith HS, Barkin RL. Fibromyalgia syndrome: a discussion of the syndrome and pharmacotherapy. Am J Ther 2010;17:418-39.

(2.) Arnold LM. The pathophysiology, diagnosis and treatment of fibromyalgia. Psychiatr Clin North Am 2010;33:375-408.

(3.) van West D, Maes M. Neuroendocrine and immune aspects of Fibromyalgia. BioDrugs 2001;15:521-31.

(4.) Arnold LM. Strategies for managing fibromyalgia. Am J Med 2009;122:31-43.

(5.) Williams DA. The role of non-pharmacologic approaches in the management of fibromyalgia. CNS Spectr 2009; 14:10-2.

(6.) Hauser W, Thieme K, Turk DC. Guidelines on the management of fibromyalgia syndrome--a systematic review. Eur J Pain 2010;14:5-10.

(7.) Kelley GA, Kelley KS, Hootman JM, Jones DL. Exercise and global well-being in community-dwelling adults with fibromyalgia: a systematic review with meta-analysis. BMC Public Health 2010;20:198.

(8.) Ortega E, Garc'a JJ, Bote ME, et al. Exercise in fibromyalgia and related inflammatory disorders: known effects and unknown chances. Exerc Immunol Rev 2009;15:42-65.

(9.) Staud R, Robinson ME, Price DD. Isometric exercise has opposite effects on central pain mechanisms in fibromyalgia patients compared to normal controls. Pain 2005;118:176-84.

(10.) Staud R. Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome. Arthritis Res Ther 2006;24:208.

(11.) Park JH, Phothimat P, Oates CT, Hernanz Schulman M, Olsen NJ. Use of P-31 magnetic resonance spectroscopy to detect metabolic abnormalities in muscles of patients with fibromyalgia. Arthritis Rheum 1998;41:406-13.

(12.) Deschenes MR, Kraemer WJ. Performance and physiologic adaptations to resistance training. Am J Phys Med Rehabil 2002;81:3-16.

(13.) Brosse AL, Sheets ES, Lett HS, Blumenthal JA. Exercise and the treatment of clinical depression in adults: Recent findings and future directions. Sports Med 2002;32:741-60.

(14.) Dunn AL, Trivedi MH, O'Neal HA. Physical activity dose-response effects on outcomes of depression and anxiety. Med Sci Sports Exerc 2001;33:587-97.

(15.) King AC, Oman RF, Brassington GS, Bliwise DL, Haskell WL. Moderate-intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial. JAMA 1997;277:327.

(16.) Singh NA, Clements KM, Fiatarone MA. A randomized controlled trial of the effect of exercise on sleep. Sleep 1997;20:95101.

(17.) Jones KD, Liptan GL. Exercise interventions in fibromyalgia: clinical applications from the evidence. Rheum Dis Clin North Am 2009;35:373-91.

(18.) Hauser W, Klose P, Langhorst J, et al. Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials. Arthritis Res Ther 2010;12:79.

(19.) Bircan C, Karasel SA, Akgun B, El O, Alper S. Effects of muscle strengthening versus aerobic exercise program in fibromyalgia. Rheumatol Int 2008;28:527-32.

(20.) Hakkinen A, Hakkinen K, Hannonen P, Alen M. Strength training induced adaptations in neuromuscular function of premenopausal women with fibromyalgia: comparison with healthy women. Ann Rheum Dis 2001;60:21-6.

(21.) Jentoft ES, Kvalvik AG, Mengshoel AM. Effects of pool-based and land-based aerobic exercise on women with fibromyalgia /chronic widespread muscle pain. Arthritis Rheum 2001;45:42-7.

(22.) Valkeinen H, Alen M, Hannonen P, Hakkinen A, Airaksinen O, Hakkinen K. Changes in knee extension and flexion force, EMG and functional capacity during strength training in older females with fibromyalgia and healthy controls. Rheumatology (Oxford) 2004;43:225-8.

(23.) Jones KD, Burckhardt CS, Clark SR, Bennett RM, Potempa KM. A randomized controlled trial of muscle strengthening versus flexibility training in fibromyalgia. J Rheumatol 2002;29:1041-8.

(24.) Mannerkorpi K, Nyberg B, Ahlmen M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. J Rheumatol 2000;27:2473-81.

(25.) Giannitti C, Bellisai B, Iacoponi F, Petraglia A, Fioravanti A. New evidences on spa therapy in fibromyalgia. Clin Ter 2008;159:377-80.

(26.) Langhorst J, Musial F, Klose P, Hauser W. Efficacy of hydrotherapy in fibromyalgia syndrome--a meta-analysis of randomized controlled clinical trials. Rheumatology (Oxford) 2009;48:1155-9.

(27.) Evcik D, Kizilay B, Gokcen E. The effects of balneotherapy on fibromyalgia patients. Rheumatol Int 2002;22:56-9.

(28.) Kaada B, Torsteinb0 O. Increase of plasma beta-endorphins in connective tissue massage. Gen Pharmacol 1989;20:487- 9.

(29.) Gordon C, Emiliozzi C, Zartarian M. Use of a mechanical massage technique in the treatment of fibromyalgia: a preliminary study. Arch Phys Med Rehabil 2006;87:145-7.

(30.) Wahner-Roedler DL, Elkin PL, Vincent A, et al. Use of complementary and alternative medical therapies by patients referred to a fibromyalgia treatment program at a tertiary care center. Mayo Clin Proc 2005;80:55-60.

(31.) Sunshine W, Field T, Quintino O, et al. Fibromyalgia benefits from massage therapy and transcutaneous electrical stimulation. J Clin Rheumatol 1996;2:18-22.

