Resistance exercise training for fibromyalgia

Resistance exercise training for fibromyalgia (Review)

Busch AJ Webber SC Richards RS Bidonde J Schachter CL Schafer LA Danyliw A Sawant

A Dal Bello-Haas V Rader T Overend TJ

This is a reprint of a Cochrane review prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2013 Issue 12

httpwwwthecochranelibrarycom

Resistance exercise training for fibromyalgia (Review)

Copyright copy 2013 The Cochrane Collaboration Published by John Wiley amp Sons Ltd

T A B L E O F C O N T E N T S

1HEADER 1ABSTRACT 2PLAIN LANGUAGE SUMMARY 5SUMMARY OF FINDINGS FOR THE MAIN COMPARISON 8BACKGROUND 9OBJECTIVES

10METHODS Figure 1 15

16RESULTS Figure 2 17Figure 3 19Figure 4 20

23ADDITIONAL SUMMARY OF FINDINGS 30DISCUSSION 33AUTHORSrsquo CONCLUSIONS 34ACKNOWLEDGEMENTS 35REFERENCES 47CHARACTERISTICS OF STUDIES 63DATA AND ANALYSES

Analysis 11 Comparison 1 Resistance training versus control Outcome 1 Multidimensional function 66Analysis 12 Comparison 1 Resistance training versus control Outcome 2 Physical function 66Analysis 13 Comparison 1 Resistance training versus control Outcome 3 Pain 67Analysis 14 Comparison 1 Resistance training versus control Outcome 4 Tenderness 67Analysis 15 Comparison 1 Resistance training versus control Outcome 5 Muscle strength max concentric leg extension 68Analysis 16 Comparison 1 Resistance training versus control Outcome 6 Fatigue 69Analysis 17 Comparison 1 Resistance training versus control Outcome 7 Patient-rated global 69Analysis 18 Comparison 1 Resistance training versus control Outcome 8 Mental health 70Analysis 19 Comparison 1 Resistance training versus control Outcome 9 Depression 70Analysis 110 Comparison 1 Resistance training versus control Outcome 10 Sleep 71Analysis 111 Comparison 1 Resistance training versus control Outcome 11 Muscle power 71Analysis 112 Comparison 1 Resistance training versus control Outcome 12 Muscle size 72Analysis 113 Comparison 1 Resistance training versus control Outcome 13 Muscle activation 72Analysis 114 Comparison 1 Resistance training versus control Outcome 14 All-cause attrition 73Analysis 21 Comparison 2 Resistance versus aerobic training Outcome 1 Multidimensional Function 73Analysis 22 Comparison 2 Resistance versus aerobic training Outcome 2 Self reported physical function 74Analysis 23 Comparison 2 Resistance versus aerobic training Outcome 3 Pain 74Analysis 24 Comparison 2 Resistance versus aerobic training Outcome 4 Tenderness 75Analysis 25 Comparison 2 Resistance versus aerobic training Outcome 5 Fatigue 75Analysis 26 Comparison 2 Resistance versus aerobic training Outcome 6 Mental health 76Analysis 27 Comparison 2 Resistance versus aerobic training Outcome 7 Sleep 76Analysis 28 Comparison 2 Resistance versus aerobic training Outcome 8 Depression 77Analysis 29 Comparison 2 Resistance versus aerobic training Outcome 9 Anxiety 77Analysis 210 Comparison 2 Resistance versus aerobic training Outcome 10 Cardio respiratory submax 78Analysis 211 Comparison 2 Resistance versus aerobic training Outcome 11 All-cause attrition 78Analysis 31 Comparison 3 Resistance versus flexibility exercise Outcome 1 Multidimensional function 79Analysis 32 Comparison 3 Resistance versus flexibility exercise Outcome 2 Pain 79Analysis 33 Comparison 3 Resistance versus flexibility exercise Outcome 3 Tenderness 80Analysis 34 Comparison 3 Resistance versus flexibility exercise Outcome 4 Strength 80Analysis 35 Comparison 3 Resistance versus flexibility exercise Outcome 5 Self efficacy 81Analysis 36 Comparison 3 Resistance versus flexibility exercise Outcome 6 Fatigue 81Analysis 37 Comparison 3 Resistance versus flexibility exercise Outcome 7 Sleep 82

iResistance exercise training for fibromyalgia (Review)


Analysis 38 Comparison 3 Resistance versus flexibility exercise Outcome 8 Depression 82Analysis 39 Comparison 3 Resistance versus flexibility exercise Outcome 9 Anxiety 83Analysis 310 Comparison 3 Resistance versus flexibility exercise Outcome 10 Musclejoint flexibility 83Analysis 311 Comparison 3 Resistance versus flexibility exercise Outcome 11 All-cause attrition 84Analysis 41 Comparison 4 Acceptability - Attrition Outcome 1 Attrition 84Analysis 51 Comparison 5 Follow-up resistance training versus control Outcome 1 Multidimensional function 86Analysis 52 Comparison 5 Follow-up resistance training versus control Outcome 2 Physical function 87Analysis 53 Comparison 5 Follow-up resistance training versus control Outcome 3 Pain 88Analysis 54 Comparison 5 Follow-up resistance training versus control Outcome 4 Tenderness 89Analysis 55 Comparison 5 Follow-up resistance training versus control Outcome 5 Fatigue 90Analysis 56 Comparison 5 Follow-up resistance training versus control Outcome 6 Mental health 91Analysis 61 Comparison 6 Follow-up resistance training versus aerobic training Outcome 1 Multidimensional function 92Analysis 62 Comparison 6 Follow-up resistance training versus aerobic training Outcome 2 Physical function 93Analysis 63 Comparison 6 Follow-up resistance training versus aerobic training Outcome 3 Pain 94Analysis 64 Comparison 6 Follow-up resistance training versus aerobic training Outcome 4 Tenderness 95Analysis 65 Comparison 6 Follow-up resistance training versus aerobic training Outcome 5 Fatigue 96Analysis 66 Comparison 6 Follow-up resistance training versus aerobic training Outcome 6 Mental health 97

97ADDITIONAL TABLES 102APPENDICES 108WHATrsquoS NEW 109HISTORY 109CONTRIBUTIONS OF AUTHORS 110DECLARATIONS OF INTEREST 110SOURCES OF SUPPORT 110NOTES

iiResistance exercise training for fibromyalgia (Review)


[Intervention Review]

Resistance exercise training for fibromyalgia

Angela J Busch1 Sandra C Webber2 Rachel S Richards3 Julia Bidonde4 Candice L Schachter5 Laurel A Schafer6 Adrienne Danyliw7 Anuradha Sawant8 Vanina Dal Bello-Haas9 Tamara Rader10 Tom J Overend11

1School of Physical Therapy University of Saskatchewan Saskatoon Canada 2School of Medical Rehabilitation Faculty of MedicineUniversity of Manitoba Winnipeg Canada 3North Vancouver Canada 4Community Health amp Epidemiology University ofSaskatchewan Saskatoon Canada 5Windsor Canada 6Central Avenue Physiotherapy Swift Current Canada 7Saskatoon Canada8Department of RenalClinical Neurosciences London Health Sciences Center London Canada 9School of Rehabilitation ScienceMcMaster University Hamilton Canada 10Cochrane Musculoskeletal Group Ottawa Canada 11School of Physical Therapy Uni-versity of Western Ontario London Canada

Contact address Angela J Busch School of Physical Therapy University of Saskatchewan 1121 College Drive Saskatoon SaskatchewanS7N 0W3 Canada angelabuschusaskca

Editorial group Cochrane Musculoskeletal GroupPublication status and date New published in Issue 12 2013Review content assessed as up-to-date 5 March 2013

Citation Busch AJ Webber SC Richards RS Bidonde J Schachter CL Schafer LA Danyliw A Sawant A Dal Bello-Haas VRader T Overend TJ Resistance exercise training for fibromyalgia Cochrane Database of Systematic Reviews 2013 Issue 12 Art NoCD010884 DOI 10100214651858CD010884


A B S T R A C T

Background

Fibromyalgia is characterized by chronic widespread pain that leads to reduced physical function Exercise training is commonlyrecommended as a treatment for management of symptoms We examined the literature on resistance training for individuals withfibromyalgia Resistance training is exercise performed against a progressive resistance with the intention of improving muscle strengthmuscle endurance muscle power or a combination of these

Objectives

To evaluate the benefits and harms of resistance exercise training in adults with fibromyalgia We compared resistance training versuscontrol and versus other types of exercise training

Search methods

We searched nine electronic databases (The Cochrane Library MEDLINE EMBASE CINAHL PEDro Dissertation Abstracts CurrentControlled Trials World Health Organization (WHO) International Clinical Trials Registry Platform AMED) and other sources forpublished full-text articles The date of the last search was 5 March 2013 Two review authors independently screened 1856 citations766 abstracts and 156 full-text articles We included five studies that met our inclusion criteria

Selection criteria

Selection criteria included a) randomized clinical trial b) diagnosis of fibromyalgia based on published criteria c) adult sample d)full-text publication and e) inclusion of between-group data comparing resistance training versus a control or other physical activityintervention

1Resistance exercise training for fibromyalgia (Review)


Data collection and analysis

Pairs of review authors independently assessed risk of bias and extracted intervention and outcome data We resolved disagreementsbetween the two review authors and questions regarding interpretation of study methods by discussion within the pairs or whennecessary the issue was taken to the full team of 11 members We extracted 21 outcomes of which seven were designated as majoroutcomes multidimensional function self reported physical function pain tenderness muscle strength attrition rates and adverseeffects We evaluated benefits and harms of the interventions using standardized mean differences (SMD) or mean differences (MD)or risk ratios or Peto odds ratios and 95 confidence intervals (CI) Where two or more studies provided data for an outcome wecarried out a meta-analysis

Main results

The literature search yielded 1865 citations with five studies meeting the selection criteria One of the studies that had three armscontributed data for two comparisons In the included studies there were 219 women participants with fibromyalgia 95 of whom wereassigned to resistance training programs Three randomized trials compared 16 to 21 weeks of moderate- to high-intensity resistancetraining versus a control group Two studies compared eight weeks of progressive resistance training (intensity as tolerated) using freeweights or body weight resistance exercise versus aerobic training (ie progressive treadmill walking indoor and outdoor walking) andone study compared 12 weeks of low-intensity resistance training using hand weights (1 to 3 lbs (045 to 136 kg)) and elastic tubingversus flexibility exercise (static stretches to major muscle groups)

Statistically significant differences (MD 95 CI) favoring the resistance training interventions over control group(s) were found inmultidimensional function (Fibromyalgia Impact Questionnaire (FIQ) total decreased 1675 units on a 100-point scale 95 CI -2331 to -1019) self reported physical function (-629 units on a 100-point scale 95 CI -1045 to -213) pain (-33 cm on a 10-cm scale 95 CI -635 to -026) tenderness (-184 out of 18 tender points 95 CI -26 to -108) and muscle strength (2732 kgforce on bilateral concentric leg extension 95 CI 1828 to 3636)

Differences between the resistance training group(s) and the aerobic training groups were not statistically significant for multidimensionalfunction (548 on a 100-point scale 95 CI -092 to 1188) self reported physical function (-148 units on a 100-point scale 95CI -669 to 374) or tenderness (SMD -013 95 CI -055 to 030) There was a statistically significant reduction in pain (099 cmon a 10-cm scale 95 CI 031 to 167) favoring the aerobic groups

Statistically significant differences were found between a resistance training group and a flexibility group favoring the resistance traininggroup for multidimensional function (-649 FIQ units on a 100-point scale 95 CI -1257 to -041) and pain (-088 cm on a 10-cm scale 95 CI -157 to -019) but not for tenderness (-046 out of 18 tender points 95 CI -156 to 064) or strength (477 footpounds torque on concentric knee extension 95 CI -240 to 1194) This evidence was classified low quality due to the low numberof studies and risk of bias assessment There were no statistically significant differences in attrition rates between the interventions Ingeneral adverse effects were poorly recorded but no serious adverse effects were reported Assessment of risk of bias was hampered bypoor written descriptions (eg allocation concealment blinding of outcome assessors) The lack of a priori protocols and lack of careprovider blinding were also identified as methodologic concerns

