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A systematic review of the effects of strength training in patients with fibromyalgia: clinical outcomes and design considerations
Advances in Rheumatologyvolume 58, Article number: 36 (2018)
Fibromyalgia (FM) is characterized by chronic and generalized musculoskeletal pain. There is currently no cure for FM, but palliative treatments are available. One type of treatment is strength training (ST). However, there is a need for more information on optimal training protocols, intensity, and volume needed to improve symptoms. The aim of this study was to analyze the effects of ST in the treatment of FM through a systematic review of experimental research.
Medical Subject Headings search terms and electronic databases including Scientific Electronic Library Online, PubMed, Science Direct, Web of Science, and Physiotherapy Evidence Database were used to identify studies.
The inclusion criteria were met by 22 eligible studies. Most of the studies were conducted in the United States (36%), Finland (23%), Brazil (18%), and Sweden (18%). The studies showed that ST reduces the number of tender points, fatigue, depression, and anxiety, and improves sleep quality and quality of life in patients with FM. The intervention period ranged from 3 to 21 weeks, with sessions performed 2 times a week in 81.81% of the studies, at initial intensities of 40% of 1-repetition maximum. The repetitions ranged from 4 to 20, with no specific protocol defined for ST in FM.
The main results included reduction in pain, fatigue, number of tender points, depression, and anxiety, with increased functional capacity and quality of life. Current evidence demonstrates that ST is beneficial and can be used to treat FM.
Fibromyalgia (FM) is a chronic disease characterized by generalized skeletal muscle pain [1, 2], and other common symptoms include fatigue, sleep disorders, depression, and excessive anxiety [3,4,5,6]. The pathogenesis of FM is still not well understood , and FM is considered by some researchers to be a neurobiological disease caused by abnormal processing of pain . Owing to the lack of markers that can identify the disease, the diagnosis is made through clinical examination, according to the guidelines of the American College of Rheumatology [1, 3].
As FM has no cure, treatments are palliative, and multidisciplinary approaches involving the use of medications, physical exercise (PE), and psychological treatments are recommended [4, 9,10,11,12]. PE has been advised in several studies and guidelines for the treatment of FM [13,14,15,16], and the inclusion of aerobic, resistance, and water exercises has been strongly recommended [5, 15,16,17]. The severity of FM symptoms can affect the level of physical fitness, and patients commonly perform little physical activity because of pain [18,19,20].
The relationship between PE and FM has been investigated, and strength training (ST) has been compared with other PE modalities. Studies have shown that ST has favorable results on pain, sleep, depression, and the number of tender points [17, 21]. However, studies on the effect of PE present poor quality evidence owing to small sample sizes and methodological problems [22, 23]. Recent studies have attempted to better understand the effects of ST in patients with FM [21, 24,25,26]. However, research has emphasized physical aspects with conflicting results [27, 28]. Despite recent research on the effects of ST in patients with FM, the duration, frequency, and intensity required to improve the symptoms remain unknown because the protocols differ among studies [29,30,31]. Thus, there is no consensus on the use of ST in clinical practice. The aim of this study was to analyze the effects of ST in the treatment of FM through a systematic review of experimental research.
The present study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines . The PRISMA Statement is a protocol that guides the construction of systematic reviews in a transparent and consistent manner using a checklist of 27 items and a 4-phase flow diagram . This systematic review was registered as CRD42016048480 in the International Prospective Register of Systematic Reviews (PROSPERO) . A primary goal of PROSPERO is to make known the intention to conduct a systematic review, in order to reduce duplication and to facilitate transparency in the review process .
In order to include the entire publication period, no time limit was set. The eligibility criteria were determined according to the PICOS (Population, Intervention, Comparison, Outcomes, Setting) strategy.
Adults 18 years and older with a diagnosis of FM according to the 1990 criteria of the American College of Rheumatology (1).
Any intervention with ST or resistance training for patients with FM was included. We excluded studies with combined interventions, such as those with ST combined with aerobic training.
