Fitness with Fibromyalgia

Becoming physically fit is essential to maximizing your successful management of fibromyalgia (FM). You probably already realize this but, like many, do not know how to achieve fitness. Chances are you have had well-meaning health care providers tell you to just go out and exercise. Often this has left you feeling much worse. While exercise is critical for FM patients, it must be done correctly. For most of you, this means modification of your old exercise habits. Oregon Health Sciences University has found that those patients who exercise on a regular basis have been able to decrease their pain and increase their endurance.

A proper fitness program must include a comprehensive stretching program and an endurance (aerobic) program. Before starting with these, you need a few facts. The first thing is to become aware of how you are using your muscles. When you use a muscle, it contracts. Contracting and shortening a muscle will usually be well tolerated, but contracting and lengthening a muscle at the same time, called eccentric contraction, will increase your chances of muscle soreness. This soreness does not occur right away but rather is soreness that you will feel one to five days after the activity. Consequently, you must become aware of eccentric work and learn to minimize it. Examples of eccentric work include:

• Doing overhead motions such as drying your hair, putting things into cupboards;
• Vacuuming, mopping, making beds;
• Gardening with flower or vegetable beds far in front of you;
• Putting dishes into a dishwasher; and
• Walking down steps or down hill.

If these types of activities cause you to feel increased pain or have a flare of your FM, then eccentric work is a problem for you. While you cannot totally eliminate this type of work, you need to become aware of the activities you perform that are eccentric in nature and limit the number of minutes you continue them. The 20-minute rule should apply here: Change the type of activity, or at least stretch those working muscles, after 20 minutes of any activity.

I cannot overemphasize the importance of following a regular stretching program. This will help to improve your ability to move your muscles (such as looking over your shoulder) and will help to decrease your pain. Stretching must be done daily - or even more than once a day. It is important that you do not stretch too far as this will cause a reflex contraction and increase your pain. Your eventual goal will be able to hold a stretch for one full minute; however, do not start at one minute if stretching is new to you. It is better to start at 10 or 15 seconds. Keep working up to the full minute, as you will get more benefit.

After you are doing an exercise program, start to increase your daily activity. Your goal here is to build up to 30 minutes a day. This can be done in three 10-minute sessions, two 15-minute sessions, or one 30-minute session. Walking is a good way to do this, although there are several activities you can do. It is best to choose one or several that you really like. The important thing is to start low and build up gradually; this will help prevent a flare caused by activity that is too intense for your current level of fitness.
You will increase your chances of becoming physically fit if you start to keep a record of your activity. Once each week, write your exercise goals for the week. Each time you increase your activity (such as walking up one flight of stairs instead of taking the elevator), note it on your activity chart. Your activity should be a level that gives you a slight sense of exertion.

Also very important is to avoid the pitfall of trying to make up for lost time on days you feel good.

Tips for Staying Active

1. Set your sights on starting small and make incremental increases each week.
2. Note the time that you are most likely to feel your best and increase your activity during this time. If 2:00 p.m. is a good time for you, walk 10-15 minutes each day at 2:00 p.m.
3. Discuss your program with family and friends and enlist their support.
4. Keep track of each day that you exercise and note how many minutes you have increased your activity.

Exercise

Beginning a new exercise program may be difficult initially.  New routines must be established and new priorities set. After a few days of regular exercise you will begin to notice some positive changes:

1. More confidence and independence
2. Sense of well being and vigor
3. May find it easier to maintain or reduce weight
4. Decreasing stiffness, soreness or discomfort
5. May note a decrease in your resting heart rate

Aerobic Conditioning

The type of exercise should be a low-impact aerobic program, such as walking, bicycling, water aerobics, or swimming. These minimize the risk for undue joint trauma.

Cross training can enhance participation by reducing the monotony of an exercise program. Therapeutic pools heated to 86 degrees Fahrenheit or higher are helpful in promoting relaxation and ease of movement.

These are four factors to be considered in an aerobics program:

• Frequency: Generally recommended to be three to four times per week on non-consecutive days. When first beginning a program, you may need to exercise more frequently (5-7 days/week) at a lower intensity to build up strength and endurance. As the duration of each exercise session increases, the frequency can be decreased.
• Duration: Twenty minutes at the training heart rate zone to receive maximum cardiovascular benefit. (Can range from 15-60 minutes; 20-30 minutes for most people).
• Intensity: Determined best by monitoring heart rate during exercise. It is monitored by the "Target Heart Rate" (THR). Recommended to be between 60-75% of maximum Target Heart Rate.
• Mode: Type of exercise. The ideal exercise for you is one that you will enjoy and that is convenient. The exercise should be low impact, continuous and rhythmical in nature.

To determine “Target Heart Rate”, use one of the following formulas.  The first formula is better suited for those who are not regular exercisers and/or are over 35 years of age.  It offers a more conservative THR zone.  The second formula is best suited for those who are under age 35 and are regular exercisers.  It takes into account the current level of fitness, which involves one’s heart rate.

Regular Method - Target Heart Rate:

Karvonen Method - Target Heart Rate:

How to Take Your Pulse
The best way to take your pulse is to find it on the radial artery at your wrist. Place your index and middle fingers side by side on your wrist, just below the base of the thumb and press very lightly. Another place is to press lightly on your neck, just to the right of your Adam's Apple. (Do not use your thumb to check your pulse. It has a strong pulse of its own and may confuse you).

Count the number of beats you feel in 10 seconds to get your exercise heart rate. To take a resting pulse, count the beats for 30 seconds and multiply by two or take it for a full minute.

