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Clin Rheumatol (2007) 26:1843–1849DOI 10.1007/s10067-007-0587-0 Exercise-based motivational interviewing for female patientswith fibromyalgia: a case series Dennis Ang & Ramesh Kesavalu & Jennifer R. Lydon &Kathleen A. Lane & Silvia Bigatti Received: 6 December 2006 / Revised: 31 January 2007 / Accepted: 1 February 2007 / Published online: 20 February 2007 Abstract The objective of the study is to determine the improvement in both FIQ-pain (−2.6±2.6, p<0.001) and effects of motivational interviewing (MI), a novel technique FIQ-physical impairment (−1.3±2.1, p=0.01). Likewise, of behavioral counseling to promote exercise, on pain and BPI-pain severity and pain interference were reduced by physical function in patients with fibromyalgia (FMS).
−2.4±2.1 (p<0.001) and −2.4±2.0 (p<0.001), respectively.
Patients who met the American College of Rheumatology While the median NEM per week increased from 0 to criteria for FMS and had a visual analog pain score of ≥6 32 min (p=0.001) at week 30, AIMS-depression score was were enrolled in a single group intervention pilot study.
unchanged. In this pilot study, we conclude that telephone- Participants received two supervised exercise sessions and delivered MI to promote exercise was associated with an an exercise prescription. Thereafter, six exercise-based MI improvement in patient’s level of pain and physical phone calls were made over a 10-week period. Assessments were done at baseline, week 12 (immediate postinterven-tion) and week 30 (follow-up). The primary endpoints were Keywords Adherence . Exercise . Fibromyalgia .
changes from baseline in the fibromyalgia impact question- Motivational interviewing . Pain and physical function naire (FIQ)-pain and physical impairment at week 30.
Secondary measures were brief pain inventory (BPI)-painseverity and BPI-pain interference, the number of exercise minutes (NEM) per week, and the arthritis impact mea-surement scale (AIMS)-depression. The 19 enrolled female Fibromyalgia (FMS) is a poorly understood somatic participants had a mean age of 52.2±9.1 years, mean syndrome, consisting mainly of chronic widespread pain disease duration of 7.5±5.0 years, and a mean FIQ-pain (CWP) and tenderness. The impact of FMS and CWP is far score of 7.7±1.4. By week 30, there was significant reaching, affecting society as a whole in terms of economicconsequences and lost work productivity and FMS patientsindividually, in terms of symptom burden, decreased physical functioning, and perhaps even increased mortality Division of Rheumatology, Department of Medicine, Currently, there are no medical therapies that have been approved by the US Food and Drug Administration 1110 West Michigan St. Room 545,Indianapolis, IN 46202, USA for FMS. Nonetheless, a current evidence from two recent systematic reviews and one meta-analysis supports theefficacy of supervised aerobic exercise in reducing the Department of Psychology, Indiana University, shown to improve pain, aerobic capacity, function, andwell-being ].
Fundamental to the efficacy of exercise is the require- Division of Biostatistics, Department of Medicine, ment that adherence be maintained. Unfortunately, adher- ence to an exercise regimen after a structured supervised program is disappointingly low –Individuals who consistently exercise are most likely to experiencebenefits, both with respect to improvement in symptoms After providing written informed consent, qualified partic- ipants entered a 30-week study protocol that included two simple educational component to an exercise intervention phases: active intervention (weeks 1 to 12) and follow-up does not appear to result in higher compliance with training (weeks 12 to 30). All the subjects were given two education sessions either , As adherence to exercise is difficult classes for 30 min each at weeks 1 and 2. The classes were to achieve, behavioral intervention to promote exercise taught in small groups of three to four subjects. The first class included information on FMS and the importance of Miller et al. , ] have developed an approach to exercise. During this visit, subjects were also given a clinician–client interactions that focuses on enhancing handwritten individualized exercise prescription for the client’s motivation to change. This approach, called next 30 weeks and a heart rate monitor. The second class motivational interviewing (MI), was initially developed to was devoted to barriers to exercise adherence. Both classes help problem drinkers cut down on, or abstain from, were taught by a rheumatology fellow (RK). At the end of drinking alcohol. Within the principle of MI, motivation each lecture, participants received a 15-min supervised to change is viewed as something which is evoked in the exercise session with a fitness instructor (MR). The fitness patient, rather than imposed [MI is a directive, client- instructor had no prior experience in working with FMS centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence ].