With any other type of group (such as sedentary controls and healthy controls) and with other types of intervention (such as aerobic exercise and flexibility exercise).
All possible effects of ST and the intervention protocols used in the studies in patients with FM.
Type of study
Randomized or non-randomized trials reporting clinical outcomes demonstrating the effects of ST. The frequency of ST and the extent to which ST was provided were the minimum necessary data for a research to be defined as an intervention study. Revised articles, dissertations, theses, and congress abstracts were excluded.
The studies were identified through electronic databases, including PubMed, Science Direct, Web of Science, Physiotherapy Evidence Database, and Scientific Electronic Library Online. The last survey was conducted in December 2017.
The searches and selection of articles were independently performed by 2 researchers; in case of disagreement, a third party was asked to make the final decision. An initial analysis was performed based on reading the title. From these selected articles, the abstracts were read and the articles included in the review were read in their entirety. A review of the references and citations of these articles was also carried out in order to identify other potentially relevant studies. From the selected studies, an analysis of the use of ST for the treatment of patients with FM was performed.
For the analysis and discussion of the results, the following data were extracted: author and study design; study participant number, age, sex, and treatment group; type of exercise, time of intervention, intensity, and adherence (based on either the number of attending patients at the beginning and end of the study or from data provided by the authors); and conclusions of the study.
Quality of study and risk of Bias
This systematic review evaluated the quality of the included studies and the risk of bias using the Cochrane Collaboration Risk of Bias tool , which includes criteria to identify bias in the selected studies that can interfere with the interpretation and conclusion. Bias risk assessment was performed by 2 researchers. The kappa concordance index  between the reviewers for each of the criteria was determined, and differences were resolved by consulting a third reviewer for a final opinion.
Identification and selection of studies
The first stage of selection using the databases identified 211 studies, with 1 additional study manually inserted. Sixty-two duplicate studies were excluded and 48 abstracts were selected after reading the titles. At the abstract review stage, 17 studies were excluded, of which 9 used combined exercise, 7 were congress abstracts, and 1 did not evaluate patients with FM. In the fourth stage, the complete texts of 31 studies were read; 5 were excluded because of the intervention protocol, 1 was a short communication, and 1 was a congress article. Thus, 22 studies were selected for the analysis, as shown in Fig. 1.
Characteristics of included studies
Of the 22 studies included in the review, the oldest was published in 2001  and the most recent was published in 2017 [24, 39, 40] (Table 2). Most of the studies were conducted in the United States (36%, n = 8), followed by Finland (23%, n = 5), Brazil (18%, n = 4), Sweden (18%, n = 4), and Turkey (5%, n = 1). Women aged 18–65 years comprised the total sample, and the main variables analyzed were pain, strength, muscular activity, functional capacity, fatigue, quality of life, and sleep [24, 25, 27, 29, 38, 39, 41,42,43,44]. Among the tests used in the evaluations, the Fibromyalgia Impact Questionnaire, which evaluates the impact of FM on quality of life, was used in most of the studies [25, 27,28,29, 31, 45,46,47,48]. To measure strength, the 1-repetition maximum (1RM) was the most used test [27,28,29, 31, 38, 49, 50] and studies that verified muscle activity used electromyography [38, 41, 51,52,53]. The visual analogue scale was used to evaluate pain in most of the studies [29, 41, 42, 45, 48, 53]. Concerning adherence, most of the studies did not provide this information. Therefore, adherence was calculated based on the patients’ attendance, and an average adherence percentage of 84% (range, 54–100%) was obtained. Five studies provided the average attendance rate, ranging from 71 to 100%.
Summary of evidence and practical implications
The analysis of the results revealed that ST reduced the symptoms of patients with FM, such as pain, fatigue, number of tender points, depression, and anxiety, with improved functional capacity and quality of life [24, 25, 27, 29, 38, 39, 41, 42] (Table 2), despite the different training protocols used.
