Aerobic exercise for pain management in fibromyalgia

Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

The effectiveness of aerobic exercise for pain management in patients

with fibromyalgia
Eva Ivana Kopše, Denisa Manojlović

Faculty of Health Sciences, University of Primorska, Izola, Slovenia.

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits
any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract
The effectiveness of exercise therapy is being increasingly studied in patients with fibromyalgia.
The aim of our systematic review was to determine the effectiveness of different types of aerobic
exercise programs for pain management in patients with fibromyalgia. The literature search was
performed by two independent researchers in the PubMed, CINAHL and PEDro databases using
various combinations of the following keywords: fibromyalgia, pain and aerobic exercise.
Studies were eligible if they included adults diagnosed with fibromyalgia and examined the
effectiveness of at least one aerobic exercise program on pain management. A total of 14
randomized controlled trials were screened in full-text, nine of which were included in the
systematic review. Overall, our results indicate that aerobic exercise is effective for pain
management in patients with fibromyalgia. The results of the aerobic exercise programs were
more effective for pain management than stretching exercises, but did not differ significantly
from those of pilates, muscle strengthening exercises, relaxation techniques and stress
management treatment. Additional high-quality studies are warranted to determine accurate
clinical guidelines in terms of aerobic exercise programs for pain management in patients with
fibromyalgia.
Key Words: myofascial pain syndrome; cardio-respiratory exercise; chronic pain.
Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

Fibromyalgia (FM) is a syndrome characterized by consistent pattern, they may indicate that the patients'
chronic musculoskeletal pain that can be felt in different immune processes are impaired.12 Both trauma and
parts of the body.1 FM affects about 2-7% of the world's infections that can trigger autoimmunity are among the
population.2-4, and its prevalence is similar in different most common causes of FM.13 A significantly increased
countries, cultures and ethnic groups.5 The main prevalence of FM has been found in individuals with
symptoms of the disease are widespread musculoskeletal COVID-19, herpes simplex, hepatitis C, and Epstein-
pain, muscle and joint stiffness, insomnia, fatigue, mood Barr viral infections, as well as in individuals with
disorders, cognitive dysfunction, anxiety, depression, autoimmune rheumatologic diseases.14-16
general sensitivity and inability to perform daily Chronic pain may affect an individual in various ways.
activities.6,7 Although factors contributing to the These often include physical, psychological, social, or
development of FM include neuroendocrine disorders, economic distress.17 Pain has a significant impact on an
genetic predisposition, oxidative stress, environmental individual's quality of life, self-esteem and emotions.
and psychosocial changes, clear factors leading to the Normal participation in everyday and work activities is
onset of FM are still unclear and are the subject of often limited for the patient. Research of chronic pain
numerous studies.8,9 FM seems to be triggered by central usually begins with the assumption that the patients'
and peripheral mechanisms of excessive excitability, primary goal is to reduce pain and increase control over
which can cause changes in pain perception, such as their condition.18 However, complete and/or permanent
hyperalgesia and allodynia, muscle stiffness, reduced pain relief is rarely achieved, nor does it lead to better
functional capacity, and sleep disturbances.10,11 Several functioning and quality of life for patients with FM.19,20
features of FM suggest an autoimmune component in the Sometimes, the goal of reducing pain can have the
pathogenesis. Altered levels of inflammatory and opposite effect if coping methods are perceived as pain
immunoregulatory cytokines have been found in FM avoidance.21 Avoidance is associated with increased pain
patients. Although these changes do not follow a intensity, greater anxiety and depression, as well as
mental and work disability.22 Therefore, accepting pain is

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Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