During the first visit, the participant, in consultation with The use of MI to encourage exercise is relatively new the fitness instructor, decided on the duration and type of ]. A recent meta-analysis showed medium effect sizes aerobic exercise activity (e.g., brisk walking, jogging, (0.53) of MI for increased physical activity in the general running, etc.). The initial exercise duration was between 5 medical patient population , MI has also been to 10 min, at an intensity of 60% of the age predicted effective in increasing exercise among diabetic patients and maximum heart rate (maxHR). Subjects were to increase patients with chronic heart failure ]. Because the exercise duration by 1–2 min each week to a maximum exercise adherence is a critical factor to maintain improve- of 30 min. At every 4-week period, the exercise intensity ments in FMS [, , ], we hypothesized that a increased by 5% to attain a maximum of 70% of age telephone-delivered counseling, using MI technique to predicted maxHR [To help participants avoid over- or encourage home-based exercise, would improve exercise underdoing the prescribed exercise regimen, they were adherence and symptoms of FMS. In this quasi-experimen- encouraged to wear the heart rate monitor every time they tal pilot study, we used a prepost design to determine the exercised. They were also advised to exercise on their own effect of exercise-based MI on patients’ self-reported pain three times a week. Previous exercise trials in FMS utilized the same frequency of exercise per week , ].
No attempt was made to try to control drug therapy or routine physician visits during the study.
From weeks 3 to 12, subjects received six sessions of Participants were recruited by referral from two rheumatol- telephone-delivered counseling, each session averaging ogy group practices (one university-based and one com- 25 min. The MI interviewer (JL) was a third year doctoral munity-based). To be included, a patient had to fulfill the student in clinical psychology. Before the intervention, the American College of Rheumatology criteria [for the interviewer was trained in MI within a classroom environ- diagnosis of FMS, with a visual analog pain score of ≥6 in ment and received further training through videotapes and the past 1 week, and be on stable doses of FMS textbooks. During the intervention, the interviewer partici- medications for at least 4 weeks. Subjects were excluded pated in weekly supervision sessions with a clinical if they (1) had been diagnosed with symptomatic cardiac or psychologist. Supervision entailed a number of different pulmonary disease; (2) had a severe degree of depression as activities related to fidelity of treatment and included the defined by the patient health questionnaire nine-item following: each participant’s progress was discussed, the use depression scale (PHQ-9)>15 [, or (3) had been of techniques was evaluated, audiotapes were used to doing at least moderately intense level of exercise (e.g., critique MI components, and role-play was used to practice running, biking, jogging, brisk walking, etc.) for at least MI interviewing for specific situations. An important focus three times a week in the past 6 months.
of these supervision sessions was a discussion of differences between the MI interviewing technique and other frequently and enjoyment of life , Multiple measures of pain used techniques, such as cognitive behavioral techniques.
were included because there is no current consensus about The MI technique for chronic pain by Jensen ] was adapted to promote exercise adherence. Table outlines the Another secondary measure was the arthritis impact measurement scale (AIMS)-depression, a 6-item measure ofpsychological distress In two previous FMS studies, AIM-depression was shown to be sensitive tochange [An AIMS-depression score of ≥4 is The fibromyalgia impact questionnaire (FIQ) instrument is indicative of clinical depression ].
