Fibromyalgia (FM), also known as Fibromyalgia Syndrome, is a condition that causes widespread pain across the body, affecting 2-4% of the world’s population (Franco et al., 2023; Häuser & Fitzcharles, 2018; Silva et al., 2019). It can be challenging to manage as the pain, lack of sleep, and fatigue can make day-to-day tasks very difficult. While FM is not curable, there are many treatment options, such as exercise, that help people manage the symptoms (Altan et al.,  2009; Komatsu et al., 2016). Any form of low-intensity exercise is fantastic for clients with FM, but Pilates can be particularly helpful.

WHAT IS FIBROMYALGIA?

Fibromyalgia is a chronic disorder that amplifies musculoskeletal pain signals throughout the body, causing regions of pain (Çağlayan et al., 2023; de Medeiros et al., 2020; Silva et al., 2019). Pain is the brain’s way of telling the body that something is wrong, but for people with Fibromyalgia, there is a ‘glitch’ where the brain tells their body something is extremely painful when it shouldn’t be (Franco et al., 2023; Silva et al., 2019). The pain is real, but the stimulus that would normally trigger that level of pain is not there. For example, clients with Fibromyalgia have described the condition as waking up and feeling like they have run a marathon with no preparation, when in reality they’ve only just woken up. The chronic condition causes pain to be amplified and while this pain can fluctuate, it usually means clients are uncomfortable, or in pain at all times. The pain, fatigue, and loss of muscle strength caused by Fibromyalgia can make day-to-day tasks very difficult to complete and can significantly impact a person’s quality of life (Franco et al., 2023; Silva et al., 2019).

SYMPTOMS

While Fibromyalgia causes a number of symptoms, pain is the most common, consistent, and challenging part of managing the condition. Symptoms can include-

Pain Symptoms

• Widespread aching, stabbing, or burning pain in muscles, back, neck, legs, and abdomen
• Regions of pain or tender points
• Hypersensitivity to pain

Physical Symptoms

• Restless Leg Syndrome
• Muscle and joint weakness, stiffness, tenderness, and spasms
• Pins and needles/tingling
• Increased sensitivity to temperature, sound, pressure, scent, and light
• Chronic fatigue
• Nausea
• IBS

Common Trigger/Tender Points

• Knees
• Hips
• Back of the head
• Chest
• Shoulders
• Neck
• Elbows
• Pelvic Girdle

Cognitive Symptoms

• Cognitive difficulties
• ‘Fibro Fog’ – forgetfulness, lack of concentration and alertness, difficulty focusing
• Anxiety
• Depression
• Stress
• Mood swings
• Headaches
• Irritability
• Insomnia
• Feeling unrested

As Fibromyalgia is dynamic, the symptoms can change over time, or worsen after stressful or traumatic events. Stress, hormones, or even changes in weather can cause a flare up of symptoms in Fibromyalgia. 

CAUSES

Up until recently, a number of medical professionals denied the existence of Fibromyalgia, as it presents such similar symptoms to various other diseases. Due to this, we still don’t know very much about what causes the chronic condition. However, some researchers believe that Fibromyalgia can be triggered by genetics, environmental factors, neuromodulatory changes, or a combination of these factors (Franco et al., 2023; Häuser, W., & Fitzcharles., 2018).

Fibromyalgia can run in families, but the condition is typically triggered by an event, such as an infection or traumatic experience. For those without a genetic predisposition, the condition can be caused by an illness, infection, repeated injury, traumatic physical/psychological event, the way the body metabolises specific substances, or lower levels of serotonin or norepinephrine (Silva et al., 2019).

