Abstract
In 2007, an article was published in this journal about the effects of exercise on two older men with fibromyalgia syndrome (FMS). This new article is an update on how exercise has affected them during a 4-year period since 2007. Results suggest that both these men still function at approximately the same levels (physically and psychosocially) as reported in 2007. This is viewed as a positive finding, because even with all of their FMS symptoms, these two men managed to maintain their functional capacity. It is hard for most older people without FMS to remain motivated enough to accomplish this. Because it is difficult to find specifically published data on men (vs. women) with FMS, this long-term information on these two men is important for professionals who are involved in exercise programming for men with FMS and for those interested in studying exercise effects on men with FMS.
Introduction
In 2007, the author reported the effects of a university-based exercise research and service program on two men with fibromyalgia syndrome (FMS) in this journal (Karper, 2007). These men were studied because it was assumed that men and women experienced FMS in different ways and therefore might respond to exercise differently. Before 2007 and up to the present time, only a small number of research reports have been available that directly address issues related to men with FMS. Most of these have examined gender-based symptom and functional differences versus any exercise effect differences. Therefore, in the absence of hardly any research on exercise effects in men with FMS, it made sense to continue studying the two cases mentioned above.
Regarding general gender differences, Buskila, Neumann, Alhoashle, and Abu-Shakra (2000) examined the differences between men and women with FMS regarding clinical characteristics and spectrum of the disorder. They reported worse health outcomes for men versus women, and in particular, more severe symptoms, decreased physical function, and lower quality of life. Women reported lower tender thresholds than men. Mean point counts were similar between the groups. In 2002, Paulson, Danielson, and Soderberg qualitatively studied 14 men with FMS and found that three themes emerged: body as an obstruction, being a different man, and striving to endure. As a result of FMS, these men experienced negative body change, self-perception change, and change in relationships. Hooten, Townsend, and Decker (2007) found gender differences on psychosocial measures before and after a rehabilitation program between men and women with FMS. They reported that at pretreatment, men in their study had a lower perception of health and more physical limitations than women, but women had greater life interference because of pain than men. At posttreatment, men scored lower on health perception, physical role limitations, and social functioning.
Lange, Karpinski, Krohn-Grimberghe, and Petermann (2010) compared women and men on psychological measures and coping with pain, and suggested from their results that women require more treatment for psychological problems than men and men may require more help with pain management than women. However, Hauser et al. (2011) studied the demographic and clinical features of a large group of men and women with FMS in various settings and found no overall relevant gender differences. Their work does not support the general assumption of differences often reported in the professional literature. However, they do mention that women reported a longer duration of chronic widespread pain, longer time since FMS diagnosis, and a higher tender point count versus men. But in contrast with this new information, Miro, Diener, Martinez, Sanchez, and Valenza (2012) studied clinical differences in women and men with FMS compared with a healthy control group and found that sensibility threshold to pain was lower in women with FMS versus men with FMS. Also, they reported that sleep quality best predicted pain in men with FMS and the catastrophying of pain best predicted pain in women with FMS. Additionally, Aparicio et al. (2012) studied quality of life and FMS symptoms in men and women and found that women reported more overall fatigue than men, but men had higher overall Fibromyalgia Impact Questionnaire scores versus those of women.
Because of the mixed findings cited above, it is still not clear how men and women with FMS experience their disorder differently, but it does appear there may be some differences that might affect a response to exercise training. This coupled with much evidence (especially regarding research results on women subjects) that suggests that aerobic exercise and strength training are useful in the management of FMS (Brosseau et al., 2008a, 2008b) provides a rationale for why the author’s exercise research with the same two men has continued. Because research results on exercise effects in men with FMS are lacking, there is very little evidence to use as a basis for giving direction to this type of inquiry. One of the few reported studies exclusively on men with FMS and exercise involved handgrip strength analysis. Aparicio et al. (2010) reported that grip strength test results were associated with FMS symptoms in their investigation and that measuring handgrip strength may be useful in monitoring FMS. Also, Carbonell-Baeza et al. (2011) reported that 4 months of tai chi training improved lower body flexibility in six men with FMS, and that after a detraining phase, four of the six men maintained their improvements. Additionally, there were positive changes in other physical function factors, anxiety and depression, and on the Fibromyalgia Impact Questionnaire scores in four of the six men.
Therefore, the purpose of this article is to report how the previously described FMS program and exercise protocol (Karper, 2007) have affected the same two men (who were subjects of the previous report) over these past 4 years. Even though this information only involves two case reports and precludes any analysis for the purpose of generalizing results to a greater population, it is considered to be important. These new data on these two men are the only long-term exercise effect information on men with FMS known to the author. These data can add to the very small amount of preliminary information to help guide the organization and conduct of exercise service programs for men with FMS and the planning of research designs when the effects of exercise on FMS will be studied in men.