a reliable, validated self-assessment measure widely used in For exercise adherence, participants were asked to state clinical trials for FMS [. The physical impairment how many days per week, and how many minutes per day, subscale (FIQ–PI) consists of 11 items that inquire about they engaged in any moderate or vigorous type of exercise the subject’s ability to do 11 different types of physical in the past 7 days. For this study, exercise was defined as a activity, with each item rated on a four-point Likert-type planned, structured, and repetitive bodily movement done scale. The scores for the items that the patient has rated are to improve or maintain one or more components of physical summed and divided by the number of items rated. The fitness ]. The number of days and the number of minutes average score is then normalized to yield a score range were multiplied to generate the number of exercise minutes between 0 and 10, where a higher score indicates a negative impact. As a coprimary outcome measure, the FIQ-pain All patients completed the self-administered question- asks about the subject’s level of pain over the prior week, naires, either online or via mail, at baseline (or week 1), with a score range of 0 (no pain) to 10 (very severe pain).
week 12 (immediate post intervention) and week 30(follow-up). The study was approved by the Indiana University Institutional Review Board (IU-IRB), and allthe subjects gave informed consent according to the The subjects also completed the brief pain inventory (short form), which measured pain severity during the past 24 h[from 0 (no pain) to 10 (pain as bad as you can imagine)] and interference [from 0 (does not interfere) to 10(completely interferes)] with general activity, mood, walk- Descriptive statistics were calculated for all continuous ing ability, normal work, relations with other people, sleep, primary and secondary outcome variables. For each Table 1 Components of motivational interviewing intervention Elicit self-motivational statements that support the following: The patient’s recognition of the full nature and extent of the problemThe patient’s concern about how he or she is currently managing the problemThe patient’s intention of changing in the direction of adaptive The patient’s optimism that change is possible Help the patient develop a plan for change (i.e., shift from why the patient should consider change to how the patient will make changes) Communicating free choicesReviewing consequences of exercise vs inactivityUsing a change plan worksheetAsking for a commitment Any and all approximations of progress should be praised and reinforced as much as possible Review behavioral indicators of motivation, as well as the patient’s responses to questions concerning reasons for making or maintaining changes Refine the change plan worksheet (if needed) and obtain a commitment outcome measure for each subject, we computed the change baseline, the mean FIQ-pain score was 7.7±1.4, and the from baseline (week 1) to week 12 (immediate post- mean AIMS-depression score was 5.8±2.8. With a median intervention) measurements and the change from baseline NEM per week of 0 (interquartile range or IQR: 0 min), the to week 30 (follow-up). Paired t tests were used to compare study cohort was relatively inactive.
the primary and secondary outcome variables at baselinewith both follow-up assessments.The nonparametric Wilcoxon Signed Rank test was used when thenormality assumption for the paired t test was not met.
As compared to baseline, FIQ–PI and pain scores improved Pearson correlation coefficients were used to assess the significantly at both weeks 12 and 30 (Table Further, linear relationship between the change in FIQ (-physical BPI-pain intensity and BPI-pain interference paralleled the impairment and -pain) and the change in the NEM per improvement seen in the FIQ scores at both time points (Fig. ). Simultaneously, the median NEM per weekincreased from 0 to 16 min (IQR, 90 min) at week 12 (p=0.004), and to 32 min (IQR: 39 min) at week 30 (p=0.001).
Additionally, the proportion of participants who reporteddoing ≥30 min of exercise per week increased from 15% at baseline to 52% at week 30 (p=0.01). During the 30-weekstudy period, there was a statistically significant correlation Of the 70 patients referred to the study, 21 (30%) enrolled between the change from baseline in the NEM per week in our pilot project. The remaining 49 patients were and the score change in FIQ–PI (r=−0.57, p=0.01), but not excluded because of a pain score of <6 (n=20), lack of with the change in FIQ-pain (r=0.20, p=0.4). The mean interest in the study (n = 13), symptomatic cardiac or AIMS-depression score, which suggested clinical depres- pulmonary disease (n=5), severe depression (n=9), or sion for this sample as a whole, was relatively unchanged already engaged in a regular exercise program (n=2). Of the 21 patients who entered the study, 2 (10%) were lost to Due to difficulty in time scheduling, six (31.5%) partic- follow-up and did not complete the posttreatment ques- ipants completed ≤4 telephone-delivered MI sessions. How- tionnaires. There were no differences in the baseline ever, the majority (13 or 68%) finished 5 or 6 phone calls. As characteristics of those who were lost to follow-up from compared to participants who had ≤4 phone calls, participants those who completed the study (data not shown).