Authorsrsquo conclusions

The evidence (rated as low quality) suggested that moderate- and moderate- to high-intensity resistance training improves multi-dimensional function pain tenderness and muscle strength in women with fibromyalgia The evidence (rated as low quality) alsosuggested that eight weeks of aerobic exercise was superior to moderate-intensity resistance training for improving pain in womenwith fibromyalgia There was low-quality evidence that 12 weeks of low-intensity resistance training was superior to flexibility exercisetraining in women with fibromyalgia for improvements in pain and multidimensional function There was low-quality evidence thatwomen with fibromyalgia can safely perform moderate- to high-resistance training

P L A I N L A N G U A G E S U M M A R Y

Resistance training for fibromyalgia

Research question



We conducted a review of studies on resistance training for people with fibromyalgia We found five studies with 219 women withfibromyalgia 95 of whom were assigned to resistance training programs Because all of the participants were women we do not knowif these results would be the same for men

Background what is fibromyalgia and what is resistance training

People with FM have chronic widespread body pain and often experience many other symptoms such as difficulty sleeping fatiguestiffness and depression

Resistance training is a type of exercise that may involve lifting weights using resistance machines or using elastic resistance bandsAlthough exercise is part of the overall management of fibromyalgia this review examined the effects of resistance exercise trainingsupervised by a trained professional compared with no exercise and compared with other types of exercise

Study characteristics

After searching for all relevant studies in March 2013 we found five studies with 219 women Three studies compared effects onwellness symptoms and fitness in 54 women with fibromyalgia who participated in supervised resistance interventions using exerciseequipment free weights and body weight to major muscle groups twice to three times a week over 16 to 21 weeks to 53 women whodid not do exercise

Key results what happens to women with fibromyalgia who take part in resistance exercise training after 16 to 21 weeks

Overall well-being (multidimensional function) on a scale of 0 to 100

- Women who did resistance training rated their overall well-being to be 17 units better than women who did not do resistance trainingat the end of the study than at the beginning

- Women who did not do resistance training rated their overall well-being to be 8 units better

- Women who did resistance training rated their overall well-being to be 25 units better

Physical function on a scale of 0 to 100

- Women who did resistance training rated their ability to function at least 6 units better than women who did not do resistance trainingat the end of the study than at the beginning

- Women who did not do resistance training rated their ability to function 2 units better

- Women who did resistance training rated their ability to function 8 units better

Pain on a 10 cm visual analogue scale

- Women who did resistance training rated their pain to be 2 cms better than women who did not do resistance training at the end ofthe study than at the beginning

- Women who did not do resistance training reported pain of 1 cm better

- Women who did resistance training reported pain of 35 cms better

Tenderness

- Women who did resistance training reported two fewer active tender points out of 18 than women who did not do resistance trainingat the end of the study than at the beginning A tender point is identified as active when pressure of 4 kg is perceived as painful

- Women who did not do resistance training reported two fewer active tender points

- Women who did resistance training reported four fewer active tender points

Muscle strength

- Women who did resistance training were able to lift 27 kg more than women who did not do resistance training at the end of thestudy than at the beginning

- Women who did not do resistance training were able to lift 1 kg more

- Women who did resistance training were able to lift 28 kg more



Dropping out of the studies

- Nine more women out of 100 who did resistance training dropped out compared with women who did not do resistance training

- Four women out of 100 who did not do resistance training dropped out of the studies

- 13 women out of 100 who did resistance training dropped out of the studies

Quality of evidence

Resistance training exercise probably improves the ability to do normal activities after 16 to 21 weeks and pain tenderness fatigue andmuscle strength after 21 weeks Further research is likely to change the estimate of these results

While we do not have precise information about side effects and complications no injuries were reported in the trials



S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Resistance training compared with control for fibromyalgia

Patient or population Individuals with fibromyalgia

Settings Finland Brazil

Intervention Resistance training - supervised group exercise

Comparison Control

Outcomes Illustrative comparative risks (95 CI) Relative effect

(95 CI)

No of Participants

(studies)

Quality of the evidence

(GRADE)

Comments

Assumed risk Corresponding risk

Control Resistance training

Multidimensional func-

tion

FIQ Total Score

Scale 0-100 (lower

scores indicate greater

health)

Follow-up 16 weeks

The mean change (post

minus pre) in multidimen-

sional function in the con-

trol group was

-816 FIQ units1



sional function in the in-

tervention group was

-2491 FIQ units1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD -127 (95 CI -183

to -072)8

Absolute difference5 -16

75 FIQ units (95 CI -23

31 to -1019)

Relative per cent change6 26 (95 CI 1596

to 3651) better in exer-

cise group7

NNTB 2 (95 CI 1 to 3)

Self reported physical

function

Health Assessment

Questionnaire and SF-36

Physical Function Score

Scale 0-100 (converted

so lower scores indicate

better health)

Follow-up 16-21 weeks


minus pre) in self reported

physical function in the

control groups was

-201 units1




intervention groups was

-767 units1

- 107

(3 studies2)

oplusopluscopycopy

low910

SMD -05 (95 CI -089

to -011) 11

Absolute difference -629

units (95 CI -1045 to -

213)

Relative per cent change

1448 (95 CI 49 to

241) better in exercise

groups

NNTB 5 (95 CI 3 to 22)

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Pain

Visual analog scale

Scale 0-10 cm (lower

scores indicate less pain)



minus pre) in pain in the

control groups was

-099 cm1




-353 cm1

81

(2 studies2)

oplusopluscopycopy

low91012

SMD -189 (95 CI -386

to 007)8


cm (95 CI -635 to -0

26)


446 (95 CI 35 to


groups7

NNTB 2 (95 CI 1 to 34)

Tenderness

Tender point count and

myalgic scores

Scores converted to ten-

der points 0-18 (lower

scores indicate less ten-

derness)



minus pre) in tenderness

in the control groups was

-20 tender points1

The estimated mean

change (post minus pre)

in tenderness in the inter-

vention groups was

-35 tender points1

- 107

(3 studies2)

oplusopluscopycopy

low91012SMD -073 (95 CI -112

to -033)8


tender points (95 CI -2

6 to -108)


128 (95 CI 749 to

180) better in the exer-

cise groups

NNTB 4 (95 CI 3 to 7)

Muscle strength

Maximum concentric leg

extension (loadmeasured

in kg)

Follow-up 21 weeks


minus pre) in muscle

strength in control groups

was 044 kg1



strength in the interven-

tion groups was

2771 kg1

- 47

(2 studies2)

oplusopluscopycopy

low91012

SMD 167 (95 CI 098

to 235)8

Absolute difference 2732

kg (95 CI 1828 to 36

36)


25 (95 CI 17 to


groups7

NNTB 2 (95 CI 1 to 3)

Adverse effects See comment See comment Not estimable - See comment No complaints of any

unusual exercise-induced

pain or muscle soreness

No instances of attrition

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due to adverse effects (2

studies)

All-cause attrition

Dropout rates


39 per 1000 134 per 1000

(95 CI 30 to 439)

RR 350 (079 to 1549) 107

(3 studies2)

oplusopluscopycopy

low9


(95 CI -2 to 20)


250 (95 CI -21 to

1449)

Not statistically signifi-

cant

The basis for the assumed risk (eg the median control group risk across studies) is provided in footnotes The corresponding risk (and its 95 confidence interval) is based on the

assumed risk in the comparison group and the relative effect of the intervention (and its 95 CI)

CI confidence interval FIQ Fibromyalgia Impact QuestionnaireNNTB number needed to treat for an additional beneficial outcome RR risk ratioSF Short FormSMD standardized mean

difference

GRADE Working Group grades of evidence

High quality Further research is very unlikely to change our confidence in the estimate of effect

Moderate quality Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate

Low quality Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate

Very low quality We are very uncertain about the estimate

1 Improvement2 Only women were studied3 Low risk of bias4 Evidence based on one small study5 Absolute difference = mean change in resistance training group(s) minus mean change in control group(s)

6 Relative change = absolute difference divided by mean of baseline scores in both groups ( eg - cg) [(microeg bull neg ) + (microcg bull ncg

)] N7 Clinically relevant difference (gt15)8 Large effect (SMD gt080) favoring the resistance training group(s)9 At least one study had from incomplete documentation of study methods10 Wide confidence intervals11Moderate effect (SMD 050 to 079) favoring the resistance training group(s)12 Statistical heterogeneity (I2 gt50)

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B A C K G R O U N D

Description of the condition

Fibromyalgia is a chronic syndrome marked by widespread mus-cular tenderness and pain (Mease 2005 Wolfe 1990) Most peo-ple with fibromyalgia experience concurrent gastrointestinal (egabdominal pain irritable bowel syndrome) and somatosensorysymptoms (eg hyperalgesia allodynia paresthesias) in additionto disturbances in sleep mood and cognition (Burckhardt 2005Mease 2005) The myriad of symptoms significantly affects qual-ity of life and results in both physical and psychosocial disabilitywith far-reaching implications for family employment and in-dependence (Burckhardt 1993 Burckhardt 2005 Mease 2005)Moreover people with fibromyalgia are often intolerant of physi-cal activity and tend to have a sedentary lifestyle that increases therisk of additional morbidity (Park 2007 Raftery 2009) Because ofthe presence of extensive somatic complaints and disability peoplewith fibromyalgia have a greater number of physician visits yearlyand more specialists enlisted in their care (Park 2007)The prevalence of fibromyalgia in the US has been estimated at2 of the population with a greater representation among fe-males than males (34 female to 05 male) (Wolfe 1995) TheCanadian statistics are similar to the US wherein the self reportedprevalence of fibromyalgia has been estimated at 11 across allages again with female diagnoses outnumbering male diagnoses(183 female to 033 male) (McNalley 2006) Prevalence ratesamong some European countries (France Germany Italy Por-tugal Spain) are estimated to range between 14 (France) and37 (Italy) with fibromyalgia diagnoses being twice as commonin females (Branco 2010) However similar to other rheumato-logic conditions the prevalence of fibromyalgia in China is sub-stantially lower than in Western countries at about 005 (Zeng2008)To date there is no definitive etiology or pathophysiology forfibromyalgia However current evidence supports the model ofcentral amplification of pain perception that is both developedand maintained by a variety of factors influencing neurotrans-mitter and neurohormone dysregulation (Bennett 1999 Clauw2011 Desmeules 2003) Based on this theory treatment andmanagement of fibromyalgia requires multiple modalities and anintegrative multidisciplinary approach that includes pharmaco-logic and other therapies (eg exercise cognitive therapy relax-ation education) (Bernardy 2013 Birse 2012 Burckhardt 2005Carville 2008 Haumluser 2013 Moore 2012 Seidel 2013 Tort 2012Williams 2012)Until recently the standard for diagnosing fibromyalgia has beenthe American College of Rheumatology (ACR) 1990 criteria(Wolfe 1990) According to this method a diagnosis of fibromyal-gia is appropriate when a person has experienced widespread painlasting more than three months and pain can be elicited at 11 of18 specific tender points (TP) on the body using 4-kg tactile pres-

sure In recent years the utility of this method has been criticizedfor failing to address the extent of other key somatic complaintsand secondary symptoms of fibromyalgia related to sleep moodcognition and physical function (Mease 2005 Mease 2009)A newer preliminary diagnostic tool also shows promise in im-proving upon current ACR standards and eliminates the need forthe physical TP exam (Wolfe 2010) This measure the ACR 2010criteria includes a Widespread Pain Index (WPI 19 areas repre-senting the anterior and posterior axis and limbs) and a Symp-tom Severity scale (SS 0 to 12 scale) containing items related tosecondary symptoms such as fatigue sleep disturbances cogni-tion and somatic complaints Scores on both measures are usedto determine whether a person qualifies with a rsquocase definitionrsquoof fibromyalgia An individual is classified as having fibromyalgiawhen a) WPI gt 7 and the SS gt 5 or b) WPI = 3 to 6 and SS gt9 This tool has been found to classify 881 of cases that meetACR criteria correctly and it allows for ongoing monitoring ofsymptom change in people with current or previous fibromyalgiadiagnoses (Wolfe 2010) Although the measures focusing on TPcounts have been widely applied in clinic and research settings themethod described by Wolfe 2010 shows promise to classify peoplewith fibromyalgia more efficiently while allowing for improvedmonitoring of disease status over time Wolfe and colleagues havefurther developed the ACR 2010 criteria by eliminating the physi-ciansrsquos estimate of the extent of somatic symptoms and substitut-ing the sum of three specific self reported symptoms (Wolfe 2011)

