Complementary and alternative exercise for fibromyalgia: a meta-analysis

Figures & data

Figure 1 Search strategy results.

Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; FIQ, Fibromyalgia Impact Questionnaire.

Table 1 Summary of included trials

Author	Study type/design	Intervention and dose	Sample size, age and adverse events	Post intervention follow up	Outcome measures and timing
Qigong studies
Lynch, Sawynok, Hiew, and Marcon (2012)^Citation70	Randomized controlled trial (RCT)	Qigong Intervention = three 1/2 day workshop followed by weekly review/practice sessions over 8 weeks in addition 45–60 minutes of home practice per day Control = wait list control	n= 100 Immediate intervention n = 53 Wait list control n = 47 Mean age = 52 years Immediate qigong completion rate = 83.01% at 2 months Wait-list qigong completion rate = 95.7% at 2 months Adverse events = 2/100 with one experiencing increased right shoulder pain and one experiencing plantar fasciitis	4 and 6 month follow-up	Pain (numeric rating scale) Fibromyalgia Impact Questionnaire (FIQ) Pittsburg Sleep Quality Index (PSQI) SF-36 health survey
Comments:*This is 1 of only 2 studies with 6-month follow-up; only study identified using chaoyi fanhaun qigong (CFQ).
Liu, Zahner, Cornell, Le, Ratner, Wang, Pasnoor, Dimachkie and Barohn (2012)^Citation69	Single blinded	Qigong Intervention = home practice for 15–20 minutes twice daily and group exercise class for 45–60 minutes once daily for 6 weeks Control = home practice for 15–20 minutes twice daily and group exercise class for 45–60 minutes once weekly using “sham” qigong moves for 6 weeks	n = 14 Intervention group n = 8 Mean age = 55.7 years Control group n = 6 Mean age = 57.5 years Total completion rate = 85.7% Intervention group completion rate = 75% Control group completion rate = 100% Adverse events = not addressed	No follow up	Pre/post only Short Form McGill Pain Questionnaire (SF-MPQ) Multidimensional Fatigue Inventory (MFI-20) PSQI FIQ
Comments: 1 st study to test and report sham qigong arm.
Haak and Scott (2008)^Citation66	RCT Wait list control group	Qigong 7-week qigong intervention consisting of 9 group sessions and approx. 11.5 hours total dose Home practice encouraged 2x/day	n = 57 women Intervention n = 29 Wait list Control n = 28 Mean age = 53 years Total completion rate n = 53 (93%) Adverse events = not addressed	4 month follow up	Pre/post/4 month follow up State Anxiety Inventory (STAI) Beck Depression Inventory (BDI) World Health Organization Quality of Life BREF (WHOQOL-BREF) Daily self-recordings visual numerological scale (VNS) on pain, sleep, psychological health and distress
Comments: Use of he hua qigong style, only study done outside the United States.
Mannerkorpi and Arndorw (2004)^Citation71	RCT Pre/post test Control group usual standard of care	Qigong 14 sessions over 3 month period, once weekly for 1.5 hours Home practice encouraged Data unclear regarding dose of home exercise performed	n = 36 women Mean age = 45 years Adverse events = none reported	No follow up	FIQ Body Awareness Rating Scale (BARS) Chair test hand grip Interviews
Comments: Differential attention between groups as standard care control didn’t meet in groups or receive attention from Primary Investigator (PI) other than at data collection points; significant change in body awareness and FIQ but not in measures of physical function; only qigong study with a negative outcome despite standard care group receiving no attention; 8 participants reported increased pain with qigong practice.
Astin, Berman, Bauseil, Lee, Hochberg, and Forys (2003)^Citation59	RCT 2x4	Mindfulness meditation plus qigong 2.5 hour weekly sessions of mind-body intervention over 8 weeks 1.5 hr mindfulness meditation training and 1 hr qigong practice over 8 weeks Control group 2.5 hour educational sessions for 8 weeks	n = 128 individuals Mean age = 47.7 years 8 week attrition = 39% (50) 16 week attrition = 48% (61) 24 week attrition = 49% (63) 25.8% never attended even one class (18.8% qigong; 32.8% control) Adverse events = not addressed	4 and 6 month follow up	Baseline, 8,16, and 24 weeks Tender point count Total myalgic score Medical Outcome Study Short Form FIQ 6 minute walk test; BDI Medical care history Coping strategies questionnaire
Comments: 1 st study to report qigong intervention in fibromyalgia; largest study to date; 1 of 2 studies with 6 month follow up; equal attention paid to the sedentary control group; only study to use the ‘dance of the phoenix’ qigong style.
Yoga studies