Another method for monitoring intensity is to utilize the Perceived Exertion Scale. This refers to the total amount of physical effort experienced. This scale takes into account all sensations of exertion, physical stress and fatigue. When using the rating scale, do not become preoccupied with any one factor, such as leg discomfort or labored breathing, but try to concentrate on your total inner feeling of exertion.

Perceived Exertion Scale
6 - 7 very, very light
8 - 9 very light
10 - 11 fairly light
12 - 13 somewhat hard
14 - 15 hard
16 - 17 very hard
18 - 19 very, very hard

Recommended level of exertion is 13 - 14 during the "Work Out" phase of exercise.

Phases of Exercise Program

1. Warm-Up: To prepare your body for the conditioning phase of the program. Should be two to five minutes in duration, low intensity.Warm-Up: To prepare your body for the conditioning phase of the program. Should be two to five minutes in duration, low intensity.
2. Work Out: Conditioning phase of the program. Should be enough activity to achieve target heart rate. Duration is dependant on your current level of fitness. Goal is 20 minutes. One may start with two to five minutes in the a.m. and two to five minutes in the p.m., progressing as able, or starting with two minutes of low intensity, two minutes of increased intensity, one minute low, two minutes increased until endurance and tolerance are built up.
3. Cool Down: Consists of slow walking or bicycling without resistance to decrease heart rate to pre-exercise levels. It prevents pooling of blood in the legs, which causes dizziness. Do not stop the activity until you have lowered your heart rate.
4. Stretching: Always end your conditioning sessions by stretching your legs, arms, and trunk. This is a continuation of the "Cool Down" phase. This is essential to a successful program to decrease soreness and stiffness.
5. Rest: Each exercise session should be followed by a period of quiet, seated rest to allow heart rate and blood pressure to return to resting levels. Avoid hot or very cold showers, saunas/hot tubs after exercise due to changes they can cause in your heart rate and blood pressure.

When to Take Your Pulse Rate 
Before you begin exercising, count your resting heart rate. A normal resting rate is 60 - 80 beats per minute. During exercise, periodically check your heart rate to see if it is in the target zone. Readjust your activity level to maintain your pulse within the target zone by either slowing down if your pulse is too high or increasing the intensity if your pulse is too low.

Maintain this level for 20 minutes for maximum cardiovascular benefit. After exercise, take your pulse immediately and then again after 5 minutes of stretching and cool-down. Keep a record of your resting heart rate and your recovery rate. You should notice a change in them as you become more fit. Both rates will be lower after consistent exercise patterns due to the effect of training upon the heart muscle. The heart grows stronger and does not have to beat as often to accomplish its duties. This is concrete evidence to show you the improvement in your level of fitness.

One method to determine if you are meeting the recommended goals for conditioning exercise is the following:

Intensity X Minutes X Frequency (days/week) = 40
(I.E., .70 x 10 x 3 = 21)

Watch for the Following

If you experience any of the following signs of activity intolerance, stop and rest. If the symptoms are not relieved by rest, or if they continue to limit your activity, report them to your doctor for his/her consideration.

• Dizziness or lightheadedness during or after exercise.
• Shortness of breath, making conversation difficult.
• Extremes of persistent fatigue not relieved with a brief rest.
• A change in the rhythm of your pulse, (i.e., the sensation of skipped beats, pauses, a racing pulse or a sudden, unusually slow pulse). A moderate increase in the rate of your pulse is a normal response to exercise.
• Joint, bone, or muscle pain.
• Chest pain or pain referred to jaw, teeth, ear, neck, arm, or back. If this pain is not relieved by two or three minutes of rest, and if your doctor has prescribed nitroglycerin, use it as instructed. A change in chest pain should be reported to your doctor. This would include new pain if you have not had pain since a heart attack, or an increase in the frequency or intensity of pain or pain occurring at lower levels of activity or at rest.
• Nausea, vomiting, cool and clammy sweat, or a feeling of weakness. 

To Keep Motivated

• Recruit a friend or spouse to exercise with you.
• Start out slowly. It is easier to get discouraged if you try to do too much too soon.
• Set aside a regular time for exercising. If you wait until you "find" time, chances are you never will.
• Try to schedule exercise for a time of day when you feel your best.
• A hot bath or shower before exercising may help ease stiffness.
• Wear comfortable clothing and shoes that offer proper support.
• Consider alternating between two activities for variety. You might exercise twice a week in a low impact aerobics class and substitute swimming for your third weekly workout.
• If you are considering a particular exercise class but are uncertain if it is appropriate for your needs, talk to the instructor beforehand. Still unsure? Ask if you can observe or participate in a trial class.
• Use the "Two-Hour Rule." If you still have pain as a result of exercising more than two hours after you have stopped, you may have done too much. Next time, decrease the amount of intensity of exercise.
• Set goals. Just seeing how much more you can do, either in your exercise program or your daily life will give you a big boost. ("The Good News About Exercise," by Peggy Person, Arthritis Today, May - June 1989).
• It takes two to three weeks to begin to improve your physical fitness level. It takes six weeks to three months to achieve significant improvement. It takes three to six months for maximum fitness to be achieved. It takes two days of inactivity and you start to lose endurance. Much of the benefits will be lost within two weeks of total inactivity.

Reprinted with the permission of: Abbott Northwestern Hospital,  Arthritis Care Program, Fibromyalgia  Assessment Clinic, Patient Education Workbook