Description of the intervention

This review focuses on resistance-training-only interventions(hereafter referred to as resistance training) which has beenfound to have numerous benefits including increased musclestrength muscle endurance and muscle power in healthy indi-viduals throughout the lifespan (ACSM 2009b Chodzko-Zajko2009 Faigenbaum 2009 Nelson 2007) Resistance training maybe especially important to protect individuals against the loss oflean body mass and subsequent impairments and activity limita-tions that occur with aging (Chodzko-Zajko 2009 Nelson 2007)In addition parameters such as balance coordination speed andagility may also be enhanced with this form of training (ACSM2009b Asikainen 2004)Resistance training is frequently administered concurrently withother types of exercise training (aerobic and flexibility training)we only selected studies describing resistance-training-only inter-ventions All types of resistance training (ie prescriptions that tar-get muscle strength endurance power or a combination of these)were included in this review The intensity and duration neededto produce adaptations depend on a variety of factors includingthe fitness level of the individual starting a resistance training in-tervention and the desired adaptation typically neuromuscularresistance training adaptations are apparent by 12 weeks or lessin healthy novices By definition training interventions include



a progressive component as the body adapts to a given stimulusan increase in the stimulus is required for further adaptations andimprovements Thus if the load or volume is not increased overtime progress will be limitedThe resistance load can be applied using various types of equip-ment (eg free weights elastic bandstubing weight machines)or simply by using the weight of a body segment or segmentsagainst gravity to provide resistance Training for improvementsin strength (ie the ability to produce force) typically involves pre-scription of higher loads (eg 60 to 70 of one repetition maxi-mum (RM see Table 1 - Glossary) for novices 80 to 100 of 1RM for more advanced individuals) and fewer repetitions (8 to 12repetitions for novices and six repetitions or fewer for individualsaccustomed to training) (ACSM 2009b Garber 2011 Appendix1) In comparison for muscle endurance (ie the ability to produceforce repetitively) training involves relatively light loads (40 to60 of 1 RM) and greater repetitions (15 or more) Training toimprove muscle power (ie the ability to produce force quickly)involves exercise using light-to-moderate loads (60 or less of 1RM) over one to six repetitions with high movement velocities

How the intervention might work

Although the precise etiology of fibromyalgia is not known phys-ical deconditioning is believed to play a role in the susceptibilityto fibromyalgia People with fibromyalgia typically present withreduced muscular strength and endurance which is accompaniedby greater levels of muscle fatigue compared with healthy seden-tary women (Kingsley 2009) This may contribute to the sub-stantial level of physical disability noted in fibromyalgia (Hawley1991 Raftery 2009) Improved muscular performance (strengthendurance and power) coordination and posture are recognizedbenefits of regular resistance training (ACSM 2009b) and can en-hance a personrsquos ability to perform daily activities and counteractdisabilitySeveral researchers have described metabolic findings in muscletissue from individuals with fibromyalgia that are consistent withphysical deconditioning (Bengtsson 1986a Bengtsson 1986bBennett 1989 Elvin 2006 Jubrias 1994 Lund 1986 Park 1998)Deconditioning could be linked to the etiology of fibromyalgiaby increasing an individualrsquos vulnerability to microtrauma duringdaily exposure to mechanical strain related to posture or physicalactivity (Smythe 1981) The metabolic adaptations induced byresistance training that have been observed in healthy individuals(Costill 1979 Deschenes 2002 Holloszy 1984) may normalizesome of these findings (Mizelle 2011) thus contributing to im-provements in pain Therefore exercise may contribute to a reduc-tion in pain through improving resilience to the process of musclemicrotrauma repair and adaptation during exercise Resistanceexercise also affects pain in healthy individuals Koltyn 1998 hasdemonstrated a transient increase in pain threshold (ie lower painratings) immediately after one bout of resistance exercise in healthy

individuals and Knutzen 2007 reported that progressive resistancetraining may reduce pain in older adultsOther adaptations to long-term resistance training include de-creased cortisol response to stress (Braith 2006) along with de-creased anxiety depression and insomnia in clinical depression(Brosse 2002 Dunn 2001 King 1997 Singh 1997) Singh 1997speculated that the improvements in depression may be due to theeffects that exercise has on ldquothe hormonal milieu neurotransmit-ter levels and sympathetic and parasympathetic nervous systemactivityrdquo If indeed resistance training can normalize the responseto stress and reduce pain perception anxiety depression and in-somnia this would be valuable for individuals with fibromyalgiaExercise training including resistance training that is being exam-ined in this review should be considered not only for disorder-specific effects but also from the perspective of whether trainingaffects overall health Muscle strengthening activity is importantin preventing age-related loss of muscle mass bone and physicalfunction (Chodzko-Zajko 2009 Nelson 2007) Some research alsosuggests that in the general population muscle strength and powercapabilities are predictive of all-cause and cardiovascular mortal-ity independent of an individualrsquos aerobic fitness level (Braith2006 FitzerGerald 2004 Katzmarzyk 2002) Therefore individ-uals with fibromyalgia may improve their overall health and re-duce risks associated with other chronic diseases by engaging inresistance training on a regular basis

Why it is important to do this review

It is important to evaluate whether resistance training has ben-eficial effects on fibromyalgia symptoms and whether resistancetraining will result in neuromuscular adaptations seen in healthyindividuals It is also important to document what harms may beassociated with resistance training interventions in people with fi-bromyalgia and to determine whether resistance training shouldbe recommended as a safe effective component of fibromyalgiamanagement It is also important to evaluate whether resistancetraining is more or less effective than other types of exercise train-ing Some researchers have suggested that resistance training maybe feared by individuals with fibromyalgia (van Koulil 2007) andthat special care may be needed to avoid delayed-onset musclesoreness (DOMS) when designing exercise protocols in this popu-lation (Jones 2002) In addition to reporting on injuries and otheradverse events this review will report on attrition rates and adher-ence to training protocols as these may indicate the acceptabilityof this form of intervention for individuals with fibromyalgia

O B J E C T I V E S

To evaluate the benefits and harms of resistance training in adultswith fibromyalgia



Specific comparisons that were assessed in this review included

bull resistance training versus control conditions (eg treatmentas usual wait list control physical activity as usual)

bull resistance training versus other physical activityintervention

M E T H O D S

Criteria for considering studies for this review

Types of studies

We selected randomized clinical trials (RCT) that compared aresistance training intervention versus another exercise trainingprotocol versus an untreated control or versus a non-exerciseintervention We included studies if the words randomly randomor randomization were used to describe the method of assignmentof subjects to groups (see protocol Busch 2001a)

Types of participants

We included studies that examined adults with fibromyalgia in thereview We selected those studies that used published criteria forthe diagnosis of fibromyalgia (Smythe 1981 Yunus 1981 Yunus1982 Yunus 1984 Wolfe 1990) Although some differences existbetween the diagnostic criteria for the purpose of this review allwere considered acceptable and comparable

Types of interventions

Intervention We defined resistance training as exercise performedagainst a progressive resistance on a minimum of two days per week(on nonconsecutive days) with the intention of improving musclestrength muscle endurance muscle power or a combination ofthese We did not set a specific minimum intervention durationWe placed no restriction on the type of equipment used to producethe load included studies could use a variety of equipment forresistance training including free weights elastic bands or tubingand exercise machines as well as calisthenics that use the weightof a body segment or segments moving against gravity as the loadfor the exerciseComparators We were interested in comparisons in three cat-egories a) untreated control conditions (treatment as usual ac-tivity as usual wait list control and placebo) b) other types ofexercise or physical activity interventions (eg aerobic flexibility)and c) other resistance training interventions (head-to-head com-parisons)

Types of outcome measures

Until recently there was no consensus on outcomes to guide re-search on the effectiveness of interventions for fibromyalgia In2004 a group of clinicians and researchers under the auspices ofthe Outcome Measures in Rheumatoid Arthritis Clinical Trials(OMERACT) initiative set about to improve outcome measure-ment in fibromyalgia through a data-driven interactive consensusprocess used previously for other rheumatic diseases (Mease 2009)Over the course of the next five years patient focus groups (Arnold2008) patient and clinician Delphi exercises (Mease 2008) asystematic literature review and analysis of outcomes used in fi-bromyalgia intervention trials (Carville 2008a) and analyses ofpsychometric properties of outcomes (ie face construct contentand criterion validity in fibromyalgia) (Choy 2009a) were con-ducted Based on these efforts OMERACT has recommended thefollowing core set of outcomes for inclusion in all fibromyalgiaclinical trials pain fatigue multidimensional function tender-ness and quality of sleep (Choy 2009b Mease 2009) OMER-ACT designated two additional outcomes depression and dyscog-nition as important but not core and placed anxiety morningstiffness imaging and biomarkers on the agenda for further re-search (Choy 2009b)In this review we have extracted data for 24 outcomes whichinclude all the outcomes considered important by OMERACT(Choy 2009b) We categorized the 24 outcomes into four maincategories wellness fibromyalgia symptoms physical fitness andsafety and acceptability

bull In the wellness category we extracted six outcomesmultidimensional function patient rated global clinician ratedglobal self-reported physical function self-regulation efficacyand mental health

bull In the symptom category of outcomes we extracted data foreight symptoms experienced by individuals with fibromyalgiapain fatigue sleep disturbance stiffness tenderness depressionanxiety and dyscognition

bull In the physical fitness category we extracted eight outcomesassociated with physiologic adaptation to exercise trainingmuscle strength muscle endurance muscle power musclejointflexibility muscle fiber activation muscle size maximumcardiorespiratory function and submaximal cardiorespiratoryfunction

bull The final category of outcomes was conceptualized as safetyand acceptance of resistance training This category consisted ofone outcome associated with possible harms - injuriesexacerbations of fibromyalgia or other adverse effects whileanother outcome - attrition rates served as a proxy for lack ofacceptability of resistance training

1 Outcomes representing wellness

This category of outcomes relates to generalized health or func-tioning Tools used to measure outcomes in this category included



both broad-spectrum indices designed to capture an array of tasksor characteristics to yield one summary score (eg Short Form - 36items (SF-36)) and single-item tests on which the respondent isasked to rate their status in an area of health using one item (eg avisual analog scale (VAS) on which the respondent places a markon a 10-cm line between worst health at one end and best healthat the other)

bull Multidimensional function - The outcomemultidimensional function consisted of multidimensionalindices used to measure general health status or health-relatedquality of life or both Similar to Choy 2009b we collapsedmeasures to measure general health status or health-relatedquality of life (or both) into one outcome When includedstudies used more than one instrument to measuremultidimensional function we preferentially extracted data forFibromyalgia Impact Questionnaire - Total (FIQ-total) followedby the SF-36 total the SF-12 total the EuroQol-5D theArthritics Impact Measurement Scales total (AIMS total) theQuality of Life Scale and the Illness Intrusiveness questionnaire

bull Self reported physical function - Self reported physicalfunction focuses the basic actions and complex activitiesconsidered ldquoessential for maintaining independence and thoseconsidered discretionary that are not required for independentliving but may have an impact on quality of liferdquo (Painter 1999)We classified this outcome in the wellness category of outcomesbecause it is dependent on several factors (physical sensoryenvironmental and behavioral factors) (Painter 1999) and as aself report measure represents the impact of these multiplefactors on the individualrsquos ability to meet the physical demandsof daily life Because cardiorespiratory fitness neuromuscularattributes such as muscular strength endurance and power andmuscle and joint flexibility are important determinants ofphysical function this outcome is highly relevant as an outcomeof exercise interventions We preferentially extracted data for theFIQ (English or translated) physical impairment scale followedby the Health Assessment Questionnaire (HAQ) disability scalethe SF-36Rand 36 Physical Function the Sickness ImpactProfile - Physical Disability and the Multidimensional PainInventory household chores scale

bull Patient-rated global - Patientsrsquo rating of global well-beingare commonly assessed by Likert or VAS They are highlysensitive to change (Choy 2009a Mease 2009) and appear to bereliable We extracted data preferentially for self-perceivedchange - VAS followed by self perceived change - numeric ratingscale self perceived disease severity VAS self perceived diseaseseverity - numeric rating scale self perceived sense of well-being -VAS and self perceived health status - numeric rating scale

bull Clinician rated global - Global assessments of diseaseseverity by physicians and other health professionals using aLikert or VAS are commonly used clinical settings We usedclinician-rated disease severity (VAS)

bull Self efficacy - We used self efficacy-physical functionInstruments found in this review were the Arthritis Self-EfficacyScale (Lorig 1989) the chronic Pain Self-Efficacy (Anderson1995) the Fibromyalgia Attitudes Index (Callahan 1988) andthe Freiburg Mindfulness Inventory (Buchheld 2001)

bull Mental health - The US Surgeon General has definedmental health as ldquoa state of successful performance of mentalfunction resulting in productive activities fulfilling relationshipswith people and the ability to adapt to change and to cope withadversityrdquo (wwwmedicinenetcommental_health_psychologypage2htm) In focus groups conducted by Arnold 2008participants reported that their physical and emotional ability tocomplete tasks of daily living was severely limited byfibromyalgia because of pain lack of energy fatigue anddepression Participants also expressed feelings ofembarrassment frustration guilt isolation and shame We usedSF-36Rand 36 Mental Health psychosocial scale (SicknessImpact Profile) Global Severity Index of the Symptom Checklist90 - revised (SCL-90-R) Profile Mood States (POMS)Psychological General Well-being (PGWB) total score

