Special Considerations for Chronic Pain

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The most recent U.S. statistics, from 2012, showed that the total cost for treating chronic pain disorders ranged between $560 and $635 billion annually (47). This number was estimated to increase to $873.8 billion per year by 2014 (119). The emerging prevalence of chronic pain disorders among individuals requires the health and fitness professional to have a basic understanding regarding the recognition, management, and safe exercise prescription for common chronic pain conditions. This chapter presents three common conditions: chronic nonspecific low back pain, fibromyalgia, and rheumatoid arthritis. The information presented is intended to provide the reader with an empirical perspective on management of these conditions.

CHRONIC NONSPECIFIC LOW BACK PAIN

Case Study 19-1:

Mr. Case Study-LBP

Mr. Case Study-LBP is a 54-year-old man weighing 100 kg (220 lb) with a height of 175 cm (69 in) and with a history of chronic nonspecific low back pain (CNSLBP) treated with naproxen sodium, a nonsteroidal anti-inflammatory drug (NSAID), as needed per his physician. His risk factors for cardiovascular disease (CVD) included obesity (waist circumference of 40.5 in/103 cm) and dyslipidemia (total cholesterol of 204 mg ∙ dL⁻¹). In addition, his triglycerides, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) were 165 mg ∙ dL⁻¹, 126 mg ∙ dL⁻¹, and 45 mg ∙ dL⁻¹, respectively. He is a nonsmoker, and his blood pressure (BP) and fasting glucose are 136/84 mm Hg and 90 mg ∙ dL⁻¹, respectively. His father and mother are both 74 years old and are apparently healthy. He is an assistant chief of police in a large mid-Atlantic suburb and reports working primarily at his desk and computer most of the day. He has been taking his dog on a 1.5-mile walk each day (23 min), approximately a 4–metabolic equivalent (MET) activity. He used to be an avid rock climber and also competed in weekly softball tournaments. He has had occasional episodes of low back pain throughout his adulthood. His physician told him that he has slight degeneration of a disc in his low back and is overweight. He wants him to “get in shape” and “lose weight” before he considers placing him on medications (Crestor [rosuvastatin], Lopressor SR [metoprolol], and Zestril [lisinopril]) and has cleared him medically to do so. Mr. Case Study-LBP stated that his dog is very energetic, is growing rapidly, and requires a lot of strength to control and “I’m often tired and I hurt all over after walking him.” He has no contraindications to exercise and does not currently have back pain. He was successfully discharged from 6 weeks of physical therapy for an episode of pain across his low back and buttocks 2 months ago. Shortly after discharge from physical therapy, his physician stopped his treadmill exercise test (Bruce protocol) after 6 minutes at approximately a 7-MET level without any signs or symptoms of hemodynamic intolerance. He did have back and leg pain and described the severity as being 8 out of 10 on a visual pain scale. He was able to dissipate the pain immediately by supporting his low back with his hands and leaning backward gently. One week later, he completed another treadmill test with a ramp protocol at an estimated level of 10 METs while reporting a pain severity of 4 out of 10.

His fitness assessment and respective results included the Young Men’s Christian Association (YMCA) cycle ergometer test (estimated 10 METs), one repetition maximum (1-RM) and 10 repetition maximum (10-RM) bench press (150 lb and 120 lb) and horizontal (supine) leg press (300 lb and 240 lb) tests, push-ups (9 repetitions), American College of Sports Medicine (ACSM) abdominal crunch test (23 repetitions), sit and reach (14 in) and a 10-RM latissimus pull-down (110 lb), and seated scapular row (80 lb) on selectorized resistance machines. He reported a 10 out of 10 (Extremely Hard) effort on the OMNI Perceived Exertion Scale for Resistance Exercise (OMNI-RES) during each strength test and reported that he would not be able to complete another repetition without using improper form. He experienced some pain across his low back after the bike, abdominal crunch, and sit-and-reach tests, which was alleviated very shortly after each of these tests by gentle standing back extension stretches.