particularly important, defined as the willingness to results were combined. The search strategy was carried
constantly experience pain without efforts to reduce, out in two phases: 1) the assessment of eligible articles
avoid, or otherwise change it.21 The authors found that a based on title and abstract, and 2) the assessment of
higher level of pain acceptance is associated with better eligible articles based on the full text.
daily functioning and less disability and symptoms.23 A
Eligibility criteria
multidisciplinary approach is recommended for the
treatment of FM, based on the management of physical, The eligibility criteria were structured according to the
psychological, and social factors.19,24 The treatment of PICOS tool:35
FM involves the use of pharmacological and non- • Population (P): The population included both women
pharmacological therapy. Several pharmacological and men of all age groups who had been diagnosed
interventions have solid evidence of efficacy in treating with FM. Studies with less than 40 subjects were
FM symptoms, including tricyclic antidepressants, excluded, as were studies that examined other
gabapentinoids, and serotonin - noradrenaline reuptake pathologies.
inhibitors.25-28 However, no pharmacological • Intervention (I): Studies were included if at least one
intervention is effective in managing all FM symptoms, experimental group was included in an aerobic
as they can only alleviate individual symptoms.29 exercise program. No exclusion criteria were
Accordingly, authors suggest that non-pharmacological established based on the intensity of aerobic exercise.
interventions may be more effective in increasing the However, studies where the intervention lasted less
quality of life as they relieve pain, improve physical than three weeks were excluded. Studies were also
function and the overall status of patients with FM.30,31 excluded if aerobic exercise was performed in
Non-pharmacological therapy includes patient education, combination with other types of exercise programs
exercise therapy, and cognitive-behavioral therapy. and the effectiveness of the aerobic exercise program
Exercise therapy is an important part of treatment, as could not be clearly determined.
patients often report impaired everyday function due to • Comparison (C): Studies were included if they
poor cardiovascular fitness, muscle strength and assessed the effectiveness of aerobic exercise
endurance.32 Aerobic exercise is one of the most common compared to a control group that received other forms
type of exercise intervention used for pain management of therapeutic or exercise intervention or received no
in patients with FM, as it has many positive effects when intervention at all.
dealing with chronic pain conditions. 29,32,33 During • Outcomes (O): Studies were included if they assessed
aerobic exercise, the hypothalamus releases an increased pain intensity according to the Visual Analogue Scale
level of neurotransmitters, including endorphins, which (VAS), number of painful regions, number of tender
lead to reduced pain. Furthermore, a higher level of points, pain pressure thresholds at all 18 specified
neurotransmitters is linked to improvements in mood and sites measured with an electronic algometer, Short
sleep quality. Aerobic exercise is also effective in Form-36 Health Survey (pain category), pain severity
reducing the inflammatory process and oxidative stress subscale of the Multidimensional Pain Inventory
in the body, resulting in reduced anxiety, depression, and (MPI), Fibromyalgia Impact Questionnaire Pain scale
stress responses.32 A recent systematic review of 18 (FIQ Pain) and short form McGill pain questionnaire
studies concluded that aerobic exercise, resistance (MPQ) as an outcome measure.
training, and stretching exercise have positive effects on • Study Design (S): Randomized controlled trials
pain, depression, and quality of life in adults with FM.34 including at least one experimental and control group
Although aerobic exercise is associated with pain were included.
reduction, the effectiveness of different aerobic exercise Study extraction and analysis
protocols for pain management in FM patients, compared Data extraction included the following items: sample
to other exercise interventions, has not been thoroughly characteristics (gender and age range of participants),
investigated. Therefore, we conducted a systematic intervention characteristics (treatment groups, type of
review that combines previous findings and provides the intervention, total weeks, duration, frequency), outcome
latest clinical guidelines for the use of aerobic exercise in variables and main findings. Data collection was carried
patients with FM. out by one researcher, with the supervision of the second
researcher.
Materials and Methods
Methodological quality
Information sources and search strategy
The quality of the included studies was assessed
The search for relevant studies was conducted in March independently by two researchers, using the PEDro scale,
2023. We searched the PubMed, CINAHL and PEDro which rates the quality of studies from 0 to 10.31 Studies
databases for all papers published in English language, scoring from 9-10 were considered as “excellent”, 6-8 as
regardless of the year of publication. We used the “good,” 4-5 as “fair,” and <4 as “poor” quality. The
following search strategy: fibromyalgia AND pain AND average quality of the studies was rated as “good” (mean
("aerobic exercise" OR "aerobic training"). The search = 6.33). Four studies were rated as being of “fair” quality,
was conducted by two reviewers independently and the

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Table 1. Assessment of the methodological quality of the included studies by the PEDro scale.36
N Criteria de Medeiros et Sevimli Hooten Mannerkorpi Assis Valim Schachter Richards Wigers
al.11 et al.37 et al.38 et al.39 et al.40 et al.41 et al.42 and et al.44
Scott43
1 Random Yes Yes Yes Yes Yes Yes Yes Yes Yes
allocation
2 Concealed Yes No Yes Yes Yes No No No No
allocation
3 Groups Yes Yes Yes Yes Yes Yes No No Yes
similar at
baseline
4 Subject No No No No No No No No No
blinding
5 Therapist No No No No No No No No No
blinding
6 Assessor Yes No No Yes Yes Yes Yes Yes Yes
blinding
7 Adequate Yes Yes Yes Yes Yes No No No No
follow-up
8 Intention-to- Yes No Yes Yes Yes No Yes Yes Yes
treat analysis
9 Between- Yes Yes Yes Yes Yes Yes Yes Yes Yes
groups
comparisons
10 Point Yes Yes Yes Yes Yes Yes Yes Yes Yes
estimates and
variability
PEDro scale 8 5 7 8 8 5 5 5 6
scoring

whereas the remaining five were rated as being of “good” aerobic exercise is effective in reducing pain, although
quality. the results did not significantly differ compared to mat
Results from the PEDro scale are summarized in Table 1. pilates, strengthening exercise, relaxation techniques,
and stress management treatment.11,38,40,43,44 On the other
Results hand, pain intensity did not significantly decrease over
With the initial search strategy, we found 289 potential time in the Nordic walking and low-intensity walking
articles, of which 159 were in the PubMed database, 80 group.39 It was also found that there was no reduction in
in CINAHL and 50 in PEDro databases. After removing pain, number of painful regions and increase in pain
the duplicates, a total of 188 studies were exported to MS pressure threshold in the progressive aerobic exercise
Excel (Microsoft, Redmond, USA) where key group.42
information about the studies were recorded. All studies
were screened by title and abstract in order to exclude Discussion
those not meeting the inclusion criteria. Finally, 18 The aim of our systematic review was to assess the
studies were reviewed in full text and nine of them were effectiveness of aerobic exercise for pain management in
excluded due to inappropriate content. Thus, a total of patients with FM. Studies included in the systematic
nine appropriate studies were included in the systematic review investigated the effectiveness of aerobic exercise
review. The literature search process is presented in in comparison with various forms of exercise
Figure 1. interventions on pain management in patients with FM.
Basic information of the nine studies included in the Pain threshold has been found to increase in individuals
systematic review are presented in the Table 1 of exercising at an intensity of at least 75% of maximal
Supplementary Materials. It was found that gymnastic- aerobic capacity.45 This is due to the activation of potent
based aerobic exercise program and pool-based aquatic opioidergic and other pain inhibitory mechanisms
aerobic exercise program provides better results for pain controlled by the central nervous system.46 Although
management compared to isometric strength and regular exercise programmes can have beneficial effects
stretching exercise program.37 Aerobic exercise was also in people with chronic pain, some patients report
superior to stretching exercise in terms of reducing the worsening of symptoms.47,48 In chronic pain conditions
number of tender points and pain during palpation of the characterised by central sensitization, such as FM and
tender point.41 However, four studies have reported that chronic fatigue syndrome, impairment of endogenous