Curtis, Osadchuk, and Katz (2012)^Citation67	Time series design	Hatha yoga with mindfulness technique Twice weekly, 75 minute yoga classes per week over 8 weeks	n = 22 Completion rate = 86.36% Mean age = 47.4 years Adverse events = not addressed	No follow up	Pre/mid/post measures SF-MPQ Pain numeric rating scale Sum of Local Areas of Pain (SLAP) Pain Catastrophizing Scale (PCS) Pain Disability Index (PDI) Hospital Anxiety and Depression Scale (HADS) Five Facet Mindfulness Questionnaire (FFMQ) Chronic Pain Acceptance Questionnaire (CPAQ) Salivary Cortisol measurement
Comments: Differs from the Carson study in that there was no didactic presentation prior to yoga practice; only study to measure Cortisol levels.
Hennard (2011)^Citation67	Single arm study No Control	Yoga of awareness 75 minute weekly sessions, once weekly over 8 weeks Home practice encouraged with posed illustration handouts	n = 25 participants (24 women; 1 man) Mean age = 51 years Attrition rate 36% Adverse events = none reported	No follow up	Pre/post measures FIQ
Comments: Smaller didactic proportion than the Carson study (15 vs 45 minutes); further evidence of efficacy of yoga of awareness piloted in the carson study.
Carson, Carson, Jones, Mist and Bennett (2010)^Citation62	RCT Wait list replication	Yoga with mindfulness 120 minute sessions, once weekly over 8 weeks Participants encouraged to practice at home 20—40 min/day 5–7x/week with DVD/CD	n = 39 women Immediate intervention n = 21 Wait list control n= 18 Immediate intervention group completion rate = 88% 3 month follow up rate = 84% Wait list control group completion rate = 92.9% 3 month follow up completion rate = 64.3% Adverse events = not addressed	3 months for immediate treatment group Post intervention for wait list group	Pre/post/3 month follow up Revised FIQ (FIQR) Patient global impression of change Myalgic tender points Strength deficits (timed chair rise) Balance deficits (Sensory integration for balance test) CPAQ PCS Coping strategies (Vanderbilt multidimensional pain coping inventory) Daily diaries
Comments: 1st yoga study with group didactic discussion and presentation of mindfulness and yogic coping strategies; 2012 publication describes positive longer term follow up results.
Tai Chi studies
Romero-Zurita, Carbonell-Baeza, Aparicio, Ruiz, Tercedor and Delgado-Fernandez (2012)^Citation73	Single group No control	8 form Yang style tai chi 60 minute tai chi sessions, 3 times weekly over 7 months	n = 32 women Completion rate = 73% Adherence rate to intervention = 79.8% Adverse events = none reported	3 months post intervention	Pre/post/3 months post intervention Tender points Senior functional fitness test battery Handgrip strength Blind flamingo Chair stand test Chair sit and reach test Back scratch test 8 feet up and go test 6 minute walk test FIQ Short form health survey 36 HADS Vanderbilt Pain Management Inventory (VPMI) Rosenberg Self-Esteem Scale (RSES) General self-efficacy scale
Comments: Longest tai chi study to date.
Jones, Sherman, Mist, Carson, Bennett and Li (2012)^Citation68	RCT 2 parallel arms: tai chi and educational control	8 form Yang tai chi 90 min tai chi sessions, 2 times weekly for 12 weeks (simplification of an 8-form Yang style program) Educational session lasting 90 minutes, 2 times weekly	n = 101 participants Mean age = 54 years Completion rate = 97% At least 20/24 classes attended by 72% of participants Adverse events = none reported	No follow up	Pre/post measures FIQ FIQ Numeric Rating Scale (NRS) for pain severity Brief Pain Inventory (BPI) PSQI Arthritis self-efficacy questionnaire Functional mobility 8-foot Timed Up and Go (TUG) Balance-maximum reach test Static balance-timed single leg stance (STORK) Upper extremity flexibility-external and internal rotation of the shoulders by a hand to scapula movement
Comments: Enrolled 1/3 more subjects; tested increase functional mobility; used 8 form versus 10 form yang style tai chi.
Carbonnell-Baeza, Romero, Aparicio, Ortega, Tercedor, Delgado-Fernandez and Ruiz (2011)^Citation61	Open label Patient own control	8 form Yang style tai chi 60 minute sessions, 3 times weekly for 16 weeks Each session included: 15 min warm-up, 30 min of tai chi, 15 minutes of relaxation exercises	27 contacted, 9 consented, 3 not included due to not meeting ACR diagnostic criteria n = 6 Mean age = 52.3 years Adherence = 79.5% Adverse events = none reported	3 month post intervention follow-up	Tenderness-algometer score Functional capacity-Height/Weight/Body Mass Index (BMI) Lower body muscular strength-30 sec chair stand test Upper body strength-handgrip strength Lower body flexibility- chair sit and reach test Upper body flexibility- the back scratch test Static balance- blind flamingo test Motor agility/dynamic balance- 8 feet up and go test Aerobic endurance- 6 minute walk test FIQ Short-form health survey (QOL) HADS