who completed 5 or 6 sessions reported greater reduction (orimprovement) in the FIQ–PI[−1.7±1.9 vs −0.3±2.3, p=0.14] and higher NEM per week [median 36 min vs 1.5 min, p=0.05] at week 30. For FIQ-pain, there was no difference The 19 completers were all women, had a mean age of 52.2± 9.1 years, mean disease duration of 7.5±5.0 years; 67% were During the study, five (26%) subjects started a new white, 83% had at least a high school education, and 50% FMS-related medication (e.g., SSRI, SNRI, tricyclic anti- were employed. At study entry, 12 (63%) were on opioid depressant, anticonvulsant, and muscle relaxant). We noted analgesics and 9 (47%) were taking either a selective no statistically significant differences in the means scores serotonin reuptake inhibitor (SSRI) or a dual serotonin- for FIQ and BPI between subjects who had a change in norepinephrine reuptake inhibitor (SNRI) antidepressant. At their medications versus those who reported no change Table 2 Mean reduction in the scores of outcome variables at weeks 12 and 30 ns non-significant, FIQ fibromyalgia impact questionnaire, BPI brief pain inventory, AIMS arthritis impact measurement scalea Scored from 0 (best health) to 10 (worst health)*p≤0.01**p<0.001 of comorbidity (≥50%) with depression which mayfurther decrease exercise adherence. Thus, this preliminaryevidence that MI can enhance exercise adherence andimprove symptoms and functioning in a FMS populationwith chronic pain and high rates of depression is noteworthy.
In contrast to delivering simple advice, a counselor trained in MI directs patients to examine the pros and consof participating in regular exercise, and guides them towardresolving any conflicts related to initiating and/or main-taining exercise. Because the patient does most of thetalking, MI is patient-centered in that the patient (not thecounselor) initiates change and takes responsibility for thatchange. These key components of MI may explain its Fig. 1 Changes of outcome measures from baseline to week 30. The success in exercise intervention research.
Y-axis on the left-hand side represents the changes in the scores for Our findings should be taken in the context of several FIQ-physical impairment, FIQ-pain, BPI-pain intensity and BPI-interference of pain. Notably, all four scales have identical score limitations. The first major limitation was the absence of a ranges (i.e., 0 to 10). The Y-axis on the right-hand side corresponds to control group. The observed benefits from MI may be the increase in the number of exercise minutes per week from baseline explained by regression to the mean or nonspecific effects of providing attention. Obviously, only a randomizedcontrolled trial (RCT) would clarify whether MI has (data not shown). None of the 19 subjects had seen a beneficial effects, independent of attention, on patient’s physical therapist during the 30-week study period.
symptoms. Despite the limitation (i.e., lack of controlgroup), however, there maybe several reasons to believe MI may have had a specific effect. First, other FMStreatment studies have not shown a placebo effect of a In this 30-week uncontrolled pilot study, telephone-deliv- magnitude that would readily explain our results [ ered exercise-based MI was associated with improvement ]. Second, if the benefits were solely from attention, in self-reported pain severity and physical impairment in improvement in patient’s mood may have been noted, patients with FMS. Concurrently, an increase in exercise which was not observed in our study. Third, in the absence adherence, as measured by self-report NEM, was noted of further contacts during the follow-up period, patient during the study period. Although participants did not reach reported sustained (or even larger degrees) improvement at the recommended NEM per week (i.e., at least 90 min per week) at week 30, the observed increased NEM per week The self-report nature of our outcome measures was correlated with improved physical function. Interestingly, another limitation. The use of an objective measure like a the beneficial effects of MI on patient’s symptoms were 6-min walk test or aerobic fitness testing or a real-time observed despite a lack of improvement in patient’s level of heart rate recording was beyond the scope of this pilot project. However, in a previous exercise trial, Mannerkorpi In the past 17 years, the FMS exercise literature has et al. , found the FIQ–PI to be correlated with largely focused on the ‘specifics’ of the exercise prescrip- improvement in the 6-min walk test. Moreover, pain and tion (i.e., intensity of exercise, pool vs land-based exercise, functional impairment are the main features of FMS; etc.) associated with symptom improvement [, , therefore, patient-reported outcomes remain the principal However, adherence to exercise remains problematic.
criteria for assessing treatment effectiveness.
