Exercise for treating fibromyalgia syndrome.

BACKGROUND: Fibromyalgia (FMS) is a syndrome expressed by chronic widespread body pain which leads to reduced physical function and frequent use of health care services. Exercise training is commonly recommended as a treatment. This is an update of a review published in Issue 2, 2002. OBJECTIVES: The primary objective of this systematic review was to evaluate the effects of exercise training including cardiorespiratory (aerobic), muscle strengthening, and/or flexibility exercise on global well-being, selected signs and symptoms, and physical function in individuals with FMS. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CINAHL, SportDiscus, PubMed, PEDro, and the Cochrane Central Register for Controlled Trials (CENTRAL, Issue 3, 2005) up to and including July 2005. We also reviewed reference lists from reviews and meta-analyses of treatment studies. SELECTION CRITERIA: Randomized trials focused on cardiorespiratory endurance, muscle strength and/or flexibility as treatment for FMS were selected. DATA COLLECTION AND ANALYSIS: Two of four reviewers independently extracted data for each study. All discrepancies were rechecked and consensus achieved by discussion. Methodological quality was assessed by two instruments: the van Tulder and the Jadad methodological quality criteria. We used the American College of Sport Medicine (ACSM) guidelines to evaluate whether interventions had provided a training stimulus that would effect changes in physical fitness. Due to significant clinical heterogeneity among the studies we were only able to meta-analyze six aerobic-only studies and two strength-only studies. MAIN RESULTS: There were a total of 2276 subjects across the 34 included studies; 1264 subjects were assigned to exercise interventions. The 34 studies comprised 47 interventions that included exercise. Effects of several disparate interventions on global well-being, selected signs and symptoms, and physical function in individuals with FMS were summarized using standardized mean differences (SMD). There is moderate quality evidence that aerobic-only exercise training at recommended intensity levels has positive effects global well-being (SMD 0.44, 95% confidence interval (CI 0.13 to 0.75) and physical function (SMD 0.68, 95% CI 0.41 to 0.95) and possibly on pain (SMD 0.94, 95% CI -0.15 to 2.03) and tender points (SMD 0.26, 95% CI -0.28 to 0.79). Strength and flexibility remain under-evaluated. AUTHORS' CONCLUSIONS: There is 'gold' level evidence (www.cochranemsk.org) that supervised aerobic exercise training has beneficial effects on physical capacity and FMS symptoms. Strength training may also have benefits on some FMS symptoms. Further studies on muscle strengthening and flexibility are needed. Research on the long-term benefit of exercise for FMS is needed.

The effect of incentive spirometry on postoperative pulmonary complications: a systematic review.

OBJECTIVE: To systematically review the evidence examining the use of incentive spirometry (IS) for the prevention of postoperative pulmonary complications (PPCs). METHODS: We searched MEDLINE, CINAHL, HealthSTAR, and Current Contents databases from their inception until June 2000. Key terms included "incentive spirometry," "breathing exercises," "chest physical therapy," and "pulmonary complications." Articles were limited to human studies in English. A secondary search of the reference lists of all identified articles also was conducted. A critical appraisal form was developed to extract and assess information. Each study was reviewed independently by one of three pairs of group members. The pair then met to reach consensus before presenting the report to the entire review group for final agreement. RESULTS: The search yielded 85 articles. Studies dealing with the use of IS for preventing PPCs (n = 46) were accepted for systematic review. In 35 of these studies, we were unable to accept the stated conclusions due to flaws in methodology. Critical appraisal of the 11 remaining studies indicated 10 studies in which there was no positive short-term effect or treatment effect of IS following cardiac or abdominal surgery. The only supportive study reported that IS, deep breathing, and intermittent positive-pressure breathing were equally more effective than no treatment in preventing PPCs following abdominal surgery. CONCLUSIONS: Presently, the evidence does not support the use of IS for decreasing the incidence of PPCs following cardiac or upper abdominal surgery.

