Comparison on muscle strength, aerobic capacity and ... · muscle strength was lower than the...

ARTIGO ORIGINAL: Biehl-Printes, C. et al (2019) Comparison on muscle strength, aerobic capacity and respiratory function in women with fibromyalgia, 8 (1): 141 – 159

JOURNAL OF AGING AND INNOVATION, ABRIL, 2019, 8 (1) ISSN: 2182-696X http://journalofagingandinnovation.org/ 141

Comparison on muscle strength, aerobic capacity and respiratory function in women with fibromyalgia

Comparação na força muscular, capacidade aeróbia e função respiratória em mulheres com fibromialgia

Comparación en la fuerza muscular, capacidad aeróbica y

función respiratoria en mujeres con fibromialgia Biehl-Printes Clarissa1, Tomas-Carus Pablo2, Pessoa Fernando3, Branco Jaime C.4, Parraca José A.5, Lancho Carolina 6

Poblador María S.7, Lancho José L.8

1Ph.D, Laboratorio de Ciencias Morfofuncionales del Deporte, Departamento de Ciencias Morfológicas, Facultad de Medicina Universidad de Córdoba, España, Instituto de Geriatria e Gerontologia, Pontifícia Universidade Católica do Rio Grande do Sul, Brasil 2Ph.D, Departamento de Desporto e Saúde, Escola de Ciência e Tecnologia, Universidade de Évora, Portuga, Comprehensive Health Research Center (CHRC), University of Évora, Portugal. Research Centre in Sports Sciences, Health Sciences and Human Development (CIDESD), Portugal 3Ph.D Centro Universitário do Serviço Nacional de Aprendizagem Industrial,SENAI CIMATEC, Brasil 4MD, Ph.D, CEDOC, Faculdade Ciências Médicas, Universidade Nova de Lisboa, Serviço de Reumatologia, CHLO, EPE-Hospital Egas Moniz, Lisboa, Portugal. 5Departamento de Desporto e Saúde, Escola de Ciência e Tecnologia, Universidade de Évora, Portuga; Comprehensive Health Research Center (CHRC), University of Évora, Portugal.

6 MD Clínica ASPACE.Donostia-San Sebastian. España. 7MD, Ph.D , Laboratorio de Ciencias Morfofuncionales del Deporte, Departamento de Ciencias Morfológicas, Facultad de Medicina Universidad de Córdoba, España

8 MD, Ph.D Laboratorio de Ciencias Morfofuncionales del Deporte, Departamento de Ciencias Morfológicas, Facultad de Medicina Universidad de Córdoba, España

Corresponding Author: [email protected]

Abstract

Objective: To compare two workout programs: the mode aerobic-breath to the mode combining aerobic-strength-breath, in order

to know the effects in the strength, aerobic fitness and respiratory function of women with fibromyalgia (FM) after a period of 24

weeks.

Methods: A prospective longitudinal study using two groups of women with fibromyalgia has been conducted. Nine participants

were monitored with regular exercise in the mode aerobic-breath group (AbG) and eight in the mode combining aerobic-strength-

breath group (CG). Both groups were complemented with respiratory exercise through diaphragmatic breathing (DB). The

measures used in the study were: measurements at rest, maximum and submaximal oxygen consumption (VO2); maximum and

submaximal aerobic power (W); concentric isokinetic strength at 60º/s of the extensor and flexor muscles of the leg (N.m);

pulmonary function measurements by spirometry (ventilatory test) and maximum respiratory pressures (MRP).

Results: Significant improvements in aerobic condition, strength and respiratory function were obtained by both groups. Initially

the participants AbG vs. CG presented decreased aerobic condition (20-24 ml/kg/min). The range of functional normality of the

strength for the classification of the Freedson percentile was reduced (≤ 10). Even discarding respiratory diseases, the respiratory

muscle strength was lower than the values predicted for healthy people. Over the 24 weeks, there were no differences between

AbG vs. CG in aerobic and respiratory exercises. The differences were mostly observed in the results of strength.

Biehl-Printes, C. et al (2019) Comparison on muscle strength, aerobic capacity and respiratory function in women with fibromyalgia, 8 (1): 141 – 159

Artigo Original

mailto:[email protected]



Conclusion: Our results suggest that intervention programs may be supplemented with respiratory exercises. However, new

studies with longer-term programs are required to compare the absolute impact of different workouts. It is also mandatory to know

if the isolated practice of respiratory exercises has any applicability for patients with FM.

Key words: aerobic training, combined training, breathing exercise, fibromyalgia.

Resumo

Comparar dois treinos, um no modo aeróbio-respiratório e outro no modo combinado: aeróbio-força-respiratório, para conhecer

os efeitos na força muscular, capacidade aeróbia e função respiratória de mulheres com fibromialgia depois de um período de

24 semanas.

Métodos: Se realizou um estudo longitudinal prospectivo utilizando dois grupos de mulheres com fibromialgia. Nove participantes

foram monitoradas com o exercício regular aeróbio-respiratório (AbG) e oito no modo combinado: aeróbio-força-respiratório (CG).

Ambos foram complementados com exercicio respiratório a través de respiração diafragmática (RD). As medidas utilizadas foram:

medidas em repouso; consumo máximo e submáximo de oxigénio (VO2); potência aeróbia (W) máxima y submáxima; força

isocinética concéntrica a 60º/s dos músculos extensores y flexores da perna (N.m); medidas de função pulmonar por espirometria

(prova ventilatória) e pressões máximas respiratórias (PMR).

Resultados: Melhoras significativas na condição aeróbia, na força e na função respiratória foram obtidas por ambos os grupos.

Inicialmente os participantes AbG e CG apresentaram diminuída condição aeróbia (20-24 ml/kg/min). A escala de normalidade

funcional da força para a classificação do percentil de Freedson foi diminuído (≤ 10). Mesmo descartando patologias respiratórias,

a força muscular respiratória foi inferior a aos valores previstos para as pessoaos saudáveis. Ao longo de 24 semanas não se

observou diferenças entre os tipos de treino AbG vs CG no exercício aeróbio e respiratório. As diferenças foram mostradas em

grande parte dos resultados da força.

Conclusão: Nossos resultados sugerem que os programas de intervenção sejam complementados com exercícios respiratórios.

