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Physical therapy is minimally effective in the treatment of fibromyalgia, with immediate post-treatment improvement in pain and tender points, and both short- and longer-term improved self-efficacy (confidence in performing tasks) (strength of recommendation [SOR]: B, 1 small, high-quality randomized controlled trial, 4 additional small randomized controlled trials).
Multidisciplinary rehabilitation is probably not effective for this disorder but warrants future research, as trial quality is poor (SOR: B, systematic review of 4 small or low-quality and 3 additional randomized controlled trials on widespread pain conditions).
Evidence summary
The goal of physical therapy is to maximize function and reduce impairment to limit disability in patients with musculoskeletal conditions.1 Based on a British study, physical therapists most commonly use exercise, education about correct posture and functional activity, relaxation, and energy conservation and fatigue management.2 For this review, physical therapy is defined as a treatment program that includes patient education and supervised exercise.
In the highest-quality trial, Buckelew and colleagues3 randomized 119 subjects to 1 of 4 groups: biofeedback and relaxation training, exercise training, combination treatment, and an education and attention control program. Individuals were evaluated on measures of pain, function, disease impact, and self-efficacy. Evaluators were blinded to treatment group. Patients were followed for 2 years, and follow-up information was available on 85% of patients.
At immediate postintervention follow-up, all treatment groups were significantly improved on tender-point index score compared with the control group, but this was due to a modest deterioration for the control group rather than improvements in the treatment groups. In addition, all groups showed improvements in self-efficacy for function compared with the control group but not for other self-efficacy measures. While within-group improvements in the treatment groups were seen, no significant differences were seen from the control group.
Another trial randomized 99 patients to 3 groups: education and cognitive behavioral therapy; education, cognitive behavioral therapy and exercise; or a wait-list control group.4 At the 6-month follow-up, the education group scored significantly higher than the others—but only on self-reported measures of daily functioning and self-efficacy.
In another study, 45 patients with fibromyalgia were randomly assigned to a 6-week program combining exercise and multidisciplinary education or to a control group.5 The treatment group had significant improvements in walking distance and for 2 measures on the Fibromyalgia Impact Questionnaire (feeling bad and morning fatigue). Keel and colleagues6 found no immediate treatment benefit following 15 weeks of education, cognitive behavioral therapy, and exercise vs relaxation training in their small randomized controlled trial.6
In contrast, another study reported significant and immediate improvements in 2 groups— exercise and education; exercise, education, and cognitive behavioral therapy—when compared with control patients on self-reported symptoms and knowledge.# The exercise and education group was also better than the control patients in self-reported daily functioning.
We identified 2 additional trials examining different types of physical therapy for fibromyalgia that did not include control groups. In a trial of muscle strengthening vs flexibility training, investigators found no difference between groups on measures including tender points and disease and symptom severity.8 They did find benefits in symptoms and self-efficacy over baseline, but it is not known whether these were sustained.
In a trial comparing 2 physical therapies— body awareness therapy and the Mensendieck system—Kendall and colleagues9 found greater improvements at 18-month follow-up in the Mensendieck group.9 Benefits were seen on the Fibromyalgia Impact Questionnaire, self-efficacy measures, and pain at worst site. The Mensendieck system uses individual interview, analysis of movement patterns, a discussion of possible corrections followed by practice, and relaxation exercises.
Multidisciplinary rehabilitation, often including physical therapy, has also been studied in a limited way. In a systematic review of 7 studies fulfilling inclusion criteria (a total of 1050 patients), Karjalainen and colleagues10 concluded that although education combined with physical training seemed to have some positive results at long-term follow-up, the level of scientific evidence required for recommending these programs for fibromyalgia was lacking.10
Because exercise is believed to be an essential component of physical therapy, we examined the results of a systematic review of exercise for treating fibromyalgia. The authors found 7 high-quality studies, 4 of aerobic training, and concluded that supervised aerobic exercise training had beneficial effects on physical capacity, tender-point threshold, and pain.11 Other investigators have questioned the usefulness of aerobic exercise because long-term benefit remains unclear and compliance is poor.
Recommendations from others
We were unable to find any guidelines for the treatment of fibromyalgia. Patient information sheets from both the American College of Rheumatology (www.rheumatology.org) and American Academy of Orthopaedic Surgeons (orthoinfo.aaos.org) recommend physical modalities such as heat application, massage, and exercise, including fitness training.