He then performed 16 weeks of supervised exercise with a personal trainer at a medical fitness center where his physician sent him. Details from this program follow. Table 19.1 presents the exercise program recommended for Mr. Case Study-LBP by his personal trainer. During the first 4 weeks, his exercise training program consisted of cardiovascular endurance training 3 days a week and full-body resistance training 2 days a week on selected machines. He trained 10 minutes on the recumbent bike, Nu-Step (recumbent arm and leg ergometer) and elliptical trainer (foot pedal-only model), and treadmill (no elevation), respectively, at between 50% and 70% of heart rate (HR) reserve, which in his case coincided with an intensity of 6–7 METs. He also performed two sets of trunk stability exercises, which included opposite arm/leg raises in the quadruped position (bird dogs) and two isometric half-side (knees flexed approximately 90°) and half-prone (knees, shins and feet on the ground) bridges/planks for 10 seconds each. Flexibility exercises for the hamstrings and pectorals in an upright position were emphasized. Although the percentage of 1-RM is frequently used to assign load intensities during resistance exercise sessions, the 10-RM, an acceptable alternative, was used instead to help him increase his strength and endurance while avoiding the need for frequent interruptions for testing.

Table 19.1

16-Week Progressive Resistance Training Program for Mr. Case Study-LBP

Week

Monday (Sets × Repetitions and OMNI-RES)

Friday (Sets × Repetitions and OMNI-RES)

Baseline 1-RM and multiple-RM testing

1 × 10 with actual 10-RM at an OMNI-RES of 9

1 × 10 with actual 10-RM and OMNI-RES of 10

1 × 10 with actual 10-RM at an OMNI-RES of 8

1 × 5 for trunk stability exercises

2 × 10-RM and at an OMNI-RES of 8

2 × 10-RM and at an OMNI-RES of 7

2 × 12 with 10-RM and OMNI-RES of 7 at the end of week 3

2 × 14 with 10-RM at an OMNI-RES of 6

2 × 10-RM with newly established 10-RM and at an OMNI-RES of 10

2 × 10-RM and at an OMNI-RES of 8

Increased trunk stability exercises to 2 sets of 10

2 × 10-RM and at an OMNI-RES of 9

2 × 10-RM and OMNI-RES of 7

3 × 10-RM and at an OMNI-RES of 8 at the end of third set on Monday of week 7

3 × 10-RM and at an OMNI-RES of 7

3 × 10-RM and at an OMNI-RES of 8

Increased trunk stability exercises to 3 × 10

Repetitions increased to 12 and OMNI-RES dropped to 6

3 sets with newly established 10-RM for machines and new free weight and standing exercises and with an OMNI-RES of 10

3 × 10-RM and with an OMNI-RES of 9

3 × 10-RM with an OMNI-RES of 9

3 × 10-RM and with an OMNI-RES of 8

3 × 12 with 10-RM and an OMNI-RES of 7

Adjusted exercise and load intensities during week 12

3 × 10 with newly established 10-RM and at an OMNI-RES of 10

3 × 14 with 10-RM and an OMNI-RES of 7

3 × 10-RM established on the previous Monday at an OMNI-RES of 9

3 × 10 at an OMNI-RES of 8 added sled push/pull and assisted pull-ups

3 × 8 with a newly established 8-RM and at an OMNI-RES of 10

3 × 10 at an OMNI-RES of 7

3 × 8 at an OMNI-RES of 10

3 × 9 with the 8-RM loads established the previous week and with an OMNI-RES of 9

3 × 10 with the same loads as previous week and at an OMNI-RES of 8

3 × 9 with the same loads as Monday and at an OMNI-RES of 8

3 × 10 with the same 8-RM at an OMNI-RES of 7

Mr. Case Study-LBP increased his aerobic endurance training time to 45 minutes, frequency to five times per week, added the elliptical trainer with arm rails to his routine, and began selecting exercises he enjoyed and could tolerate from the Compendium of Physical Activities. The complexity of the workout for Mr. Case Study-LBP was increased over time by substituting standing exercises with free weights, stability ball exercises, advanced trunk/core stability exercises, sled pushing and pulling activities, and assisted pull-ups. He added curl-up exercises to the trunk stability part of his workout and stated that his back felt good after doing them. Table 19.1 provides a description of his exercise program.