No entanto, novos estudos com programas a mais longo prazo são necessários para comparar o impacto absoluto dos diferentes

treinos. Igualmente, é necessário saber se a prática isolada de exercícios respiratórios tem alguma relevância em pacientes com

FM.

Palavras chaves: Treino aeróbio, treino combinado, exercício respiratório, fibromialgia.

1. Introduction

Fibromyalgia (FM) is a rheumatologic disorder characterized by widespread muscle

pain and tenderness of at least 11 of 18 specific tender points (Wolfe et al., 1990) usually

accompanied by a wide spectrum of symptoms such as: morning stiffness, fatigue, non-

restorative sleep, mood alterations and poor health-related quality of life (HRQoL) (Silverman,

Harnett, Zlateva & Mardekian, 2010; Segura-Jiménez, 2015). In addition, the population with

this disorder presents deterioration of articular amplitude, muscular resistance and strength

likewise below average cardiovascular fitness levels (Busch, Schachter, Overend, Peloso &



Barber, 2008). The deterioration of respiratory function is also described as a common feature

in these patients (Forti, Zamunér, Andrade & Silva, 2016).

The necessity of the recovery of the physical components of strength, aerobic fitness

and flexibility is supported by literature and associated to relieving symptoms like pain and

fatigue (de Bruijn et al., 2011). The decrease in respiratory muscle function, as it has been

described, is an important component which also needs to be explored in therapeutic physical

recovery (Sahin, Ulubas, Calikoglu & Erdogan, 2004). The respiratory alterations may

exacerbate the symptoms of fibromyalgia and chronic fatigue syndrome, including the

aggravation of these diseases (Uveges et al., 1990).

Proliferating studies on FM have contributed to disclose different clinical trials through

exercise and have showed interest in dose-response, impact on functionality, symptoms and

adherence (García-Hermoso, Saavedra & Escalante, 2015). On the other hand, along the last

years, the comparison between models of intervention exercise has been little approached.

One single review study with FM compared several clinical trials using different types

of exercise, but the investigation did not describe the direct comparison of aerobic exercise

(AE) vs. combined exercise (Aerobic and Strength); and did not include breathing exercises

as a supplement or isolated intervention (Valim, 2006). The combination of a 20-week

progressive program including strength and aerobic exercises was described as a secure

application, well tolerated and effective manner to improve the functional status of women with

FM (Rooks, Silverman & Kantrowitz, 2002). A more recent study, which adopted a program of

24-weeks, did a direct comparison between aerobic and combined exercises (aerobic, strength

and flexibility) taking into account the time-program. The authors reported that women with FM

gained additional health benefits when engaged in a combined exercise program (Sañudo et

al., 2010). The breathing exercises were recommended as complements in multi-modal, mind-

body yoga or water-based programs, all aiming at the improvement of symptoms such as pain,

anxiety and relaxation (Ayan, 2009; Carson, 2010; Ide, Laurindo, Rodrigues‐Júnior & Tanaka,

2008). The effectiveness of the response to respiratory muscle training was not directly

assessed.

The latest reviews are interested in the most accurate exercise prescription and in its

impact on functional status, symptom reduction and permanence in the workout programs

(Busch, Schachter, Overend, Peloso & Barber, 2008; Bidonde, Jean Busch, Bath &

Milosavljevic, 2014). The comparison between different types of programs that explore and

add new interventions seems a gap yet to be explored in these patients. The objective of this

study was to compare different types of exercise programs used in FM and to know their effects

phisiological on muscle recovery, aerobic fitness and respiratory function over a 24-week

period.



Material and method

Participants

All members of a local FM association in Portugal were invited to participate in the

study. Thirty-nine potentially eligible subjects searched for more information, twenty persons

signed a written consent to participate in the study. Inclusion criteria were: i) women who were

diagnosed with FM according to the American College of Rheumatology criteria (Wolfe et al.,

1990; Wolfe et al., 2010), ii) sedentary for more than six months, and iii) aged between 35 and

55 years old. Exclusion criteria were: i) other diseases that could prevent physical loading, and

ii) who has attended other physical therapy in the last 6 months. These 20 female were

distributed either to an aerobic-breath group (AbG; n=10) or combined group – aerobic-

strength-breath (CG; n=10). From the 20 participants, one of AbG and two of CG were

excluded leaving voluntarily or failure to attend 80% of the exercise sessions. Finally, 9

participants from the AbG and 8 participants from the CG fully completed the study protocol

and their results were included in the analysis. The study was approved by the Committee on

Biomedical Ethics of the University of Córdoba and followed the updates of the Declaration of

Helsinki.

Procedure

Each participant performed the physical tests in two sessions. The order of application

was the same from the beginning to the end of the 24-week intervention. The first session was

divided in: lung function test (1) and cardiorespiratory exercise test (2) (CPET). After an interval

of 48 hours for recovery, the second session was performed by using a strength test (3).

Materials and measures

Lung function test was assessed by global body plethysmography Masterlab (Medizintechnik

mit System Erich Jaeger Gmbh®, Wuerzburg, Germany), with a specific software and

complying with the standards of the ERS and ATS. Conventional pulmonary function test was

used, based on the determination of the Spirometry (ventilatory proof) and Maximal

Respiratory Pressure (PMR). The spirometry was used as a diagnostic evaluation with the aim

to exclude additional diseases. The monitored parameters were: forced vital capacity (FVC),

maximum expiratory volume in the first second (FEV1), Tiffeneau index = FEV1/FVC, ratio and

maximal expiratory flow at 50% of FVC (MEF50). In the study of muscular efficiency, three

parameters were monitored: the maximal inspiratory pressure (MIP), maximal occlusion

pressure (P0.1 max) and maximal expiratory pressure (MEP). Basically, a high MIP (> - 80

cmH2O = 7.85Kpa) or a MEP high (> 90 cmH2O = 8.80Kpa) excludes inspiratory or expiratory

weakness as clinically important. The measurement of P0.1 max. is used because it is more



specific and is not affected by external interference. A minimum of 5 attempts was carried out

to demonstrate a consistent effort, being two of these maximum reproducible manoeuvres (i.e.

that were not different among themselves more than 5%) (ATS/ERS, 2002). The predicted

values for healthy persons were calculated according to sex, age and height (Wilson, Cooke,

Edwards & Spiro, 1984). This calculation was performed by global body plethysmography

Masterlab software (Medizintechnik mit System Erich Jaeger Gmbh®).