2 Outcomes representing fibromyalgia symptoms

This category of outcomes includes nine symptoms associated withfibromyalgia

bull Pain - The International Association for the Study of Paindefines pain as ldquoan unpleasant sensory and emotional experienceassociated with actual or potential tissue damage or described interms of such damagerdquo (Merskey 1994) For the purpose of thisreview we focused on one aspect of the pain experience - painintensity When more than one measure of pain was reported inone study we preferentially extracted pain VAS (FIQ Pain FIQ-Translated McGill pain VAS current pain) followed by theNumerical Pain Rating Scale the SF-36Rand 36 Bodily Painscale and the Pain Severity scale of the Multidimensional PainInventory

bull Tenderness - Tenderness was defined as discomfortproduced as an evoked response to mechanical pressure(Dadabhoy 2008 Gracely 2003) Although there are concernsthat measures of tenderness can be biased by cognitive andemotional aspects of pain perception many studies havesupported the utility of measurement of tenderness infibromyalgia using either TP counts or pain pressure threshold(Dadabhoy 2008) A TP is identified when pressure of 4 kg isperceived as painful When included studies used more than oneinstrument to measure tenderness we preferentially extracted theTP count followed by pain pressure threshold (dolorimetryscore based on at least six of the 18 ACR TPs) and the totalmyalgic score (summean of ordinal rating of response to thumbpressure across 18 TPs)

bull Fatigue - Fatigue is recognized by individuals withfibromyalgia and clinicians alike as an important symptom in



fibromyalgia Fatigue can be measured in a global manner aswhen an individual rates their fatigue on a single-item scale or asa multidimensional tool that breaks the experience of fatiguedown into two or more dimensions such as general fatiguephysical fatigue mental fatigue reduced motivation reducedactivity and degree of interference with activities of daily living(Boomershine 2012) We accepted both unidimensional andmultidimensional measures for this outcome When includedstudies used more than one instrument to measure fatigue wepreferentially extracted the fatigue VAS (FIQFIQ-TranslatedFatigue or single-item fatigue VAS) followed by the SF-36Rand36 Vitality subscale the Chalder Fatigue Scale (total) the FatigueSeverity Scale and the Multidimensional Fatigue Inventory

bull Sleep disturbance - Sleep problems are almost universal infibromyalgia occurring in 95 of people (Boomershine 2012)Measurement of sleep disturbance is challenging and there hasbeen a lack of consensus on the most valid measures (Choy2009a Choy 2009b) When included studies used more thanone instrument to measure sleep we preferentially extracted thePittsburg Sleep Quality Index followed by the Sleep QualityVAS Sleep Quantity nightsweek hournight hours of good-to-disturbed sleep and the Hamilton Depression Sleep Items

bull Stiffness - In focus groups conducted by Arnold 2008individuals with fibromyalgia ldquoremarked that their muscleswere constantly tense Participants alternately described feeling asif their muscles were rsquolead jellyrsquo or rsquolead Jell-Orsquo and this resultedin a general inability to move with ease and a feeling of stiffnessrdquoThe only measure we encountered for stiffness was the FIQstiffness VAS

bull Depression - Depression is a common mental disordercharacterized by depressed mood loss of interest or pleasurefeelings of guilt or low self worth disturbed sleep or appetitelow energy and poor concentration These problems can becomechronic or recurrent and lead to substantial impairments in anindividualrsquos ability to take care of his or her everydayresponsibilities (WHO 2012) In focus groups conducted byArnold 2008 the emotional disturbances most commonlyexperienced by participants with fibromyalgia includeddepression and anxiety A complete understanding of depressionand how best to assess it in fibromyalgia trials is still uncertainand is an active research issue (Mease 2009) However becausepeople with significant depression are commonly excluded fromfibromyalgia intervention studies the discriminatory power ofthese instruments is underestimated (Choy 2009b) Wepreferentially extracted Beck Depression Inventory (BDI)CognitiveAffective subscale scores followed by BDI total BDIwithout fibromyalgia Symptoms Beck Depression Scale shortform translated SF Hamilton Depression Scale Center forEpidemiologic Studies-Depression (CES-D) FIQFIQ translated- depression Mental Health Inventory subscale depressionAIMS - depression subscale Hospital Anxiety and DepressionQ-depression Symptom Checklist 90 - depression and the

PGWB depression score

bull Anxiety - Anxiety is a feeling of apprehension and fearcharacterized by physical symptoms such as palpitationssweating irritability and feelings of stress (wwwmedicinenetcomanxietyarticlehtm) Some participantsin OMERACT focus groups exploring key symptoms infibromyalgia reported that acute anxiety and panic weredisruptive to activities that they were trying to complete (Choy2009b) We preferentially extracted data for anxiety using theanxiety scale of the AIMS followed by the State AnxietyInventory the Hospital Anxiety and Depression Q-anxiety theBeck Anxiety Inventory the Mental Health Inventory anxietysubscale the SC-90 - anxiety scale PGWB anxiety score and theFIQ anxiety scale

bull Dyscognition - Dyscognition pertains to difficulty withcognitive tasks especially memory and thought processesAlthough this outcome was identified as important as anoutcome on fibromyalgia trials by OMERACT (Choy 2009b) itis rarely measured in studies of physical activity interventions forindividuals with fibromyalgia

3 Outcomes representing physical fitnessneuromuscular

adaptation

This category consisting of eight outcomes is associated with phys-iologic adaptation to exercise training There are several facets tophysical fitness including cardiovascular endurance body com-position muscle strength muscle endurance flexibility agilitycoordination balance power reaction time and speed (ACSM2009a) Given the nature of the intervention outcomes reflectingphysical fitness are highly relevant

bull Muscle strength - Muscular strength is a measure of amusclersquos ability to generate force It is generally expressed asmaximal voluntary contraction (MVC) for isometricmeasurements and as the 1RM for dynamic isotonicmeasurements (Howley 2001) and peak torque for isokineticmeasurements For the purpose of this review when more thanone measure of strength was reported we preferentially extracteddynamic tests over isometric tests lower limb over upper limbtests and contraction of extensor muscles over flexor muscles

bull Muscle endurance - Muscular endurance is the ability of amuscle group to exert submaximal force for extended periods itcan be assessed for static or dynamic muscular contractions(Heyward 2010) For the purpose of this review when more thanone measure of muscle endurance was reported we preferentiallyextracted lower extremity dynamic endurance (stair step sit tostand chair tests or fatigue curve) followed by lower extremitystatic endurance including fatigue curve number of squatsperformed in 60 seconds fatigue index (the ratio of mean powerin last five repetitions to the mean power in first five during a testof 60 repetitions) and upper extremity dynamic endurancemeasured using a fatigue curve and grip endurance test



bull Muscle power - Power (the explosive aspect of strength) isdefined as rate of doing muscle work (Trew 2005) Power is theproduct of force (torque) and speed of movement [power =(force x distance)time] (ACSM 2009b) For the purpose of thisreview when more than one measure of power was reported wepreferentially extracted the vertical jump test (m) horizontaljump isokinetic power (lower extremity before upper extremity)and maximum power test (maximum power in watts on best ofthree repetitions doing squats)

bull Musclejoint flexibility - Flexibility is the ability of a jointor a series of joints to move fluidly through its complete range ofmotion (ROM) (Heyward 2010) It is important in the ability tocarry out activities of daily living Flexibility depends on severalspecific variables including joint geometry and the distensibilityof the joint capsule ligaments tendon and muscles spanningthe joint (Heyward 2010) Flexibility is joint specific so nosingle test can evaluate total body flexibility For the purpose ofthis review the following were used sit and reach test forwardreach test and ROM measures (when there were multiple ROMmeasures we took the first measure in the researcherrsquos data table)

bull Muscle fiber activation - Muscle fiber activation(recruitment) occurs progressively the level of activation isrelated to the degree of effort required (Sale 1987) For thisreview we extracted data from electromyographic recordingsduring isometric contractions of lower extremity contractions

bull Muscle size - One effect of strength training is an increasein the size of the muscle tissue Muscle size and strength are oftenpositively correlated The increase in size of the muscle (alsoknown as exercise-induced hypertrophy) results from an increasein the total amount of contractile proteins the number and sizeof myofibrils per fiber amount of connective tissue surroundingthe muscle fibers (Heyward 2010) For this review we extracteddata on cross-sectional area (cm2) of the quadriceps muscle

bull Maximum cardiorespiratory function - Cardiorespiratoryendurance is the ability of the heart lungs and circulatory systemto supply oxygen and nutrients to working muscles efficientlyRhythmic aerobic-type exercises involving large muscle groupsare recommended for improving cardiovascular fitness Maximaloxygen uptake (VO2 max) is accepted as the best criterion tomeasure cardiorespiratory fitness Maximal oxygen uptake is theproduct of the maximal cardiac output (liters of bloodminute)and arterial-venous oxygen difference (milliliters O2liter ofblood) Maximal tests have the disadvantage of requiring theparticipant to exercise to the point of volitional fatigue and oftenrequire medical supervision and emergency equipment For thisreason maximal exercise testing is not always feasible in healthand fitness settings For this review we preferentially extracteddata from maximal or symptom-limited treadmill or cycleergometer tests in units of milliterskilogramminute energyexpended peak workload or test duration We also accepted datafrom exercise tests that yielded predicted maximum oxygenuptake

bull Submaximal cardiorespiratory function - Measuring VO2 max requires expensive laboratory equipment and considerableamounts of time as well as a high level of motivation on the partof the participant Submaximal tests to predict or estimate VO2

max are similar except that they are terminated at somepredetermined point (usually based on heart rate intensity orperceived exertion) Assumptions associated with submaximalexercise testing include a) a steady-state heart rate is reached ateach exercise intensity and there is a linear relationship betweenheart rate oxygen uptake and work intensity b) the mechanicalefficiency on the cycle or treadmill is constant for all individualsand c) the maximum heart rate for participants of a given age issimilar (Heyward 1998) In this review we preferentiallyextracted data from work completed at a specified exercise heartrate (eg PWC170 test) followed by distance walked in sixminutes (meters) the two-minute walk test (meters) walkingtime for a set distance (seconds) anaerobic threshold test andtimed walking distance (eg Quarter Mile Walk Test)

Major outcomes

We designated seven of the 24 outcomes as major outcomesbull multidimensional function (wellness)bull self reported physical function (wellness)bull pain (symptoms)bull tenderness (symptoms)bull muscle strength (fitness)bull attrition ratesbull adverse effects (injuries exacerbations of pain and other

symptoms other adverse events)