The graduation from a supervised to an unsupervised In general, research participants are usually more environment is usually associated with loss of effectiveness motivated compared to nonresearch FMS patients. If because of poor exercise adherence , –].
baseline level of motivation (i.e., how willing and commit- Although exercise-based MI has been used with success ted the participants were) was associated with improvement among patients in various clinical setting the in patient’s symptoms, selection bias may have influenced technique has not been formally tested and reported for the study outcome. Unfortunately, baseline measure of patients with chronic pain. Unlike other clinic populations, motivation was not collected; thus, we could not assess the chronic pain patients are fearful that exercise might trigger relationship of baseline motivation on patient-oriented their existing pain or result in a new injury or pain site, outcome measures. Nonetheless, it was reassuring to note which can then serve as a barrier to pursue a consistent that only 18.5% (13 out of 70 referred subjects) refused to exercise program. Furthermore, chronic pain has a high rate participate owing to lack of interest.
Despite the above limitations, in the ‘real’ world clinic 10. Rossy LA, Buckelew SP, Dorr N et al (1999) A meta-analysis of setting, exercise-based MI may have potential benefits over fibromyalgia treatment interventions. Ann Behav Med 21:180–191 and beyond a simple advice from the treating clinician to 11. Wigers SH, Stiles TC, Vogel PA (1996) Effects of aerobic exercise exercise. Notably, all the enrolled participants in our study versus stress management treatment in fibromyalgia. A 4.5 year had previously received instruction from their private prospective study. Scand J Rheumatol 25:77–86 rheumatologists to exercise. Despite such an advice, the 12. Redondo JR, Justo CM, Moraleda FV et al (2004) Long-term efficacy of therapy in patients with fibromyalgia: a physical study cohort was barely exercising at study entry. In exercise-based program and a cognitive-behavioral approach.
addition, the telephone-administration of MI may also be more doable and more flexible for patients whose schedules 13. Gowans SE, Dehueck A, Voss S, Richardson M (1999) A do not permit attending in-person counseling and/or randomized, controlled trial of exercise and education forindividuals with fibromyalgia. Arthritis Care Res 12:120–128 14. Gowans SE, Dehueck A, Voss S, Silaj A, Abbey SE (2004) Six- In conclusion, telephone-delivered MI counseling to month and one-year follow-up of 23 weeks of aerobic exercise for promote home-based exercise was associated with symp- individuals with fibromyalgia. Arthritis Rheum 51:890–898 tom improvement for FMS patients. Because of the 15. Bennett RM, Burckhardt CS, Clark SR, O’Reilly CA, Wiens AN, Campbell SM (1996) Group treatment of fibromyalgia: a 6 month uncontrolled nature of the study, we could not implicate a outpatient program. J Rheumatol 23:521–528 cause and effect relationship. Therefore, an RCT is 16. Ramsay C, Moreland J, Ho M, Joyce S, Walker S, Pullar T (2000) indicated to determine its efficacy in FMS. Given the An observer-blinded comparison of supervised and unsupervised prevalence of FMS and CWP in the general population and aerobic exercise regimens in fibromyalgia. Rheumatology(Oxford) 39:501–505 the associated disability, effective means to promote 17. Nielson WR, Jensen MP (2004) Relationship between changes in sustained exercise could have large individual and societal coping and treatment outcome in patients with fibromyalgia 18. Wigers SH (1996) Fibromyalgia outcome: the predictive values of symptom duration, physical activity, disability pension, andcritical life events—a 4.5 year prospective study. J Psychosom This work was supported by a grant from the General Clinical Research Center of Indiana University