Cardiopulmonary test was evaluated by cardiopulmonary exercise test (CPET) in a cycle-

ergometer (oxy-ergometry) with direct determination of VO2 and blood gases.

It was used an electromagnetic bicycle ergometer JAEGER (0-600 Watt), an

electrocardiograph 12-channel, a sphygmomanometer, a microanalyser equipment blood

gases Radiometer ABL 5 and a set ergo-spirometric computerized Oxicon Pró - JAEGER

(RFA) for the registration of volumes and ventilatory debits by pneumatocagrofia open circuit

(Medizintechnik mit System Erich Jaeger Gmbh®, Wuerzburg, Germany). The parameters that

were used for this study were: the measurements at rest, the submaximal and maximum

oxygen consumption (VO2) and the submaximal and maximal of aerobic power (W). The

Wassermann incremental protocol was adopted in cycle ergometer (Wasserman, Van Kessel

& Burton, 1967). The level of aerobic fitness for women according to age – VO2max (ml/kg/min)

is based on the classification of the American Heart Association – AHA reference (American

College of Cardiology & American Heart Association, 2000). The predicted values for healthy

people were calculated by specific software.

Strenght Test was evaluated by isokinetic dynamometer (Biodex, System 3, NY, U.S.A.) to

measure isokinetic concentric strength of knee flexion/extension (N.m). The participant was

positioned according to the instructions established for this equipment by Biodex Medical

System. The test was preceded by 5 minutes of warming of the lower limbs on a bicycle

(Monark) at 60 rpm and load regulation at 2% of total body weight. Moreover, before testing

the participants, there was still a previous period of familiarization with the dynamometer. For

the test interpretation, we evaluated the absolute values of the peak torque (N.m): three

repetitions at 60º/s. The Freedson classification to the degree of muscular strenght to 60º/s

(low) was applied (Zeevi, 2002).

Exercise intervention

Aerobic-breath group (AbG). The exercise program consisted of 3 weekly sessions of 60

minutes for 24-weeks. Each session included 30 minutes of aerobic exercise divided in static

bicycle and treadmill. The intensity of aerobic exercise was individualized by power

measurements (W) and heart rate of the anaerobic threshold (HR-AT) obtained through CPET

with controlled speed between 50 and 60 RPM (revolutions per minute). After aerobic training,



joint mobilization exercises, stretches of major and the most contracted muscle groups were

held. The workout ended with breathing exercises.

Combined group (CG). Combined exercise: aerobic-breath-strength training. The program

consisted of 3 weekly sessions of 60 minutes. Each session included 30 minutes of aerobic

exercise divided alike in static bicycle and treadmill. The intensity was also individualized

through the measures of power (W) and anaerobic threshold (HR-AT) obtained CPET and the

same 50 and 60 RPM. After and following aerobic exercises, it was combined strength

exercises (muscular resistance) for 15 minutes in two of the three-day programs. This research

complied with the recovery of 48 hours recommended. The strength exercises were carried

out on bodybuilding machines for the large muscle groups of the trunk, with upper and lower

limbs, based on guidelines suggested in the bibliography for fibromyalgia (Jones, Clark &

Bennett, 2002). The measurements of the lower limbs were selected to analyse and interpret

the results of this experiment. The CG patients also ended with breathing exercises.

Breathing exercises (carried out in both groups): At the end of each session, the exercise

programs were completed with 15 minutes of breathing exercises (Goldstein, 1997). This

consisted in five exercises (3 minutes for each) which were performed in the form of a circuit:

an exercise on awareness of breathing, an exercise on costal expansion, and three

diaphragmatic breathing exercise (Biehl-Printes & Costa, 2006).

Statistical analysis

Normality and homogeneity of variance of data were initially tested using the Shapiro-

Wilke and Levene tests, respectively. The statistical significance between groups was

evaluated using non-parametric Mann-Whitney test to compare independent samples, in

baseline (M0), in 24-week (M1). Wilcoxon test was implicated to compare paired data before

and after intervention (M0-M1) and also to compare the values of ventilatory parameters,

maximum respiratory pressures and VO2max with predicted values calculated for healthy

persons. The relationships between the selected variables were assessed by the Spearman

test. The effect size (ES) analysis for all outcomes that did not achieve statistical significance

was conducted using Cohen interpretation (< 0.5 small, 0.5 - 0.8 average, and > 0.8 large)

(Sullivan & Feinn, 2012). For all tests it was considered a significance level < 0.05. The

analyses were performed using SPSS v.22.0 (IBM, New York, USA).

Results

Baseline data did not show any significant differences in characteristics

Table 1. Characteristics of females with fibromyalgia at baseline.



Table 1. Values expressed as mean ± standard deviation. P-values of Mann-Whitney test to

compare differences between groups in baseline. AbG: aerobic-breath group (n=9); CG:

combined group (n=8). Considered a significance level < 0.05

between groups (table 1). nor in ventilatory parameters compared to predicted values

calculated for healthy people used to exclude respiratory diseases (figure 1).

Figure 1: Ventilatory parameters used as a diagnostic to exclude respiratory diseases in

baseline. Values of forced vital capacity (FVC), maximum expiratory volume in the first second

(FEV1), FEV1/FVC ratio, and maximal expiratory flow at 50% of FVC (MEF50) in women with

fibromyalgia syndrome and predicted values for healthy persons calculated according to sex,

age and height in software (Medizintechnik mit System Erich Jaeger Gmbh®, Wuerzburg,

Germany). Values expressed as mean. AbG: aerobic-breath group (n=9); CG: combined group

AbG CG P

Age (years) 49.0 ± 6.3 46.1 ± 5.8 0.435

Weight (kg) 64.2 ± 7.5 60.5 ± 7.7 0.520

Height (m) 1.57 ± 0.05 1.55 ± 0.03 0.260

Body mass index (kg/m2) 26.1 ± 3.5 25.2 ± 3.3 0.873

Number of tender points (scale 1-18) 16.3 ± 2.1 17.0 ± 1.8 0.181

Duration of condition (years) 12.1 ± 10.6 10.8 ± 7.3 0.747

Diagnostic (years) 4.0 ± 1.1 5.1 ± 1.9 0.204

Number of specific drugs (antidepressives,

muscular relaxants, analgesics)

2.2 ± 1.8 2.8 ± 2.1 0.870



(n=8). P-value of Wilcoxon test; n.s. = not significant differences. It was considered a

significance level < 0.05.