Comments: A 4 month tai chi intervention improved lower body flexibility in men with fibromyalgia that persisted through a detraining period.
Wang, Schmid, Rones, Kalish, Yinh, Goldenberg, Lee and McAlindon (2010)^Citation75	Single blind RCT	10 form Yang style tai chi 60 minute tai chi sessions twice weekly for 12 weeks Control: 60 minute wellness education and stretching program twice weekly for 12 weeks	n = 66 Control n = 33 Intervention n = 33 Mean age = 50 years 85% women 12 week class completion rate = 92.4% 24 week follow up completion rate = 89.4% Intervention adherence = 77% Control group adherence = 70% Adverse events = none reported	24 week follow up	Measures 0,12 and 24 weeks FIQ measurement FIQ Patient global assessment (PGA) Physical global assessment PSQI 6 min walk test BMI SF-36 Health Survey
Comments: Only study complementary alternative medicine (CAM) or exercise trial in fibromyalgia to be published in the New England Journal of Medicine to date.
Taggart, Arslanian, Bae and Singh (2003)^Citation74	Open label No Control	Yang style short form tai chi 1 hour tai chi classes twice weekly for 6 weeks	n = 37 Mean age = 56.2 (35 women and 2 men) 2 withdrew; 2 couldn’t do exercises; 1 had back surgery; 9 had incomplete data sheets Adverse events = not addressed	None	FIQ SF-36 Health Survey Baseline only: Wellbeing health history questionnaire
Comments: Meta analysis is based on pain not total FIQ; 1st attempt at tai chi study in fibromyalgia.
Other CAM exercise studies
Altan, Korkmaz, Bingol and Gunay (2009)^Citation58	RCT	Pilates 1 hour pilates program 3 times weekly for 12 weeks following basic principles of Pilates method and using resistance bands and 26 cm pilates ball Control group usual care = home exercise relaxation/stretching program 3 times weekly for 12 weeks	n = 50 Mean age = 49.16 years Total completion rate = 98% Intervention completion rate = 100% Adverse events = none reported	Week 24 follow up measurement	Baseline, 12 and 24 weeks Pain-visual analog scale FIQ Tender point count- using standard pressure algometer Algometric score Lower extremity endurance-chair test SF-36 Health Survey Nottingham Health Profile (NHP)
Comments: Only study to look at pilates; merits further investigation due to positive findings and pilates emphasis on core muscles that articulate with the spine potential decreasing spine pain in fibromyalgia.
Maddali-Bongi, Di Felice, Del Rosso, Landi, Maresca, Giambalvo Dal Ben, and Matucci-Cerinic (2011)^Citation72	Pilot open study No control group Pre/post test 100% completion	Body movement and perception method following resseguier method Twice weekly 50 minute sessions for 8 weeks 4 groups of 10 people each	n = 40 women Mean age = 51.7 years Completion rate = 100% Adverse events = none reported	No follow up	Visual Analog Scale (VAS) Pain intensity Pain temporal characteristics Pain during work activities Pain during recreational activities Interference of pain in night time rest General conditions (fatigue, irritability, well-being) Movement quality (Stiffness, agility) Subjective availability to focus on perception Ability to perceive the whole body Perceived postural self-control Ability to relax mind and body
Comments: Outcome measure pain intensity versus FIQ total; least physically active of all trials reviewed; may be a niche for those unwilling to do vigorous exercise.
Carbonell-Baeza, Aparicio, Martins-Pereira, Gatto-Cardia, Ortega, Huertas, Tercedor, Ruiz, and Douglas-Fernandez (2010)^Citation60	Non-random clinical trial with wait list replication	Biodanza 120 minute weekly sessions divided into 2 phases: Verbal (education/sharing) 35–45 minutes Vivencia (living experience) moving and dancing 75–80 minutes	255 invited, 79 eligible, 7 did not meet inclusion criteria n = 71 Total completion rate = 83.1% Intervention completion rate = 72.97% Control completion rate = 94.12% Adverse events = none reported	No follow-up	Pre and post assessment Tender points Body composition Physical fitness (functional senior fitness test battery) Lower body muscle strength (30 second chair stand test) Upper body muscle strength (handgrip strength) Lower body flexibility (chair sit and reach test) Upper body flexibility (back scratch test) Static balance (blind flamingo test) Aerobic endurance (6 min walk test) FIQ Short form health survey (health r/t QOL) HADS VPMI RSES General self-efficacy scale
Comments: Another example of didactic and movement component combined; unique dance style intervention; comprehensive outcome measures.

