Introduction

The main complaint in fibromyalgia is pain, but subjects often have a considerable degree of anxiety and depression. Exercise has been shown in various studies to improve general fitness and reduce tender-point pain, as well as having a beneficial effect on global assessment ratings. It's known that exercise can improve mood in a variety of conditions, but results in this regard in subjects with fibromyalgia have been mixed. A recent randomized study from Canada has now provided fairly conclusive findings.

Method

Participants in the study, who were recruited by advertisements, had to meet the diagnostic criteria for fibromyalgia, namely widespread pain in combination with tenderness at 11 or more of 18 specific tender point sites.¹ They were excluded if they had cardiovascular disease or any serious condition that might impair their ability to exercise, or if they anticipated changing any prescribed anxiety or depression medication during the course of the study.

After stratification by gender, participants were randomly assigned to a supervised exercise group (EX) or a control group (CN). To eliminate any possible seasonal effects on mood, enrollment was done in cohorts at intervals during the year. Tests were conducted at entry, 6 weeks, 12 weeks, and 23 weeks.

The exercise group had 3 hospital-based exercise classes a week, for 23 weeks: 5 minutes stretching before, and again after, a 20-minute aerobic exercise (walking or water-aerobics). Target heart rates were 60% to 75% of age-adjusted maximum heart rates (210 - age).

The primary outcomes were tests of the depressive fraction of mood (the Beck Depression Inventory, or BDI) and physical function (the 6-minute walk test).² Secondary outcome measures were for mood (State-Trait Anxiety Inventory, Mental Health Inventory), disease status (number of tender points, isokinetic strength of knee, Fibromyalgia Impact Questionnaire, or FIQ), and self-efficacy (Arthritis Self-Efficacy Scale).

Two sets of analyses were made -- one using all those subjects that enrolled who were tested at the end of the study ('Intent-To-Treat' analysis), and one of those who met the criteria for efficacy analysis -- i.e. who hadn't changed their medications, missed more than 45% of the exercise classes, or failed to return at 23 weeks.

Results

While 51 subjects were enrolled in the study, only 50 returned for the final tests at 23 weeks -- 27 EX and 23 CN participants. As 19 subjects were excluded from the efficacy analysis (10 changed their medications, 3 obtained professional support for stress, and 6 failed to attend 45% or more of the exercise classes), there were only 31 in the efficacy analysis set -- 15 EX and 16 CN.

The mean age of the 50 'completing' subjects was 47 years; there were 44 women and 6 men. The mean duration of symptoms was 9 years, and the mean time since diagnosis of fibromyalgia was 3.4 years. The EX and CN groups were similar in their demographics, but the EX subjects were more likely to be taking antidepressants (13/27 vs. 8/23). Mean attendance at exercise classes over the 23-week period was 67%.

The mean values for the 5 important efficacy analyses are given in the following table:

	Control Group (n=16)	Control Group (n=16)	Exercise Group (n=15)	Exercise Group (n=15)
	Baseline	23 Weeks	Baseline	23 Weeks
BDI total	20.1	19.4	20.1	13.6*
BDI Cog./Affect.	11.9	11.4	11.9	7.1*
6-min walk (m)	420	409	414	489*
Tender Pts	14.7	15.0	15.2	15.1
FIQ	57.8	54.4	53.8	44.1*

*changes from baseline significantly different from those for controls, p<0.05

Other significant changes were found for anxiety, positive affect, behavioral/emotional control, and pain and function scores on the Arthritis Self Efficacy Scale.

In the Intent-To-Treat analyses, similar statistically significant beneficial effects of exercise were seen for both primary and many of the secondary outcome variables. However, the magnitude of the mean effect was smaller in all instances; this was to be expected, as results from non-exercising EX subjects would lessen the mean effect of the intervention.

Conclusions

This study was unusual in so far that the period of exercise (23 weeks) was longer than that generally employed in such trials. The length of the study may be partially responsible for the beneficial effects demonstrated; on the other hand, it probably triggered a number of the exclusions from the full efficacy analysis set.

Nevertheless, the results of the trial were clear: exercise conducted regularly, for 23 weeks, can improve the depressed mood and physical function of people with quite long-standing fibromyalgia. Although pain (the number of tender points) was not reduced by exercise, the Fibromyalgia Impact Questionnaire, as well as a number of other measures, showed that exercise had a beneficial effect on anxiety and general mental health, beyond it's effect on depressed mood and poor physical functioning. A recent publication in the same journal (full reference not yet available) suggests that strength (anaerobic) exercise can also have beneficial effects in fibromyalgia. Once again, exercise regimes have shown their benefits, without obvious adverse effects.

One of our readers, Nancy Morrison, sent us this feedback on the above article, and gave us permission to post it here. If you want to make contact, her e-mail address is nmorri3924@aol.com . If you would like to contribute to this discussion, please use the box in the feedback form below. Robert Griffith MD, Content Editor.

One of the causes of fibromyalgia is Familial Mediterranean Fever (FMF). This inherited illness has been thought to be rare in the USA. I believe it is not so rare, just not well known.³

Colchicine taken as directed for FMF relieves most of the pain and problems connected to fibromyalgia for many patients. At the very least, a 30-day trial of colchicine (0.6mg twice daily) will eliminate FMF as the cause of a patient's fibromyalgia symptoms. I am told that taken in this amount for this time period, colchicine will not harm the patient even if they do not have FMF.

I know of 300 people who have a tried this in the past two years and are finding relief from their symptoms. These people all have connections to the Mediterranean or to a fascinating group of people who we believe have a Mediterranean origin and who were originally found in the southeast of the USA in the 1560s. These people are called Melungeons (muh-LUNGE-uhns) - see http://www.geocities.com/mikenassau/definition.htm.

This ancestry was thought to be limited but recent research shows that it has been hidden and is not well known, simply because it includes a multi-cultural, multi-ethnic background. I would like to see more research into the FMF/fibromyalgia connection and more patients being given a trial of colchicine without having their doctors laugh at them and tell them it is all in their heads!

It is not. I have this illness. I found it through my genealogical research and after 57 years and 17 different diagnoses including fibromyalgia, I diagnosed myself with Familial Mediterranean Fever. I took this information to 4 doctors, who did indeed laugh at me, before finding one who said that he didn't believe that I had this illness even though I had the ancestry. He was willing to give me a 30-day trial of colchicine, however. Two hours after taking the first pill I knew it was going to work. Today I am better than I have been in 20 years. For more information please visit my website at: http://www.melungeonhealth.org