Minor outcomes

We designated the 17 remaining outcomes as minor outcomesThere were four wellness outcomes six symptom outcomes andseven physical fitness outcomes

Minor wellness outcomes

bull patient-rated globalbull mental healthbull self efficacybull clinician-rated (single-item instrument)

Minor symptom outcomes

bull fatiguebull sleep disturbancebull stiffnessbull depressionbull anxietybull dyscognition



Minor physical fitness outcomes

bull muscle endurancebull muscle powerbull muscle fiber activation (EMG)bull muscle size (cross-sectional area of muscle)bull maximum cardiorespiratory functionbull submaximal cardiorespiratory functionbull musclejoint flexibility

Search methods for identification of studies

Interventions in this review are part of a comprehensive search forall physical activity interventions The citations found in the elec-tronic searches were screened and then classified by type of exercisetraining (eg aerobic resistance flexibility and yoga aquatic exer-cise mixed exercise and composite interventions and innovativeexercise interventions)

Electronic searches

We searched the following databases from database inception to5 March 2013 using current methods outlined in Chapter 6 ofthe Cochrane Handbook for Systematic Reviews of Interventions (Lefebvre 2011) We applied no language restrictions Full searchstrategies for each database are found in the appendices as indicatedin the list

bull MEDLINE (Ovid) 1946 to 5 March 2013 (Appendix 2)bull EMBASE (Ovid) EMBASE Classic + EMBASE 1947 to 4

March 2013 (Appendix 3)bull The Cochrane Library 2013 Issue 2 (

wwwthecochranelibrarycomview0indexhtml) (Appendix 4) Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effects (DARE) Cochrane Central Register of Controlled Trials

(CENTRAL) Health Technology Assessment Database (HTA) NHS Economic Evaluation Database (EED)

bull CINAHL (EBSCO) 1982 to 5 March 2013 (Appendix 5)bull PEDro (wwwpedroorgau) accessed 5 March 2013

(Appendix 6)bull Dissertation Abstracts (Proquest) accessed 5 March 2013

(Appendix 7)bull Current Controlled Trials accessed 5 March 2013

(Appendix 8)bull World Health Organization (WHO) International Clinical

Trials Registry Platform (wwwwhointictrp) accessed 5 March2013 (Appendix 9)

bull AMED (Allied and Complementary Medicine) (Ovid)1985 to February 2013 (accessed 5 March 2013) (Appendix 10)

Searching other resources

Two review authors independently searched reference lists fromkey journals identified articles meta-analyses and reviews of alltypes of treatment for fibromyalgia with all promising or potentialreferences scrutinized and appropriate titles added to the searchoutput


Review team

The review team was made up of 11 members including two con-sumers and one librarian and nine review authors Review authorscame from the following backgrounds physical therapy kinesiol-ogy and dietetics Review authors were trained in data extractionusing a standardized orientation program designed for this reviewReview authors worked in pairs (with at least one physical thera-pist in each pair) to extract data The team met monthly to discussprogress to clarify procedures and to make decisions regardinginclusionexclusion and classification of outcome variables and towork collaboratively in the production of this review

Selection of studies

Two review authors independently examined the titles and re-viewed abstracts of studies generated from searches using a set ofcriteria (see Appendix 11 - Screening and Classification Criteria -Level 1 and Level 2) We retrieved full-text publications for all po-tential abstracts We translated the methods and results sections forall non-English reports Two review authors then independentlyexamined the full-text reports and translations to determine if thestudy met the selection criteria (see Appendix 11 - Screening andClassification Criteria - Level 3) We resolved disagreements andquestions regarding interpretation of inclusion criteria by discus-sion with partners unless the pair agreed to take the issue to theteam

Data extraction and management

We developed electronic data extraction forms to facilitate inde-pendent data extraction and consensus Pairs of review authorsworked independently to extract the descriptive and quantitativedata from the studies After the data were extracted the reviewauthors reviewed the data together and reached a consensus Wefrequently encountered questions regarding the acceptability ofoutcome measures used in the studies we referred these questionsto the team for resolution if not solved with partners



Assessment of risk of bias in included studies

We followed the procedure to assess bias recommended in theCochrane Handbook for Systematic Reviews of Interventions Tworeview authors independently evaluated the risk of bias in each in-cluded study using a customized form based on the Cochrane rsquoRiskof biasrsquo tool (Higgins 2011c) The tool addresses seven specificdomains sequence generation allocation concealment blindingof participants and personnel blinding of outcome assessmentincomplete outcome data selective outcome reporting and othersources of bias For other sources of bias we considered potentialsources of bias such as baseline inequities despite randomizationor inequities in the duration of interventions being comparedEach criterion was rated as low risk of bias high risk of bias orunclear risk of bias (either lack of information or uncertainty overthe potential for bias) In a consensus meeting we discussed andresolved disagreements among the review authors If we could not

reach consensus we referred the issue to the review team who madethe final decision Due to the nature of the intervention blindingof study participants and care providers is very difficult

Measures of treatment effect

The outcome measures of interest were most often presented ascontinuous data with pre-test means post-test means and stan-dard deviations We calculated change scores and estimated stan-dard deviations for the change scores using the formula describedin the Cochrane Handbook for Systematic Reviews of Interventions(Figure 1) We used Review Manager 5 (RevMan 2012) analysissoftware to (1) calculate effect sizes in the form of mean differences(MD) standardized mean differences (SMD) and 95 confidenceintervals (CI) for continuous outcomes risk ratios (RR) and Petoodds ratio (OR) and 95 CI for dichotomous outcomes and (2)generate forest plots to display the results

Figure 1 Formula for calculating standard deviations of change scores based on pre- and post-test standard

deviations (see Section 16132 in Higgins 2011c)

Unit of analysis issues

This review of RCTs included studies with two or more parallelgroups We preferentially used data (mean change scores) from in-tention-to-treat analysis so that the number of observations in theanalyses matched the number of individuals that were random-ized However in some cases the researchers presented data forcompleters only in which case the number of individuals whosedata were analyzed was less than the number of individuals thatwere randomized In trials with three arms if the control groupwas used as a comparator twice within the same analysis we halvedthe sample size of the control group

Dealing with missing data

When numerical data were missing we contacted the authors ofstudies requesting additional data required for analysis Whendata were available only in graphic form we used Engauge version41 (Mitchell 2002) to extrapolate means and standard deviationsby digitizing data points on the graphs When unavailable wecalculated the standard deviations of the change scores using the

formulae in Higgins 2011c (see Figure 1) The correlation betweenbaseline and end of study measurements was estimated at 08We contacted authors using open-ended questions to obtain theinformation needed to assess risk of bias or the treatment effect(Bircan 2008 Hakkinen 2001 Jones 2002)

Assessment of reporting biases

We found too few studies to assess reporting bias

Data synthesis

When two or more sets of data were available for the same outcomewe used the Review Manager analyses to pool the data (meta-analysis fixed-effect model) (RevMan 2012) In order to carry outmeta-analysis we performed transformation of the point estimatesof outcomes a) to express results in the same units (eg centimeterswere transformed to millimeters) or b) to resolve differences inthe direction of the scale (when scores derived from scales withhigher score indicating greater health were combined with scoresderived from scales with high scores indicating greater disease) To



evaluate the magnitude of the effect we used Cohenrsquos guidelines(small effect = 02 to 049 moderate effect = 05 to 079 largeeffect gt 079) (Cohen 1988)

Subgroup analysis and investigation of heterogeneity

We found too few studies to conduct subgroup analysis We as-sessed statistical heterogeneity among the trials using the hetero-geneity statistics (Chi2 test and I2 statistic) We considered P val-ues lt 010 or I2 gt 50 to be indicative of significant heterogeneityWhere P value lt 010 or I2 gt 50 (or both) we used a random-effects model instead of the fixed-effect model for meta-analysisIn addition in the case of statistical heterogeneity we scrutinizedthe studies for sources of clinical heterogeneity and methodologicdifferences

Sensitivity analysis

We found too few studies to conduct sensitivity analysis

rsquoSummary of findingsrsquo tables

We used Grade-Pro (version 36) (Schuumlnermann 2009) to preparersquoSummary of findingsrsquo tables with the seven major outcomes foreach of the three comparisons - resistance training versus controlresistance training versus aerobic training and resistance train-ing versus flexibility exercise In the rsquoSummary of findingsrsquo tableswe integrated analysis concerning the quality of evidence and themagnitude of effect of the interventions We applied the GRADEWorking Group grades of evidence which considers the risk ofbias and the body of literature to rate quality into one of fourlevels

bull High quality Further research is very unlikely to changeour confidence in the estimate of effect

bull Moderate quality Further research is likely to have animportant impact on our confidence in the estimate of effect andmay change the estimate

bull Low quality Further research is very likely to have animportant impact on our confidence in the estimate of effect andis likely to change the estimate

bull Very low quality We are very uncertain about the estimate

Quality ratings were made separately for each of the seven ma-jor outcomes Because of the comprehensive nature of the out-come variable - rsquomultidimensional functionrsquo we gave it primacy

over all the other variables and chose it as the variable to high-light in the rsquoSummary of findingsrsquo table and the lay summary Wecarried out calculations based on the guidelines of the CochraneMusculoskeletal Review GroupWhen we found statistically significant results we calculated num-bers needed to treat for an additional beneficial outcome (NNTB)and for an additional harmful outcome (NNTH) We also eval-uated the clinical relevance of the effects in major outcomes bycalculating the absolute and relative difference in change from apooled baseline in the intervention group as compared with thechange from a pooled baseline in the control or comparison groupWe calculated the pooled baseline as followsPooled baseline = (X1pren1 + X2pre n2) (n1 + n2)Relative difference () = MDpooled baselinewhere the MD was calculated by Review Manager (RevMan 2012)X1pre and X2pre are the pre-test means in the experimental andthe control groups respectively and n1 and n2 are the number ofparticipants in the experimental and control groups respectivelyIn keeping with the practice of the Philadelphia Panel we used15 as the level for clinical relevance (Philadelphia 2001)

R E S U L T S

Description of studies

Results of the search

The search resulted in 1856 citations We excluded 1090 studieson citation screening and 605 studies based on abstract screening(see Figure 2) On examination of full-text articles we excluded58 studies because they did not meet the selection criteria relatedto a) diagnosis of fibromyalgia (five studies) b) physical activityintervention (10 studies) c) study design (34 studies) or d) out-comes (nine studies) Ninety-eight research publications described84 RCTs with physical activity interventions for individuals withfibromyalgia We screened the 84 RCTs to identify studies thatcompared interventions that were exclusively resistance traininginterventions versus control groups or other interventions withthe result that an additional 79 trials were screened out (see Table2) Five additional studies are awaiting classification



Figure 2 Study flow diagram (note a Discrepancy between the number of articles and studies denotes that

multiple papers have described the same study)



Included studies

Seven research publications met our selection criteria and wereincluded for analysis (Bircan 2008 Hakkinen 2001 (Primary)Hakkinen 2002 (Secondary) Jones 2002 Kayo 2011 Valkeinen2004 (Primary) Valkeinen 2005 (Secondary)) As Hakkinen 2002(Secondary) reported on additional variables from the Hakkinen2001 (Primary) study the two reports were counted as one studyfor analysis (hereafter both reports are identified as Hakkinen2001) Likewise Valkeinen 2005 (Secondary) reported on addi-tional variables to the Valkeinen 2004 (Primary) study and this pairwas also counted as one study (hereafter both reports are identi-fied as Valkeinen 2004) Thus although there were seven separatepublications there were only five included studies In total therewere 241 participants in the included studies and of these therewere 219 women with fibromyalgia (note two studies Hakkinen2001 and Valkeinen 2004 had comparison groups consisting ofhealthy women) One hundred and sixty-six of the 219 womenwith fibromyalgia were assigned to exercise interventions 95 toresistance training 43 to aerobic training and 28 to flexibilitytraining We were hampered by missing data pertaining to char-

acteristics of the study assessment of risk of bias assessment ofexercise interventions outcome data or a combination of these inall included studies We requested additional information from allauthors and received responses to our queries from four of the fiveauthors (Bircan 2008 Hakkinen 2001 Jones 2002 Kayo 2011)