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Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

Fig 1. PRISMA flowchart of study selection process.

pain inhibition has been reported with excessively finding of Hooten et al.38 was that aerobic exercise and
intense exercise and worsening of symptoms after strength training had comparable effects on pain
exercise.47-49 management and increasing pain pressure threshold.
Sevimli et al.37 concluded that aquatic aerobic exercise Previous studies suggest that aerobic exercise and
and gymnastics are more effective methods for pain strength training may improve muscle oxygenation,
management in patients with FM compared to isometric leading to a reduction in peripheral and central
resistance exercise and stretching exercises. Similar sensitization and thus a reduction in pain intensity.51,52
findings were reported by Valim et al.41 who compared Richards and Scott43 compared the results of aerobic
walking and stretching exercises for pain management in exercise and relaxation techniques and found that both
patients with FM. Aerobic exercise was found to be more methods were equally effective for pain management and
effective than stretching exercises in pain management, in reducing the number of painful points three months
number of tender points, and increasing pressure after the conclusion of the intervention. At the one year
tolerance. Assis et al.40 examined the effectiveness of follow up, the reduction in the number of painful points
water running, walking, and running on land. Authors was maintained in both groups, although the difference
reported that pain scores decreased in both groups, with was greater and in patients that were included in the
an average reduction of 40% in water running and 30% aerobic exercise program. Wigers et al.44 found that both
in walking and running on land. However, it is aerobic exercise and stress management treatment were
emphasized that although walking is a practical form of short-term effective methods for pain management,
exercise for most patients, it may be difficult and painful number of painful regions, and increasing pain pressure
for some with concurrent diseases (e.g. arthritis). threshold, but no significant long-term changes were
Therefore, aerobic exercise in water is particularly observed in symptom severity. Mannerkorpi et al.39
suitable for people with lower limb limitations.40 It is investigated the effectiveness of moderate-to-high-
assumed that hydrostatic pressure and higher water intensity Nordic walking and low-intensity walking
temperatures may increase sensory input and block program. Surprisingly, some patients in the Nordic
nociceptors, thereby contributing to pain relief.50 walking group as well as in the low-intensity walking
Accordingly, De Medeiros et al.11 reported the positive group reported temporary increases in pain, which could
effects of aerobic exercise in water on pain management, be due to dysfunctions in peripheral and central pain
although the results did not differ significantly compared mechanisms in FM.39 In a study that evaluated the
to the control group that performed mat pilates. The main effectiveness of aerobic dance, it was found that there

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Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

