Cochrane review: Aerobic exercise training for adults with fibromyalgia June 2017

Sly Saint · Jun 7, 2020

Julia Bidonde

Angela J Busch

Candice L Schachter

Tom J Overend

Soo Y Kim

Suelen M. Góes

Catherine Boden

Heather JA Foulds

Abstract
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Background

Exercise training is commonly recommended for individuals with fibromyalgia. This review is one of a series of reviews about exercise training for people with fibromyalgia that will replace the "Exercise for treating fibromyalgia syndrome" review first published in 2002.

Objectives
• To evaluate the benefits and harms of aerobic exercise training for adults with fibromyalgia

• To assess the following specific comparisons
० Aerobic versus control conditions (eg, treatment as usual, wait list control, physical activity as usual)
० Aerobic versus aerobic interventions (eg, running vs brisk walking)
० Aerobic versus non‐exercise interventions (eg, medications, education)

We did not assess specific comparisons involving aerobic exercise versus other exercise interventions (eg, resistance exercise, aquatic exercise, flexibility exercise, mixed exercise). Other systematic reviews have examined or will examine these comparisons (Bidonde 2014; Busch 2013).

Search methods
We searched the Cochrane Library, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Physiotherapy Evidence Database (PEDro), Thesis and Dissertation Abstracts, the Allied and Complementary Medicine Database (AMED), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and the ClinicalTrials.gov registry up to June 2016, unrestricted by language, and we reviewed the reference lists of retrieved trials to identify potentially relevant trials.

Selection criteria
We included randomized controlled trials (RCTs) in adults with a diagnosis of fibromyalgia that compared aerobic training interventions (dynamic physical activity that increases breathing and heart rate to submaximal levels for a prolonged period) versus no exercise or another intervention. Major outcomes were health‐related quality of life (HRQL), pain intensity, stiffness, fatigue, physical function, withdrawals, and adverse events.

Data collection and analysis
Two review authors independently selected trials for inclusion, extracted data, performed a risk of bias assessment, and assessed the quality of the body of evidence for major outcomes using the GRADE approach. We used a 15% threshold for calculation of clinically relevant differences between groups.

Main results
We included 13 RCTs (839 people). Studies were at risk of selection, performance, and detection bias (owing to lack of blinding for self‐reported outcomes) and had low risk of attrition and reporting bias. We prioritized the findings when aerobic exercise was compared with no exercise control and present them fully here.

Eight trials (with 456 participants) provided low‐quality evidence for pain intensity, fatigue, stiffness, and physical function; and moderate‐quality evidence for withdrawals and HRQL at completion of the intervention (6 to 24 weeks). With the exception of withdrawals and adverse events, major outcome measures were self‐reported and were expressed on a 0 to 100 scale (lower values are best, negative mean differences (MDs)/standardized mean differences (SMDs) indicate improvement). Effects for aerobic exercise versus control were as follows: HRQL: mean 56.08; five studies; N = 372; MD ‐7.89, 95% CI ‐13.23 to ‐2.55; absolute improvement of 8% (3% to 13%) and relative improvement of 15% (5% to 24%); pain intensity: mean 65.31; six studies; N = 351; MD ‐11.06, 95% CI ‐18.34 to ‐3.77; absolute improvement of 11% (95% CI 4% to 18%) and relative improvement of 18% (7% to 30%); stiffness: mean 69; one study; N = 143; MD ‐7.96, 95% CI ‐14.95 to ‐0.97; absolute difference in improvement of 8% (1% to 15%) and relative change in improvement of 11.4% (21.4% to 1.4%); physical function: mean 38.32; three studies; N = 246; MD ‐10.16, 95% CI ‐15.39 to ‐4.94; absolute change in improvement of 10% (15% to 5%) and relative change in improvement of 21.9% (33% to 11%); and fatigue: mean 68; three studies; N = 286; MD ‐6.48, 95% CI ‐14.33 to 1.38; absolute change in improvement of 6% (12% improvement to 0.3% worse) and relative change in improvement of 8% (16% improvement to 0.4% worse). Pooled analysis resulted in a risk ratio (RR) of moderate quality for withdrawals (17 per 100 and 20 per 100 in control and intervention groups, respectively; eight studies; N = 456; RR 1.25, 95%CI 0.89 to 1.77; absolute change of 5% more withdrawals with exercise (3% fewer to 12% more).

Three trials provided low‐quality evidence on long‐term effects (24 to 208 weeks post intervention) and reported that benefits for pain and function persisted but did not for HRQL or fatigue. Withdrawals were similar, and investigators did not assess stiffness and adverse events.

We are uncertain about the effects of one aerobic intervention versus another, as the evidence was of low to very low quality and was derived from single trials only, precluding meta‐analyses. Similarly, we are uncertain of the effects of aerobic exercise over active controls (ie, education, three studies; stress management training, one study; medication, one study) owing to evidence of low to very low quality provided by single trials. Most studies did not measure adverse events; thus we are uncertain about the risk of adverse events associated with aerobic exercise.

Authors' conclusions
When compared with control, moderate‐quality evidence indicates that aerobic exercise probably improves HRQL and all‐cause withdrawal, and low‐quality evidence suggests that aerobic exercise may slightly decrease pain intensity, may slightly improve physical function, and may lead to little difference in fatigue and stiffness. Three of the reported outcomes reached clinical significance (HRQL, physical function, and pain). Long‐term effects of aerobic exercise may include little or no difference in pain, physical function, and all‐cause withdrawal, and we are uncertain about long‐term effects on remaining outcomes. We downgraded the evidence owing to the small number of included trials and participants across trials, and because of issues related to unclear and high risks of bias (performance, selection, and detection biases). Aerobic exercise appears to be well tolerated (similar withdrawal rates across groups), although evidence on adverse events is scarce, so we are uncertain about its safety.
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https://www.cochranelibrary.com/cds...ll?highlightAbstract=fibromyalgi|fibromyalgia

rvallee · Jun 7, 2020

benefits for pain and function persisted but did not for HRQL
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Sorry but that's the tell that the benefits are a total illusion from poorly worded biased questionnaires. The idea that there could be a significant reduction in pain and significant benefits to function with no impact on HRQoL is laughable. If factors highly significant to HRQoL have no impact on HRQoL then something's very wrong with how things are being measured or interpreted, one of those problems being that nothing is actually measured, only feelings adapted into arbitrary scoring.

And yet:

aerobic exercise probably improves HRQL
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This is "participants on average gained weight but also lost weight" level of self-contradictory given the first sentence I quoted. Is no one checking the substance of those reviews? It really seems to be more of a creative technical writing club where review is limited to style.

Aerobic exercise appears to be well tolerated (similar withdrawal rates across groups)
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That statement makes as much sense as saying that a problem manager is not so bad since no one went postal and set the office on fire in protest. The participants invested themselves in this and people will tolerate a lot of crap if they have little choice. That they did not quit in protest is a weird interpretation of tolerating something. Especially given:

Most studies did not measure adverse events
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It's frankly not even clear what the recommendations are in the conclusion. It doesn't seem to be recommended but also seems to suggest there is no reason not to recommend it if one feels like it. The original question is not at all answered.

I have a friend who has been subjected to that, group exercise therapy. Did no good, obviously. Looks like there's no reason for it in the first place, it's all just part of the belief system, recommended without reason. What a mess.

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Cochrane review: Aerobic exercise training for adults with fibromyalgia June 2017

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