Abbreviations: BARS, Body Awareness Rating Scale; BDI, Beck Depression Inventory; BMI, Body Mass Index; BPI, Brief Pain Inventory; CAM, Complementary Alternative Medicine; CFQ, chaoyi fanhaun qigong; CPAQ, Chronic Pain Acceptance Questionnaire; FFMQ, Five Facet Mindfulness Questionnaire; FIQ, Fibromyalgia Impact Questionnaire; FIQR, Fibromyalgia Impact Questionnaire Revised; HADS, Hospital Anxiety and Depression Scale; MFI-20, Multidimensional Fatigue Inventory; NHP, Nottingham Health Profile; NRS, Numeric Rating Scale; PCS, Pain Catastrophizing Scale; PDI, Pain Disability Index; PGA, Patient Global Assessment; PI, Primary Investigator; PSQI, Pittsburg Sleep Quality Index; QOL, Short form health survey; RCT, Randomized Controlled Trial; RSES, Rosenberg Self-Esteem Scale; SF-36, Short Form-36; SF-MPQ, Short Form McGill Pain Questionnaire; SLAP, Sum of Local Areas of Pain; STAI, State Anxiety Inventory; STORK, Static balance-timed single leg stance; TUG, Timed Up and Go; VAS, Visual Analog Scale; VNS, Visual Numerological Scale; VPMI, Vanderbilt Pain Management Inventory; WHO, World Health Organization; WHOQOL-BREF, WHO Quality of Life BREF.