was a worsening of FM symptoms, particularly an warranted to be included in daily clinical practice when
increase in pain intensity.53 Van Santen et al.54 also treating patients with FM. However, high-quality studies
concluded that pain intensity increased in the group that with large numbers of participants and long-term follow-
performed high-intensity aerobic exercise compared to up are needed to clearly determine clinical guidelines for
the control group that underwent low-intensity exercise. implementing aerobic exercise program for pain
Within high-intensity walking, the use of poles was management in patients with FM.
advised, which facilitates walking and relieves the lower
extremities. Walking in short intervals, allowing for a List of acronyms
short rest after each intense interval, can also be CINAHL - cumulative index to nursing and allied health
beneficial in reducing the risk of pain.39 Schachter et al.42 literature
compared the effectiveness of progressive low-intensity FIQ Pain - fibromyalgia impact questionnaire pain scale
aerobics with a control group that did not receive any FM - Fibromyalgia
intervention. They found that pain intensity, the number MPI - multidimensional pain inventory
of painful regions, and pain pressure threshold did not MPQ - McGill pain questionnaire
significantly change between groups. This could be PEDro - physiotherapy evidence database
attributed to the lack of supervision during the exercise PRISMA - preferred reporting items for systematic
program, as patients performed exercises independently reviews and meta-analyses
at home. Therefore, it was not possible to verify the SF-36 - short form-36 health survey
reported data on exercise duration and whether patients VAS - visual analogue scale
exercised at the targeted intensity.42 Contributions of Authors
Despite the lack of agreement on the most effective form
of exercise, authors assume that combined exercise with EIK: Substantial contributions to the conception and
two to three moderate-intensity training sessions per design of the work; EIK, DM: acquisition, analysis, or
week lasting 30-45 minutes, is most effective in reducing interpretation of data for the work, drafting the work and
FM symptoms.33 It is important to adjust the type, revising it critically for important intellectual content;
duration, frequency, and exercise intensity according to EIK, DM: Agreement to be accountable for all aspects of
the individual's goals and abilities. the work in ensuring that questions related to the
Our systematic review has several limitations. Firstly, it accuracy or integrity of any part of the work are
is difficult to determine clear clinical recommendations appropriately investigated and resolved.
because of the high heterogeneity of the included studies Acknowledgments None
in terms of the aerobic exercise type, duration of the
program, differences in volume (number of repetitions, Funding
sets or exercises) and the intensity of aerobic exercise. The study was supported by the Slovenian Research
Therefore, further studies are needed to limit the high Agency through the research program KINSPO -
variability of exercise programs. Secondly, most of the Kinesiology for the effectiveness and prevention of
included studies did not directly investigate the musculoskeletal injuries in sports (P5-0443), but the
effectiveness of aerobic exercise for pain management in authors certify that they have not received any other
FM patients, but instead compared the effectiveness of financial compensation for this research from any
different intervention on both physical and psychological funding agency in commercial or profit sectors.
parameters. Additionally, in none of the included studies
was the therapist or the subject blinded to group Conflict of Interest
allocation. One of the limitations is also the lack of The authors have no conflict of interest to declare.
studies comparing the effectiveness of aerobic exercise
with a control group that did not receive the intervention. Ethical Publication Statement
Finally, the findings of most studies were based on short- We confirm that we have read the Journal’s position on
term measurements and further studies are needed to issues involved in ethical publication and affirm that this
clarify the long-term effectiveness of aerobic exercise for report is consistent with those guidelines.
pain management in patients with FM. In conclusion, our
systematic review indicate that aerobic exercise is Corresponding Author
effective for pain management in patients with FM. The Denisa Manojlović, Faculty of Health Sciences
results indicate that aerobic exercise programs are more University of Primorska, 6310 Izola, Slovenia
effective for pain management in patients with FM Telephone: +386 66 35 802
compared to stretching exercises. However, the results ORCID iD: 0000-0002-2864-5957
showed no significant difference between aerobic e-mail: [email protected]
exercise and pilates, muscle strength training, relaxation E-mails and ORCID iD of co-author
techniques or stress management treatment in terms of
pain management in patients with FM. Due to the Eva Ivana Kopše: [email protected]
favorable effects on pain, aerobic exercise programs are ORCID iD: 0009-0005-2195-8722

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References Lins CA, de Souza MC. Mat Pilates is as effective