When analyzing the training protocol, 81.81% of the studies submitted the patients to interventions twice a week, whereas only 13% (3 studies) submitted the patients to 3 sessions per week and 1 study verified the effect of a single session. Concerning the intervention time, the shorter studies lasted for 3 weeks whereas the longer studies lasted for 21 weeks. Most of the studies had an intervention time of 21 (22.72%), 12 (22.72%), 16 (18.18%), and 15 (18.18%) weeks. The studies used similar training protocols, starting with 40% of 1RM and progressing to 85%. During the training, exercises using machines and free weights worked the large and small muscle groups.
Pain was the most studied variable, showing a reduction after ST [27, 29, 30, 45, 53,54,55]. No study reported increased pain after or during the intervention period. Kayo et al.  found at the end of 16 weeks of intervention that only 41.4% of patients in the ST group were using pain medication, whereas in 80% of the patients in the control group regularly used pain medication. Other well-analyzed variables were strength, quality of life, heart rate variability (HRV), and depression. With regard to muscle strength, increases between 33 and 63% were observed after 21 and 16 weeks [41, 49]. In terms of the variability of heart rate, the effects of ST on patients with FM presented controversial results; however, the evidence shows little effect on this variable . Studies analyzing quality of life and functionality showed that ST is effective in improving these variables [28, 29, 31, 41, 42, 45].
The most investigated psychological variable was depression. The studies of Jones et al. , Gavi et al. , and Assumpção et al.  showed that ST reduces depressive symptoms; however, the study of Ericsson et al.  did not find a significant difference after 15 weeks of intervention.
We also analyzed the results related to sleep quality. Andrade et al.  found that sleep disorders were reduced after ST and that sleep correlated with pain. The results of Ericsson et al.  also disclosed that ST yielded better results than relaxation sessions in improving sleep quality. In addition, another important result is that patients with FM presented similar responses to those of healthy persons; thus, they recommended ST to assist in the treatment of patients.
The intervention protocols, results, and conclusions of each study are presented in Table 2.
Quality of studies and risk of Bias
The kappa concordance index between the two reviewers was 87.1% for all criteria. Of the 22 studies, 13 had low risk of adequate sequence generation bias; four were unclear regarding the risk of adequate sequence generation bias and six were not randomized. Only four studies had low risk of allocation concealment bias. Ten studies had a high risk of blinded participant bias; only four had a low risk and eight were unclear. Twenty-one studies presented low risk of incomplete data bias. Similar findings were noted for selective results bias; only two studies were unclear. The descriptions of interventions (characteristics of exercises) were another source of bias, with only two studies having a high risk (Fig. 2).
This systematic review aimed to analyze the efficacy of ST in the treatment of FM by examining the existing experimental research. The studies showed that the intervention has favorable results, such as reducing physical and psychological symptoms. However, there are still gaps that need to be investigated.
Concerning the ST sessions, it was observed that there is no specific training protocol for patients with FM; thus, the researchers developed their own protocol. Jones et al.  submitted the patients to a series of four to five repetitions, progressively increasing the number of repetitions up to 12. This protocol was similar to that used by Bircan et al. , who instructed patients to perform a series of four repetitions and progressively increased the repetitions by up to 12. Kingsley et al.  and Figueroa et al.  also submitted the patients to a series in each exercise; however, from the beginning of the intervention, the patients were instructed to perform from 8 to 12 repetitions. As the first studies analyzed were published in 2001 and 2002, and at that time there was little knowledge about the development of the disease and the effects of ST on the patients, those first studies chose to use low load and series. On the basis of the results of the earlier studies, more studies were performed and chose to use more series with more repetitions from the beginning [24, 27, 44, 48]. Despite some differences in the protocols, the intensity of the exercises increased gradually. In some studies, the intensity reached 80% of 1RM at the end of the intervention [25, 27]. Another issue concerns weekly frequency, but this differed slightly between 2 and 3 weekly sessions. Despite the differences in the protocols, it was observed that, in general, the studies followed the recommendations of the American College of Sports Medicine for beginners in ST.