In (table 2) significant differences were detected in MIP and P0.1 max in favour of

predicted values calculated for healthy persons. Additionally, no significant differences in

baseline data for muscular efficiency of the MRP between AbG and CG. After 24-weeks MIP

and P01 max were significant in both groups. There were not observed any significant

differences between groups for these variables. The effect size was small in most of the

variables (ES <0.5). For MEP no significant difference was observed. Moreover, the significant

correlations were shown between P0.1 max and MIP in baseline (r = 0.61; p = 0.030) and week

24 (r = 0.60; p = 0.030).

Table 2. Maximal respiratory pressures in women with fibromyalgia syndrome at baseline and after 24 weeks of intervention.

Baseline (M0)

Week 24 (M1)

Effect Size Cohen´s d

AbG CG AbG CG †P AbG

†P CG

¶P

M0

¶P

M1

(M0-M1) AbG

(M0-M1) CG

M0 M1

MIP (kPa) 5.2 ±

1.7

4.3 ±

0.9

6.3 ±

1.2

5.8 ±

1.5

.027 .027 .521 .748 N.A. N.A. 0.59 0.33

MIP (kPa) 11.0 ±

0.0

11.0 ±

0.0

11.0±

0.0

11.0±

0.0

.027 .027 N.A. N.A. N.A. N.A. N.A. N.A.

MEP (kPa) 5.8 ±

1.4

6.6 ±

2.5

5.9 ±

1.8

7.0 ±

3.2

.753

.345 .872 .471 0.06 0.12 0.35 0.38

MEP (kPa) 7.2 ±

0.6

7.7 ±

0.3

7.2 ±

0.6

7.7 ±

0.3

.115 .173 N.A. N.A. N.A. N.A. N.A. N.A.

P0.1max

(kPa)

1.1 ±

0.4

1.4 ±

0.72

1.6 ±

0.7

2.4

±

0.7

.043

.027 .423 .128 N.A. N.A. 1.13 0.89

P0.1 max

(kPa)

7.6 ±

0.0

7.7 ±

0.0

7.6 ±

0.0

7.7±

0.0

.027

.027 N.A. N.A. N.A. N.A. N.A. N.A.

Table 2. Values expressed as mean ± standard deviation. P-values of Wilcoxon test to

compare differences within group after 24 weeks of intervention and to compare the values

maximum respiratory pressures with predicted values calculated for healthy persons.

P-values of Mann-Whitney test to compare differences between groups in baseline (M0) and

week 24 (M1). M0-M1: effect size within group; M0: effect size between groups in baseline;

M1: effect size between groups in week 24; (ES>0.8): N.A: not applied. Parameters: MIP:



maximum inspiratory pressure; MEP: maximum expiratory pressure; P0.1max: maximum

occlusion pressure and MIP; MEP; P01max predicted values to health persons calculated

according with software (Medizintechnik mit System Erich Jaeger Gmbh®, Wuerzburg,

Germany). AbG: aerobic-breath group (n=9); CG: combined group (n=8). Considered a

significance level < 0.05.

In (Table 3) at baseline, each group has physiological parameters within normal limits, as well

the basal rate shows no significant differences. After 24-weeks, differences (p <0.05) were

found in the oxygen consumption by both groups on the aerobic-anaerobic transition i.e.

anaerobic threshold (VO2AT) at maximum VO2max (ml/min), VO2max (ml/kg/min) and in the

% VO2max. The power (W) was significant in either group. There were no significant

differences between groups for these variables. The effect size was small in most of the

variables (ES <0.5).

Table 3. Oxygen consumption, and power in women with fibromyalgia syndrome at baseline and after 24 weeks of intervention.

Baseline (M0) Week 24 (M1)

AbG

CG AbG CG †P AbG †P CG

¶P M0 ¶P M1

(M0-

M1) AbG

M0-M1) CG

M0 M1

VO2 basal

(mL/min)

198.5±50.

4

219.0±72.2 239.5±80.2 264.5±83.0 .086 .057

.287 .260

0.55

0.52

0.31 0.27

VO2AT

(mL/min)

1051.5±

204.5

1017.6±116.

7

1210.3±172 1264.8±170.

6

.013 .013

.436 .131

N.A.

N.A.

-0.18

0.28

VO2Max

(mL/min)

1330.8±

225.6

1428.1±

101.5

1497.0±141

.3

1628.3±143.

9

.013 .013

.186 .039

N.A.

N.A.

0.50

N.A.

VO2Max

health persons predicted (mL/min)

1461.1±

186.4

1525.3±

111.2

1423.5±

182.7

1537.6±97.1 .053 .102

N.A. N.A.

N.A

N.A

.

N.A.

N.A.

VO2Max (mL/kg/mi

n)

20.6± 3.3 24.4± 5.0 24.3± 3.4 27.1± 4.4 .027 .027

.200 .298

N.A.

N.A.

0.80

0.64

%VO2

Max 91.1%±

12.3

94.1± 11.3 106.6± 12.1 106.5± 13.7 .013 .013

.344 .436

N.A.

N.A.

0.23 -0.01

W-AT 44.0±11.4 45.0±10.

5

60.0±4.5 63.0±5.

2

.033 .013

.374 .315

N.A.

N.A.

0.08

0.55



W-Max 59.5±9.6 60.3±5.2 80.0±8.2 83.3±10.

3

.03

3

.01

3

.315 .189

N.A.

N.A.