Description of Participants
Participant 1, who was 61 years old at the last reporting, is now 65 years old. His weight has essentially remained the same as previously reported. His symptoms remain relatively the same as before with an increase in bilateral lower limb neuropathy. His still spends significant time practicing and playing the bassoon in a community orchestra. On a regular basis, he takes testosterone (muscle injection, 1 mg every 2 weeks) for muscle strength; flaticasone (nasal spray, as needed) for allergy; lisinopril (5 mg, one per day) and hydrochlorothiazide (25 mg, one half per day) for hypertension; triazolam (0.125 mg, one per day) for sleep; tizanidine HCl (4 mg, as needed) as a muscle relaxant; gabapentine (300 mg, two per day) and tramadol HCl (50 mg, as needed) for pain; mirtazapine (30 mg, one per day) for depression; ropinirole HCl (1 mg, two per day) to improve muscular movements; and lorazepam (0.05 mg, three per day) for anxiety. He attended approximately 79% of sessions over the 4-year period. Almost all of his absences were due to vacations.
Participant 2, who was 69 years old at the last reporting, is now 74 years old. His weight is approximately 6 pounds lighter than previously reported. Lately, he has complained about total body weakness and being overly tired. In this regard, he has recently been diagnosed with anemia and is being treated with daily iron supplements. Previous to that, blood in the urinary tract was investigated relative to radioactive pellets used for prostate cancer treatment and/or active kidney stones. Both potential causes remain a possibility. Related to this, he has been cancer free for 27 years and has a long history of producing kidney stones. The physical ordeal of all this and associated anxiety may be the reason for his weight loss. His FMS symptoms have remained the same over the years. He still enjoys machine and mechanical work. Regularly, he takes poly-iron (150 mg, one per day); losartan potassium (100 mg, one per day) for hypertension; simcor (1000-2000 mg, one per day) to lower cholesterol and triglycerides; janumet (50 mg and 1000 mg, one each per day) to lower blood sugar; and finasteride (5mg, one per day) for prostate gland issues. He attended approximately 74% of the sessions over the 4-year period. Almost all of his absences were due to kidney stone flare-ups, travel, and time spent at a family-owned beach house.
Program
Basically, the exercise program over the years consisted of a walking warm up for approximately 15 minutes at a self-selected pace followed by light-dumbbell weight training (gradually moving from 8-pound dumbbells during the first 14 months to between 12 and 20 pounds depending on daily FMS symptoms) and other callisthenic-type strengthening exercises. Specifically and over the past 2 years, these men completed one set of 15 repetitions of the following exercises in a seated position: arm curls, triceps extensions, shoulder shrugs, military presses, wrist flexions/extensions, and shoulder abductions/adductions (arms extended). This was followed by one set of 15 repetitions of the following exercises in a standing position: lateral bends (each side—arms extended by sides), one quarter squats (two sets), heel raises along with hand, and finger flexions/extensions (two sets), and wall push-ups (two sets). Following these, the men engaged in mat exercises and additional chair exercises. On the mats, they held various exercise positions to a 15-count cadence or completed various numbers of repetitions in those positions during the 15-count cadence: seated—one leg extended—lowering upper body over the extended knee then repeating with other extended leg; laying supine—one leg extended—opposite knee pulled to chest then extending bent knee and pulling other knee to chest; laying supine—both knees flexed and feet flat on mat with heels in front of hips—dropping both knees to the same side at the same time then dropping both knees to the other side; back bridge in supine position—only feet and shoulders supporting body weight with extended spine; side bridge with body weight on knees held together and on one forearm with extended spine then repeating on the other side; prone bridge with body weight on knees and forearms with extended spine; execution of single hip abductions/adductions with top leg extended while side-laying then repeating on the other side; standing hamstring flexions/extensions while standing and balancing on one leg and flexing and extending the opposite hamstring muscle then repeating on the other side; lateral neck flexions (ear to shoulder)/extensions while seated; forward neck flexions and “straight up” extensions (not hyperextensions) while seated; and neck rotations (looking over each shoulder) while seated. More details about these exercises can be obtained directly from the author.
Evaluation
As reported and described in detail previously (Karper, 2007), physical fitness data continued to be collected on the quarter mile walking capacity test (a modified form of the 880 yard walk test; Osness et al., 1990), 30-second arm curl muscle strength/endurance test (Osness et al., 1990), handgrip dynamometer strength test (Stoelting, Chicago, IL, or Country Technology, Inc., Gay Mills, WI), 30-second wall push-up muscle strength/endurance test (developed by the author and a graduate student for use with people who have FMS), and the 30-second chair stand muscle strength/endurance test (Rikli & Jones, 1999) every 6 months. Psychosocial and FMS symptom data continued to be collected using a10-point analog scale developed by the author to rate the following: upper body pain, lower body pain, fatigue, brain fog, restorative sleep, perceived stress, perceived depression, perceived quality of life, anger at FMS (pain), and fear of FMS (pain) once per week (1 = extremely negative response and 10 = extremely positive response). Using analog scales are considered good ways to measure perceptions of those with FMS (Burkhardt, Clark, & Bennett, 1991). All exercise was directly supervised and all evaluation information was collected by the author. Normally, participants took the walking test during one session and completed the other fitness tests (arm curl, grip strength, chair stand, and push-up) at the next session.