With regard to the main symptoms, there was a greater interest in pain, strength, quality of life, HRV, and depression. Pain is the main symptom of FM and is associated with other symptoms such as depression, sleep disorders, and poor quality of life [24, 56]; thus, finding treatments that improve these symptoms are of crucial clinical relevance for patients. The results of the present review demonstrate that the pain of patients with FM is significantly reduced by the ST intervention. Valkeinen et al.  evaluated 23 women with FM, of whom 13 were submitted to 2 ST sessions for 21 weeks and 10 were part of the control group. At the end of the 21 weeks of intervention, significant improvement in pain was observed. Other studies examined the effect of shorter periods of ST, and found that pain can be reduced in a short time. Hooten et al.  analyzed the effect of 3-week ST on pain. Participants performed 2 weekly sessions, consisting of a series of 10 repetitions of knee and elbow flexion and extension exercises. At the end of the study, a significant reduction of pain was observed. This result is interesting for health professionals and for patients with FM, because it demonstrates that ST can help reduce symptoms in a few weeks and with few exercises.
Studies indicate that patients with FM have less strength and reduced functional capacity compared with healthy persons of the same age and without the disease . The reduced muscle strength of patients with FM may be related to pain; because of pain, it is common for patients to avoid making physical efforts. However, studies that aimed to verify the responses of patients with FM after muscular effort showed positive results. In studies that applied ST, strength and hypertrophy were similar between patients with and those without the disease.
The first studies in this sense were those of Hakkinen et al. , Hakkinen et al. , Valkeinen et al.  and Valkeinen et al. . The first 2 studies analyzed the effect of 21-week ST in patients with FM, and compared the results with those of healthy persons. From the results of these studies, it can be observed that there was an increase of force, activation, and hypertrophy in the ST group and in controls. Hakkinen et al.  verified an increase of 18% in the muscular strength of patients with FM, and of 22% in the control group, concluding that the neuromuscular adaptations derived from ST are similar between patients with FM and healthy persons. Reinforcing this result, Valkeinen et al.  observed a significant increase of the strength in the extension and flexion of the knee in patients with FM [33% and 20%, respectively], whereas in the control group the gains were 12% and 17%, respectively. Valkeinen et al.  that analyzed strength found that after 21 weeks of ST, patients with FM had a 36% increase in isometric force and 33% in concentric force. In addition, the authors verified a 5% increase in the cross-sectional area of the thigh and increased activation by 57%. After analyzing the results, the authors concluded that ST is safe for patients with FM and that the patients can undergo training with higher intensities.
Another variable that was investigated in the studies was the HRV. Some authors suggested that FM occurs because of dysregulation of the central nervous system [6, 8], causing an autonomic dysfunction that induces the appearance of some symptoms such as fatigue and anxiety. Figueroa et al.  verified the heart rate behavior of patients with FM who also had autonomic dysfunction. The researchers subjected the patients to 16 weeks of ST and verified improvements in HRV, parasympathetic activity, and pain reduction. Kingsley et al.  compared the effects of 12 weeks of ST on patients with FM and healthy women, in terms of various symptoms such as pain, number of tender points, impact of FM on quality of life, and HRV. The results showed an increase in strength in both groups, besides the reduction of pain and tender points in patients with FM; however, in terms of the behavior of HRV, no significant difference was observed between patients with FM and the healthy group. In contrast, in the study of Kingsley et al.  that aimed to verify the autonomic modulation of patients with FM after a ST session, the results demonstrated that patients with FM had a lower sympathetic response and greater vagal modulation, without altering the baroreflex sensitivity, a response different from that presented by the control group. Concerning a possible autonomic dysfunction in patients with FM, further studies need to be carried out in order to reach a conclusion.