Excluded studies

Following screening of citations and abstracts we excluded 106studies based on examination of full-text reports We based exclu-sions on unmet criteria (44 studies) related to a) diagnosis (sevenstudies) b) study design (26 studies) c) intervention (five studies)d) lack parallel data (six studies) (see Characteristics of excludedstudies) and e) duplicate studies identified progressively acrossmultiple searches (62 studies)

Risk of bias in included studies

Results of the risk of bias assessment are provided in theCharacteristics of included studies table and in Figure 3 and Figure4



Figure 3 Risk of bias summary review authorsrsquo judgments about each risk of bias item for each included

study



Figure 4 Risk of bias graph review authorsrsquo judgments about each risk of bias item presented as

percentages across all included studies

Allocation

Four of the five included studies used an acceptable method ofrandom sequence generation (computer-generated sequence cointoss drawing of cards or lots) and were rated low risk (Bircan2008 Jones 2002 Kayo 2011 Valkeinen 2004) Although twostudies (Bircan 2008 Kayo 2011) used opaque sealed envelopesto conceal allocation and were rated as low risk the remainingthree included studies were rated as unclear risk as they did notprovide sufficient information to determine allocation methodsand whether treatment allocation was concealed

Blinding

No specific information regarding blinding of the care provider orparticipants was provided in any of the included studies howeverin exercise studies blinding of participants and care providers isvery rare Performance and detection bias were rated as high riskfor the five studies Two studies blinded outcome assessors to par-ticipant group assignment (Jones 2002 Kayo 2011) one studydid not (Bircan 2008) and the other included studies did not pro-vide specific information about blinding of outcome assessors thestudies were rated as low (Jones 2002 Kayo 2011) high (Bircan2008) and unclear risk (Hakkinen 2001 Valkeinen 2004)

Incomplete outcome data

Three studies were rated as low risk related to incomplete outcomedata two studies had no dropouts (Hakkinen 2001 Valkeinen2004) and one study used an intention-to-treat analysis (Kayo2011) There was insufficient information provided by Jones 2002to determine whether incomplete outcome data were adequatelyaddressed Missing outcome data were balanced in numbers acrossintervention groups with similar reasons for missing data acrossgroups suggesting low risk of bias in Bircan 2008 Attrition rateswere reported to be 18 (634 participants) in Jones 2002 and13 (215 participants) in Bircan 2008

Selective reporting

It was difficult to assess selective reporting bias because a priori re-search protocols were not available for any of the reviewed studiesThree studies were rated as having a high risk of selective reportingbecause some of the reported outcome measures were not prespec-ified and pointvariability estimates were not provided for all out-comes (Hakkinen 2001 Kayo 2011 Valkeinen 2004) Anotherstudy was also rated as high risk because it compared the effects ofresistance training and aerobic training yet did not evaluate resultsfor muscle strength muscle endurance or muscle power (Bircan2008)



Other potential sources of bias

The studies appear to be free of other serious potential sourcesof bias Only one of the included studies reported differences be-tween intervention groups at baseline that could have biased finalresults Kayo 2011 reported a significantly longer disease durationin the control group Kayo 2011 included the greatest number ofparticipants (analyzed 30 per group) Small sample sizes are associ-ated with low power and it is possible that detection of treatmenteffects were missed Poor adherence is also a potential source ofbias in exercise studies Two studies reported attendance at orga-nized exercise sessions (Bircan 2008 Jones 2002) but none of theincluded studies reported detailed results of systematic data collec-tion and analysis of participant adherence to exercise performancein a way that would allow the review authors to understand theamount of training actually performed by participants Overallwe rated the risk due to other sources as low

Effects of interventions

See Summary of findings for the main comparison Resistancetraining compared with control for fibromyalgia Summary of

findings 2 Resistance training compared with aerobic trainingfor fibromyalgia Summary of findings 3 Resistance trainingcompared with flexibility exercise for fibromyalgiaAll studies but one (Kayo 2011) used the end of the interven-tion as the final data collection point None of the interventionsextended beyond 21 weeks Kayo 2011 measured the effects ofphysical activity midway through the intervention (eight weeks)immediately following the intervention (16 weeks) and followedstudy participants for an additional period of 12 weeks after thesupervised intervention concluded The results related to effectsof the interventions have been grouped below to correspond toobjectives of the review

Resistance training versus control

Two of the three studies that compared resistance training versuscontrol were very similar in structure - both studies (Hakkinen2001 Valkeinen 2004) described 21-week resistance training in-terventions that were congruent with American College of SportsMedicine (ACSM) guidelines (Garber 2011) Both studies hadthree arms a) women with fibromyalgia carrying out the resistancetraining intervention b) women with fibromyalgia in a controlgroup and c) healthy women carrying out resistance the trainingintervention Both studies used similar resistance machines andintensities (moderate- to high-intensity levels) Sample sizes forthe fibromyalgia exercise group the fibromyalgia control groupand the healthy control group were 11 10 and 12 respectivelyin Hakkinen 2001 and 13 13 and 11 respectively in Valkeinen2004 The fibromyalgia control group in Valkeinen 2004 contin-ued with their normal medication and daily activities howeverHakkinen 2001 did not describe the fibromyalgia control group

conditions with respect to medications or activity A key differ-ence between the two studies was age of the study participants -in Hakkinen 2001 the participants were premenopausal womenwhile Valkeinen 2004 studied older women (mean age of partic-ipants in the exercise group was 602 plusmn 25 years) The results ofthe comparisons of the fibromyalgia training groups and the fi-bromyalgia control groups will be considered in this sectionThe third study Kayo 2011 compared three 16-week interven-tions a resistance training group who used body weight againstgravity and free weights as resistance with exercise load and inten-sity increased every two weeks to tolerance (n = 30) an aerobicexercise group who did moderate-intensity indoor and outdoorwalking (n = 30) and an untreated control group (n = 30) Out-comes were measured at baseline eight weeks 16 weeks (post-in-tervention) and 28 weeks (follow-up) The results of the compar-ison between the resistance training group and the control groupat 16 weeks will be considered in this sectionHakkinen 2001 provided data for five major outcomes (self re-ported physical function pain tenderness muscle strength andattrition) and seven minor outcomes (patient-rated global fa-tigue sleep depression muscle power muscle size and muscle ac-tivation) Valkeinen 2004 presented data on five major outcomes(self reported physical function tenderness muscle strength ad-verse effects and attrition) and two minor outcomes (muscle sizeand muscle activation) In their published report Kayo 2011 pro-vided data for four major outcomes (multidimensional functionpain adverse effects and attrition) but upon request they sup-plied data for two additional major outcomes (self reported phys-ical function and tenderness) Kayo 2011 provided data for twominor outcomes (mental health and fatigue) Kayo 2011 was theonly study to include a follow-up point after the resistance train-ing protocol was completed (12 weeks) Thus meta-analyses werecarried out on five major outcomes (self reported physical func-tion pain tenderness muscle strength and attrition) and threeminor outcomes (fatigue muscle size and muscle activation) andwere restricted to postintervention analysis onlyMajor outcomes Among the major outcomes large effects (SMDgt 079) favoring resistance training were found for multidimen-sional function (MD -1675 FIQ units on a 100-point scale 95CI -2331 to -1019 1 study 60 of 60 participants analyzedAnalysis 11) pain (MD -330 cm on 10-cm VAS 95 CI -635 to -026 2 studies 81 participants Analysis 13) and musclestrength (MD 2732 kg 95 CI 1828 to 3636 2 studies 47 of47 participants analyzed Analysis 15) while a moderate effectsfavoring resistance training were found in self reported physicalfunction (MD -629 less on 100-point scale 95 CI -1045 to-213 3 studies 107 of 107 participants analyzed Analysis 12)and tenderness (MD -184 out of 18 TPs 95 CI -26 to -108 3studies 107 of 107 participants analyzed Analysis 14) Relative tothe control groups these represented incremental improvements of26 in multidimensional function 159 in self reported phys-ical function 446 in pain 126 in tenderness and 25 in



muscle strength in the resistance groupsOnly two of the three studies provided information on adverseeffects of resistance training (eg injuries exacerbations or otheradverse effects related to exercise) Valkeinen 2004 reported ldquoaf-ter the initial phase of training the patients did not complain ofany unusual exercise-induced pain or muscle sorenessrdquo (page 227)Although Kayo 2011 expected to find ldquoworsening of pain or fearof exercise-induced painrdquo they reported that no instances of attri-tion due to adverse effects were observed during the study WhileHakkinen 2001 did not report on adverse effects the lack of drop-outs among the women who undertook this high-intensity resis-tance exercise regimen suggests that individuals with fibromyalgiacan tolerate resistance training exercise All-cause attrition rates forthe resistance groups (n1N1) versus control groups (n2N2) were011 versus 010 (Hakkinen 2001) 013 versus 013 (Valkeinen2004) and 730 versus 230 (Kayo 2011) The pooled RR forattrition in the intervention groups compared with the controlgroups at the end of the intervention was 350 (95 CI 079 to1549)

Minor outcomes Large effects favoring resistance training werefound for several minor outcomes patient-rated global well-be-ing (MD -4000 mm on a 100-mm scale 95 CI -5431 to -2569 relative difference 91 1 study 21 of 21 participants an-alyzed Analysis 17) fatigue (MD -1466 on a 100-unit scale95 CI -2055 to -877 relative difference 224 2 studies 81of 81 participants analyzed Analysis 16) depression (MD -37095 CI -637 to -103 relative difference 57 1 study 21 par-ticipants of 21 analyzed Analysis 19) muscle power (MD 2 cmhigher on a squat jump 95 CI 1 to 3 relative difference 121 study 21 of 21 participants analyzed Analysis 111) and mus-cle activation (MD 4092 microVs more on integrated EMG 95CI 335 to 4834 relative difference 352 2 studies 47 of 47participants analyzed Analysis 113) No differences were foundin mental health (Analysis 18) sleep (Analysis 110) or musclesize (Analysis 112) Although the SMD for muscle size was 048due to the high variability in these data this was not statisticallysignificant

Regarding effects on fitness Valkeinen 2004 stated that their re-sults ldquoclearly show changes in fitness and the trainability of mus-clesrdquo in people with fibromyalgia In addition Hakkinen 2001 andValkeinen 2004 found no differences in magnitude and timingof adaptations of the neuromuscular system to strength trainingduring the 21-week resistance training program in women withfibromyalgia compared with healthy women performing the sameroutine The researchers also found a similar response in systemicgrowth hormone levels during an acute bout of exercise in partic-ipants with fibromyalgia and healthy controlsQuality of evidence These data indicate that resistance traininghas positive effects on wellness symptoms and physical fitnesswithout serious adverse effects but due to the limited number

of studies the paucity of study participants and the risk of biasfindings for these studies this evidence is categorized as low-qualityevidence (see Summary of findings for the main comparison)

Long-term effects Kayo 2011 was the only study to investigateretention of effects following the intervention Kayo 2011 did notreport any details about the activities of the participants during thefollow-up period They found that differences favoring resistancetraining in multidimensional function (MD -1067 on a 100-point scale 95 CI -1788 to -346) fatigue (MD -911 on a 100-point scale 95 CI -1618 to -204) and pain (MD -085 cmon 10-cm scale 95 CI -177 to 007) were retained at week 28(12 weeks after end of intervention) No differences were found atfollow-up in tenderness (MD -192 tenderness rating 95 CI -706 to 322) self reported physical function (MD 100 on a 100-point scale 95 CI -504 to 704) or mental health (MD 054on a 100-point scale 95 CI -701 to 809)