0.09 0.32

Table 3. Values expressed as mean ± standard deviation. †P-values of Wilcoxon test to compare differences within group after 24 weeks of intervention and to compare the values VO2 max (mL/min) with predicted values VO2 max (mL/min) calculated for healthy persons. ¶P-values of Mann-Whitney test to compare differences between groups in baseline (M0) and week 24 (M1). M0-M1: effect size within group; M0: effect size between groups in baseline; M1: effect size between groups in week 24; (ES>0.8); N.A.: not applied. Parameters: Oxygen consumption (VO2): Oxygen consumption basal (VO2 basal), Anaerobic Threshold (VO2AT), Maximal oxygen consumption in absolute values VO2 max (mL/min), Maximal oxygen consumption for health persons predicted (VO2 max health persons) calculated by specific software. Maximal oxygen consumption in relative values VO2 max (mL/(kg/min), Percentage maximal oxygen consumption VO2Max/VO2Max health persons predicted (%VO2 max); Power (W) in Anaerobic Threshold (W-AT), Watts in Maximal (W-Max); In the AbG: aerobic-breath group (n=9); CG: combined group (n=8). Considered a significance level < 0.05.

In (Table 4) it is seen that both groups show significant differences in the strength after

24- weeks. In the M1, in the majority of the results significant differences were found (p <0.05)

between the groups. The effect size was medium on right extensors and flexor 60°/s. The level

of classification of the normative values (N.m) of Freedson was initially low with evolution no

more than an percentile of 50 after 24 weeks.

Table 4. Isokinetic concentric strength of knee flexion/extension and normative values in women with fibromyalgia syndrome at baseline and after 24 weeks of intervention.

Baseline (M0)

Week 24 (M1)

Effect Size Cohen´s d

AbG CG AbG CG †P AbG

†P CG

¶P

M0

¶

P

M

1

(M0-M1)

AbG

(M0-M1)

CG

M0

M1

Right leg strength Extensors 60°/s Percentile Freedson (10-30-50-70- 90)

90.3

5±2

0.6

<10

102.23±1

7.23

10

102.71±25

.99

10

118.7±18.

33

30

.013

.013

.168

.168

N.A.

N.A.

0.56

0.64



Right leg strength Flexors 60°/s Percentile Freedson (10-30-50-70- 90)

46.6

1±8.

22

<10

55.23±13

.32

<10

55.23±13.

32

<10

65.33±9.41

10

.013

.13 .078

.100

N.A.

N.A.

N.A.

0.78

Left leg strength Extensors 60°/s Percentile Freedson (10-30-50-70- 90)

90.5

3±2

2.20

<10

105.66±1

6.78

10

99.86±23.

22

10

122.87±21

.22

50

.013

.013

.100

.027

N.A.

N.A.

0.69

N.A.

Left leg strength Flexors 60°/s Percentile Freedson (10-30-50-70- 90)

43.9

8±1

0.92

<10

55.11±5.

88

<10

52.25±12.

56

<10

65.99±7.2

3

10

.013

.013

.051

.027

N.A.

N.A.

N.A.

N.A.

Table 4. Values expressed in N.m (mean ± standard deviation). †P-values of Wilcoxon test to compare differences within group after 24 weeks of intervention. ¶P-values of Mann-Whitney test to compare differences between groups in baseline (M0) and week 24 (M1). M0-M1: effect size within group; M0: effect size between groups in baseline; M1: effect size between groups in week 24; (ES>0.8); N.A.: not applied. Normative value Freedson. AbG: aerobic-breath group (n=9); CG: combined group (n=8). Considered a significance level < 0.05.

Discussion

In the last 25 years aerobic exercise and strength training has been strongly

recommended for the management of FM (Busch et al., 2011). The respiratory disorders,

identified as a common factor for these individuals, is attributed to a dysfunction of the

respiratory muscles much associated with the diaphragm (Lurie, Caidahl, Johansson &

Bake,1990; Sahin, Ulubas, Calikoglu & Erdogan, 2004). Despite this, the literature is still

scarce about the effects of respiratory intervention on these patients. In this sense, the present

study showed that patients with FM recover in 24 weeks the functional performance in

traditional physical components, aerobic fitness, strength and respiratory function, without

differences between the programs.

Symptoms such as tiredness, fatigue and non-restorative sleep directly influence the

functional response of people with FM, impairing the carrying out the activities of daily living

(ADLs) (Huijnen, Verbunt, Meeus & Smeets, 2015). Still associated with this low capacity of

strength and resistance aerobic, the limitations in respiratory muscle function interfere in the

best performance of cardiorespiratory function (Pamplona & Morais, 2007). Therefore, seems

more prudent a guideline of exercise focused on the simultaneous recovery of diminished

parameters through a combination of these elements than interventions in isolation.



As reported in other studies with combined training (aerobic strength) in patients with

FM, this study also shows significant evidence through the combined program in mode

gradually and progressively (Rooks, Silverman & Kantrowitz, 2002). Studies on the strength

production of the lower limbs with isokinetic assessment in patients with FM also reported a

reduction of this capacity and indicated these patients have this function impaired (Tomas-

Carus et al., 2009). According with these authors, the present study shows that participants

with FM have the muscle strength in the lower limbs decreased relatively to baseline. This is

confirmed according to Freedson's percentile as the FM participants have this decreased

functional condition, in both extension and flexion of the knees 21. After the interventions, the

improvements are remarkable, the normative level is increasing up to 50 of the percentiles as

can be seen by the greater expressiveness of the results in CG. The muscle strengthening

through the resistance muscle training appears as the most effective method for the recovery

of muscle strength and has been described by many health organizations for the improvement

of health and muscular conditio (Pollock et al., 1998). The extensor and flexor muscles of the

knees play a determining role in the stability of the body and locomotion. The use in the slow

and fast walking, climbing stairs and raising from a chair has been well documented in studies

kinematics, electromyography and kinetic analysis (Collado-Mateo et al., 2016). It also has

been considered essential to enable the activities of daily living in patients with FM (Tomas-

Carus et al., 2009). The effect of strength exercises applied to the lower limbs of CG caused

an increase in muscle strength contributing to better performance on tasks such as locomotion,

crouch down and up and down stairs.