Determination of prefracture physical function in community-dwelling people who fracture their hip.

BACKGROUND: Prefracture physical function must be accurately determined to set appropriate and attainable goals for rehabilitation following hip fracture. This is especially important for people who were living independently prior to their fracture. This study determines reliability and internal consistency of a prefracture physical function questionnaire (PFPFQ) completed by both patients and knowledgeable informants (KIs). METHODS: A 20-item PFPFQ, including ambulation, transfers, balance, and self-care domains, was developed using focus groups. Community-dwelling patients with a hip fracture (N = 40, 77.9 +/- 8 years) completed the PFPFQ on two occasions during postoperative acute care. Forty KIs were identified by the patients and also completed the PFPFQ on two occasions via telephone interview. Day-to-day reliability of the patients and KIs [intraclass correlation coefficients (ICC)], and internal consistency [Kuder-Richardson coefficient (KR)] of the PFPFQ were determined. RESULTS: Intrarater reliability was high with ICCs (95% confidence interval) of 0.94 (0.89, 0.96) for patients and 0.96 (0.93, 0.98) for KIs. Interrater reliability on occasion 1 had an ICC of 0.81 (0.69, 0.88). Internal consistency of the patient responses on the first occasion was high (KR coefficient = 0.896). CONCLUSIONS: The PFPFQ is a reliable and internally consistent instrument for determining prefracture physical function in community-dwelling people who fracture their hip. In situations where patients with a hip fracture are unable to provide this necessary information, KIs can provide reliable estimates of prefracture function to assist in setting appropriate rehabilitation goals.

Cardiovascular stress associated with concentric and eccentric isokinetic exercise in young and older adults.

Heart rate (HR), mean arterial blood pressure (MAP), and rate-pressure product (RPP) responses to submaximal isokinetic concentric (CON) and eccentric (ECC) knee extension exercise were compared at the same absolute torque output in 20 young (mean+/-SD=23.2+/-1.7 years) and 20 older (mean+/-SD=75.2+/-4.6 years) adults. After determination of peak CON and ECC torques, subjects performed separate, randomly ordered, 2-minute bouts of isokinetic CON and ECC exercise (90 degrees/s, exercise intensity: 50% of CON peak torque). CON exercise elicited greater changes in HR, MAP, and RPP than ECC exercise (p<.001) for both age groups. There were no age-related differences in HR, MAP, or RPP responses for either CON or ECC exercise. At the same absolute torque output, isokinetic CON knee extension exercise elicited significantly greater increases in cardiovascular stress than ECC exercise in both young and older adults. This result has implications for determining appropriate fitness and rehabilitation programs.

Reliability of the six-minute walk test in people with fibromyalgia.

OBJECTIVE: To determine the test-retest reliability of the 6-minute walk test in people with fibromyalgia. METHODS: Twenty-six subjects (27-59 years of age) performed 3 walk tests over consecutive days before and after a 4-week treatment program. Reliability was determined using a one-way repeated measures analysis of variance and the intraclass correlation coefficient (ICC2,1). RESULTS: Reliability of the 6-minute walk test was excellent both at program intake (ICC2,1 = 0.91) and program completion (ICC2,1 = 0.98). On program intake, significant differences (P < 0.01) were found between test 1 (478 +/- 61 m) and test 2 (492 +/- 57 m), and between test 1 and test 3 (495 +/- 60 m). On program completion, there were no significant differences across the 3 replicate tests (507 m, 505 m, and 509 m). CONCLUSIONS: The 6-minute walk test is a reliable measure in people with fibromyalgia. In this study, two trials were required to achieve a stable walk performance before a treatment program. This learning effect was not present following the intervention.

Reliability of a patient-rated forearm evaluation questionnaire for patients with lateral epicondylitis.