Authors of chapters on fibromyalgia in both Kelly’s Textbook of Rheumatology and Harrison’s Principles of Internal Medicine suggest that patients may benefit from regular low-impact aerobic exercise.12,13
Exercise, physical therapy ease pain, “helplessness”
Wail Malaty, MD
Mountain Area Health Education Center, Rural Track Family Practice Residency, Hendersonville, NC, Department of Family Medicine, University of North Carolina, Chapel Hill
Fibromyalgia is a disease of chronic pain. It engenders feelings of helplessness, depression, and loss of control in many patients. In my experience, both physical therapy and exercise can help alleviate these feelings. Physical therapy helps motivated patients perform body movements that they believe may be painful. In this sense, it demonstrates to them the possibility of exercising without excruciating pain. As the evidence suggests, patients who exercise have less pain and feel better in general. Thus, physical therapy can teach patients to actively participate in the management of their disease.
1. Guccione AA. Physical therapy for musculoskeletal syndromes. Rheum Dis Clin North Am 1996;22:551-562.
2. Adams N, Sim J. An overview of fibromyalgia syndrome: mechanisms, differential diagnosis and treatment approaches. Physiotherapy 1998;84:304-318.
3. Buckelew SP, Conway R, Parker J, et al. Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial. Arthritis Care Res 1998;11:196-209.
4. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J Rheumatol 1994;21:714-720.
5. Gowans SE, deHueck A, Voss S, Richardson M. A randomized, controlled trial of exercise and education for individuals with fibromyalgia. Arthritis Care Res 1999;12:120-128.
6. Keel PJ, Bodoky C, Gerhard U, Muller W. Comparison of integrated group therapy and group relaxation training for fibromyalgia. Clin J Pain 1998;14:232-238.
7. Vlaeyen JW, Teeken-Gruben NJ, Goossens ME, et al. Cognitive-educational treatment of fibromyalgia: a randomized clinical trial. I. Clinical effects. J Rheumatol 1996;23:1237-1245.
8. 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;29:1041-1048.
9. Kendall SA, Ekselius L, Gerdle B, Soren B, Bengtsson A. Feldenkrais intervention in fibromyalgia patients: A pilot study. J Musculoskeletal Pain 2001;9:25-35.
10. Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults. Cochrane Database Syst Rev2000; (2):CD001984. Updated quarterly.
11. Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev2002; (3):CD003786. Updated quarterly.
12. Claus DJ. Fibromyalgia. In: Ruddy S, Harris ED Jr., Sledge CB, eds. Kelley’s Textbook of Rheumatology. 6th ed. Philadelphia, Pa: W.B. Saunders; 2001;417-427.
13. Gilliland BC. Relapsing polychondritis and other arthritides. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001;2005-2016.
Physical therapy is minimally effective in the treatment of fibromyalgia, with immediate post-treatment improvement in pain and tender points, and both short- and longer-term improved self-efficacy (confidence in performing tasks) (strength of recommendation [SOR]: B, 1 small, high-quality randomized controlled trial, 4 additional small randomized controlled trials).
Multidisciplinary rehabilitation is probably not effective for this disorder but warrants future research, as trial quality is poor (SOR: B, systematic review of 4 small or low-quality and 3 additional randomized controlled trials on widespread pain conditions).
Evidence summary
The goal of physical therapy is to maximize function and reduce impairment to limit disability in patients with musculoskeletal conditions.1 Based on a British study, physical therapists most commonly use exercise, education about correct posture and functional activity, relaxation, and energy conservation and fatigue management.2 For this review, physical therapy is defined as a treatment program that includes patient education and supervised exercise.
In the highest-quality trial, Buckelew and colleagues3 randomized 119 subjects to 1 of 4 groups: biofeedback and relaxation training, exercise training, combination treatment, and an education and attention control program. Individuals were evaluated on measures of pain, function, disease impact, and self-efficacy. Evaluators were blinded to treatment group. Patients were followed for 2 years, and follow-up information was available on 85% of patients.
At immediate postintervention follow-up, all treatment groups were significantly improved on tender-point index score compared with the control group, but this was due to a modest deterioration for the control group rather than improvements in the treatment groups. In addition, all groups showed improvements in self-efficacy for function compared with the control group but not for other self-efficacy measures. While within-group improvements in the treatment groups were seen, no significant differences were seen from the control group.