1. Siracusa R, Paola RD, Cuzzocrea S, Impellizzeri D. as aquatic aerobic exercise in treating women with
Fibromyalgia: Pathogenesis, Mechanisms, fibromyalgia: a clinical, randomized and blind trial.
Diagnosis and Treatment Options Update. Int J Mol Adv Rheumatol. 2020 Apr 6;60(1):21. doi:
Sci. 2021 Apr 9;22(8):3891. doi: 10.1186/s42358-020-0124-2. PMID: 32252822.
10.3390/ijms22083891. PMID: 33918736; 12. Andrés-Rodríguez L, Borràs X, Feliu-Soler A,
PMCID: PMC8068842. Pérez-Aranda A, Angarita-Osorio N, Moreno-Peral
2. Vincent A, Lahr BD, Wolfe F, Clauw DJ, Whipple P, Montero-Marin J, García-Campayo J, Carvalho
MO, Oh TH, Barton DL, St Sauver J. Prevalence of AF, Maes M, Luciano JV. Peripheral immune
fibromyalgia: a population-based study in Olmsted aberrations in fibromyalgia: A systematic review,
County, Minnesota, utilizing the Rochester meta-analysis and meta-regression. Brain Behav
Epidemiology Project. Arthritis Care Res Immun. 2020 Jul;87:881-889. doi:
(Hoboken). 2013 May;65(5):786-92. doi: 10.1016/j.bbi.2019.12.020. Epub 2019 Dec 27.
10.1002/acr.21896. PMID: 23203795; PMCID: PMID: 31887417.
PMC3935235. 13. Buskila D, Atzeni F, Sarzi-Puttini P. Etiology of
3. Branco JC, Bannwarth B, Failde I, Abello fibromyalgia: the possible role of infection and
Carbonell J, Blotman F, Spaeth M, Saraiva F, Nacci vaccination. Autoimmun Rev. 2008 Oct;8(1):41-3.
F, Thomas E, Caubère JP, Le Lay K, Taieb C, doi: 10.1016/j.autrev.2008.07.023. Epub 2008 Aug
Matucci-Cerinic M. Prevalence of fibromyalgia: a 13. PMID: 18706528.
survey in five European countries. Semin Arthritis 14. Kocyigit BF, Akyol A. The relationship between
Rheum. 2010 Jun;39(6):448-53. doi: COVID-19 and fibromyalgia syndrome:
10.1016/j.semarthrit.2008.12.003. Epub 2009 Feb prevalence, pandemic effects, symptom
27. PMID: 19250656. mechanisms, and COVID-19 vaccines. Clin
4. Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. Rheumatol. 2022 Oct;41(10):3245-3252. doi:
The prevalence and characteristics of fibromyalgia 10.1007/s10067-022-06279-9. Epub 2022 Jul 8.
in the general population. Arthritis Rheum. 1995 PMID: 35804273.
Jan;38(1):19-28. doi: 10.1002/art.1780380104. 15. Reshkova V, Kalinova D, Milanov I. Evaluation of
PMID: 7818567. antiviral antibodies against Epstein-Barr Virus and
5. McBeth J, Jones K. Epidemiology of chronic neurotransmitters in patients with fibromyalgia. J.
musculoskeletal pain. Best Pract Res Clin Neurol Neurosci. 2015;6 doi: 10.21767/2171-
Rheumatol. 2007 Jun;21(3):403-25. doi: 6625.100035.
10.1016/j.berh.2007.03.003. PMID: 17602991. 16. Lichtenstein A, Tiosano S, Amital H. The
6. Gerdle B, Björk J, Cöster L, Henriksson K, complexities of fibromyalgia and its comorbidities.
Henriksson C, Bengtsson A. Prevalence of Curr Opin Rheumatol. 2018 Jan;30(1):94-100. doi:
widespread pain and associations with work status: 10.1097/BOR.0000000000000464. PMID:
a population study. BMC Musculoskelet Disord. 29040155.
2008 Jul 15;9:102. doi: 10.1186/1471-2474-9-102. 17. White KP, Harth M. The occurrence and impact of
PMID: 18627605; PMCID: PMC2488345. generalized pain. Baillieres Best Pract Res Clin
7. Bennett RM, Jones J, Turk DC, Russell IJ, Rheumatol. 1999 Sep;13(3):379-89. doi:
Matallana L. An internet survey of 2,596 people 10.1053/berh.1999.0027. PMID: 10562368.
with fibromyalgia. BMC Musculoskelet Disord. 18. Kratz AL, Davis MC, Zautra AJ. Pain acceptance
2007 Mar 9;8:27. doi: 10.1186/1471-2474-8-27. moderates the relation between pain and negative
PMID: 17349056; PMCID: PMC1829161. affect in female osteoarthritis and fibromyalgia
8. Bradley LA. Pathophysiology of fibromyalgia. Am patients. Ann Behav Med. 2007 Jun;33(3):291-301.
J Med. 2009 Dec;122(12 Suppl):S22-30. doi: doi: 10.1007/BF02879911. PMID: 17600456;
10.1016/j.amjmed.2009.09.008. PMID: 19962493; PMCID: PMC2593934.
PMCID: PMC2821819. 19. Macfarlane GJ, Kronisch C, Dean LE, Atzeni F,
9. Yunus MB, Khan MA, Rawlings KK, Green JR, Häuser W, Fluß E, Choy E, Kosek E, Amris K,
Olson JM, Shah S. Genetic linkage analysis of Branco J, Dincer F, Leino-Arjas P, Longley K,
multicase families with fibromyalgia syndrome. J McCarthy GM, Makri S, Perrot S, Sarzi-Puttini P,
Rheumatol. 1999 Feb;26(2):408-12. PMID: Taylor A, Jones GT. EULAR revised
9972977. recommendations for the management of
10. Bhargava J, Hurley JA. Fibromyalgia. 2022 Oct 10. fibromyalgia. Ann Rheum Dis. 2017
In: StatPearls [Internet]. Treasure Island (FL): Feb;76(2):318-328. doi: 10.1136/annrheumdis-
StatPearls Publishing; 2023 Jan–. PMID: 2016-209724. Epub 2016 Jul 4. PMID: 27377815.
31082018. 20. Turk DC. Customizing treatment for chronic pain
11. de Medeiros SA, de Almeida Silva HJ, do patients: who, what, and why. Clin J Pain. 1990
Nascimento RM, da Silva Maia JB, de Almeida

-6-
 Aerobic exercise for pain management in fibromyalgia
Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

Dec;6(4):255-70. doi: 10.1097/00002508- 10.1186/1477-7525-4-67. PMID: 16999856;