On the other hand, another aspect that has been described in patients with FM and

elderly is the consequence of the reduced muscle mass associated with the alterations in

energy metabolism and aerobic capacity which predisposes the weakness and atrophy that

leads the condition of increased risk of falls (Jones, Horak, Winters, Morea & Bennett, 2009;

Lord, Ward, Williams & Strudwick, 1995). In this sense, un low aerobic capacity were assessed

in the present study, which showed that both groups presented alterations, both at the

submaximal level and at the maximum level of the evaluated parameters. In the basal rate

there was an improvement in the availability of oxygen but expressionless in the statistical

level. Therefore, the measurement of the maximum oxygen uptake (VO2max), which

corresponds to the maximum aerobic capacity of each individual, is the estimated parameter

that best reflects the capacity of the cardiocirculatory and respiratory systems, and more

specifically, the performance of the system for collecting, transport and peripheral utilization

O2 (American College of Cardiology & American Heart Association, 2000). Indeed, these

results corroborate with other studies based on the American Heart Association (AHA)

classification, which described that most FM patients is below average levels of conditioning,



as well as the maximum oxygen consumption and the decreased anaerobic threshold are

attributed to the consequences of physical inactivity, pain or fatigue (Pollock et al., 1998; Valim

et al., 2002). Additionally, as also has been prized and recommended by the literature the use

of submaximal parameters for the assessment and exercise prescription (Valim, 2006; Valim

et al., 2002). As such, the criteria for classification of participants with FM in this study were

initially low, classified as steady (24 ml/kg/min) to the CG and weak (20 ml/kg/min) to AbG.

The CPET were suspended in all participants due to early muscle fatigue. The results obtained

in the CPET show that in the baseline the physiological tolerance of the FM participants is

normal to the effort. The average value of VO2max is within the normal range for either group,

i.e, above 84% of VO2max (Saltin & Rowel, 1980). Concluding that, the functional capacity of

the organism involved in O2 transport system and the use of peripheral muscles is normal or

that those small non-relevant changes that exist would be compensated by intervention. This

includes the normality respiratory system (ventilation, diffusion capacity, exchanges of

alveolar-capillary gases and pulmonary circulation) from the heart (HR and Systolic Volume)

of the circulation (blood vessels and hemoglobin concentration) and the ability of the skeletal

muscles to remove enough O2 during exercise.

In sedentary individuals changes in aerobic condition are expected when they are

subjected to an exercise program for a period of 6 months, 3 times / week, 30 min / day and

the intensity of 75% VO2max (Pollock, 1973). The established aerobic training for both groups

showed significant evidence for obtaining VO2max. This response was most evident in CG. In

accordance with the proposed of training aerobic for patients with FM, based on submaximal

measures, a greater effect of gains was obtained in the anaerobic threshold of VO2 (VO2AT)

than in the maximum level (VO2max) in both groups. Studies of sedentary individuals and

patients with FM have demonstrated that lactic anaerobic threshold can increase with training,

even without significant changes in VO2max (Saltin & Rowel, 1980; Denis, Fouquet, Poty,

Geyssant & Lacour, 1982). The significant increase in the VO2AT obtained in both groups adds

value to submaximal training and shows the positive effect of this. Once interested in the

impact of submaximal training on fitness of the lower limbs, it is also important to highlight the

changes in aerobic power (W) in both groups. Basically, in the analysis of oxygen consumption

the CG shows a tendency to be more effective than AbG in 24 weeks. The results obtained in

the study of aerobic condition were important because it enabled the accomplishment of most

activities of daily living (ADLs) in aerobiosis. This way and through regular training the pain

caused by physical effort may be excluded in moderate AVD.

The respiratory function associated with physical intervention in patients with FM has

been a shortcoming in physical activity programs of non-pharmacological treatment. Although

there nearly three decades of conclusions on respiratory muscle weakness in these patients,



it was shown little besides characteristics of these parameters (Lurie, Caidahl, Johansson &

Bake, 1990; Sahin, Ulubas, Calikoglu, & Erdogan, 2004).

Considering the set of physical disorders in FM, this study considered relevant

integration of breathing exercises aiming to develop conditions to better explore the effect of

aerobic training. The re-education of breath of a person interferes directly in the work and

action of the respiratory muscle. The MRP have been used for assessing the respiratory

muscle strength in patients with FM, showing that these patients have lower MIP and MEP

values, which may indicate respiratory muscle dysfunction, including the diaphragm muscle

(Forti, Zamunér, Andrade & Silva, 2016; Printes, 2012).

However, the influence of a possible mechanism related to the central brainstem

should not be completely eliminated (Green, 2002). This study showed lower MIP and MEP

values in these patients. In this sense, the test of spirometry was initially conducted to rule out

any pathology superimposed. Thus, as shown in other studies, ours also showed that the

parameters analysed for ventilator exclude the possibility of respiratory pathology (Forti,

Zamunér, Andrade & Silva, 2016; Sahin, Ulubas, Calikoglu, & Erdogan, 2004).

The previous literature reported that factors such as motivation and cooperation of

patients may affect maximal respiratory pressures measurements (ATS/ERS, 2002; Vincken,

Ghezzo & Cosio, 1987). In this sense the use of plethysmografhy provides the measure of

occlusion maximum pressure of air in the airways using 0.1 second (P0.1 max), measure that

is not influenced by cooperation or motivation of the patient and has been explored in studies

of respiratory function as a complement of MIP and MEP (Vincken, Ghezzo & Cosio, 1987;

Burki, Mitchell, Chaudhary & Zechman, 1977). According to these bases, our study showed

significant correlation between MIP and P0.1 max in baseline (r=0.61) and after 24 weeks of

intervention (r=0.60), which could rule out any effect related to lack of motivation of patients in

the measurements. Furthermore, the influence of the factor learning effect was excluded for

having complied accurately with the conventional protocol of the European Respiratory Society

(ERS) (ATS/ERS, 2002).

In the present study, differences for MIP were observed between participants with FM

and predicted values calculated for healthy persons. The respiratory muscle training focused

on the DB uses exclusively the muscle diaphragm (abdominal wall), reducing the movement

of upper thoracic region, with a normal tidal volume and passive expiration (Goldstein, 1997;

Biehl-Printes & Costa, 2006). Thus, our results indicate that the respiratory muscle training DB

could also be useful for improving respiratory muscle strength and tolerance to exercise in

patients with FM, as already proved for patients with asthma and subjects with subacute stroke

(Burgess, Ekanayake, Lowe, Dunt, Thien & Dharmage, 2011; Sutbeyaz, Koseoglu, Inan &

Coskun, 2010). As suggested in the few studies of respiratory function in FM patients, the



present study corroborates and proposes that PMR values are attributed to probable muscle

weakness of the respiratory muscles due to lack of use (Forti, Zamunér, Andrade & Silva,

2016; Sahin, Ulubas, Calikoglu, & Erdogan, 2004; Lurie, Caidahl, Johansson & Bake, 1990).