Another trial randomized 99 patients to 3 groups: education and cognitive behavioral therapy; education, cognitive behavioral therapy and exercise; or a wait-list control group.4 At the 6-month follow-up, the education group scored significantly higher than the others—but only on self-reported measures of daily functioning and self-efficacy.
In another study, 45 patients with fibromyalgia were randomly assigned to a 6-week program combining exercise and multidisciplinary education or to a control group.5 The treatment group had significant improvements in walking distance and for 2 measures on the Fibromyalgia Impact Questionnaire (feeling bad and morning fatigue). Keel and colleagues6 found no immediate treatment benefit following 15 weeks of education, cognitive behavioral therapy, and exercise vs relaxation training in their small randomized controlled trial.6
In contrast, another study reported significant and immediate improvements in 2 groups— exercise and education; exercise, education, and cognitive behavioral therapy—when compared with control patients on self-reported symptoms and knowledge.# The exercise and education group was also better than the control patients in self-reported daily functioning.
We identified 2 additional trials examining different types of physical therapy for fibromyalgia that did not include control groups. In a trial of muscle strengthening vs flexibility training, investigators found no difference between groups on measures including tender points and disease and symptom severity.8 They did find benefits in symptoms and self-efficacy over baseline, but it is not known whether these were sustained.
In a trial comparing 2 physical therapies— body awareness therapy and the Mensendieck system—Kendall and colleagues9 found greater improvements at 18-month follow-up in the Mensendieck group.9 Benefits were seen on the Fibromyalgia Impact Questionnaire, self-efficacy measures, and pain at worst site. The Mensendieck system uses individual interview, analysis of movement patterns, a discussion of possible corrections followed by practice, and relaxation exercises.
Multidisciplinary rehabilitation, often including physical therapy, has also been studied in a limited way. In a systematic review of 7 studies fulfilling inclusion criteria (a total of 1050 patients), Karjalainen and colleagues10 concluded that although education combined with physical training seemed to have some positive results at long-term follow-up, the level of scientific evidence required for recommending these programs for fibromyalgia was lacking.10
Because exercise is believed to be an essential component of physical therapy, we examined the results of a systematic review of exercise for treating fibromyalgia. The authors found 7 high-quality studies, 4 of aerobic training, and concluded that supervised aerobic exercise training had beneficial effects on physical capacity, tender-point threshold, and pain.11 Other investigators have questioned the usefulness of aerobic exercise because long-term benefit remains unclear and compliance is poor.
Recommendations from others
We were unable to find any guidelines for the treatment of fibromyalgia. Patient information sheets from both the American College of Rheumatology (www.rheumatology.org) and American Academy of Orthopaedic Surgeons (orthoinfo.aaos.org) recommend physical modalities such as heat application, massage, and exercise, including fitness training.
Authors of chapters on fibromyalgia in both Kelly’s Textbook of Rheumatology and Harrison’s Principles of Internal Medicine suggest that patients may benefit from regular low-impact aerobic exercise.12,13
Exercise, physical therapy ease pain, “helplessness”
Wail Malaty, MD
Mountain Area Health Education Center, Rural Track Family Practice Residency, Hendersonville, NC, Department of Family Medicine, University of North Carolina, Chapel Hill
Fibromyalgia is a disease of chronic pain. It engenders feelings of helplessness, depression, and loss of control in many patients. In my experience, both physical therapy and exercise can help alleviate these feelings. Physical therapy helps motivated patients perform body movements that they believe may be painful. In this sense, it demonstrates to them the possibility of exercising without excruciating pain. As the evidence suggests, patients who exercise have less pain and feel better in general. Thus, physical therapy can teach patients to actively participate in the management of their disease.
Physical therapy is minimally effective in the treatment of fibromyalgia, with immediate post-treatment improvement in pain and tender points, and both short- and longer-term improved self-efficacy (confidence in performing tasks) (strength of recommendation [SOR]: B, 1 small, high-quality randomized controlled trial, 4 additional small randomized controlled trials).
Multidisciplinary rehabilitation is probably not effective for this disorder but warrants future research, as trial quality is poor (SOR: B, systematic review of 4 small or low-quality and 3 additional randomized controlled trials on widespread pain conditions).