TREATMENT

Fibromyalgia can mimic other disorders, making it incredibly hard to diagnose and treat as there isn’t a definitive test to diagnose the condition. While Fibromyalgia has no cure, it does not get progressively worse with time, nor does it cause damage to the muscles as the issue is with the brain signals

After diagnosis, the main goal of treatment is to improve sleep, lower fatigue, but most importantly to reduce the pain and tenderness (Çağlayan et al., 2021). The treatment approach may be different for each person, but requires active participation from the client. Treatment is often multidisciplinary in order to help improve clients’ overall quality of life (Franco et al., 2023). Treatments can include –

• Physical and psychological therapy
• Medication (e.g. analgesics, anti-inflammatories, antidepressants, muscle relaxants)
• Cognitive Behavioural Therapy
• Lifestyle changes 
• Sleep
• Exercise
• Healthy diet (certain foods may inflame symptoms e.g. gluten)
• Self-care
• Mindfulness and meditation
• Occupational therapy
• Acupuncture

GENERAL EXERCISE GUIDELINES

The experience of pain, fatigue, and decreased muscle strength may contribute to clients feeling demotivated with exercise. However, exercise is the most recommended, non-pharmacological treatment for Fibromyalgia and is a fantastic way to help manage symptoms (Franco et al., 2023; Silva et al., 2019). Regular exercise is a safe, low-cost, and effective treatment option, which can help improve overall well-being, sleep, mood, quality of life, physical and cognitive function, but most importantly it can help reduce pain and fatigue through increasing physical conditioning, strength, flexibility, and endurance (Çağlayan et al., 2023; de Medeiros et al., 2020; Silva et al., 2019). Aerobic exercise, strength training, and Pilates are all well-researched and recommended options (Franco et al., 2023; Häuser & Fitzcharles, 2018). However, it is essential that an exercise regime is introduced slowly and gradually increases in frequency and intensity.

PILATES AND FIBROMYALGIA

Pilates considers the link between mind and body; incorporating mobility, concentration, control, body awareness, strengthening, stretching, and breathing into the workout (Franco et al., 2023). This mind-body connection is very important because it can help distract clients from the pain by shifting their focus to be on the movement and the breathing (Franco et al., 2023).

Recent research has taken a closer look at how Pilates can help clients with Fibromyalgia. Some results suggest that Pilates is more effective at helping to improve Fibromyalgia symptoms than other forms of exercise (e.g. yoga, aquatic aerobics, treadmill walking), while others found that Pilates produces similar outcomes. Either way, Pilates is a fantastic form of exercise for clients with Fibromyalgia (Altan et al., 2009; Çağlayan et al., 2021; de Medeiros et al., 2020).

Research has found Pilates to be a safe, low-impact, and effective exercise option that can help to reduce pain, depression, and anxiety, while improving functionality, mobility, flexibility, fitness, posture, balance, strength, mood, and sleep quality symptoms in clients with Fibromyalgia (Çağlayan et al., 2023; Franco et al., 2023; de Medeiros et al., 2020; Komatsu, 2016). Pilates is particularly helpful for Fibromyalgia, as it can isolate specific muscle groups and use isometric contractions, making it easier to reduce fatigue throughout the workout or add unnecessary strain on other muscle groups (Altan et al., 2009).

GENERAL PILATES GUIDELINES

Class Types

• One-on-one classes allow more freedom to tailor the program to the individual, and increase the intensity and frequency of classes at the client’s pace (Çağlayan et al., 2023)
• It might be helpful to begin with one-on-one sessions before moving clients into group classes when they are ready
• Running small group classes, specifically for clients with Fibromyalgia, can help the clients connect with others who are managing the same condition and experiences. This social element can help improve depression and creates a social network of people who understand and empathise (Ekici et al., 2017; Çağlayan et al., 2023)
• Group Pilates classes can also help clients improve their functionality more quickly than when attending individual classes (Ekici et al., 2017; Çağlayan et al., 2023). It is possible that being in a group helps clients motivate each other, while the social element encourages clients to maintain the exercise regime. This combination results in clients attending more classes, progressing more quickly, and ultimately regaining more functionality (Ekici et al., 2017; Çağlayan et al., 2023)

Change the Focus of Your Classes

• A client with Fibromyalgia may feel hesitant and possibly anxious about participating in Pilates, or exercise in general. It will be important to build up confidence, motivation and encouragement
• Keep the goal in mind and be sensitive to what your client is experiencing. Improving muscle strength, functionality, mobility, stretching, and overall well-being will be the key focus for your client. Avoid focusing on losing weight or the toning benefits of exercise
• Creating a safe space for the client is essential. Setbacks will happen, progress will be slow, but in the long run, exercise can make a significant difference in a client’s life 
• Don’t dismiss or minimise the pain clients are experiencing. The pain is very real and it will be important to validate and listen to the client

