What type of exercise should you as a professional prescribe to an individual whose constant companions are pain and overwhelming fatigue?

I. Fitness level of fibros
1. Aerobic capacity of fibros is ½ to that of normal individuals 
2. 30-50% reduction in aerobic capacity, reduced range of motion (ROM), and some reduction in muscle strength and endurance
3. Since fibros in general are less fit they may not be able to tolerate normal progressions in a one-size-fits-all exercise prescription

II. The Preconditioning phase
(Flare-ups or chronic fatigue, and no restorative deep sleep) 

Summary of the Preconditioning phase

III. The Beginner's level (experiences daytime exhaustion, an endless cycle of no restorative deep sleep, and may have tension headaches)

Summary of the Beginner level

The major goals of a Beginner program are too:
The beginner level may take 3-6 months or longer. 
She can progress to the next level when:
1. Residual fatigue or exhaustion is not experienced the following day
2. Capable of performing aerobic and ST routine (warm, and cool 
down) at least 45 min.
3. Capable of working at an intensity of 70-75% of max heart rate and between ½ to of their body weight for resistive exercise for major muscle group exercises of upper and lower body, respectively.

New formula
Remember that the formula for estimating Max HR has changed, based upon a meta-analysis of dozens of research articles. The new formula published this year (2000) in the Journal of the American College of Cardiology states that the new formula is:

"Age-Predicted Maximal Heart Rate Revisited by Tanaka, Monahan, and Seals Vol.37 #1 2001". 

208 - .75 x age. This applies to both sexes.

For example in the old formula: the max HR of a 20 year old would be: 220 - age 20 = 200. 
Using the new formula it would be estimated at 208 -.75 (20) =193.

IV. Exercise prescription for the Moderate group 
(Pain and chronic fatigue is not constant. Experiences some restorative deep sleep, however, symptoms of FM may still be present) 

The moderate group is comprised of 2 groups of people. It includes those who have progressed from the beginning level as previously described as well as those who have been engaging in some consistent activity over the last several months, such as walking consistently or other kinds of light to moderate activity such as water aerobics or light calisthenics. 
To qualify for this group, individuals should be able to sustain a minimum of 20-30 min. of light to moderate aerobic activity. They need not have been involved in a weight-training program. 

Summary of the Moderate level

The major goals of a Moderate program are to:
1. Increase aerobic levels to 80% max HR or 65-70% of their aerobic capacity and the intensity of resistive exercise to or more of their body weight
Upper body is based upon how much weight they can lift for 1 rep for the lat pull and bench press
Lower body is based upon how much weight they can lift for 1 rep for squats or seated leg press

The equation for calculating 1-RM is:

1-RM (lb or kg) = lb or kg at RM between 2-20 /
[100% - (RM X 2)]
2. Incorporate variety and cross training
3. Incorporate eccentric exercise
 

Progress to Advanced level when:
Your client can use body weight resistance for lower body and at least 60-70% for upper body resistive exercise and can complete 30-40 min. of aerobic activity at 80% of max heart rate.
Initially, it will be rare if you find a fibro that meets the advanced standards without coming up through the ranks. 

VI. Exercise prescription for Advanced (experiences restorative deep sleep, and chronic fatigue has dissipated and symptoms of tiredness are occasional)

Your client can do about anything you recommend to your normal clients or recommended by the American College of Sports Medicine. 
Your client should not experience chronic fatigue or exhaustion for up to two days after the exercise. 

Summary of Advanced level

Goals of Advanced stage
1. To increase volume and duration of activity
2. To develop extensive variety of different exercises
3. To graduate each client into self-sufficiency

Intensity levels need not be increased beyond 85% of max heart rate You can combine high and low intensity to complete the time goal of each aerobic activity session.

VII. Benefits of advanced fitness level for FM clients
1. Wigers (Wigers SH, Stiles TC, Vogal PA. Effects of aerobic exercise versus stress management treatment in fibromyalgia: a 4.5 year prospective study. Scan J Rheumatol. 1996; 25:77-86) found that after 4.5 years of aerobic exercise former FM patients no longer fulfilled the American College of Rheumatology 1990 criteria for FM. 
2. Hakkinen et al. reported in Ann Rheum Dis Jan 2001 that FM subjects increased their maximal and explosive strength and EMG activity to the same level as the healthy controls. The ST data indicate that fibros had the same trainability of the neuromuscular system as healthy subjects. It stated that ST might safely be used in the treatment of FM to decrease the impact of the syndrome on the neuromuscular system, perceived symptoms, and functional ability. Moreover the progressive ST showed immediate benefits on perceived fatigue, depression, and neck pain of training patients with FM. For this reason researchers believe that the pain response is not in the muscle but located in the CNS.

VIII. Frequency
Now that we have talked about intensity let's focus on frequency of training. Clients should participate in an aerobic and strength-training program at least 3 days per week. Consistency is the key. Fatigued and beginner clients may benefit from two 10-20 min. rather than one long session. 
Also beginners starting ST may tolerate a mini session working one body part per day rather than exercising every body part 3X per week. 

IX. Exercises not recommended
Because tender points tend to be aggravated by certain exercises we recommend that you limit the use of the following exercises. Since there is individual variability in response to various exercises some clients may be able to tolerate the exercises I caution against using. In general, however, the following are not recommended.

Quads
Knee extension - in some people causes pressure on the kneecap. (Location of the tender point is located before kneecap on the medial side of the knee.)
Smith machine - squats-maybe for advanced group only, because of tender points on the neck and shoulder area.

Traps 
Upright row- puts tension on the tender point of the scapula.

Back
Chin ups
Pull-ups (or any hanging exercises)
Roman chair for lower back. More injuries have occurred on this machine in clubs than any other piece of equipment.
Cables - because of the eccentric contractions this is suggested for advanced groups.
Rowers - are questionable even for advanced and since a lot of the tender points are around the neck and shoulder area the high repetitions may cause potential injury. (For advanced only) 

Equipment with repetitive motion to the shoulders like rowers, skiers and ergometers should be monitored to see if it aggravates the shoulder/neck area. 
The Nordic Track is okay but be aware of hip related problems due to moderate resistance and high repetitions. Keep in mind this exercise takes a lot of coordination causing problems for some fibros.

Not recommended for any phase
Kickboxing or movements that jolt or have an impact to the joint or muscle should be avoided.

X. Summary
Be positive and encouraging to your clients. Let them see by your action and words that you enjoy being with them and that you strongly believe in the value of exercise.

For fibros exercise is not an option it's a requirement. The symptoms of FM can be devastating but with your help fibro clients can experience a better quality of life. Exercise can help mask their pain and start them on the journey towards better health and better living.
Your challenge as a health and fitness professional is to give your client the gift of health. 

Happy Health

This information was developed and written by Colleen Black-Brown. If you wish to use this information in a publication or presentation please contact me. 
Home Phone: (479) 750-4004
e-mail: bbrown@uark.edu

Thank You