Table 19. 2 provides a functional rationale for Mr. Case Study-LBP’s specific resistance exercises. He was able to meet and exceed his weekly exercise duration and MET-min goals of >300 minutes per week and ≥1,000 MET-min per week for improving his health and for helping him manage his weight.

Table 19.2

Resistance Exercises and Functional Rationale

Exercise	Muscle Groups Involved	ADL Impacted by Exercise
Leg press	Glutes, quadriceps, hamstrings	Walking uphill; walking a big dog
Squats	Glutes, quadriceps, hamstrings	Proper floor-to-waist lifting
Lunges	Glutes, quadriceps, hamstrings	Resisting a large dog pulling Walking up/down elevations
Sled pushes/pulls	Glutes, quadriceps, hamstrings	Maintain a stable trunk when a large dog pulls its leash; walking up/down elevations
Knee extensions	Quadriceps	Walking up/down elevations/stairs
Knee flexion	Hamstrings	Walking up/down elevations/stairs
Shoulder press	Deltoids, triceps	Putting heavy loads on overhead surfaces
Row with machines or cables	Latissimus dorsi, rhomboids, Trapezius, biceps	Pulling a leash to control a large dog, rock climbing
Lat pull-down	Latissimus dorsi, teres major	Rock climbing
Assisted pull-up	Rhomboids, brachialis, biceps
Chest press	Pectorals, deltoids, triceps	Pulling a big dog inward or in front of the body on a leash or pushing a lawn mower up a hill
Biceps curl	Brachialis, biceps	Rock climbing
Seated triceps dip	Triceps	Pushing a lawnmower up a hill

Description, Prevalence, and Etiology

Low back pain (LBP) is a common musculoskeletal condition affecting between 49% and 70% of persons living in Westernized nations and 70% and 85% of persons living in the United States during their lifetimes. It is often attributed to either nociceptive (sensitization of pain receptors within spinal/mechanical structures and myofascial tissues), neuropathic (radicular or nerve-related pain), or central (sensitization within the brain) sources (98). Persons aged 45–64 years have the highest reporting rate for LBP (22). One in four adults experiences chronic LBP lasting more than 12 months, and approximately 14% of them (58.8 million) also report having difficulty performing activities of daily living (ADL) (32,120). The annual U.S. cost for treatment and lost wages due to back pain increased by 91% from $132.4 during the periods of 1996–1998 to $253 billion during the period of 2009–2011 (1). Generally, back pain is categorized by its etiology, location, and duration of symptoms and classified as being either of the following:

Specific: pain caused by unique or unusual pathophysiologic mechanisms (disc herniation, tumor, osteoporosis, arthritis, diseases, trauma, mechanical disorders or spinal pathology)

Nonspecific: pain not caused by a specific disease or spine pathology

Acute: pain lasting less than 6 weeks

Subacute: pain lasting 6–12 weeks

Chronic: pain lasting longer than 12 weeks

CNSLBP is generally defined as pain, muscle tension, or stiffness localized below the costal margins (ribs) and above the inferior gluteal folds with or without leg pain (sciatica) lasting ≥12 months (33,73). CNSLBP is the second leading cause of physician’s visits, the leading cause of lost work time, the second leading cause of disability, and most common cause of physical activity limitations in persons younger than the age of 45 years.

Evidence indicates that persons with LBP experience intolerance and avoidance of physical activity, and lower levels of physical fitness and function, and thus engage in a more sedentary lifestyle than age- and gender-matched persons without CNSLBP (35,36,51,77,114,123,128,129).

LBP can also contribute to lost work time, reduced health-related quality of life, decreased neuromuscular function and strength, and fear/avoidance of physical activity secondary to anticipation of pain (34,36,51,55,61,66,67,88,113,114).

The reader is directed to two resources providing examples that list a number of “red flags” (identified by qualified health care providers) as conditions often accompanying specific LBP that can indicate possible underlying spinal pathology, nerve root problems, and a need to consult the patient’s physician or health care provider (42,125–127). LBP is generally diagnosed or “ruled in” when red flags, magnetic resonance imaging, and radiograph results are found to be negative for spine or nerve pathology, respectively (129).