PURPOSE: To determine the reliability of a questionnaire designed to assess forearm pain and function in patients with lateral epicondylitis. METHODS: Forty-seven patients with unilateral lateral epicondylitis completed a patient-related forearm evaluation questionnaire (PRFEQ) on two occasions. Intraclass correlation coefficients (ICC 2,1), standard error of measurement (SEM), and 95% confidence intervals (CIs) were determined for the whole group and for three subgroup comparisons of male vs. female subjects, subacute vs. chronic lateral epicondylitis, and work-related vs. non-work-related lateral epicondylitis. RESULTS: The test-retest reliability for the overall PRFEQ (ICC, 0.89), and its pain (ICC, 0.89) and function (ICC, 0.83) subscales was excellent. Test-retest reliability for patients with work-related lateral epicondylitis (ICC, 0.80) was significantly (p = 0.018) less than for patients with non-work-related lateral epicondylitis (ICC, 0.94). CONCLUSIONS: The PRFEQ can provide a simple, quick, and reliable estimate of arm pain and function in patients with lateral epicondylitis. However, large SEM and 95% CIs limit its ability to accurately predict individual scores.

Strength and pain measures associated with lateral epicondylitis bracing.

OBJECTIVE: To determine the effect of bracing on measures of pain-free grip strength and pain scores in individuals with unilateral lateral epicondylitis through a comparison of two elbow braces, a placebo brace, and a no-brace situation. DESIGN: Repeated-measures design in which the subjects acted as their own controls. SETTING: A clinical research laboratory at a hand and upper limb clinic. PATIENTS: Fifty individuals diagnosed by a physician with unilateral lateral epicondylitis, having symptoms for at least 3 weeks, were recruited from the community. INTERVENTIONS: The braces studied were the Count'R-Force Tennis Elbow Brace, the Body Glove Airprene Elbow Support, and a placebo brace that consisted of a modified DePuy Levy Clinic Patella Strap. MAIN OUTCOME MEASURES: Pain-free grip strength measured using an NK Biotechnical Corporation Hand Assessment System DIGIT-grip Device and pain scores measured on a visual numeric rating scale. RESULTS: No significant differences in pain-free grip strength or pain were observed between any of the test situations (p > .05). Pain during the test, however, was greater than pain before or after the test (p < .05). CONCLUSIONS: When tests were completed on one occasion with the brace on, no advantages of elbow bracing were detected. Whether bracing is effective when used as a treatment technique for an extended period of time should be addressed in future research.

Anthropometric and computed tomographic assessment of the thigh in young and old men.

Anthropometric (AP) and computed tomographic (CT) methods of determining limb and muscle-plus-bone cross-sectional area (CSA) and volume (Vol) were compared in 13 young (M = 24.5 yrs) and 11 old (M = 71.0 yrs) men. CSA of total thigh, muscle-plus-bone, quadriceps, and hamstring muscle compartments and muscle were measured from CT scans. Corresponding muscle Vol were estimated from anthropometric equations. Prediction equations for CT measures were developed from AP measures using multiple linear regression. AP and CT techniques produced different values for thigh component CSA and Vol, especially in the old men. AP overestimated muscle-plus-bone CSA and Vol (4-6%) and underestimated skin and subcutaneous tissue CSA and Vol (17-33%). Prediction equations for quadriceps CSA and Vol (R2 = 80-96%) were more accurate than equations for hamstrings (R2 = 42-65%). Specific thigh muscle CSA and Vol can be predicted from AP measures (SEE 5-15%). These findings may have clinical significance when normalizing strength per unit of muscle size.

Thigh composition in young and elderly men determined by computed tomography.