Other symptoms investigated were quality of life, depression, and sleep disturbance. As quality of life is a variable that is directly related to other symptoms, the improvements observed in the other symptoms suggest that the quality of life could also be expected to increase. In the study of Gavi et al. , significant improvements in pain, functionality, quality of life, and depression were found after 16 weeks of ST. Similar results were found by Larsson et al.  and Palstam et al. . In the first study, there was a reduction in pain and an increase in strength and quality of life. In the second study, in addition to the results seen in previous studies, the researchers noticed a reduction in the fear of performing exercises. With regard to sleep disturbance, some studies found a reduction after ST intervention [24, 25]. In addition, sleep quality correlated with pain, with patients having less pain experiencing less sleep disorders .
With the new possibility of using ST as an alternative treatment for patients with FM, some researchers began to compare the effects of ST with those of other physical exercise interventions. In the study of Bircan et al. , 13 women with FM were submitted to aerobic exercise and 13 were submitted to ST. The researchers found that both interventions have benefits for patients, including reduction of pain, fatigue, sleep disorders, and depression, and improvement of aerobic capacity. However, no significant improvements in anxiety were observed in either group. In the studies by Kayo et al.  and Hooten et al. , the effects of ST were also compared with those of aerobic exercise. It was noted that the 2 interventions presented similar results, particularly in reducing the pain of patients. In addition, other studies compared ST with relaxation or flexibility exercises. Assumpção et al.  verified the effects of ST and flexibility exercises after 12 weeks of intervention. The results demonstrated that ST is more effective in reducing depression, whereas flexibility exercises are better at improving the quality of life, especially physical function and pain. Gavi et al.  found similar results: ST and flexibility training were effective for reducing symptoms; however, the best results in terms of pain were found in the ST group. The study of Jones et al.  also compared ST and flexibility training, and verified that both interventions are effective; however, the most significant results were found in the ST group. Lorena et al.  performed a systematic review on the effects of stretching in patients with FM, and reported the importance of this intervention in improving the physical and mental aspects of patients. Nevertheless, they emphasized the need for studies with greater methodological rigor. The same can be emphasized in the present review: the positive effect of ST in patients with FM is visible, but it is necessary to carry out more studies with greater methodological rigor to address possible gaps.
Another interesting result is about adherence to treatments. It is known that patients with FM have difficulties adhering to the practice of physical exercise; however, few studies reported the adherence of patients to the interventions [59, 60]. In the present review, the mean adherence percentage was 84%, a result similar to that of the study by Sanz-Baños et al.  in patients undergoing aerobic exercises [adherence percentage 87.2%]. This result is a further indication that ST can be used as part of the treatment for patients with FM, because in addition to improving the symptoms, the patients show high adherence to the intervention.
Concerning the strengths and limitations of the study, we were able to verify through a broad literature review that ST improves the symptoms of patients with FM; however, some studies presented a high risk of bias and further studies are needed to consolidate the obtained results. In addition, future reviews including the gray literature are warranted in order to identify other studies on the subject.
In conclusion, ST had positive effects on physical and psychological symptoms, in terms of reducing pain, the number of tender points, and depression, and improving muscle strength, sleep quality, functional capacity, and quality of life. Intervention protocols should start at low intensity (40% of 1RM) and gradually increase the intensity. ST should be performed 2 or 3 times a week to exercise the main muscle groups. The current studies showed that ST is a safe and effective method of improving the major symptoms of FM and can be used to treat patients with this condition.
One maximum repetition
Heart Rate Variability
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The authors thank FAPESC (Foundation for Research and Innovation of the State of Santa Catarina) for financial support through a research grant (Project No. 2442-2011/12), CAPES for a Master scholarship (grant No. 02/2017), and the State University of Santa Catarina for a UDESC study opportunity.
Foundation for Research and Innovation of the State of Santa Catarina grant (Project No. 2442–2011/12).
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Alexandro Andrade, Ricardo de Azevedo Klumb Steffens, Sofia Mendes Sieczkowska, Leonardo Alexandre Peyré Tartaruga and Guilherme Torres Vilarino declare that they have no conflict of interest.
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