• Fatigue,
• Stress,
• Catastrophizing (thinking overly negative thoughts),
• Unrealistic expectations (2).

People diagnosed with FM are very heterogeneous and cannot be treated with universally accepted strategies. What works for one person may not work for another. An individualized multidisciplinary, multimodal approach is more effective, including (2,44,64,83):

Pharmacological

• Non-steroidal anti-inflammatory drugs (NSAIDs), analgesic drugs, antidepressants, and muscle relaxants improve symptoms such as pain, sleep fatigue, anxiety/depression in the short-term, but many abandon medications because symptoms do not continue to improve. More study needed for long-term effects (44,74,76,83).
• Glucocorticoid injections except for those with concomitant carpal tunnel syndrome (83).

Non-pharmacological

• Education about FM and self-management techniques may not directly decrease pain but doesn't appear to increase it and may increase quality of life, self-efficacy and satisfaction while minimizing unrealistic expectations (2,7,83).
• Stress reduction techniques.
• Individually adapted exercise (45,83).
• Stretching (44,45).
• Cognitive behavioral strategies like biofeedback, counseling, meditation, relaxation, and stress management can lead to an increased sense of control over pain, a belief that one is not necessarily disabled by FM, that pain is not necessarily a sign of damage, decreased guarding, increased use of exercise, increased seeking of support, activity pacing and use of coping self-statements (44,64).
• Physical strategies such as graded exercise, increasing activity, and resting (55,76,83).
• Social support (2,83).

Other promising alternative treatment approaches that need further study to verify effectiveness and efficacy in treating pain in FM:

• Balnotherapy (sulfur baths) (83).
• Osteopathic manipulation (83). NOTE: Spinal manipulation of the cervical vertebrae can lead to serious complications that make it less compelling (95).
• Acupuncture (20).
• Green algae supplements (Chlorella pyrenoidosa) (20).
• S-adenosyl methionine supplements (20).
• Massage (20).

General Guidelines

• Do a very thorough pre-assessment to determine fitness level (many are extremely deconditioned), any concomitant conditions, medications and any other pain generators such as previous injuries, arthritis, tendonitis, and myofascial trigger points (45).
• Exercise carries both risks and benefits for people with FM. Have a thorough understanding of FM before attempting to develop an exercise program. Some medications commonly taken with FM may increase likelihood of orthostatic hypotension, dizziness, and balance problems. Know potential side effects. As a precaution, gradually change positions from movement to movement (2,43,44,45,83).
• If fatigue rather than pain is primary complaint, consider that orthostatic hypotension and/or disrupted sleep (common in FM) may be the cause. Seek medical guidance to manage (45).
• Prescribed exercise can be performed in the community by personal trainers previously unfamiliar with the management of people with FM (76).
• Exercise is most effective in persons whose pain control is optimized (44,45).
• All components of an exercise program (strength, aerobic, flexibility, and balance) can fit and appear safe and beneficial if individually tailored. Customization will increase likelihood of compliance and minimize risks (43,45,74,83).
• Spend time teaching how to properly perform the exercises, being aware of bodily signals, and how to modify exercises to match threshold of pain and fatigue, and minimize eccentric contractions in daily activities (45,55).
• Educate client that even when exercise is started at a suitable level and progressed slowly, it may produce a small and transient increase in pain that will abate after the first few weeks of exercise (27,44,76).
• Exercise prescription should combat deconditioning without triggering pain (45,83).
• Start at low intensity and very gradually increase to moderate intensity (months rather than weeks). It may not result in traditional changes associated with fitness, but should minimize the progression of deconditioning while managing pain (27,45).
• Exercise program must be ongoing to provide long-term pain management. As adherence declines, musculoskeletal pain increases (2,7,27,60,74,76). Ways to increase compliance may be:
  