Evidence summary
The goal of physical therapy is to maximize function and reduce impairment to limit disability in patients with musculoskeletal conditions.1 Based on a British study, physical therapists most commonly use exercise, education about correct posture and functional activity, relaxation, and energy conservation and fatigue management.2 For this review, physical therapy is defined as a treatment program that includes patient education and supervised exercise.
In the highest-quality trial, Buckelew and colleagues3 randomized 119 subjects to 1 of 4 groups: biofeedback and relaxation training, exercise training, combination treatment, and an education and attention control program. Individuals were evaluated on measures of pain, function, disease impact, and self-efficacy. Evaluators were blinded to treatment group. Patients were followed for 2 years, and follow-up information was available on 85% of patients.
At immediate postintervention follow-up, all treatment groups were significantly improved on tender-point index score compared with the control group, but this was due to a modest deterioration for the control group rather than improvements in the treatment groups. In addition, all groups showed improvements in self-efficacy for function compared with the control group but not for other self-efficacy measures. While within-group improvements in the treatment groups were seen, no significant differences were seen from the control group.
Another trial randomized 99 patients to 3 groups: education and cognitive behavioral therapy; education, cognitive behavioral therapy and exercise; or a wait-list control group.4 At the 6-month follow-up, the education group scored significantly higher than the others—but only on self-reported measures of daily functioning and self-efficacy.
In another study, 45 patients with fibromyalgia were randomly assigned to a 6-week program combining exercise and multidisciplinary education or to a control group.5 The treatment group had significant improvements in walking distance and for 2 measures on the Fibromyalgia Impact Questionnaire (feeling bad and morning fatigue). Keel and colleagues6 found no immediate treatment benefit following 15 weeks of education, cognitive behavioral therapy, and exercise vs relaxation training in their small randomized controlled trial.6
In contrast, another study reported significant and immediate improvements in 2 groups— exercise and education; exercise, education, and cognitive behavioral therapy—when compared with control patients on self-reported symptoms and knowledge.# The exercise and education group was also better than the control patients in self-reported daily functioning.
We identified 2 additional trials examining different types of physical therapy for fibromyalgia that did not include control groups. In a trial of muscle strengthening vs flexibility training, investigators found no difference between groups on measures including tender points and disease and symptom severity.8 They did find benefits in symptoms and self-efficacy over baseline, but it is not known whether these were sustained.
In a trial comparing 2 physical therapies— body awareness therapy and the Mensendieck system—Kendall and colleagues9 found greater improvements at 18-month follow-up in the Mensendieck group.9 Benefits were seen on the Fibromyalgia Impact Questionnaire, self-efficacy measures, and pain at worst site. The Mensendieck system uses individual interview, analysis of movement patterns, a discussion of possible corrections followed by practice, and relaxation exercises.
Multidisciplinary rehabilitation, often including physical therapy, has also been studied in a limited way. In a systematic review of 7 studies fulfilling inclusion criteria (a total of 1050 patients), Karjalainen and colleagues10 concluded that although education combined with physical training seemed to have some positive results at long-term follow-up, the level of scientific evidence required for recommending these programs for fibromyalgia was lacking.10
Because exercise is believed to be an essential component of physical therapy, we examined the results of a systematic review of exercise for treating fibromyalgia. The authors found 7 high-quality studies, 4 of aerobic training, and concluded that supervised aerobic exercise training had beneficial effects on physical capacity, tender-point threshold, and pain.11 Other investigators have questioned the usefulness of aerobic exercise because long-term benefit remains unclear and compliance is poor.
Recommendations from others
We were unable to find any guidelines for the treatment of fibromyalgia. Patient information sheets from both the American College of Rheumatology (www.rheumatology.org) and American Academy of Orthopaedic Surgeons (orthoinfo.aaos.org) recommend physical modalities such as heat application, massage, and exercise, including fitness training.