School of 19. King SJ, Wessel J, Bhambhani Y, Sholter D, Maksymowych W Medicine. The authors wish to thank Melanie Roberts, MS, for (2002) The effects of exercise and education, individually or combined, in women with fibromyalgia. J Rheumatol 29:2620–2627 20. van Santen M, Bolwijn P, Verstappen F et al (2002) A randomized clinical trial comparing fitness and biofeedback training versus basic treatment in patients with fibromyalgia. J Rheumatol29:575–581 1. Van HB, Neerinckx E, Onghena P, Vingerhoets A, Lysens R, 21. Miller WR, Rollnick S (1991) Motivational interviewing: prepar- Vertommen H (2002) Daily hassles reported by chronic fatigue ing people to change addictive behavior. Guilford, New York syndrome and fibromyalgia patients in tertiary care: a controlled 22. Miller WR, Yahne CE, Moyers TB, Martinez J, Pirritano M quantitative and qualitative study. Psychother Psychosom 71:207– (2004) A randomized trial of methods to help clinicians learn motivational interviewing. J Consult Clin Psychol 72:1050–1062 2. Robinson RL, Birnbaum HG, Morley MA, Sisitsky T, Greenberg 23. Jensen M (2002) Enhancing motivation to change in pain PE, Claxton AJ (2003) Economic cost and epidemiological treatment. In: Turk DC, Gatchel RJ (eds) Psychological treatment characteristics of patients with fibromyalgia claims. J Rheumatol for pain: a practitioner’s handbook. Guilford Publications, New 3. Burckhardt CS, Clark SR, Bennett RM (1993) Fibromyalgia and 24. Rollnick S, Miller W (1995) What is motivational interviewing? quality of life: a comparative analysis. J Rheumatol 20:475–479 4. Dryer L, Kendall SA, Falk W et al (2004) Increased suicide, liver 25. Jones KD, Burckhardt CS, Bennett JA (2004) Motivational disease and cerebrovascular disease mortality in a cohort of interviewing may encourage exercise in persons with fibromyalgia Danish patients with fibromyalgia followed for 16 years. Europe- by enhancing self efficacy. Arthritis Rheum 51:864–867 an League against Rheumatism Annual Conference 26. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D 5. Macfarlane GJ, McBeth J, Silman AJ (2001) Widespread body (1999) The Newcastle exercise project: a randomised controlled pain and mortality: prospective population based study. BMJ trial of methods to promote physical activity in primary care. BMJ 6. Wolfe F, Anderson J, Harkness D et al (1997) Work and disability 27. Burke BL, Arkowitz H, Menchola M (2003) The efficacy of status of persons with fibromyalgia. J Rheumatol 24:1171–1178 motivational interviewing: a meta-analysis of controlled clinical 7. Wolfe F, Anderson J, Harkness D et al (1997) A prospective, trials. J Consult Clin Psychol 71:843–861 longitudinal, multicenter study of service utilization and costs in 28. Smith DE, Heckemeyer CM, Kratt PP, Mason DA (1997) fibromyalgia. Arthritis Rheum 40:1560–1570 Motivational interviewing to improve adherence to a behavioral 8. Busch A, Schachter CL, Peloso PM, Bombardier C (2002) weight-control program for older obese women with NIDDM. A Exercise for treating fibromyalgia syndrome. Cochrane Database 29. Brodie DA, Inoue A (2005) Motivational interviewing to promote 9. Goldenberg DL, Burckhardt C, Crofford L (2004) Management of physical activity for people with chronic heart failure. J Adv Nurs fibromyalgia syndrome. JAMA 292:2388–2395 30. Lemstra M, Olszynski WP (2005) The effectiveness of multidis- 43. Meenan RF, Gertman PM, Mason JH, Dunaif R (1982) The ciplinary rehabilitation in the treatment of fibromyalgia: a arthritis impact measurement scales. Further investigations of a randomized controlled trial. Clin J Pain 21:166–174 health status measure. Arthritis Rheum 25:1048–1053 31. Oliver K, Cronan T (2002) Predictors of exercise behaviors 44. Meenan RF, Gertman PM, Mason JH (1980) Measuring health among fibromyalgia patients. Prev Med 35:383–389 status in arthritis. The arthritis impact measurement scales.