Preparticipation Health Screening, Medical History, and Physical Examination

Case Study 19-1 Quiz:

Preparticipation Health Screening, Medical History, and Physical Examination

1. What other conditions beside LBP need to be addressed in the exercise program? How can this be accomplished?

2. What motion(s) and position(s) seem to cause and reduce Mr. Case Study-LBP’s back pain?

Many persons with LBP are sedentary and experience physical activity intolerance. Other health issues (e.g., overweight, obesity, metabolic syndrome, hypertension, and Type 2 diabetes) may be present in this population. Exercise professionals should conduct a thorough preactivity screening and determine patients’ exercise and history of physical activity, presence of or signs suggestive of cardiovascular, metabolic, or renal disease as well as the risks for adverse events during exercise according to the guidelines set by the ACSM (6). Depending on the level of risk, the patient may require a medical examination and/or potentially a physician-supervised graded exercise test prior to exercise program initiation. Persons with LBP are typically treated with NSAIDs and acetaminophen (nonopioid analgesic) and are advised to stay active and avoid bed rest (129). Occasionally, muscle relaxants and narcotic analgesics, which can cause drowsiness, increased reaction time, and impaired judgment, are prescribed for severe pain (129).

NSAIDs are used to relieve pain and inflammation, but long-term use of them has been associated with gastrointestinal irritation, ulcers, heartburn, diarrhea, fluid retention, and, in rare cases, kidney dysfunction and CVD. Nonopioid analgesics are used to reduce pain, but long-term use in some cases has been associated with liver damage.

Although many persons with LBP are less physically active and physically fit than apparently healthy age-matched cohorts, it is believed that LBP does not by itself exert specific effects on the exercise response (113). Exercise responses and activity limitations are typically affected by individual pain severity and location, physical fitness and strength, and body positions required during exercise testing and training. Some individuals with LBP are intolerant of specific motions such as trunk flexion or extension, and some positions such as prolonged standing and sitting can cause discomfort, which can prevent them from producing their best exercise and/or testing efforts and results.

Exercise Testing Considerations

Case Study 19-1 Quiz:

Exercise Testing Considerations

3. How is maximal effort during multiple-repetition maximum testing ensured?

4. Why did the patient not achieve as high an aerobic capacity during the graded exercise test with the Bruce protocol? Why was a second protocol attempted later?

Cardiorespiratory fitness testing using either a treadmill, a bicycle, or a step ergometer with a ramp or incremental protocol, as well as field tests such as the 6-minute walk test (6MWT), have been well-tolerated, effective assessments for persons with LBP (36,100). Multiple repetition maximum testing is an effective alternative to 1-RM testing for determining muscular strength, exercise training loads, and postprogram strength increases in persons with LBP (61,67,68). The standard rating of perceived exertion (RPE) and the OMNI-RES can approximate intensity of patients’ effort during cardiorespiratory fitness and musculoskeletal testing and training (7,17,107).

An OMNI-RES rating of 9 and 10 approximate near-maximal and maximal effort during multiple repetition testing (107). The “timed up and go” (TUG) and multiple repetition sit-to-stand (STS) tests are appropriate tools for measuring neuromotor performance in older individuals (60 yr and older) with LBP (6). The inability to tolerate prolonged sitting, standing, frequent bending (trunk flexed postures), and pain exacerbations can negatively affect patient test tolerance and performance efforts (36,77,100,113).

Exercise Prescription and Progression Considerations

Case Study 19-1 Quiz:

Exercise Prescription and Progression Considerations

5. What precaution(s) need to be taken to enhance safety during workouts for persons with LBP?

6. How can strength be increased while ensuring patient safety?

7. Can you suggest other exercises that would be beneficial for this patient given the strong desire to return to rock climbing, walking a big dog, and competing in court sports?