  • Designing an exercise program with flexible goals (2).
  • Identifying potential high-risk situations before they occur (2).
  • For people with a low threshold for pain, exercising in the late afternoon rather than the morning may lessen the perception of pain based on diurnal rhythm patterns (3).
  • Developing coping skills (2,76).
  • Education on specific techniques to help adjust a program when a relapse or flare occurs (2,55,76).
  • Pacing (breaking down tasks into manageable segments).
  • Multiple short sessions vs. one long session (2).
  • Cognitive reappraisal (changing reaction pattern to flares or set-backs) (2).
  • Social support from professionals is as crucial in promoting positive health behaviors as family and friends (2).
  • Maximize self-efficacy (belief in one's capabilities) to encourage continued exercise compliance (45).
• An exercise videotape depicting modifications needed for people with FM and other pain-related conditions is available at www.myalgia.com. Proceeds fund FM research (44).

Aerobic Exercise

• Emphasize non-impact loading exercise such as walking, water aerobics in a heated pool, and stationary bicycles to reduce pain (27,45,55).
• In general, intensity should be based on perceived exertion and pain limitations (2,44).
• People with significant musculoskeletal pain or those who are more fearful that exercise will increase their pain may benefit most from a water-based program (27).
• Warm (therapeutic) pools (93 F) may reduce pain but can be difficult to find in the community. This makes compliance more difficult, but even pools with a water temperature 85 F will be better tolerated than a standard community pool (27,44).
• Some suggest avoiding overhead movements in aerobic activity, even during water activities (44). Others suggest that overhead movements can be tolerated in aerobic exercise if introduced gradually (27).
• Stationary bicycles may aggravate gluteal tender points and produce symptoms resembling sciatica (2,45).
• In order to engage in a walking program, client must be able to rise from chair and hold the trunk stable. If unable, begin a strength-training program or perform aerobic conditioning while sitting in a chair (45).
• Walking should be done at an intensity that makes it possible to talk but not sing (44).
• A lower-intensity aerobic exercise program of longer duration may be more effective in FM treatment, resulting in less pain, greater compliance, and more enjoyment than a high-intensity program (2,27,90)

• Some experts feel strength training might be the best first step in preparing a deconditioned person with FM to engage in a more comprehensive program that includes other dimensions (43,45). Strategies include:
• Actively or passively warm up muscles (44).
• Focus on functional strength and muscle toning rather than 'body building' (45)
• Use bands, soft weights, machines such as Nautilus or Universal that don't require a tight grip, and sustained contractions (43,45).
• Allow a 4-count pause between each repetition to allow return to resting state or work the opposing limb during the pause period (43,45).
• Minimize eccentric contractions such as walking downhill and using overhead movements (44,45).
• Minimize plyometrics. One small study (n=11) showed increased leg pain and reduced neck pain in a strength training regimen that included 'explosive' strength training at the end of the 21-week regimen (32).
• Increase ratio of contractions near the body midline vs. farther from midline (43).
• Maximize the concentric phase (8 count) and minimize the eccentric phase (4 count) (27,43,45).
• Start with small sets of 3 to 5 repetitions and add sets as tolerated (43, 45).
• Be aware that there appears to be a delayed onset of muscle relaxation in people with FM. Consider a twice-weekly program consisting of one day upper-body followed by a day of no strength training, a day of lower body training followed by a day of no strength training (44).
  
  Flexibility Training
• Actively or passively warm up muscles before stretching them (44).
• Actively or passively warm up muscles, stretch to point of resistance, but not pain, then hold stretch (27,44,45).
• One method to help client identify stop point is to stretch with eyes closed. Use cues that discourage overstretching such as 'hang your head toward your chest' rather than 'stretch your chin toward your chest' (43,44).
• Do not bounce and do not stretch to point of increased pain (45).
• Minimize stretching in FM tender point locations (43).
• Care must be taken to avoid overstretching, especially for those with joint hypermobility (27,44).
  
  Exercise recommendations that may help during a flare:
• Stress need for passive warm-up and warm-down using a hot bath or hot tub (45).
• Consult with physician regarding medical pain management (45).
• Use NSAIDs before exercise (45).
• Decrease intensity of exercise before altering frequency or duration (2,45).
• If pain continues, discontinue exercise until pain flare has subsided by 75% (45).