199012000-00002. PMID: 2135025. PMCID: PMC1590013.
21. McCracken LM. Learning to live with the pain: 31. Busch AJ, Barber KA, Overend TJ, Peloso PM,
acceptance of pain predicts adjustment in persons Schachter CL. Exercise for treating fibromyalgia
with chronic pain. Pain. 1998 Jan;74(1):21-27. doi: syndrome. Cochrane Database Syst Rev. 2007 Oct
10.1016/S0304-3959(97)00146-2. PMID: 17;(4):CD003786. doi:
9514556. 10.1002/14651858.CD003786.pub2. PMID:
22. Vlaeyen JWS, Linton SJ. Fear-avoidance and its 17943797.
consequences in chronic musculoskeletal pain: a 32. Bidonde J, Busch AJ, Schachter CL, Overend TJ,
state of the art. Pain. 2000 Apr;85(3):317-332. doi: Kim SY, Góes SM, Boden C, Foulds HJ. Aerobic
10.1016/S0304-3959(99)00242-0. PMID: exercise training for adults with fibromyalgia.
10781906. Cochrane Database Syst Rev. 2017 Jun
23. Tangen SF, Helvik AS, Eide H, Fors EA. Pain 21;6(6):CD012700. doi:
acceptance and its impact on function and 10.1002/14651858.CD012700. PMID: 28636204;
symptoms in fibromyalgia. Scand J Pain. 2020 Oct PMCID: PMC6481524.
25;20(4):727-736. doi: 10.1515/sjpain-2020-0049. 33. Sosa-Reina MD, Nunez-Nagy S, Gallego-Izquierdo
PMID: 32759409. T, Pecos-Martín D, Monserrat J, Álvarez-Mon M.
24. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Effectiveness of Therapeutic Exercise in
Davies M, Hübscher M. Exercise for chronic Fibromyalgia Syndrome: A Systematic Review and
musculoskeletal pain: A biopsychosocial approach. Meta-Analysis of Randomized Clinical Trials.
Musculoskeletal Care. 2017 Dec;15(4):413-421. Biomed Res Int. 2017;2017:2356346. doi:
doi: 10.1002/msc.1191. Epub 2017 Mar 30. PMID: 10.1155/2017/2356346. Epub 2017 Sep 20. PMID:
28371175. 29291206; PMCID: PMC5632473.
25. Häuser W, Thieme K, Turk DC. Guidelines on the 34. Couto N, Monteiro D, Cid L, Bento T. Effect of
management of fibromyalgia syndrome - a different types of exercise in adult subjects with
systematic review. Eur J Pain. 2010 Jan;14(1):5-10. fibromyalgia: a systematic review and meta-
doi: 10.1016/j.ejpain.2009.01.006. Epub 2009 Mar analysis of randomised clinical trials. Sci Rep. 2022
4. PMID: 19264521. Jun 20;12(1):10391. doi: 10.1038/s41598-022-
26. Tzellos TG, Toulis KA, Goulis DG, Papazisis G, 14213-x. PMID: 35725780; PMCID:
Zampeli VA, Vakfari A, Kouvelas D. Gabapentin PMC9209512.
and pregabalin in the treatment of fibromyalgia: a 35. Methley AM, Campbell S, Chew-Graham C,
systematic review and a meta-analysis. J Clin McNally R, Cheraghi-Sohi S. PICO, PICOS and
Pharm Ther. 2010 Dec;35(6):639-56. doi: SPIDER: a comparison study of specificity and
10.1111/j.1365-2710.2009.01144.x. PMID: sensitivity in three search tools for qualitative
21054455. systematic reviews. BMC Health Serv Res. 2014
27. Arnold LM, Clauw DJ, Wohlreich MM, Wang F, Nov 21;14:579. doi: 10.1186/s12913-014-0579-0.
Ahl J, Gaynor PJ, Chappell AS. Efficacy of PMID: 25413154; PMCID: PMC4310146.
duloxetine in patients with fibromyalgia: pooled 36. Maher CG, Sherrington C, Herbert RD, Moseley
analysis of 4 placebo-controlled clinical trials. Prim AM, Elkins M. Reliability of the PEDro scale for
Care Companion J Clin Psychiatry. rating quality of randomized controlled trials. Phys
2009;11(5):237-44. doi: 10.4088/PCC.08m00680. Ther. 2003 Aug;83(8):713-21. PMID: 12882612.
PMID: 19956462; PMCID: PMC2781036. 37. Sevimli D, Kozanoglu E, Guzel R, Doganay A. The
28. Arnold LM. Duloxetine and other antidepressants in effects of aquatic, isometric strength-stretching and
the treatment of patients with fibromyalgia. Pain aerobic exercise on physical and psychological
Med. 2007 Sep;8 Suppl 2:S63-74. doi: parameters of female patients with fibromyalgia
10.1111/j.1526-4637.2006.00178.x. PMID: syndrome. J Phys Ther Sci. 2015 Jun;27(6):1781-6.
17714117. doi: 10.1589/jpts.27.1781. Epub 2015 Jun 30.
29. Chen J, Han B, Wu C. On the superiority of a PMID: 26180320; PMCID: PMC4499983.
combination of aerobic and resistance exercise for 38. Hooten MW, Qu W, Townsend CO, Judd JW.
fibromyalgia syndrome: A network meta-analysis. Effects of strength vs aerobic exercise on pain
Front Psychol. 2022 Sep 28;13:949256. doi: severity in adults with fibromyalgia: a randomized
10.3389/fpsyg.2022.949256. PMID: 36248603; equivalence trial. Pain. 2012 Apr;153(4):915-923.
PMCID: PMC9554347. doi: 10.1016/j.pain.2012.01.020. Epub 2012 Feb
30. Jones KD, Adams D, Winters-Stone K, Burckhardt 15. PMID: 22341565.
CS. A comprehensive review of 46 exercise 39. Mannerkorpi K, Nordeman L, Cider A, Jonsson G.
treatment studies in fibromyalgia (1988-2005). Does moderate-to-high intensity Nordic walking
Health Qual Life Outcomes. 2006 Sep 25;4:67. doi: improve functional capacity and pain in
fibromyalgia? A prospective randomized controlled