General guidelines for exercise prescription and progression for individuals with LBP resemble those of apparently healthy persons without it, which are presented in Tables 6.5, 6.6, and 6.7 in ACSM’s Guidelines for Exercise Testing and Prescription, 10th edition (GETP10) (6,100). Exercise program goals should be individualized and address overall health and fitness requirements. Exercise selections should be determined by patients’ comfort and activity tolerance (2,34,46,67,100). The Compendium of Physical Activities can help patients with CNSLBP select exercises they can perform comfortably while meeting their exercise goals (2,6,46).

Persons with LBP should follow resistance training guidelines for apparently healthy sedentary individuals (6,46,100). In terms of resistance training, the “two for two” rule of intensity load progression (increase intensity after two or more repetitions per exercise set are performed beyond the goal repetitions for two consecutive sessions) is appropriate (7). Proper technique and posture should be maintained during each exercise (106). Equipment type (machines, body weight, tubing, free weights) and exercise position (sitting, standing, prone, supine) should be dictated by patients’ tolerance or directional preference (52,58,76).

Case Study 19-1 Quiz:

Exercise Prescription and Progression Considerations

8. What are appropriate core/trunk conditioning exercises? How can they be progressed?

Trunk/core conditioning exercise, like most resistance training exercises, can be modified and performed in standing sitting, prone, or supine (hook lying) positions. Some patients are more intolerant of trunk/spine movements like flexion or extension and often find trunk conditioning exercises with extension and flexion bias, respectively, more comfortable (52,58,76). Isometric activities such as side and prone bridges, pelvic tilts, supine bridges, and derotation exercises can precede more dynamic activities (52,58,76,88,113,136).

Extension exercises can be progressed from easier (lying prone on floor with arms at sides) to more challenging (the swimmer and superman on the floor or a stability ball), to “bird-dogs” on the floor in quadruped position (87–89,100,135).

Stretches should be preceded by light aerobic activity (11–13 RPE or 4–5 OMNI-RES) for 8–10 minutes. Static, dynamic, and proprioceptive neuromuscular facilitation stretching are all acceptable as tolerated (6,40). Hamstring, hip flexors, and anterior shoulder girdle muscle flexibility exercises should be emphasized (6,100).

A summary of exercise training and prescription considerations for individuals with LBP are found in frequency, intensity, time, and type (FITT) table (Table 19.3) and is presented as follows:

Exercise program should be individualized, and goals should address all health and fitness needs of persons with LBP.

Comorbid health conditions might be present and should also dictate exercise program development decisions.

If present, movement directional preferences/biases can dictate the positions in which continuous resistance training, resistance training, and flexibility exercises are performed.

Exercises causing pain during or after workout sessions should be eliminated and substituted with alternative activities.

New or worsening symptoms warrant exercise termination and communication with a physician and/or health care provider.

Exercises/activities that are high-impact (e.g., running) should be avoided or introduced gradually with caution.

Persons with LBP should learn fundamental movement patterns like squatting, hip hinging, and lifting from the floor and should avoid sitting for long periods (89,113).

TABLE 19.3 FITT RECOMMENDATIONS FOR EXERCISE PRESCRIPTION MODIFICATIONS AND SPECIAL CONSIDERATIONS FOR INDIVIDUALS WITH LOW BACK PAIN, FIBROMYALGIA, AND RHEUMATOID ARTHRITIS