Resistance training versus aerobic training

Bircan 2008 compared the effects of eight weeks of resistancetraining (n = 13) involving free weights and body weight resis-tance to major muscle groups versus aerobic interventions (n = 13treadmill walking) Both the aerobic training group and resistancetraining groups met three times per week Women in the aerobicgroup walked on a treadmill for 20 to 30 minutes each session at60 to 70 of predicted maximum heart rate while those in theresistance training group used body segment loads free weights orboth to perform exercises progressing from four to five repetitionsto 12 repetitions over the course of the program Attendance wasnot reported to be a problem with participants attending all super-vised exercise sessions over the eight-week program Kayo 2011compared the effects of resistance training (n = 30 free weightsand body weight resistance to major muscle groups) versus aero-bic training (n = 30 indoor and outdoor walking) at eight weeks(mid-test) 16 weeks (post-test) and 26 weeks (12 weeks after theconclusion of the intervention)Since both Bircan 2008 and Kayo 2011 provided data at eightweeks we used eight-week data in our assessment of resistanceversus aerobic training Bircan 2008 provided data for five majoroutcome measures self reported physical function pain tender-ness adverse effects and attrition and six minor outcome mea-sures mental health fatigue sleep depression anxiety and car-diorespiratory submaximal Kayo 2011 provided data for six ma-jor outcomes multidimensional function self reported physicalfunction pain tenderness adverse effects and attrition and twominor outcomes mental health and fatigue Thus meta-analyseswere carried out on four major outcomes (self reported physicalfunction pain tenderness and attrition) and two minor outcomes(fatigue and mental health) Kayo 2011 included a follow-up pointafter the exercise training protocols were completed (12 weeks)Major outcomes Our analyses showed a moderate difference be-



tween resistance and aerobic training favoring aerobic training forpain (MD 099 cm on a 10-cm VAS 95 CI 031 to 167 rela-tive difference 1294 2 studies 86 of 90 participants analyzedAnalysis 23) No significant differences were found between theresistance training interventions and the aerobic interventions formultidimensional function measured by FIQ total (MD 548 ona 100-point scale 95 CI -092 to 1188 1 study 60 of 60 par-ticipants analyzed Analysis 21) self reported physical functionmeasured by SF-36 Physical Function Scale (MD -148 on a 100-point scale 95 CI -669 to 374 2 studies 86 of 90 participantsanalyzed Analysis 22) or tenderness measured using TP countsand myalgic scores (SMD -013 95 CI -055 to 030 2 studies86 of 90 participants analyzed Analysis 24)Although Kayo 2011 expected to find ldquoworsening of pain or fear ofexercise-induced painrdquo they reported that no instances of attritiondue to adverse effects were observed during the study LikewiseBircan 2008 stated ldquono patient experienced musculoskeletal in-juryduring the interventionrdquo (page 529) All-cause attrition-ratesfor the resistance training groups (n1N1) versus aerobic traininggroups (n2N2) in the included studies were 215 versus 216(Bircan 2008) and 730 versus 830 (Kayo 2011) to yield a PetoOR of 100 (95 CI 024 to 423 Analysis 211)Minor outcomes A large effect (SMD gt 079) was found favoringaerobic training for sleep (Analysis 27) but no differences werefound between resistance and aerobic training for fatigue (Analysis25) mental health (Analysis 26) depression (Analysis 28) oranxiety (Analysis 29)Long-term effects Based on Kayo 2011 positive effects favoringaerobic training emerged at 12 weeks after the conclusion of theintervention for self reported physical function (SMD 068 95CI 016 to 120) and mental health (SMD 058 95 CI 006to 110) However the positive effects for pain favoring aerobictraining found after eight weeks were no longer statistically sig-nificant (SMD 041 95 CI -010 to 092) 12 weeks after theconclusion of the interventionQuality of evidence Although these data indicate that aero-bic training may have advantages over resistance training in pain(short term) and physical function (short term) and mental health(emerging 12 weeks post-intervention) this evidence is catego-rized as low-quality evidence (see Summary of findings 2)

Resistance training versus flexibility exercise

Jones 2002 compared a 12-week resistance training program (n= 28) designed to be sensitive to peripheral and central dysfunc-tions versus a stretching intervention (n = 28) consisting of staticstretching exercises the same 12 muscle groups were targeted inboth programs Resistance training utilized hand weights (up to3 lb (14 kg)) and elastic tubing Jones 2002 provided data for sixmajor outcomes - multidimensional function pain tendernessstrength adverse effects and attrition and five minor outcomes -self efficacy sleep depression anxiety and musclejoint flexibilityNo meta-analyses were possible for this comparisonMajor outcomes Jones 2002 found a moderate-sized effect favor-ing resistance training for multidimensional function using FIQtotal (scale 0 to 100) (MD -649 95 CI -1257 to -004 1 study56 of 68 participants analyzed Analysis 31 relative difference136) and VAS pain (MD -088 cm on a 10-cm scale 95 CI-157 to -019 1 study 56 of 68 participants analyzed Analysis32 relative difference 14) No between-group differences werefound for tenderness (number of TPs) (MD -046 95 CI -156to 064 1 study 56 of 68 participants analyzed Analysis 33) ormuscle strength (MD 477 95 CI -240 to 1194 1 study 56 of68 participants analyzed Analysis 34) Jones 2002 indicated thatthere were ldquono adverse events or injuries during the interventionrdquo(page 1045) However Jones 2002 further stated ldquosix participants(3 per group) experienced a worsening of one or more of the fol-lowing pain measures FIQ VAS for pain total myalgic score andnumber of tender pointsrdquo (page 1045) All-cause attrition-ratesfor the resistance group (n1N1) versus flexibility group (n2N2)were 628 versus 628 RR 100 (95 CI 037 to 273 Analysis311)Minor outcomes Jones 2002 found a large effect favoring resis-tance training on fatigue (Analysis 36) and sleep (Analysis 37)However there was a moderate effect favoring the flexibility groupon the hand-to-scapula test reflecting muscle and joint flexibility(MD 030 on a 4-point scale 95 CI 001 to 059 1 study 56of 68 participants analyzed Analysis 310) No differences werefound in self efficacy (Analysis 35) depression (Analysis 38) oranxiety (Analysis 39)Quality of evidence Considering there is only one study in thiscategory there was very-low-quality evidence that 12 weeks oflow-intensity resistance training yielded greater improvements inwellness and symptoms fitness safety and acceptability than doesflexibility exercise (see Summary of findings 3)



A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]

Resistance training compared with aerobic training for fibromyalgia


Settings Brazil and Turkey

Intervention Resistance training supervised group exercise

Comparison Aerobic training supervised group exercise


(95 CI)

No of Participants

(studies)


(GRADE)

Comments7


Aerobic Training Resistance Training


tion

FIQ Total Score Scale 0-

100 (lower scores indi-

cate greater health)

Follow-up 8 weeks



sional function in the aer-

obic training group was

-2133 FIQ units1



sional function in the re-

sistance training group

was

-1585 FIQ units 1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD 043 (95 CI -008

to 094)6

Absolute difference5 548

FIQ units (95 CI -092

to 1188)


cant


function

SF-36 Physical Func-

tion Scale Scale 0-100

(higher scores indicate

greater health)

Follow-up 8 weeks

The mean change (pre

to post) in self reported


aerobic training groups

was

581 SF-36 units 1




resistance training groups

was

454 SF-36 units 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -011 (95 CI -053

to 031) 6


SF-36 units (95 CI -6

69 to 374)6


cant

Pain

Visual analog scale Scale

0-10 cm (lower scores

indicate less pain)

Follow-up 8 weeks




was

-357 cm12




was

-27 cm 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD 053 (95 CI 010

to 097)8


cm (95 CI 031 to 167)


24

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7 129 (95 CI 405

to 2405) better in the


NNTB 5 (95 CI 3 to 24)

Tenderness


myalgic scores Scores

converted to tender

points 0 to 18 (lower


derness)

Follow-up 8 weeks



in the aerobic training

groups was

-515 tender points1



in the resistance training

groups was

-49 tender points 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -013 (95 CI -055

to 03)6



68 to 033)


cant

Adverse effects See comment See comment Not estimable See comment See comment No lsquo lsquo worsening of pain

or fear of exercise-in-

duced painrsquorsquo lsquo lsquo no pa-

tient experienced mus-

culoskeletal injurydur-

ing the interventionrsquorsquo (2

studies)

All-cause attrition

Dropout rates

Follow-up 8 weeks

89 per 1000 89 per 1000

(22 to 296)

Peto OR 1

(024 to 423)

90

(2 studies2)

oplusopluscopycopy

low


(95 CI -12 to 12)


0


cant



CI confidence interval FIQ Fibromyalgia Impact QuestionnaireOR odds ratio RR risk ratioSF Short FormSMD standardized mean difference





Very low quality We are very uncertain about the estimate25

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1 Improvement pretest to post-test2 Only women were studied3 Evidence derived from one study4 Wide confidence intervals5 Absolute difference = mean change in resistance training group(s) minus mean change in control group(s)6 Not statistically significant


)] N8 Moderate effect (SMD 05 to 079) favoring aerobic exercise

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

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Resistance training compared with flexibility exercise for fibromyalgia


Settings USA

Intervention Resistance training

Comparison Flexibility exercise


(95 CI)

No of Participants

(studies)


(GRADE)

Comments


Flexibility exercise Resistance training


tion

FIQ Total Scale 0-100

(lower scores indicate

greater health)

Follow-up 12 weeks

The mean change in mul-

tidimensional function in

the flexibility group was

-378 FIQ units 1



the resistance training

group was

-1027 units 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -055 (95 CI -109

to -002) 6

Absolute difference 4 -6


57 to -041)


to 264) better in resis-

tance group


cant

Pain

VAS 0-10 cm (lower


Follow-up 12 weeks



flexibility group was

-101 cm 1



resistance training group

was

-189 cm 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -066 (95 CI -12

to -012)6


cm (95 CI -157 to -0

19)12


14 (95 CI 30 to 24

8) better in the resis-

tance group


cant27

Resista

nce

exerc

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Tenderness

Tender point count

scores 0-18 (lower


derness)

Follow-up 12 weeks

The mean change in ten-

derness in the flexibility

group was

-1 tender points 1


derness in the resistance

training group was

-146 tender points 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -022 (95 CI -074

to 031)7



56 to 064)


cant

Strength

Maximal isokinetic

strength of nondominant

knee extension measured

in foot-pounds8

Follow-up 12 weeks

The mean change in

strength in the flexibility

group was

97 foot-pounds 1

The mean change in

strength in the resistance

training group was

1447 foot-pounds 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD 034 (95 CI -018

to 087)7


foot- pounds (95 CI -2

40 to 1194)


cant

Adverse effects lsquo lsquo No adverse events or injuries during the interventionrsquorsquo but lsquo lsquo six participants (3 per group) experienced a worsening of one or more of the following pain

measures FIQ VAS for pain total myalgic score and number of tender pointsrsquorsquo (1 study)

All-cause attrition

Dropout rates

Follow-up 12 weeks

214 per 1000 214 per 1000 RR 100 (037 to 273) 56

(1 study)

oplusopluscopycopy

low23



0


cant



CI confidence interval FIQ Fibromyalgia Impact Questionnaire RR risk ratio SMD standardized mean difference VAS visual analog scale






1 Improvement2 Evidence based on one small study3 Refer to rsquoRisk of biasrsquo assessment2

8R

esista

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4 Absolute difference = mean change in resistance training group(s) minus mean change in control group(s)


)] N6 Moderate effect (SMD 05 to 079) favoring the resistance exercise group7 Not statistically significant8 A foot-pound is a unit of force used to rotate an object about an axis (1 foot-pound = 13558 Newton meters)