Results
Table 1 displays fitness scores and psychosocial symptom ratings for both participants during 2005-2006 as compared with the 2010-2011 averaged data. The 2005-2006 data are lifted directly from Table 1 in the previous article in this journal (Karper, 2007). For Participant 1, walking appears to have slowed by 8 seconds and arm strength has weakened by four repetitions in 30 seconds when comparing 2006 data to a 2010-2011 average. Improvement was shown in comparing the other three measures of physical fitness over that time period. On the psychosocial symptom ratings, he remained the same on six ratings and improved slightly on four ratings. For Participant 2, walking appears to have slowed by 1 second and grip strength lowered considerably when comparing 2006 data to a 2010-2011 average. Improvement was shown in comparing the other three measures of physical fitness over that time period. On psychosocial symptom ratings, he remained the same on eight ratings, improved on one and slipped lower on one. It should be mentioned that both men consistently scored on the positive side of the psychosocial symptom analog scale throughout the total study with most ratings being very positive.
Fitness Scores and Psychosocial Symptom Ratings
Minutes and seconds (lower time good).
Number of repetitions in 30 seconds (higher score good).
Number of push-ups in 30 seconds (higher score good).
Best of three maximal attempts in kg m (higher score good).
Number of repetitions in 30 seconds (higher score good).
1 = extremely negative, 10 = extremely positive (scores are rounded up from 0.5).
Discussion
It is important to clarify a couple of the results found in the Table 1. The 61-kg handgrip score for Participant 2 recorded after 14 months may appear abnormally high, but that was the actual score. He obtained that score in a standardized manner used throughout the study. The author was immediately surprised by that performance. However, this participant had excellent grip strength as a result of doing a lot of hard physical labor all of his life and from auto and other machine mechanical work as a hobby. As noted, his later grip strength average dropped to 48 kg. This may have happened because he developed a painful condition at the base of his thumb on his dominant hand. This would also explain why his arm strength increased whereas his grip strength decreased. His thumb condition did not affect the arm curl motion.
Also, a number of the arm strength/endurance scores may appear irregularly high in this study when compared with published norms of healthy people in the age-group of the participants (Rikli & Jones, 1999). This is probably because a 5-pound weight was used for testing in this project instead of the recommended 8-pound weight normally used for men. This decision was made at the beginning of the project for fear of causing severe delayed onset muscle soreness in new male participants with a heavier weight and because the intent was to collect data that might be used later for male/female comparisons. Another reason for the appearance of high arm strength/endurance scores is probably because a high percentage of the participants used in the comparison tables developed by Rikli and Jones (1999) were female.
Regarding the choice of walking test, the well-validated and often used 6-minute walk test was experimented with using a number of female participants with FMS and was not well-tolerated. This test appeared to be too long in time, yielded poor results, and caused an increase in symptoms and fatigue in those with FMS that lasted for a number of days and negatively affected the training programs that followed testing. In contrast, the quarter mile walking test has proven to yield better results and to be well tolerated in the author’s exercise program for those with FMS over a long period of time. Therefore, the quarter mile walking test was used with these two men.
Any positive movement forward on any measure was considered a positive and important finding. These two men continue to consistently attend the exercise program because even their small gains translate into maintaining important activities of daily living functional capacity (Karper, 2007). Further, the ongoing pain, fatigue and psychological factors associated with FMS cause some people with it to decondition over time and become increasingly disabled as a result of moving their bodies less in all aspects of their lives (Karper, 2011). Therefore, preventing deconditioning and simply maintaining ones level of physical fitness over time is a positive accomplishment and can positively affect the maintenance of activities of daily living. On average and from a functional perspective, these two men appeared to remain about the same over the years concerning overall fitness and psychosocial scores. They improved on some measures and declined on others.
It is common knowledge among health professionals that fitness levels decline with age, especially when people do not regularly participate in physical activity Men the same ages as these two participants, without FMS, would likely be expected to decline to a certain degree relative to their fitness levels over a 4-year period. Common diseases/disorders of older age would have a negative impact. Consequently, the results from this study are viewed as positive. Globally, both these men appear to be functioning very well with their FMS. It would be helpful if more exercise data on men with FMS were available to make comparisons and confirm the appearance of positive findings here. There is no way to know whether the improvement or decline of certain fitness components would be expected. In this regard, more data are needed.
This two-case investigation cannot be representative of a larger population of men with FMS, but it does demonstrate that selected men with FMS, just like certain healthy men in the general population, can successfully continue in a long-term exercise program at least 3 days per week. This is important preliminary information because there does not appear to be any other published long-term data available confirming this in men with FMS. As a result, health-related professionals working with men who have FMS might doubt the potential efficacy for this type of intervention. That may be a mistake. Also, it will be important for future researchers interested in FMS/exercise to investigate which personal (physical and emotional), social, and/or environmental characteristics are predictive of perseverance in this regard.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.