Angela J Busch

Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials

IntroductionThe efficacy and the optimal type and volume of aerobic exercise (AE) in fibromyalgia syndrome (FMS) are not established. We therefore assessed the efficacy of different types and volumes of AE in FMS.MethodsThe Cochrane Library, EMBASE, MEDLINE, PsychInfo and SPORTDISCUS (through April 2009) and the reference sections of original studies and systematic reviews on AE in FMS were systematically reviewed. Randomised controlled trials (RCTs) of AE compared with controls (treatment as usual, attention placebo, active therapy) and head-to-head comparisons of different types of AE were included. Two authors independently extracted articles using predefined data fields, including study quality indicators.ResultsTwenty-eight RCTs comparing AE with controls and seven RCTs comparing different types of AE with a total of 2,494 patients were reviewed. Effects were summarised using standardised mean differences (95% confidence intervals) by random effect models. AE reduced pain (-0.31 (-0.46, -0.17); P < 0.001), fatigue (-0.22 (-0.38, -0.05); P = 0.009), depressed mood (-0.32 (-0.53, -0.12); P = 0.002) and limitations of health-related quality of life (HRQOL) (-0.40 (-0.60, -0.20); P < 0.001), and improved physical fitness (0.65 (0.38, 0.95); P < 0.001), post treatment. Pain was significantly reduced post treatment by land-based and water-based AE, exercises with slight to moderate intensity and frequency of two or three times per week. Positive effects on depressed mood, HRQOL and physical fitness could be maintained at follow-up. Continuing exercise was associated with positive outcomes at follow-up. Risks of bias analyses did not change the robustness of the results. Few studies reported a detailed exercise protocol, thus limiting subgroup analyses of different types of exercise.ConclusionsAn aerobic exercise programme for FMS patients should consist of land-based or water-based exercises with slight to moderate intensity two or three times per week for at least 4 weeks. The patient should be motivated to continue exercise after participating in an exercise programme.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Aerobic Fitness Exercises in the Management of Fibromyalgia: Part 1

Background and Purpose: The objective of this study was to create guidelines for the use of aerobic fitness exercises in the management of adult patients (>18 years of age) with fibromyalgia, as defined by the 1990 American College of Rheumatology criteria. Methods: Following Cochrane Collaboration methods, the Ottawa Methods Group found and synthesized evidence from comparative controlled trials and formed the Ottawa Panel, with nominated experts from key stakeholder organizations. The Ottawa Panel then developed criteria for grading the recommendations based on experimental design (I for randomized controlled trials, II for nonrandomized studies) and strength of evidence (A, B, C+, C, D+, D, or D−). From the rigorous literature search, 13 randomized control trials and 3 controlled clinical trials were selected. Statistical analysis was based on Cochrane Collaboration methods. Continuous data were calculated with weighted mean differences between the intervention and control groups, and dichotomous data were analyzed with relative risks. Clinical improvement was calculated using absolute benefit and relative difference in change from baseline. Clinical significance was attained when an improvement of 15% relative to a control was found. Results: There were 24 positive recommendations: 10 grade A, 1 grade B, and 13 grade C+. Of these 24 positive recommendations, only 5 were of clinical benefit. Discussion and Conclusion: The Ottawa Panel recommends aerobic fitness exercises for the management of fibromyalgia as a result of the emerging evidence (grades A, B, and C+, although most trials were rated low quality) shown in the literature.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Strengthening Exercises in the Management of Fibromyalgia: Part 2

Background and Purpose: The objective of this study was to create guidelines for the use of strengthening exercises in the management of adult patients (>18 years of age) with fibromyalgia (FM), as defined by the 1990 American College of Rheumatology criteria. Methods: Following Cochrane Collaboration methods, the Ottawa Methods Group found and synthesized evidence from comparative controlled trials and formed the Ottawa Panel, with nominated experts from key stakeholder organizations. The Ottawa Panel then developed criteria for grading the recommendations based on experimental design (I for randomized controlled trials, II for nonrandomized studies) and strength of evidence (A, B, C+, C, D+, D, or D−). From the rigorous literature search, 5 randomized controlled trials were selected. Statistical analysis was based on Cochrane Collaboration methods. Continuous data were calculated with weighted mean differences between the intervention and control groups, and dichotomous data were analyzed with relative risks. Clinical improvement was calculated using absolute benefit and relative difference in change from baseline. Clinical significance was attained when an improvement of 15% relative to a control was found. Results: There were 5 positive recommendations: 2 grade A and 3 grade C+. All 5 were of clinical benefit. Discussion and Conclusion: The Ottawa Panel recommends strengthening exercises for the management of fibromyalgia as a result of the emerging evidence (grades A, B, and C+, although most trials were rated low quality) shown in the literature.