(32.) Field T, Diego M, Cullen C, Hernandez-Reif M, Sunshine W, Douglas S. Fibromyalgia pain and substance P decrease and sleep improves after massage therapy. J Clin Rheumatol 2002;8:72-6.

(33.) Richards KC. Effect of a back massage and relaxation intervention on sleep in critically ill patients. Am J Crit Care 1998;7:288-99.

(34.) Ejindu A. The effects of foot and facial massage on sleep induction, blood pressure, pulse and respiratory rate: crossover pilot study. Complem Ther Clin Pract 2007;13:266-75.

(35.) Hernandez-Reif M, Field T, Krasnegor J, Theakston H. Lower back pain is reduced and range of motion increased after massage therapy. Int J Neurosci 2001;106:131-45.

(36.) Coelho HF, Boddy K, Ernst E. Massage therapy for the treatment of depression: a systematic review. Int J Clin Pract 2008;62:325-33.

(37.) Cherkin DC, Eisenberg D, Sherman KJ, et al. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Arch Intern Med 2001;161:1081-8.

(38.) Hsieh CY, Phillips RB, Adams AH, Pope MH. Functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial. J Manipulative Physiol Ther 1992;15:4-9.

(39.) Preyde M. Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. CMAJ 2000;162:1815-20.

(40.) Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004;292:2388-95. 40.

(41.) Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation: basic science mechanisms and clinical effectiveness. J Pain 2003;4:109-21.

(42.) Maeda Y, Lisi TL, Vance CG, Sluka KA. Release of GABA and activation of GABA(A) in the spinal cord mediates the effects of TENS in rats. Brain Res 2007;1136:43-50.

(43.) Lofgren M, Norrbrink C. Pain relief in women with fibromyalgia: a cross-over study of superficial warmth stimulation and transcutaneous electrical nerve stimulation. J Rehabil Med 2009;41:557-62.

(44.) Thomas AW, Drost DJ, Prato FS. Human subjects exposed to a specific pulsed (200 microT) magnetic field: Effects on normal standing balance. Neurosci Lett 2001;297:121-4.

(45.) Cook CM, Thomas AW, Prato FS. Resting EEG is affected by exposure to a pulsed ELF magnetic field. Bioelectromagnetics 2004;25:196-203.

(46.) Nuti C, Peyron R, Garcia-Larrea L, et al. Motor cortex stimulation for refractory neuropathic pain: four year outcome and predictors of efficacy. Pain 2005;118:43-52.

(47.) Passard A, Attal N, Benadhira R, et al. Effects of unilateral repetitive transcranial magnetic stimulation of the motor cortex on chronic widespread pain in fibromyalgia. Brain 2007;130:2661-70.

(48.) Sampson SM, Rome JD, Rummans TA. Slow-frequency rTMS reduces fibromyalgia pain. Pain Med 2006;7:115-8.

(49.) Thomas AW, Graham K, Prato FS, McKay J, Forster PM, Moulin DE, Chari S. A randomized, double-blind, placebo- controlled clinical trial using a low-frequency magnetic field in the treatment of musculoskeletal chronic pain. Pain Res Manag 2007;12:249-58.

(50.) Sutbeyaz ST, Sezer N, Koseoglu F, Kibar S. Low-frequency pulsed electromagnetic field therapy in fibromyalgia: a randomized, double-blind, sham-controlled clinical study. Clin J Pain 2009;25:722-8.

(51.) Valle A, Roizenblatt S, Botte S, et al. Efficacy of anodal trans-cranial direct current stimulation (tDCS) for the treatment of fibromyalgia: results of a randomized, sham-controlled longitudinal clinical trial. J Pain Manag 2009;2:353-61.

(52.) Roizenblatt S, Fregni F, Gimenez R, et al. Site-specific effects of transcranial direct current stimulation on sleep and pain in fibromyalgia: a randomized, sham-controlled study. Pain Pract 2007;7:297-306.

(53.) Matsutani LA, Marques AP, Ferreira EA, et al. Effectiveness of muscle stretching exercises with and without laser therapy at tender points for patients with fibromyalgia. Clin Exp Rheumatol 2007;25:410-5.

(54.) Gur A, Karakoc M, Nas K, Cevik R, Sarac J, Ataoglu S. Effects of low power laser and low dose amitriptyline therapy on clinical symptoms and quality of life in fibromyalgia: a single-blind, placebo-controlled trial. Rheumatol Int 2002;22:188-93.

(55.) Citak-Karakaya I, Akbayrak T, Demirturk F, Ekici G, Bakar Y. Short and long-term results of connective tissue manipulation and combined ultrasound therapy in patients with fibromyalgi-a. J Manipulative Physiol Ther 2006;29:524-8.

(56.) Ricci NA, Dias CN, Driusso P. The use of electrothermal and phototherapeutic methods for the treatment of fibromyalgia syndrome: a systematic review. Rev Bras Fisioter 2010;14:1-9.

(57.) Almeida TF, Roizenblatt S, Benedito-Silva AA, Tufik S. The effect of combined therapy (ultrasound and interferential current) on pain and sleep in fibromyalgia. Pain 2003;104:665-72.

Levent Ediz, Ozcan Hiz

Yuzuncu Yil University Medical Faculty, Physical Medicine and Rehabilitation Department, Van, Turkey

Corresponding Author

Yazisma Adresi

Levent Ediz

Yuzuncu Yil University, Medical Faculty, Physical Medicine and Rehabilitation Department, 65000, Van, Turkey

Phone: +90 432 226 90 07

E-mail: and

Received/Gelis Tarihi: 23.04.2011

Accepted/Kabul Tarihi: 25.05.2011
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Author:Ediz, Levent; Hiz, Ozcan
Publication:Turkish Journal of Physical Medicine and Rehabilitation
Article Type:Report
Geographic Code:7TURK
Date:Mar 1, 2011
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