The present study also included limitations which require further discussion. The limited

size of the sample may have contributed to lower statistical power to detect changes in some

variables. Nevertheless, the most variables measured that did not show positive effects

presented a small effect size (<0.5). The lack of difference after 24 weeks of different trial of

exercise, AbG vs. CG, is attributed to the introduction of the training mode: “gradual and

progressive”. We emphasize the importance of following the initial procedure indicated to

preserve the security, adaptation, comfort and furthermore ensure adhesion and permanency

of patients in programs (Rooks, D. S., Silverman, C. B., & Kantrowitz, F. G. (2002); Sañudo et

al., 2010; Bidonde, Jean Busch, Bath & Milosavljevic, 2014; Jones, Clark & Bennett, 2002).

In conclusion, breathing exercises applied to both groups have an impact to be

considered for rehabilitation due to the lack of studies applying the intervention of the DB as a

co-adjuvant of physical exercise in the treatment of fibromyalgia. However, new studies with

long-term programs are suggested to compare the absolute impact of different workouts, as

well as the isolated practice of breathing exercises can be considered.

References

1. American College of Cardiology, & American Heart Association. (2000). Clinical competence

statement on stress testing. J Am Coll Cardiol, 36, 1441-53.

2. Ayan, C., Alvarez, M. J., Alonso-Cortés, B., Barrientos, M. J., Valencia, M., & Martín, V.

(2009). Health education home-based program in females with fibromyalgia: a pilot study.

Journal of back and musculoskeletal rehabilitation, 22(2), 99-105.

3. Bidonde, J., Jean Busch, A., Bath, B., & Milosavljevic, S. (2014). Exercise for adults with

fibromyalgia: an umbrella systematic review with synthesis of best evidence. Current

rheumatology reviews, 10(1), 45-79.

4. Biehl-Printes C, Costa RG. (2006). Fibromialgia em movimento: prática diária de exercícios

(p. 21-26). Lisboa. (Eds) Myos – Associação Nacional Contra a Fibromialgia e Síndrome da

Fadiga Crónica.

5.Burgess, J., Ekanayake, B., Lowe, A., Dunt, D., Thien, F., & Dharmage, S. C. (2011).

Systematic review of the effectiveness of breathing retraining in asthma management. Expert

review of respiratory medicine, 5(6), 789-807.



6.Burki, N. K., Mitchell, L. K., Chaudhary, B. A., & Zechman, F. W. (1977). Measurement of

mouth occlusion pressure as an index of respiratory centre output in man. Clinical Science,

53(2), 117-123.

7.Busch, A. J., Schachter, C. L., Overend, T. J., Peloso, P. M., & Barber, K. A. (2008). Exercise

for fibromyalgia: a systematic review. The Journal of rheumatology, 35(6), 1130-1144.

8.Busch, A. J., Webber, S. C., Brachaniec, M., Bidonde, J., Dal Bello-Haas, V., Danyliw, A. D.,

... & Schachter, C. L. (2011). Exercise therapy for fibromyalgia. Current pain and headache

reports, 15(5), 358.

9.Carson, J. W., Carson, K. M., Jones, K. D., Bennett, R. M., Wright, C. L., & Mist, S. D. (2010).

A pilot randomized controlled trial of the Yoga of Awareness program in the management of

fibromyalgia. PAIN®, 151(2), 530-539.

10.Collado-Mateo, D., Adsuar, J. C., Olivares, P. R., Dominguez-Muñoz, F. J., Maestre-

Cascales, C., & Gusi, N. (2016). Performance of women with fibromyalgia in walking up stairs

while carrying a load. PeerJ, 4, e1656.

11.de Bruijn, S. T., van Wijck, A. J., Geenen, R., Snijders, T. J., van der Meulen, W. J., Jacobs,

J. W., & Veldhuijzen, D. S. (2011). Relevance of physical fitness levels and exercise-related

beliefs for self-reported and experimental pain in fibromyalgia: an explorative study. JCR:

Journal of Clinical Rheumatology, 17(6), 295-301.

12.Denis, C., Fouquet, R., Poty, P., Geyssant, A., & Lacour, J. R. (1982). Effect of 40 weeks

of endurance training on the anaerobic threshold. International Journal of Sports Medicine,

3(04), 208-214.

13.European, R. S., & American Thoracic Society. (2002). ATS/ERS Statement on respiratory

muscle testing. American journal of respiratory and critical care medicine, 166(4), 518.

14.García-Hermoso, A., Saavedra, J. M., & Escalante, Y. (2015). Effects of exercise on

functional aerobic capacity in adults with fibromyalgia syndrome: a systematic review of

randomized controlled trials. Journal of back and musculoskeletal rehabilitation, 28(4), 609-

619.

15.Green, M. (2002). Road J, Sieck GC, Similowski T. Tests of respiratory muscle strength.

Am J Respir Crit Care Med, 166(4), 528-47.

16.Goldstein RS. (1997). Inspiratory Muscle Training. In: Morgan M, and Singh S. Pratical

Pulmonary Rehabilitation (p. 99-115). United Kingdom. Chapman and Hall.

17.Huijnen, I. P., Verbunt, J. A., Meeus, M., & Smeets, R. J. (2015). Energy expenditure during

functional daily life performances in patients with fibromyalgia. Pain Practice, 15(8), 748-756.

18.Ide, M. R., Laurindo, I. M. M., Rodrigues‐Júnior, A. L., & Tanaka, C. (2008). Effect of aquatic

respiratory exercise‐based program in patients with fibromyalgia. International Journal of

Rheumatic Diseases, 11(2), 131-140.



19.Jones, K. D., Horak, F. B., Winters, K. S., Morea, J. M., & Bennett, R. M. (2009).