Exercise for Adults with Fibromyalgia: An Umbrella Systematic Review with Synthesis of Best Evidence

The objective of this umbrella systematic review was to identify, evaluate, and synthesize systematic reviews of physical activity interventions for adults with fibromyalgia (FM) focussing on four outcomes: pain, multidimensional function (wellness or quality of life), physical function (self-reported physical function or measured physical fitness) and adverse effects. A further objective was to link these outcomes with details of the interventions so as to guide and shape future practice and research. Electronic databases including Medline, EMBASE, CINAHL, AMED, the Cochrane Library, and DARE, were searched for the January 1(st) 2007 to March 31(st) 2013 period. Nine systematic reviews (60 RCTs with 3816 participants) were included. Meta-analysis was not conducted due to the heterogeneity of the sample. We found positive results of diverse exercise interventions on pain, multidimensional function, and self-reported physical function, and no supporting evidence for new (to FM) interventions (i.e., qigong, tai chi). There were no serious adverse effects reported. The variability of the interventions in the reviews prevented us from answering important clinical questions to guide practical decisions about optimal modes or dosages (i.e., frequency, intensity, duration). Finally, the number of review articles is proliferating, leading researchers and reviewers to consider the rigor and quality of the information being reviewed. As well, consumers of these reviews (i.e., clinicians, individuals with FM) should not rely on them without careful consideration.

A Randomized Clinical Trial of Aquatic versus Land Exercise to Improve Balance, Function, and Quality of Life in Older Women with Osteoporosis

PURPOSE Despite the decreased gravitational loading that is experienced in an aquatic environment, little research has been conducted on this exercise medium for women with osteoporosis (OP). Aquatic exercise (AE) may improve function and balance, thus ultimately decreasing fall risk and the potential for hip fractures in this high-risk population. METHOD A total of 68 women with OP, aged 60 years or older, were recruited into a randomized clinical trial evaluating the impact of AE, land exercise (LE), and no exercise (NE) on balance, functional mobility, and quality of life (QOL). RESULTS Only one balance measure (backward tandem walk) significantly improved with AE compared to LE, but this did not translate into a greater improvement in self-report function. There were no significant differences between the exercise interventions and NE, except for in ratings of global change, where participants in the AE group were three times more likely to report improvement than those in the NE group. CONCLUSION There were no differences in balance, function, or QOL in women with OP who followed an AE or LE programme compared to those in an NE control group. However, the significant differences in backward tandem walk between the AE and LE groups and self-reported global change between the AE and NE groups warrant further investigation. Significant improvements in balance and global change suggest that AE is a viable alternative for older women with OP who have difficulty exercising on land.

Effect of Transfer, Lifting, and Repositioning (TLR) Injury Prevention Program on Musculoskeletal Injury Among Direct Care Workers

Musculoskeletal injuries among health care workers is very high, particularly so in direct care workers involved in patient handling. Efforts to reduce injuries have shown mixed results, and strong evidence for intervention effectiveness is lacking. The purpose of our study was to evaluate the effectiveness of a Transfer, Lifting and Repositioning (TLR) program to reduce musculoskeletal injuries (MSI) among direct health care workers. This study was a pre- and post-intervention design, utilizing a nonrandomized control group. Data were collected from the intervention group (3 hospitals; 411 injury cases) and the control group (3 hospitals; 355 injury cases) for periods 1 year pre- and post-intervention. Poisson regression analyses were performed. Of a total 766 TLR injury cases, the majority of injured workers were nurses, mainly with back, neck, and shoulder body parts injured. Analysis of all injuries and time-loss rates (number of injuries/100 full-time employees), rate ratios, and rate differences showed significant differences between the intervention and control groups. All-injuries rates for the intervention group dropped from 14.7 pre-intervention to 8.1 post-intervention. The control group dropped from 9.3 to 8.4. Time-loss injury rates decreased from 5.3 to 2.5 in the intervention group and increased in the control group (5.9 to 6.5). Controlling for group and hospital size, the relative rate of all-injuries and time-loss injuries for the pre- to post-period decreased by 30% (RR = 0.693; 95% CI = 0.60–0.80) and 18.6% (RR = 0.814; 95% CI = 0.677–0.955), respectively. The study provides evidence for the effectiveness of a multifactor TLR program for direct care health workers, especially in small hospitals.

Best practice: E-Model—Prescribing physical activity and exercise for individuals with fibromyalgia

Fibromyalgia (FM) is a serious and debilitating condition, encompassing a wide range of symptoms. Physical therapists often advocate the incorporation of leisure time physical activity (exercise training or recreational physical activity) as an important management strategy for individuals with FM. Decisions about physical activity prescription in clinical practice are informed by a variety of sources. This topical review considers physical activity prescription using the E-Model as a framework for best practice decision making. We examine findings from randomized trials, published experts, and qualitative studies through the lens of the models five Es: 1) evidence, 2) expectations, 3) environment, 4) ethics, and 5) experience. This approach provides a robust foundation from which to make best practice decisions. Application of this model also facilitates the identification of gaps and discrepancies in the literature, future opportunities for knowledge exchange and translation, and future research.