32. Wolfe F, Smythe HA, Yunus MB et al (1990) The American College of Rheumatology 1990 criteria for the classification of 45. Poyhia R, Da CD, Fitzcharles MA (2001) Pain and pain relief in fibromyalgia. Report of the Multicenter Criteria Committee.
fibromyalgia patients followed for three years. Arthritis Rheum 33. Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: validity 46. Bakker C, Rutten M, van Santen-Hoeufft M et al (1995) Patient of a brief depression severity measure. J Gen Intern Med 16:606– utilities in fibromyalgia and the association with other outcome 34. Kroenke K, Spitzer RL (2002) The PHQ-9: a new depression 47. Hawley DJ, Wolfe F (1993) Depression is not more common in diagnostic and severity measure. Psychiatr Ann 32:1–7 rheumatoid arthritis: a 10-year longitudinal study of 6,153 patients 35. Fulcher KY, White PD (1997) Randomised controlled trial of with rheumatic disease. J Rheumatol 20:2025–2031 graded exercise in patients with the chronic fatigue syndrome.
48. US Department of Health and Human Services (1996) Physical activity and health: a report of the Surgeon General. Atlanta, 36. Gowans SE, Dehueck A, Voss S, Silaj A, Abbey SE, Reynolds Centers for Disease Control and Prevention National Center for WJ (2001) Effect of a randomized, controlled trial of exercise on Chronic Disease Prevention and Health Promotion mood and physical function in individuals with fibromyalgia.
49. Buckelew SP, Conway R, Parker J et al (1998) Biofeedback/ relaxation training and exercise interventions for fibromyalgia: 37. Meiworm L, Jakob E, Walker UA, Peter HH, Keul J (2000) a prospective trial. Arthritis Care Res 11:196–209 Patients with fibromyalgia benefit from aerobic endurance 50. Bair MJ, Robinson RL, Katon W, Kroenke K (2003) Depression and pain comorbidity: a literature review. Arch Intern Med 38. Norregaard J, Lykkegaard JJ, Mehlsen J, Danneskiold S (1997) Exercise training in treatment of fibromyalgia. J Musculoskeletal 51. Arnold LM, Rosen A, Pritchett YL et al (2005) A randomized, double-blind, placebo-controlled trial of duloxetine in the treat- 39. Rooks DS, Silverman CB, Kantrowitz FG (2002) The effects of ment of women with fibromyalgia with or without major progressive strength training and aerobic exercise on muscle strength and cardiovascular fitness in women with fibromyalgia: a 52. Arnold LM, Hess EV, Hudson JI, Welge JA, Berno SE, Keck PE Jr (2002) A randomized, placebo-controlled, double-blind, flexi- 40. Burckhardt CS, Clark SR, Bennett RM (1991) The fibromyalgia ble-dose study of fluoxetine in the treatment of women with impact questionnaire: development and validation. J Rheumatol 53. Mannerkorpi K, Nyberg B, Ahlmen M, Ekdahl C (2000) Pool 41. Arnold LM, Lu Y, Crofford LJ et al (2004) A double-blind, exercise combined with an education program for patients with multicenter trial comparing duloxetine with placebo in the fibromyalgia syndrome. A prospective, randomized study.
treatment of fibromyalgia patients with or without major depres- sive disorder. Arthritis Rheum 50:2974–2984 54. Mannerkorpi K, Ahlmen M, Ekdahl C (2002) Six- and 24-month 42. Tan G, Jensen MP, Thornby JI, Shanti BF (2004) Validation of the follow-up of pool exercise therapy and education for patients with brief pain inventory for chronic nonmalignant pain. J Pain 5:133–137 fibromyalgia. Scand J Rheumatol 31:306–310

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