Session Frequency

• The frequency of sessions will likely increase as your client consistently attends classes. However, keep the frequency of sessions lower in the beginning and gradually increase these as their strength and functionality improves
• At times, clients with Fibromyalgia will have flare ups and the pain may be too intense to participate in a class. There may be last minute cancellations when this occurs

Adjusting Workout Duration and Timing

• A lunchtime or afternoon class may be more suitable, as clients can experience muscle stiffness in the morning
• It will be important to find a balance between completing a good workout that helps to improve muscle strength and functionality, but not fatiguing the client or causing pain. Finding this balance will take time
• For clients with Fibromyalgia, exercise may have previously resulted in pain, making it unappealing to continue participating in. Keeping this pain to a minimum is essential
• Progress may be slow for clients, but consistency is key. Altan et al., (2009) found that the benefits (e.g. improved functionality) of Pilates stopped when clients didn’t consistently attend workouts
• Rest after a workout will be essential. Encourage your clients to recover and take it easy after a session
• Take cues from your client about which exercises are causing pain or discomfort. The client knows their body, but as an instructor it will be important to try and progress the client over time – don’t push repetitions to the point of exhaustion
• The feedback you receive from the client, for example where they felt pain during and after the workout, will help you adjust the session frequency, length, and level of intensity
• Train consistently, not intensively
• Keep the pace of exercises slow and consider shorter workouts
• If a client experiences a flare up of symptoms it is best to focus on stretching or taking a rest

Programming

• Put together programs that help improve core strength, balance, mobility, flexibility, and functionality in the most energy efficient way possible
• Instead of layering the same muscle groups over each other, consider programming a class where you alternate the target muscle groups to help prevent fatigue

MUSCLES LIKELY TO BE TIGHT/WEAK

People with Fibromyalgia are likely to experience pain, tightness, stiffness and weakness globally.

REFORMER GUIDELINES

Reformer Pilates allows for more modifications and control over the resistance and intensity of the exercises, making it a better option for clients with Fibromyalgia (Çağlayan et al., 2023). Matwork can be too challenging for clients who are just starting an exercise regime because there aren’t as many options to alter resistance. Using Reformer Pilates allows greater control over the intensity and resistance during the workout.

General

• Keep movements and exercises simple
• The spring resistance can be incredibly beneficial for clients in developing muscle strength, but this will need to start low and increase slowly
• Focus on developing core strength so the body has the core strength to support their functionality and daily movement

Supine Abdominal Series

• Start clients with their head down or use a head cushion
• Initially avoid sustained abdominal exercises where the head and shoulders need to stay up the entire exercise and add these in gradually as strength develops

Midback Series

• A great option as the body is well supported in this position

Back Rowing Series

• This series is best performed sitting on the box as opposed to sitting on the carriage
• Do not get the client to kneel on the carriage
• A great series which helps improve posture and many of the exercises are of a lower intensity

Front Rowing Series

• Perform this series sitting on the box or sitting on the carriage (kneeling may be too challenging for balance). The box also allows clients to simply focus on their arm muscles rather than adding in the balance component of kneeling

Side Arm Series

• Perform this series sitting on the box or sitting on the carriage (kneeling may be too challenging for balance). The box also allows clients to simply focus on their arm muscles rather than adding in the balance component of kneeling

Prone Arm Series

• This series requires a lot of strength and effort to hold the body in a prone position over the box
• It is still a good series to do because it teaches the client to engage their muscles in a prone position, however keep the duration shorter to begin with

Footwork Series

• A great series to perform as it gives you a lot of flexibility as an instructor to increase or decrease intensity as required while also putting clients in a very supportive position

Feet in Straps Series

• Use caution with spring resistances and start clients off with lighter resistance and then gradually increase as clients develop strength

Side Lying Series

• The Foot on Bar exercises are great options for clients to perform 
• As a client’s control and endurance develops start adding in the Foot in Strap exercises which are more challenging and require more balance and strength

Kneeling Series

• Be mindful of Knee Stretches 2 (Knees Off), Knee Stretches 3 (Running Preparation) and Hinge as these are higher intensity exercises which require some basic strength before prescribing