Fibromyalgia and Exercise Training: A Systematic Review of Randomized Clinical Trials

Abstract Objective. This review evaluates the effects of exercise training for individuals with fibromyalgia syndrome (FMS). Methods. Seven bibliographic indices (1966–2000) were searched for experimental studies containing physical exercise training for FMS. The methodological quality and adequacy of training stimulus were rated. Studies meeting ≥50% of the quality criteria and applying adequate exercise training stimulus were classified as High Quality Training Studies (HQTS). Results. Fourteen experimental trials were found; six were HQTS of aerobic exercise. In the HQTSs, improvements reported were: tender points =4 of 4 of the HQTS using this outcome measure; cardiorespiratory fitness =3 of 4; global well-being =3 of 5; and fatigue and sleep =2 of 5. There is moderate benefit in FMS from supervised aerobic exercise training. Details about dosage for muscle strengthening or flexibility training were insufficient to evaluate the adequacy of the training stimulus. Further research is needed to describe the long term effects of all types of exercise training and to examine strengthening and flexibility training in FMS.

Hydrotherapy improves pain, knee strength, and quality of life in women with fibromyalgia

Question For women with fibromyalgia, does a hydrotherapy exercise program produce improvements in muscle strength, quality of life, and pain? Design Randomised controlled trial. Setting Participants were recruited from a fibromyalgia association in Spain. Participants Women with fibromyalgia confirmed according to American College of Rheumatology criteria. Women who attended other psychological or physical therapies, who exercised regularly, who were pregnant, or who had significant co-morbidities were excluded. Nine eligible patients refused to participate. The remaining 35 were randomised to hydrotherapy (n = 18) or a control group (n = 17). Interventions The hydrotherapy group trained in waist-high warm water, three times per week for 12 weeks. Each one-hour session included slow walking and mobility exercises, aerobic exercise at 65–75% of maximal heart rate, and overall mobility and lower-limb strength exercises. At the end of the 12-week training period, the group was instructed to avoid physical exercise training until their next evaluation. The control group was instructed to follow normal daily activities, which did not include any form of regular physical exercise. Outcomes Maximal torque of the knee flexors and extensors was recorded with an isokinetic dynamometer during fast and slow concentric and slow eccentric contractions. Maximal torque of the shoulder abductors and adductors was recorded during slow concentric contractions. Quality of life was assessed using the overall EuroQol-5D score and its five domains: mobility, self care, daily activities, pain, and anxiety/depression. Subjects also reported a visual analogue score (VAS) from 0 (no pain) to 100 (worst possible pain). All outcomes were assessed at baseline, immediately after the 12-week training period, and 12 weeks later. Results In the hydrotherapy group, slow concentric knee extensor torque improved significantly more than in the control group, by 0.2 Nm/kg (95% CI 0.15 to 0.25). Similarly, slow concentric knee flexor torque improved significantly more than in the control group, by 0.1 Nm/kg (95% CI 0.05 to 0.15). No other muscle torques differed significantly between groups. Improvement in overall quality of life was significantly greater in the hydrotherapy group, by 29% (95% CI 24 to 34). All subdomains also showed significant benefits due to hydrotherapy, except daily activities. Improvement in the pain VAS was significantly better in the hydrotherapy group, by 19 mm (95% CI 15 to 23). Most of these betweengroup differences were no longer significant 12 weeks later, apart from the self care and anxiety/depression domains. Conclusion For women with fibromyalgia, a 12-week hydrotherapy exercise program improves knee strength, quality of life, and pain, although few of these changes are maintained 12 weeks later.

Use of videoconferencing for physical therapy in people with musculoskeletal conditions: a systematic review

Background Physical therapists are key players in the management of musculoskeletal conditions, which are common in rural and remote communities. There are few physical therapists in rural regions compared to potential need, so care is either not provided or must be sought in urban centers, requiring travel and time away from work and family to access services. Telerehabilitation strategies, such as real-time videoconferencing, are emerging as possible solutions to address shortages in rural physical therapy services. Objectives This review will: (1) determine the validity and the reliability of secure videoconferencing for physical therapy management of musculoskeletal conditions; (2) determine the health, system, and process outcomes when using secure videoconferencing for physical therapy management of musculoskeletal conditions. Methods A protocol-driven systematic review of four databases was carried out by two independent reviewers. Study criteria included English language articles from January 2003 to December 2016, on physical therapy management using secure videoconferencing, pertaining to adults 18–80 years with chronic musculoskeletal disorders. Randomized controlled trials, pre-experimental studies, and case-control studies were included. Quality analysis was performed utilizing standardized tools specific for the study designs. Results and conclusions Validity and reliability studies were identified as having high risk of bias. Intervention studies were of moderate quality, and found positive impact on health outcomes and satisfaction. Two studies evaluated costs, with evidence of cost savings in one study. More robust research is required to evaluate long-term effects of telerehabilitation for physical therapy management of musculoskeletal disorders, including cost–benefit analyses.