-7-
 Aerobic exercise for pain management in fibromyalgia
Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

trial. Arthritis Res Ther. 2010;12(5):R189. doi: 50. Bender T, Karagülle Z, Bálint GP, Gutenbrunner C,
10.1186/ar3159. Epub 2010 Oct 13. PMID: Bálint PV, Sukenik S. Hydrotherapy,
20942911; PMCID: PMC2991024. balneotherapy, and spa treatment in pain
40. Assis MR, Silva LE, Alves AM, Pessanha AP, management. Rheumatol Int. 2005 Apr;25(3):220-
Valim V, Feldman D, Neto TL, Natour J. A 4. doi: 10.1007/s00296-004-0487-4. Epub 2004 Jul
randomized controlled trial of deep water running: 15. PMID: 15257412.
clinical effectiveness of aquatic exercise to treat 51. Sedlock DA, Lee MG, Flynn MG, Park KS,
fibromyalgia. Arthritis Rheum. 2006 Feb Kamimori GH. Excess postexercise oxygen
15;55(1):57-65. doi: 10.1002/art.21693. PMID: consumption after aerobic exercise training. Int J
16463414. Sport Nutr Exerc Metab. 2010 Aug;20(4):336-49.
41. Valim V, Oliveira L, Suda A, Silva L, de Assis M, doi: 10.1123/ijsnem.20.4.336. PMID: 20739722.
Barros Neto T, Feldman D, Natour J. Aerobic 52. Imamura H, Shibuya S, Uchida K, Teshima K,
fitness effects in fibromyalgia. J Rheumatol. 2003 Masuda R, Miyamoto N. Effect of moderate
May;30(5):1060-9. PMID: 12734907. exercise on excess post-exercise oxygen
42. Schachter CL, Busch AJ, Peloso PM, Sheppard MS. consumption and catecholamines in young women.
Effects of short versus long bouts of aerobic J Sports Med Phys Fitness. 2004 Mar;44(1):23-9.
exercise in sedentary women with fibromyalgia: a PMID: 15181386.
randomized controlled trial. Phys Ther. 2003 53. Nørregaard J, Bülow PM, Lykkegaard JJ, Mehlsen
Apr;83(4):340-58. PMID: 12665405. J, Danneskiold-Samsøoe B. Muscle strength,
43. Richards SC, Scott DL. Prescribed exercise in working capacity and effort in patients with
people with fibromyalgia: parallel group fibromyalgia. Scand J Rehabil Med. 1997
randomised controlled trial. BMJ. 2002 Jul Jun;29(2):97-102. PMID: 9198259.
27;325(7357):185. doi: 10.1136/bmj.325.7357.185. 54. van Santen M, Bolwijn P, Landewé R, Verstappen
PMID: 12142304; PMCID: PMC117444. F, Bakker C, Hidding A, van Der Kemp D, Houben
44. Wigers SH, Stiles TC, Vogel PA. Effects of aerobic H, van der Linden S. High or low intensity aerobic
exercise versus stress management treatment in fitness training in fibromyalgia: does it matter? J
fibromyalgia. A 4.5 year prospective study. Scand J Rheumatol. 2002 Mar;29(3):582-7. PMID:
Rheumatol. 1996;25(2):77-86. doi: 11908577.
10.3109/03009749609069212. PMID: 8614771.
45. Hoffman MD, Shepanski MA, Ruble SB, Valic Z,
Disclaimer
Buckwalter JB, Clifford PS. Intensity and duration All claims expressed in this article are solely those of the
threshold for aerobic exercise-induced analgesia to authors and do not necessarily represent those of their
pressure pain. Arch Phys Med Rehabil. 2004 affiliated organizations, or those of the publisher, the
Jul;85(7):1183-7. doi: 10.1016/j.apmr.2003.09.010. editors and the reviewers. Any product that may be
PMID: 15241771. evaluated in this article or claim that may be made by its
46. Millan MJ. Descending control of pain. Prog manufacturer is not guaranteed or endorsed by the
Neurobiol. 2002 Apr;66(6):355-474. doi: publisher.
10.1016/s0301-0082(02)00009-6. PMID:
12034378. Submission: April 19, 2023
47. Van Oosterwijck J, Nijs J, Meeus M, Van Loo M, Revision received: June 05, 2023
Paul L. Lack of endogenous pain inhibition during Accepted for publication: June 05, 2023
exercise in people with chronic whiplash associated
disorders: an experimental study. J Pain. 2012
Mar;13(3):242-54. doi:
10.1016/j.jpain.2011.11.006. Epub 2012 Jan 24.
PMID: 22277322.
48. Meeus M, Roussel NA, Truijen S, Nijs J. Reduced
pressure pain thresholds in response to exercise in
chronic fatigue syndrome but not in chronic low
back pain: an experimental study. J Rehabil Med.
2010 Oct;42(9):884-90. doi: 10.2340/16501977-
0595. PMID: 20878051.
49. Lannersten L, Kosek E. Dysfunction of endogenous
pain inhibition during exercise with painful muscles
in patients with shoulder myalgia and fibromyalgia.
Pain. 2010 Oct;151(1):77-86. doi:
10.1016/j.pain.2010.06.021. PMID: 20621420.