Authors of chapters on fibromyalgia in both Kelly’s Textbook of Rheumatology and Harrison’s Principles of Internal Medicine suggest that patients may benefit from regular low-impact aerobic exercise.12,13
Exercise, physical therapy ease pain, “helplessness”
Wail Malaty, MD
Mountain Area Health Education Center, Rural Track Family Practice Residency, Hendersonville, NC, Department of Family Medicine, University of North Carolina, Chapel Hill
Fibromyalgia is a disease of chronic pain. It engenders feelings of helplessness, depression, and loss of control in many patients. In my experience, both physical therapy and exercise can help alleviate these feelings. Physical therapy helps motivated patients perform body movements that they believe may be painful. In this sense, it demonstrates to them the possibility of exercising without excruciating pain. As the evidence suggests, patients who exercise have less pain and feel better in general. Thus, physical therapy can teach patients to actively participate in the management of their disease.
1. Guccione AA. Physical therapy for musculoskeletal syndromes. Rheum Dis Clin North Am 1996;22:551-562.
2. Adams N, Sim J. An overview of fibromyalgia syndrome: mechanisms, differential diagnosis and treatment approaches. Physiotherapy 1998;84:304-318.
3. Buckelew SP, Conway R, Parker J, et al. Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial. Arthritis Care Res 1998;11:196-209.
4. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J Rheumatol 1994;21:714-720.
5. Gowans SE, deHueck A, Voss S, Richardson M. A randomized, controlled trial of exercise and education for individuals with fibromyalgia. Arthritis Care Res 1999;12:120-128.
6. Keel PJ, Bodoky C, Gerhard U, Muller W. Comparison of integrated group therapy and group relaxation training for fibromyalgia. Clin J Pain 1998;14:232-238.
7. Vlaeyen JW, Teeken-Gruben NJ, Goossens ME, et al. Cognitive-educational treatment of fibromyalgia: a randomized clinical trial. I. Clinical effects. J Rheumatol 1996;23:1237-1245.
8. 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;29:1041-1048.
9. Kendall SA, Ekselius L, Gerdle B, Soren B, Bengtsson A. Feldenkrais intervention in fibromyalgia patients: A pilot study. J Musculoskeletal Pain 2001;9:25-35.
10. Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults. Cochrane Database Syst Rev2000; (2):CD001984. Updated quarterly.
11. Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev2002; (3):CD003786. Updated quarterly.
12. Claus DJ. Fibromyalgia. In: Ruddy S, Harris ED Jr., Sledge CB, eds. Kelley’s Textbook of Rheumatology. 6th ed. Philadelphia, Pa: W.B. Saunders; 2001;417-427.
13. Gilliland BC. Relapsing polychondritis and other arthritides. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001;2005-2016.
1. Guccione AA. Physical therapy for musculoskeletal syndromes. Rheum Dis Clin North Am 1996;22:551-562.
2. Adams N, Sim J. An overview of fibromyalgia syndrome: mechanisms, differential diagnosis and treatment approaches. Physiotherapy 1998;84:304-318.
3. Buckelew SP, Conway R, Parker J, et al. Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial. Arthritis Care Res 1998;11:196-209.
4. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J Rheumatol 1994;21:714-720.
5. Gowans SE, deHueck A, Voss S, Richardson M. A randomized, controlled trial of exercise and education for individuals with fibromyalgia. Arthritis Care Res 1999;12:120-128.
6. Keel PJ, Bodoky C, Gerhard U, Muller W. Comparison of integrated group therapy and group relaxation training for fibromyalgia. Clin J Pain 1998;14:232-238.
7. Vlaeyen JW, Teeken-Gruben NJ, Goossens ME, et al. Cognitive-educational treatment of fibromyalgia: a randomized clinical trial. I. Clinical effects. J Rheumatol 1996;23:1237-1245.
8. 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;29:1041-1048.
9. Kendall SA, Ekselius L, Gerdle B, Soren B, Bengtsson A. Feldenkrais intervention in fibromyalgia patients: A pilot study. J Musculoskeletal Pain 2001;9:25-35.
10. Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults. Cochrane Database Syst Rev2000; (2):CD001984. Updated quarterly.
11. Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev2002; (3):CD003786. Updated quarterly.
12. Claus DJ. Fibromyalgia. In: Ruddy S, Harris ED Jr., Sledge CB, eds. Kelley’s Textbook of Rheumatology. 6th ed. Philadelphia, Pa: W.B. Saunders; 2001;417-427.
13. Gilliland BC. Relapsing polychondritis and other arthritides. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001;2005-2016.
Evidence-based answers from the Family Physicians Inquiries Network