ACSM FITT Principle of the ExR_x

Chronic Medical Condition	Frequency (How often?)	Intensity (How hard?)	Time	Type (What kind?) Primary	Resistance	Flexibility	Special Considerations
Healthy Adult	≥5 d ∙ wk⁻¹ of moderate exercise, or ≥3 d ∙ wk⁻¹ of vigorous exercise, or a combination of moderate and vigorous exercise on ≥3–5 d ∙ wk⁻¹ is recommended.	Moderate to vigorous. Light-to-moderate intensity exercise may be beneficial in deconditioned individuals.	If moderate intensity: ≥30 min ∙ d⁻¹ to total 150 min ∙ wk⁻¹. If vigorous intensity: ≥20 min ∙ d⁻¹ to total 75 min ∙ wk⁻¹.	Regular, purposeful exercise that involves major muscle groups and is continuous and rhythmic in nature is recommended.	Muscle strengthening 2–3 d ∙ wk⁻¹ (nonconsecutive) Moderate-to-vigorous intensity; 2–4 sets of 8–12 repetitions	2–3 d ∙ wk⁻¹; static stretch 10–30 s; 2–4 repetitions of each exercise	Sedentary behaviors can have adverse health effects, even among those who regularly exercise. Adding short physical activity breaks throughout the day may be considered as a part of the exercise.
Low Back Pain	≥5 d ∙ wk⁻¹ of moderate exercise or ≥3 d ∙ wk⁻¹ of vigorous exercise or a combination of moderate and vigorous exercise ≥3–5 d ∙ wk⁻¹	Moderate or vigorous	≥30 min ∙ d⁻¹ of continuous or accumulated exercise with a minimum of 10-min bouts	Aerobic exercises in body positions best tolerated	2–3 d ∙ wk⁻¹ (nonconsecutive); 2–4 sets of 8–12 repetitions with 60%–70% 1-RM intensity for most adults; 10–15 repetitions with 40%–50% 1-RM for novice or elderly; for strength and power	2–3 d ∙ wk⁻¹; stretch to point of slight discomfort 10–30 s in most adults and 30–60 s in older individuals; 2–4 repetitions of each exercise according to patient tolerance	An individualized approach to exercise program development that addresses all health-related fitness variables, comorbidities (if present), and movement directional preferences can enhance program compliance, effectiveness, and health-related quality of life and contribute to the adoption of a more physically active lifestyle.
Fibromyalgia	3 d ∙ wk⁻¹	Light to moderate	20–30 min; improvements are observed after 4 wk	Aerobic Low-impact weight-bearing exercise (e.g., water exercise, cycling, walking, swimming) initially to minimize pain	2–3 d ∙ wk⁻¹ 40%–80% of 1-RM exercises for all major muscle groups using a variety of equipment and body weight; 1–3 sets, 5–20 repetitions; an individualized approach to rest between sets and workouts based on patient tolerance is warranted.	2–3 d ∙ wk⁻¹ mild-to-moderate intensity within pain-free range 10–30 s in most adults and 30–60 s in older individuals; flexibility exercise for each major muscle–tendon unit 2–4 repetitions, preceded by light-to-moderate aerobic activity warm-up	Patients with FM should use their subjective pain ratings to adjust the intensity and volume of each exercise session, be encouraged to stay as active as possible during exacerbations, and be instructed regularly to use proper exercise technique and avoid exercising when they are excessively fatigued.
Rheumatoid Arthritis	3–5 d ∙ wk⁻¹ increasing to >5 ∙ wk⁻¹	Moderate to vigorous	150 min ∙ wk⁻¹ if moderate or 75 min ∙ wk⁻¹ if vigorous or a combination of moderate and vigorous activity	Activities with low joint stress, such as walking, cycling, swimming, or aquatic exercise	2–3 d ∙ wk⁻¹ initial intensity of 50%–60% 1-RM to 60%–80% 1-RM; all major muscle groups using elastic bands, dumbbells, machines, free weights, and body weight exercises 8–12 repetitions per set 2–4 repetitions per major muscle group	2 d ∙ wk⁻¹; static stretch 10–30 s; 2–4 repetitions of each exercise	Exercise testing and program development should be individualized, and goals should address all physical health, fitness, and functional needs of persons with RA. Recognizing barriers such as fatigue, lower baseline activity levels, and a fear of detrimental effects from exercise (inflammation and accelerated joint erosion) is necessary to affect a lifestyle change that incorporates exercise.

ExR_x, exercise prescription.

Based on the FITT Recommendations present in ACSM’s Guidelines for Exercise Testing and Prescription. 10th ed. Philadelphia (PA): Wolters Kluwer; 2018. 480 p.

FIBROMYALGIA

This section discusses the management and special considerations for fibromyalgia (FM). The discussion begins with a case study outlining an exercise program for a 45-year-old woman diagnosed with FM 6 months ago. The case study illustrates a common program for these individuals, which often may be influenced by their current level of symptoms (e.g., pain) and disability (19).