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Supplementary Materials Table 1. Overview of the studies included in the systematic review.
Outcome
Authors Population Intervention Findings
measures for pain
de Medeiros et al.11 N=42 F EG: VAS; There was a statistically significant
(48,1 ± 10,2y) Aquatic aerobic exercise (n=21); SF-36 reduction in pain in EG and CG (p <
12 weeks, twice a week, each session lasted 40 min 0.05). The measurements showed no
statistically significant differences
CG: between the groups (p > 0.05).
Mat pilates (n=21);
12 weeks, twice a week; each session lasted 40 min

Sevimli et al.37 N=75 F EG: VAS There was a statistically significant

(35 ± 8,8y) Group 1: Gymnastic-based aerobic exercise program reduction in pain in EG (p < 0.001)
(n=25); compared to CG (p > 0.05). No
3 months, twice a week, each session lasted 40-50 min statistically significant difference was
found between EG (p > 0.05).
Group 2: Pool-based aquatic aerobic exercise program
(n=25);
3 months, twice a week, each session lasted 40-50 min

CG:
Home-based isometric strength and stretching exercise
program (n=25);
3 months, once a day, each session lasted 15 min

Hooten et al.38 N=72 (65 F, 7 M) EG: MPI; There was a statistically significant
(46,6 ± 10,8y) Aerobic exercise – stationary bicycle (n=36); Pain pressure reduction in pain and increase in pain
3 weeks, 10 min daily during week 1; 15 min daily during threshold pressure threshold in EG and CG (p <
week 2; 20-30 min daily during week 3 0.01). There were no statistically
significant differences between between
CG: the groups (p > 0.05).
Strengthening exercise (n=36);
3 weeks, once a day, each session lasted 25-30 min

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Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

Mannerkorpi et al.39 N=67 F EG: FIQ Pain No statistically significant reduction in

(49 ± 7,7y) Moderate-to-high intensity Nordic walking (n=34); pain was found in EG and CG (p > 0.05).
15 weeks, twice a week, each session lasted 40-45 min

CG:
Low-intensity walking (n=33);
15 weeks, once a week, each session lasted 40-45 min

Assis et al.40 N=52 F EG: VAS There was a statistically significant

(40 ± 9,6y) Deep water running (n=26); reduction in pain in EG and CG (p <
15 weeks, 3 times a week, each session lasted 60 min 0.01). There were no statistically
significant differences between the
CG: groups (p > 0.05).
Land-based exercises (walking or jogging) (n=26);
15 weeks, 3 times a week, each session lasted 60 min

Valim et al.41 N=60 F EG: VAS; Number of The reduction of pain, number of tender
(45,5 ± 10,5y) Aerobic exercise – walking (n=32); tender points; points and pain during palpation of the
20 weeks, 3 times a week, each session lasted 45 min Pain score during tender point was statistically significant
palpation of the in EG (p < 0.05). There was a
CS: tender point statistically significant difference
Stretching exercise (n=28); SF-36 between the groups (p < 0.05).
20 weeks, 3 times a week, each session lasted 45 min

Schachter et al.42 N=143 F EG: VAS; There was no statistically significant

(41,9 ± 7,97y) Progressive low-impact aerobic program; Pain distribution; reduction in pain, number of painful
16 weeks, progressed from 3 to 5 times a week and 10 to Pain pressure regions and increase in pain pressure
30 min threshold threshold in EG (p > 0.05). In the CG,
Group 1: Long bouts of exercise – once daily (n=56) pain was statistically significantly
Group 2: Short bouts of exercise – twice daily (n=51) reduced (p > 0.05). There were no
statistically significant differences
CG: between EG and CG (p > 0.05).
No exercise (n=36)

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Eur J Transl Myol 33 (3) 11423, 2023 doi: 10.4081/ejtm.2023.11423

Richards and Scott43 N=136 (126 F, 10 EG: Number of tender There was a statistically significant
M) (46,5y) Aerobic exercise – walking on a treadmill or stationary points; reduction in pain (p < 0.05) and number
bicycle (n=69); MPQ of tender points (p < 0.001) in the EG
12 weeks, twice a week, each session lasted 60 min and CG at three months. The reduction
in number of tender points persisted for
CG: 12 months (p < 0.001), though by then
Relaxation techniques and stretching exercise (n=67); the difference between the two groups
12 weeks, twice a week, each session lasted 60 min was greater and favoured the exercise
group (p < 0.05)

Wigers et al.44 N=60 (55 F, 5 M) EG: VAS; Pain In EG, there was a statistically
(44y) Aerobic exercise (n=20); distribution; significant reduction in pain (p < 0.05),
14 weeks, 3 times a week, each session lasted 45 min Pain pressure number of painful regions (0 < 0.01) and
threshold increase in pain pressure threshold (p <
CG: 0.001). Results also showed a
Group 1: Stress management treatment (n=20); statistically significant reduction in pain
6 weeks – 2 times a week, 8 weeks – once a week, each (p < 0.05), number of painful regions (p
session lasted 90 min < 0.05) and increase in pain pressure
threshold (p < 0.01) in CG.
Group 2: Treatment-as-usual (n=20);
Aquatic therapy, psychomotor treatment, tricyclic
antidepressants, analgesics, muscle relaxants, hypnotics,
tranquilizers
Legend: CG = control group; EG = experimental group; F = female; FIQ = Fibromyalgia Impact Questionaire); M = male; MPI = Multidimensional Pain Inventory; MPQ
= McGill Pain Questionnaire); n = number of participants; SF-36 = Short Form-36 Health Survey; VAS = Visual analogue scale.

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