Computed tomography (CT) was used to quantify components of the thigh in young (n = 13) and elderly (n = 11) men. Cross-sectional areas (CSA) of the total limb, total muscle plus bone, quadriceps compartment, hamstring compartment and bone were measured at each of five scan sites along the length of the thigh. Non-muscle tissue (NMT) areas within the muscle compartments were measured using changes in density based on Hounsfield units. Skin plus subcutaneous fat areas and quadriceps and hamstring lean muscle areas were calculated by subtraction. Geometric formulae were used to calculate related volumes for each thigh component. Volumes were also predicted from regression equations employing thigh length and component CSA from single mid-limb CT scans. The results showed that while total thigh CSA was not different in elderly men, they had significantly smaller total muscle plus bone (13.0%), and quadriceps (26.4%), and hamstring (17.9%) muscle areas. The elderly men also had significantly greater CSA for skin plus subcutaneous fat (37.6%), and for NMT in the quadriceps (59.4%) and hamstring (127.3%) muscle compartments. These results suggest that comparisons of relative leg muscle strength between young and elderly men may be misleading due to the decrease in actual muscle tissue associated with ageing. Appropriate quantification of muscle size and CSA must be carried out before such comparisons can be meaningful.

Knee extensor and knee flexor strength: cross-sectional area ratios in young and elderly men.

The relationships between isometric and isokinetic-concentric knee extensor and knee flexor strength, and quadriceps and hamstring cross-sectional area (CSA) were determined in young (n = 13, M = 24.5y) and elderly (n = 12, M = 70.7y) men. Quadriceps and hamstring CSA was determined by computed tomography. Knee extensor and flexor strength at 0 degree/s and 120 degree/s was determined on a Kin-Com isokinetic dynamometer. Compared to the young men, elderly men had significantly smaller quadriceps muscles and were weaker (22-32%) in knee flexion and knee extension at both angular velocities. Strength:CSA ratios were similar at 0 degree/s, but elderly men had decreased ratios for both extensors and flexors at 120 degree/s. Correlations of knee extensor and flexor strength with muscle CSA were significant at both velocities in elderly men, but not at either velocity for the knee flexors in young men. The decrease in isometric strength in elderly men can be accounted for by their decrease in muscle CSA, but their decrease in isokinetic-concentric strength was greater than their loss of CSA. Further study is required to determine the reason for this nonproportional loss of isokinetic-concentric strength.

The effect of interval and continuous training on the aerobic parameters.

The purpose of this study was to investigate changes in the parameters of aerobic function resulting from continuous training (CT) and interval training of both low power (LPO-IT) and high power output (HPO-IT). Untrained males (n = 17, 25.1 yrs) trained 10 weeks on cycle ergometers (four 40-min sessions a week) at 80% VO2max. Cycle ramp function tests at 0 and 10 weeks were used to determine the four aerobic parameters:VO2max, ventilation threshold (VeT), effective time constant for O2 uptake kinetics (MRT), and work efficiency (eta): VO2max increased significantly (3.30 to 3.66 l.min-1). Absolute VeT increased significantly (2.17 to 2.45 l.min-1) but there was no change in the relative threshold (VeT/VO2max). MRT decreased significantly from 38.8 to 33.1 seconds and there was no change in eta. There were no between-group differences; thus neither low power output nor high power output interval training offers an advantage over continuous training of the same average power output in altering the aerobic parameters.

Physiological responses of young and elderly men to prolonged exercise at critical power.

The critical power (CP) of a muscle group or individual may represent the highest rate of work which can be performed for an extended period. We investigated this concept in young (n = 13, 24.5 years) and elderly (n = 12, 70.7 years) active men by first determining CP and then comparing responses elicited by 24 min of cycle exercise at power outputs (omega) corresponding to CP. Values from the final 2 min of the 24-min ride were expressed relative to maximal values established in a ramp test. CP for the elderly was only 65% that for the young, but on a relative basis, it was significantly higher both in terms of omega (67 vs 62% of omega max) and oxygen consumption (VO2) (91.5 vs 85.2% of maximum oxygen consumption). There were no group differences in relative values for ventilation (VE), heart rate or respiratory exchange ratio (R). During the 24-min ride, VO2 and R achieved a plateau in both groups, while VE, blood lactate and arterial PCO2 continued to change in the young. It was concluded that CP can be determined in active elderly men, but that CP may not represent a true non-fatiguing work rate in either young or elderly men.