Fibromyalgia is associated with impaired balance and falls. Journal of clinical rheumatology:

practical reports on rheumatic & musculoskeletal diseases, 15(1),16.

20.Jones, K. D., Clark, S. R., & Bennett, R. M. (2002). Prescribing exercise for people with

fibromyalgia. AACN Advanced Critical Care, 13(2), 277-293.

21.Forti, M., Zamunér, A. R., Andrade, C. P., & Silva, E. (2016). Lung Function, Respiratory

Muscle Strength, and Thoracoabdominal Mobility in Women With Fibromyalgia Syndrome.

Respiratory care, 61(10), 1384-1390.

22.Lurie, M., Caidahl, K., Johansson, G., & Bake, B. (1990). Respiratory function in chronic

primary fibromyalgia. Scandinavian journal of rehabilitation medicine, 22(3), 151-155.

23.Lord, S. R., Ward, J. A., Williams, P., & Strudwick, M. (1995). The Effect of a 12‐Month

Exercise Trial on Balance, Strength, and Falls in Older Women: A Randomized Controlled

Trial. Journal of the American Geriatrics Society, 43(11), 1198-1206.

24.Pamplona, P., & Morais, L. (2007). Treino de exercício na doença pulmonar crónica.

Revista Portuguesa de Pneumologia, 13(1), 101-128.

25.Printes, C. B. (2012). La asociación de ejercicios de resistencia muscular localizada y su

influencia en la aptitud muscular en enfermos con fibromialgia.

26.Pollock, M. L., Gaesser, G. A., Butcher, J. D., Després, J. P., Dishman, R. K., Franklin, B.

A., & Garber, C. E. (1998). ACSM position stand: the recommended quantity and quality of

exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility

in healthy adults. Med Sci Sports Exerc, 30(6), 975-991.

27.Pollock, M. L. (1973). The quantification of endurance training programs. Exercise and sport

sciences reviews, 1(1), 155-188.

28.Rooks, D. S., Silverman, C. B., & Kantrowitz, F. G. (2002). The effects of progressive

strength training and aerobic exercise on muscle strength and cardiovascular fitness in women

with fibromyalgia: a pilot study. Arthritis Care & Research, 47(1), 22-28.

29.Sahin, G., Ulubas, B., Calikoglu, M., & Erdogan, C. (2004). Handgrip strength, pulmonary

function tests, and pulmonary muscle strength in fibromyalgia syndrome: is there any

relationship? Southern medical journal, 97(1), 25-30.

30.Saltin, B., & Rowell, L. B. (1980). Functional adaptations to physical activity and inactivity.

In Federation proceedings (Vol. 39, No. 5, pp. 1506-1513).

31.Sañudo, B., Galiano, D., Carrasco, L., Blagojevic, M., de Hoyo, M., & Saxton, J. (2010).

Aerobic exercise versus combined exercise therapy in women with fibromyalgia syndrome: a

randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 91(12), 1838-

1843.



32.Segura-Jiménez, V., Álvarez-Gallardo, I. C., Carbonell-Baeza, A., Aparicio, V. A., Ortega,

F. B., Casimiro, A. J., & Delgado-Fernández, M. (2015, April). Fibromyalgia has a larger impact

on physical health than on psychological health, yet both are markedly affected: the al-Andalus

project. In Seminars in Arthritis and Rheumatism (Vol. 44, No. 5, pp. 563-570). Elsevier.

33.Silverman, S. L., Harnett, J., Zlateva, G., & Mardekian, J. (2010). Identifying Fibromyalgia‐

Associated Symptoms and Conditions from a Clinical Perspective: A Step Toward Evaluating

Healthcare Resource Utilization in Fibromyalgia. Pain Practice, 10(6), 520-529.

34.Sullivan, G. M., & Feinn, R. (2012). Using effect size—or why the P value is not enough.

Journal of graduate medical education, 4(3), 279-282.

35.Tomas-Carus, P., Gusi, N., Häkkinen, A., Häkkinen, K., Raimundo, A., & Ortega-Alonso, A.

(2009). Improvements of muscle strength predicted benefits in HRQOL and postural balance

in women with fibromyalgia: an 8-month randomized controlled trial. Rheumatology, 48(9),

1147-1151.

36.Uveges, J. M., Parker, J. C., Smarr, K. L., McGowan, J. F., Lyon, M. G., Irvin, W. S., ... &

Hewett, J. E. (1990). Psychological symptoms in primary fibromyalgia syndrome: relationship

to pain, life stress, and sleep disturbance. Arthritis & Rheumatology, 33(8), 1279-1283.

37.Valim, V., Oliveira, L. M., Suda, A. L., Silva, L. E., Faro, M., Neto, T. L. B., ... & Natour, J.

(2002). Peak oxygen uptake and ventilatory anaerobic threshold in fibromyalgia. The Journal

of rheumatology, 29(2), 353-357.

38.Valim V. (2006). Benefits of Exercise in the Fibromyalgia. Review Article. Rev Bras

Reumatol, 46(1):49-55.

39.Vincken, W., Ghezzo, H., & Cosio, M. G. (1987). Maximal static respiratory pressures in

adults: normal values and their relationship to determinants of respiratory function. Bulletin

europeen de physiopathologie respiratoire, 23(5), 435-439.

40.Sutbeyaz, S. T., Koseoglu, F., Inan, L., & Coskun, O. (2010). Respiratory muscle training

improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke: a

randomized controlled trial. Clinical rehabilitation, 24(3), 240-250.

41.Wasserman, K., Van Kessel, A. L., & Burton, G. G. (1967). Interaction of physiological

mechanisms during exercise. Journal of Applied Physiology, 22(1), 71-85.

42.Wilson, S. H., Cooke, N. T., Edwards, R. H., & Spiro, S. G. (1984). Predicted normal values

for maximal respiratory pressures in caucasian adults and children. Thorax, 39(7), 535-538.

43.Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L.,

... & Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the

classification of fibromyalgia. Arthritis & Rheumatology, 33(2), 160-172.



44.Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American

College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of

symptom severity. Arthritis Care Res. 2010; 62:600-10.

45.Zeevi Dvir, (2002). Isokinetics Muscle testing, Interpretation and Clinical Applications (p.73-

143). United Kingdom. Churchill Livingstone.

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