Short Box Series

• Be mindful of the range of movement – start with a smaller range of movement and ensure that the client feels safe and comfortable on the box

Plank Abdominal Series

• Start the client on the easier modifications first (ie. Long Stretch on the knees before progressing to the version on the feet)
• Be sure to use a spring which is supportive of the client’s body weight

Standing Series

• A great series to perform but exercise caution with standing on the reformer if the client is a fall risk (especially if your reformer is higher off the ground)

Stretching Series

• All stretches should be safe to perform and are great options for releasing tight muscles
• Be cautious of stretching too aggressively 

SUMMARY

Exercise is a fantastic way for clients with Fibromyalgia to improve their mobility, strength, and flexibility, while also reducing pain. As an instructor, it will be important to work with the client and to also work within their limits in each session. Start slowly and gradually increase resistance and difficulty, celebrate the little wins with clients, and work alongside your client to help improve their overall quality of life. 

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UPCOMING COURSE DATES

REFERENCES

Note: this article has been reviewed by a Studio Pilates International physiotherapist

Altan, L., Korkmaz, N., Bingol, Ü., & Gunay, B. (2009). Effect of Pilates Training on People With Fibromyalgia Syndrome: A Pilot Study. Archives of Physical Medicine and Rehabilitation, 90(12), 1983–1988. https://doi.org/10.1016/j.apmr.2009.06.021

Çağlayan, B. Ç., Keskin, A., Gür Kabul, E., Başakcı Çalık, B., Baş Aslan, U., & Karasu, U. (2021). Effects of clinical Pilates exercises in individuals with fibromyalgia: A randomized controlled trial. European Journal of Rheumatology, 8(3), 150–155. https://doi.org/10.5152/eurjrheum.2020.20037

Çağlayan, B. Ç., Başakcı Çalık, B., Gür Kabul, E., & Karasu, U. (2023). Investigation of effectiveness of reformer pilates in individuals with fibromyalgia: A randomized controlled trial. Reumatología Clinica (Barcelona), 19(1), 18–25. https://doi.org/10.1016/j.reumae.2022.01.003

de Medeiros, S. A., De Almeida Silva, H. J., do Nascimento, R. M., da Silva Maia, J. B., De Almeida Lins, C. A., & De Souza, M. C. (2020). Mat Pilates is as effective as aquatic aerobic exercise in treating women with fibromyalgia: A clinical, randomized and blind trial. Advances in Rheumatology (London, England), 60(1), 21–21. https://doi.org/10.1186/s42358-020-0124-2

Ekici, G., Unal, E., Akbayrak, T., Vardar-Yagli, N., Yakut, Y., & Karabulut, E. (2017). Effects of active/passive interventions on pain, anxiety, and quality of life in women with fibromyalgia: Randomized controlled pilot trial. Women & Health, 57(1), 88–107. https://doi.org/10.1080/03630242.2016.1153017

Franco, K. F. M., Miyamoto, G. C., Franco, Y. R. dos S., Salvador, E. M. E. S., Nascimento, B. C. B., Menten, L. A., & Cabral, C. M. N. (2023). Is Pilates more effective and cost‐effective than aerobic exercise in the treatment of patients with fibromyalgia syndrome? A randomized controlled trial with economic evaluation. European Journal of Pain, 27(1), 54–71. https://doi.org/10.1002/ejp.2039

Häuser, W., & Fitzcharles, M. A. (2018). Facts and myths pertaining to fibromyalgia. Dialogues in clinical neuroscience, 20(1), 53–62. https://doi.org/10.31887/DCNS.2018.20.1/whauser

Komatsu M., Avila, M.A., Colombo, M.M., Gramani-Say, K., & Driusso, P. (2016). Pilates training improves pain and quality of life of women with fibromyalgia syndrome. Revista Dor, 17(4), 274–278. https://doi.org/10.5935/1806-0013.20160088

Silva, H. J., de Almeida Lins, C. A., Nobre, T. T. X., de Sousa, V. P. S., Caldas, R. T. J., & de Souza, M. C. (2019). Mat Pilates and aquatic aerobic exercises for women with fibromyalgia: a protocol for a randomised controlled blind study. BMJ Open, 9(2), e022306. https://doi.org/10.1136/bmjopen-2018-022306