BMJ 2002;325:185 ( 27 July )

The full version of this paper, together with replies, can be found at http://bmj.com/cgi/content/full/325/7357/185

Selwyn C M Richards, consultant rheumatologist a, David L Scott, professor of clinical rheumatology b.

Design: Randomised controlled trial.

Setting: Hospital rheumatology outpatients. Group based classes took place at a "healthy living centre."

Participants: 132 patients with fibromyalgia.

Interventions: Prescribed graded aerobic exercise (active treatment) and relaxation and flexibility (control treatment).

Main outcome measures: Participants' self assessment of improvement, tender point count, impact of condition measured by fibromyalgia impact questionnaire, and short form McGill pain questionnaire.

Results: Compared with relaxation exercise led to significantly more participants rating themselves as much or very much better at three months: 24/69 (35%) v 12/67 (18%), P=0.03. Benefits were maintained or improved at one year follow up when fewer participants in the exercise group fulfilled the criteria for fibromyalgia (31/69 v 44/67, P=0.01). People in the exercise group also had greater reductions in tender point counts (4.2 v 2.0, P=0.02) and in scores on the fibromyalgia impact questionnaire (4.0 v 0.6, P=0.07).

Conclusions: Prescribed graded aerobic exercise is a simple, cheap, effective, and potentially widely available treatment for fibromyalgia.

Response

Members of the Medical Advisory Board, Fibromyalgia Association UK, have written the following reply to the article in the BMJ by Richards and Scott.

Editor—We welcome the prominence given to the article on the use of exercise therapy in fibromyalgia by Richards and Scott (1), but have some concerns over the way the results may be interpreted.

The outer cover of the journal featured the picture of a swimming woman with the underlying headline, "Prescribing exercise for fibromyalgia - simple, cheap, and effective. We suggest that this is misleading. Swimming was not part of the exercise programme described in the article and there is no evidence that swimming is beneficial in this condition. The actual exercise programme was "an individualised aerobic exercise programme, mostly walking on treadmills and cycling on exercise bicycles". Individualised programmes involving expensive equipment are neither simple nor cheap.

The use of the term "effective" should be qualified. The primary outcome measure, change in self rated global impression, although statistically in favour of the exercise treatment group, resulted in only 35% of those randomised to this intervention being classified as responders. Also only 19 of the 69 subjects randomised to the exercise treatment were able to complete more than two-thirds of the twice weekly classes. In absolute terms this treatment could be described as useful for some patients but not effective for all.

Regarding the secondary outcome measures: the changes in the Fibromyalgia Impact Questionnaire (FIQ) showed deterioration in the FIQ at 3 months, a 7% improvement at 6 months and a 4% improvement at 1 year. These latter 2 results were statistically significant but do not represent a clinically meaningful improvement.

Details of the existing medications, which participants continued at entry were not provided. If there was a difference in the medications being taken by the groups who found the exercise intervention effective, ineffective or who failed to complete the course, this might mean that the effectiveness of the exercise was due to support from the drug treatments. It is therefore inappropriate to isolate the exercise programme as being responsible alone for the improvement found by some patients.

Despite these reservations we believe that this study does provide evidence of the benefits of exercise for this difficult to treat condition, as have several previous studies (2). Fibromyalgia is very heterogeneous in its severity and for many patients exercise needs to be incorporated into a multidimensional management programme, as recently highlighted in the May 2002 edition of the Rheumatic Disease Clinics of North America entitled the "Rational Management of Fibromyalgia" (3, 4,).

We are concerned that that the way this study was presented may encourage some doctors to dismiss patients with the words "go and take more exercise", without considering the complexity of the problems in those with severe symptomatology. Exercise is of benefit in most chronic disorders, but more is not always better. Indeed there are negative aspects of too much exercise done too soon (5). It is to the credit of the Richard and Scott study that the intensity of exercise was individualized each subject and started out a gentle pace.

Kathy Longley, BSc Co-ordinator, Medical Advisory Board,  Fibromyalgia Association UK,	Robert Bennett, MD, FRCP  Professor of Medicine, Oregon Health & Science University, Portland, Oregon, USA
Alan Edwards, Clinical Assistant The David Hide Asthma and Allergy Research Centre, St Mary’s Hospital, Newport. Isle of Wight. PO30 5TG. UK	Norman Farron, Biomedical Scientist
Moira Henderson,  Medical Adviser for the Department of Work and Pensions Department of Work and Pensions The Adelphi, 1-11 John Adam Street,  London. WC2N 6HT. UK	Kim Lawson,  Senior Lecturer in Pharmacology Division of Biomedical Sciences Sheffield Hallam University City Campus, Sheffield. S1 1WB, UK
Marcus Vaz, BSc(Hons) Ost. Registered Osteopath 2 Marfleet Close, Lower Earley, Reading, Berks. UK

1. Richards SC, Scott DL. Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial. BMJ 2002; 325(7357):185.
2. Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome (Cochrane Review). Cochrane Database Syst Rev 2002;(3):CD003786.
3. Bennett RM. The rational management of fibromyalgia patients. Rheum Dis Clin North Am 2002; 28(2):181-99,
4. Littlejohn GO, Walker J. A realistic approach to managing patients with fibromyalgia. Curr Rheumatol Rep 2002; 4(4):286-292.
5. Jones KD, Clark SR. Individualizing the exercise prescription for persons with fibromyalgia. Rheum Dis Clin North Am 2002; 28(2):419-436