Figure 2 Qigong forest plot.

Abbreviations: std diff, standard difference; CI, confidence interval.

Figure 3 Tai chi forest plot.

Abbreviations: std diff, standard difference; CI, confidence interval.

Figure 4 Yoga forest plot.

Abbreviations: std diff, standard difference; CI, confidence interval.

Figure 5 Other CAM forest plot.

Abbreviations: BMP, body movement and perception therapy; CAM, complementary and alternative medicine; std diff, standard difference; CI, confidence interval.

Figure 6 Funnel plot of standard error by standard difference in means.

Abbreviation: std diff, standard difference.

Figure 7 Regression of Jadad score on standard difference in means (Jadad et al, 1996).⁵⁷

Abbreviation: std diff, standard difference.

LynchMSawynokJHiewCMarconDA randomized controlled trial of qigong for fibromyalgiaArthritis Res Ther2012144R178R18922863206

 PubMed Web of Science ®Google Scholar

LiuWZahnerLCornellMBenefit of Qigong exercise in patients with fibromyalgia: a pilot studyInt J Neurosci20121221165766422784212

 PubMed Web of Science ®Google Scholar

HaakTScottBThe effect of Qigong on fibromyalgia (FMS): a controlled randomized studyDisabil Rehabil200830862563317852292

 PubMed Web of Science ®Google Scholar

MannerkorpiKArndorwMEfficacy and feasibility of a combination of body awareness therapy and qigong in patients with fibromyalgia: a pilot studyJ Rehabil Med200436627928115841606

 PubMed Web of Science ®Google Scholar

AstinJABermanBMBausellBLeeWLHochbergMForysKLThe efficacy of mindfulness meditation plus Qigong movement therapy in the treatment of fibromyalgia: a randomized controlled trialJ Rheumatol200330102257226214528526

 PubMed Web of Science ®Google Scholar

HennardJA protocol and pilot study for managing fibromyalgia with yoga and meditationInt J Yoga Therapy201121109121

 Google Scholar

CarsonJWCarsonKMJonesKDBennettRMWrightCLMistSDA pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgiaPain2010151253053920946990

 PubMed Web of Science ®Google Scholar

Romero-ZuritaACarbonell-BaezaAAparicioVARuizJRTercedorPDelgado-FernándezMEffectiveness of a tai-chi training and detraining on functional capacity, symptomatology and psychological outcomes in women with fibromyalgiaEvid Based Complement Alternat Med2012201261419622649476

 PubMed Web of Science ®Google Scholar

JonesKDShermanCAMistSDCarsonJWBennettRMLiFA randomized controlled trial of 8-form Tai Chi improves symptoms and functional mobility in fibromyalgia patientsClin Rheumatol20123181205121422581278

 PubMed Web of Science ®Google Scholar

Carbonell-BaezaARomeroAAparicioVAPreliminary findings of a 4-month Tai Chi intervention on tenderness, functional capacity, symptomatology, and quality of life in men with fibromyalgiaAm J Mens Health20115542142921406488

 PubMed Web of Science ®Google Scholar

WangCSchmidCHRonesRA randomized trial of tai chi for fibromyalgiaN Engl J Med2010363874375420818876

 PubMed Web of Science ®Google Scholar

TaggartHMArsianianCLBaeSSinghKEffects of Tai Chi exercise on fibromyalgia symptoms and health-related quality of lifeOrthop Nurs200322535336014595996

 PubMedGoogle Scholar

AltanLKorkmazNBingolUGunayBEffect of pilates training on people with fibromyalgia syndrome: a pilot studyArch Phys Med Rehabil200990121983198819969158

 PubMed Web of Science ®Google Scholar

Maddali BongiSDi FeliceCDel RossoAEfficacy of the “body movement and perception” method in the treatment of fibromyalgia syndrome: an open pilot studyClin Exp Rheumatol2011296 Suppl 69S12S1821813057

 PubMed Web of Science ®Google Scholar

Carbonell-BaezaAAparicioVAMartins-PereiraCMEfficacy of Biodanza for treating women with fibromyalgiaJ Altern Complement Med201016111191120021058885

 PubMed Web of Science ®Google Scholar

JadadARMooreRACarrollDAssessing the quality of reports of randomized controlled trials: is blinding necessary?Control Clin Trials19961711128721797

 PubMedGoogle Scholar