Case Study 19-2:

Mrs. Case Study-FM

Mrs. Case Study-FM is a sedentary, 48-year-old woman, 5 ft 2 in (157.5 cm) and 165 lb (75 kg) with a body mass index (BMI) of 30 kg ∙ m⁻². She is a kindergarten teacher and was recently diagnosed by her rheumatologist with FM. She is a nonsmoker and was an avid early morning mall walker, tennis player, and ballroom dancer but has become sedentary since developing the symptoms of FM about a year ago. Her parents are both 73 years of age and are obese with Type 2 diabetes, hypertension, and dyslipidemia controlled by medications. Her school has a pool and a student and faculty fitness center which has fully equipped cardiovascular and resistance training areas. She reports awakening after 3–4 hours of interrupted sleep every morning feeling groggy, exhausted, stiff, and depressed. She has had chronic, diffuse bilateral pain in her trunk and extremities for the last year. Laboratory tests for rheumatoid arthritis (RA) and x-rays for osteoarthritis were negative. Her pain has limited her at school from kneeling and squatting down at her students’ desks and tables, getting up and down from the floor, and participating in active games on the playground with her class. In addition, lifting heavy grocery bags and carrying laundry baskets up and down her stairs have become difficult. She gave up walking, tennis, and ballroom dancing as well. Her pain, insomnia, and depression are being managed by Lyrica (pregabalin), Flexeril (cyclobenzaprine), Lunesta (eszopiclone), and Zoloft (sertraline), respectively. She gained 10 lb in a year due to relative inactivity and overeating. Her resting HR was 80 bpm, and latest BP, cholesterol, and triglycerides were 140/84 mm Hg, 260 mg ∙ dL⁻¹, and 170 mg ∙ dL^−1, respectively. Fasting glucose was within normal limits. Since being diagnosed with FM, her physician had her complete a Bruce protocol treadmill test with a 12-lead electrocardiogram (ECG), which she stopped at just more than 7 minutes and at an estimated peak volume of oxygen consumed per unit time (O₂) of 28 mL ∙ kg⁻¹ ∙ min⁻¹ (8 METs) due to general fatigue and diffuse leg pain. Her perceived exertion and pain were each rated 8 out of 10 on category-ratio (CR) intensity and pain scales, respectively. She also had a dual-energy x-ray absorptiometry (DEXA) test that indicated the presence of reduced bone mineral density (BMD), however, not to a level constituting a diagnosis of osteopenia or osteoporosis. She achieved a peak HR of 155 bpm (90% of age-predicted maximal HR) and BP of 180/80 mm Hg. Her physician considered the test to be “normal” and unremarkable yet at a relatively low MET level. Her grip strength and 1-RM bench press and leg press scores were all below average and within the 40th, 35th, and 30th percentiles, respectively. Her physician has cleared her to participate in a comprehensive exercise program to improve her strength, stamina, cardiovascular fitness, and BMD while helping manage her risk factors for CVD. She has also been referred to a registered dietitian to address weight loss, CVD risk reduction, and bone health.

Description, Prevalence, and Etiology

FM is a chronic pain disorder that affects the joints, muscles, tendons, and soft tissue of the body. It is estimated that more than 5 million Americans have FM with a higher presence among women ages 35–60 years (25,81). FM is often underdiagnosed with 1 in 5 receiving an accurate diagnosis within an average of 5 years (132,133).

Traditionally, FM has been categorized as a rheumatic-like disorder with accompanying psychological factors such as anxiety and depression (107). More current hypotheses suggest that FM is caused by neurochemical imbalances in the central nervous system that are associated with a heightened pain perception (24,31). FM can be considered a central processing disorder where the ascending and descending neurological pathways operate abnormally which create amplified pain sensations. This creates a heightened sensitivity to stimuli called allodynia and a heightened response to painful stimuli called hyperalgesia (24,50). Individuals with FM may also suffer from myofascial pain syndrome. Research has suggested a connection between the two conditions in which 50% of individuals with FM may also suffer from myofascial pain syndrome or vice versa (83).