29

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D I S C U S S I O N

Summary of main results

This review was one part of a larger review examining the effects ofphysical activity interventions for individuals with fibromyalgiaOf the 78 studies that we found that examined the effects of phys-ical activity only five provided resistance training-only interven-tions The paucity of such studies makes this review particularlyimportant With the emphasis on multidisciplinary managementfor fibromyalgia this review provides a valuable opportunity toisolate the effects of resistance training and delivers factual infor-mation about the benefits and risks regarding an important type ofexercise to healthcare professionals and people with fibromyalgiaThe main results of our review were as followsResistance training compared with control There was low-qual-ity evidence that resistance training using moderate- to high-in-tensity levels for 16 to 21 weeks has positive effects on wellness(multidimensional function self reported physical function andpatient-rated global well-being) symptoms (pain tenderness fa-tigue and depression) and physical fitness (muscle strength mus-cle power and muscle activation) There was low-quality evidencethat some improvement was retained for an additional 12 weeksfollowing the conclusion of the supervised intervention in well-ness (multidimensional function) and some symptoms (fatiguebut not pain and tenderness)Resistance training compared with aerobic training Low-qual-ity evidence suggested that moderate-intensity resistance trainingwas not as effective as aerobic training there were greater improve-ments in the aerobic training groups in symptoms (pain and sleepbut not tenderness depression or anxiety) than in the resistancetraining groupResistance training compared with flexibility training Low-quality evidence suggested that low-intensity resistance trainingwas more effective than flexibility exercise in wellness (multidi-mensional function) and symptoms (pain fatigue sleep but nottenderness depression or anxiety) There was also low-quality ev-idence that 12 weeks of low-intensity resistance training does notresult in differences in muscle strength compared with flexibil-ity training however flexibility training appeared to yield greaterimprovement in muscle and joint flexibility than did resistancetrainingSafety and acceptability Based on evidence across all includedstudies there was low-quality evidence that suggested that resis-tance training was acceptable (attrition rates were not higher forresistance intervention than for comparators) and that womenwith fibromyalgia could safely perform resistance training (no se-rious adverse effects were reported)

Overall completeness and applicability ofevidence

Completeness There were only five studies included in this re-view with only 95 women (and no men) with fibromyalgia in totalassigned to resistance training exercise Given the lack of agreementon core outcomes to evaluate in trials examining interventions forfibromyalgia until recently researchers have not been consistentin reporting on wellness and symptom outcomes For examplemultidimensional function was only measured in two of the fivestudies Indeed one study did not report effects on pain and nostudies measured stiffness clinician-rated global or dyscognitionGiven the nature of the intervention an additional set of outcomesfocusing on physical fitness must be considered One would expectthat muscle strength would have been universally assessed how-ever only three of the five studies addressed this important out-come Neither Bircan 2008 nor Kayo 2011 measured outcomesrelated to muscle performance (ie muscle strength endurance orpower) in their trials designed to compare the effects of resistancetraining and aerobic exerciseIn terms of physical fitness outcomes the most thorough ap-praisals were carried out by Hakkinen 2001 and Valkeinen 2004Hakkinen 2001 found that women in the fibromyalgia traininggroup demonstrated gains in muscle strength and power and in-creases in neuromuscular activity to the same degree as women inthe healthy training group indicating comparable ability to trainthe neuromuscular system in women with fibromyalgia Simi-larly Valkeinen 2004 demonstrated that resistance training amongpostmenopausal women with fibromyalgia led to improvementsin physical fitness outcomes (strength muscle activation musclesize) in an equivalent manner to healthy postmenopausal womenUnaccustomed resistance exercise is frequently accompanied bydelayed onset muscle soreness (DOMS) even in healthy individ-uals (Cheung 2003) This phenomenon can result in symptomson palpation or with movement ranging from insignificant muscletenderness to severe debilitating muscle pain that usually peaks 24to 72 hours post-exercise (Cheung 2003) The etiology of DOMSis thought to be multifactorial (Lewis 2012) and related to therepair process in response to microscopic exercise-induced muscledamage (Cheung 2003) Some clinicians have suggested that ex-ercise prescription for individuals with fibromyalgia should avoideccentric exercise (Jones 2002) as eccentric exercise is known toproduce greater levels of DOMS (Cheung 2003) Indeed Jones2002 designed their program to minimize eccentric work for thisreason Unfortunately measurements that would clarify the pres-ence or absence of DOMS in response to exercise were not carriedout in these five studies thus this review cannot contribute to ourunderstanding of DOMS or eccentric exercise causing DOMS inindividuals with fibromyalgia Nevertheless since exercise that em-phasizes or overloads eccentric contractions causes more DOMSthan concentric does it would be wise to minimize this type of ex-ercise (eg plyometrics) or loads specifically chosen to train muscleeccentricallyClinicians and patients alike would like to know the optimal fea-tures of resistance training protocols Given the research available



we are unable to make specific recommendations about optimalprotocols for resistance training (types of resistance intensitiesfrequencies progression schemes) or to compare the effectivenessof resistance training versus other forms of exercise trainingGeneral applicability of the findings All included studies in thisreview involved supervised group exercise It is not known if unsu-pervised individuals with fibromyalgia would get the same resultsas seen in these studies This review deals with exercise protocolscomposed entirely of resistance exercise the review does not ad-dress the effects of mixed exercise interventions that include othertypes of exercise (eg aerobic flexibility) for more than purposesof warm-up or cool-downThere are many factors that need to be considered in determin-ing important change including a) the perspective of the audi-ence - individuals with fibromyalgia clinicians policy makers allmay have unique interpretations b) the impact that baseline statushas on the interpretation of change c) the sensitivity and stabil-ity of the measure d) the application to individual versus groups(Dworkin 2008 Philadelphia 2001) A consensus statement thatoffers guidance in this area is the Initiative on Methods Mea-surement and Pain Assessment in Clinical Trials (IMMPACT)This initiative recommended the following benchmarks for inter-preting changes in pain intensity on a 0 to 10 numerical ratingscale in chronic pain clinical trials a) 10 to 20 decrease isminimally important b) greater than 30 decrease is moder-ately important and c) greater than 50 decrease is substantial(Dworkin 2008) In keeping with this categorization resistancetraining yields clinically important differences in pain intensitythat fall between minimal and moderate (29) and if we applysimilar standards to the other outcomes important improvementsare noted in several outcomes reflecting wellness and symptomsThe Philadelphia Panel developed the standard of 15 relativebenefit based on extensive input by rheumatology and biostatisticsexperts (Philadelphia 2001) This is consistent with Bennett 2009who indicated that a minimal clinically important change in theFIQ total score (multidimensional function) was at least a 14reduction Despite the paucity of data our results suggest that16 to 21 weeks of moderate- to high-intensity resistance trainingprovides clinically relevant effects for wellness (multidimensionalfunction 26 patient-rated global 91) symptoms (pain 29fatigue greater than 33) and muscle strength (25) as comparedwith usual treatment Using the 15 relative difference as thestandard clinically important differences were found between 12weeks of low-intensity resistance training and flexibility trainingin one primary outcome fatigue (23) in contrast no clinicallyimportant differences were found when comparing eight weeks ofmoderate-intensity resistance training versus aerobic trainingThe absence of injuries or adverse events observed in high-intensity(Valkeinen 2004) moderate-intensity (Bircan 2008) and inten-sity-as-tolerated (Kayo 2011) interventions suggests that womenwith fibromyalgia can safely perform resistance training The lackof dropouts in Hakkinen 2001 (moderate- to high-intensity exer-

cise regimen n = 10) also support this conclusion Kingsley 2011who examined the cardiovascular and autonomic effects of a 12-week resistance training program in premenopausal women withfibromyalgia (n = 9) also suggests that resistance training is ldquoa safeand effective modality for increasing maximal strength withoutadversely altering vascular function in women with and without fi-bromyalgiardquo (page 261) One of the included studies involved post-menopausal women so there is some evidence that older womenwith fibromyalgia can also safely tolerate high-intensity resistancetraining (Valkeinen 2004) Not surprisingly Hakkinen 2001 andValkeinen 2004 support the use of supervised resistance trainingprograms as a safe and effective means of improving outcomes inboth pre- and postmenopausal women with fibromyalgiaDespite the low-quality evidence the large effect sizes for a num-ber of outcome measures reflecting wellness symptoms and phys-ical fitness reach the standard for clinical importance and in theabsence of serious adverse events we believe resistance training isa promising treatment for individuals with fibromyalgia Recog-nizing that resistance training may yield improvements in wellnessand symptoms can help promote this type of exercise as part of abalanced conditioning program for people with fibromyalgia anddecrease fear avoidance for this group with respect to possible in-creases in muscular tenderness post exercise It is especially relevantto note that older (postmenopausal) women with fibromyalgiahave the neuromuscular capability to make strength gains whichcan help to improve and maintain functional mobility with agingand reduce fall risk (Jones 2009) A balanced conditioning pro-gram can also help to reduce the risk of comorbidity and promotea more active lifestyle (Jones 2008 Jones 2009)Because the sample sizes of these studies were very small it wasunclear whether the people recruited represent all people withfibromyalgia It is possible that many people will not consideror tolerate resistive exercise and therefore intervention may onlybenefit a subset of people (ie selection bias)Specific questions regarding applicably of resistance training

Overall the comparison between low-intensity resistance trainingand flexibility training demonstrated more favorable effects relatedto resistance training despite the absence of improvement in mus-cle strength It is possible that the resistance or progression of re-sistance was too low to achieve a training stimulus As well testingmethods were not specific to the type of training exercises used sothat strength gains could be obscured (Morrissey 1995) In addi-tion because participants did not receive a familiarization sessionon the dynamometer prior to initial testing there may have beena learning effect that resulted in improvements in strength in bothgroups on their second tests We believe that low attendance mayalso have contributed to the lack of difference in strength betweenthe groups Jones 2002 commented that ldquo85 of the participantsattended 13 or more classesrdquo however this could mean that themajority of participants attended only slightly more than 50 ofthe 24 supervised sessionsIn this review we encountered statistical heterogeneity when meta-



analyzing two of the major outcomes (pain and tenderness) inthe resistance training versus control comparison however therewas consistency in the direction of the effect (all studies favoredthe resistance training) The day-to-day variability in pain in indi-viduals with fibromyalgia may partially explain the statistical het-erogeneity (I2 = 93) but the resistance training programs usedin Hakkinen 2001 and Kayo 2011 were different in several waysincluding duration (21 versus 16 weeks) type of resistance used(isokinetic exercise machine versus free weights) and nature of ex-ercise (strength progressing to strength and power training ver-sus strength training throughout) Despite these differences bothwere well-supervised progressive high-intensity interventions andwe deemed them similar enough to meta-analyze The statisticalheterogeneity in the meta-analysis of tenderness (I2 = 58) be-tween Hakkinen 2001 and Valkeinen 2004 cannot be attributedto the exercise programs as they were identical but may relateto the difference in age of the participants - Hakkinen 2001 in-cluded only premenopausal women whereas Valkeinen 2004 in-cluded only postmenopausal women


There were limitations inherent in the included studies includingincomplete description of the exercise protocols inadequate smallsample sizes and inadequate documentation of adherence to exer-cise prescriptions Concerns about small sample sizes and the smallnumber of RCTs is partially counterbalanced by the magnitude ofthe SMDs for several important outcomes

Potential biases in the review process

In our review process we attempted to control for biases as followsbull we did not limit our search to English-only publicationsbull we contacted primary authors for clarification and

additional information where indicated although responses werenot always obtained Our questions were asked in an open-endedfashion so as to avoid leading questions or answers

bull our multidisciplinary team had a range of expertise ie inlibrary science critical appraisal pain clinical rheumatologyexercise physiology and knowledge translation

bull two members of our multidisciplinary team also had theperspective of consumers (ie one team member had fibromyalgiaand another team member had another rheumatic disease)

bull intention-to-treat data were used preferentially

Agreements and disagreements with otherstudies or reviews

Since the early 2000s there have been several reviews and clinicalpractice guidelines regarding exercise for fibromyalgia Based on

their relevancy we have chosen to comment on four Brosseau2008 Busch 2008 Jones 2009 and Winkelmann 2012Using rigorous methodology (The Cochrane Collaboration meth-ods and Ottawa methods group procedures) Brosseau 2008 foundand evaluated clinical trials examining the effects of resistance(strengthening) exercises in the management of fibromyalgia Intheir review five trials were evaluated however Hakkinen 2002(Secondary) and Valkeinen 2005 (Secondary) were counted as sep-arate trials Due to this classification the number of subjects acrossall trials was over-reported in Brousseau Using their methodol-ogy the following Grade A evidence-based clinical practice guide-lines related to strengthening exercises were generated benefits inmuscle strength pain relief physical disability and depression (allclassed as clinically important benefits) at the end of 21 weeks(strengthening versus control) and benefits in quality of life (clini-cally important benefit) at the end of 12 weeks (strengthening ver-sus flexibility training) Our results were consistent with Brosseau2008Jones 2009 provides a synopsis on current evidence related to exer-cise and fibromyalgia with a focus on guidelines for clinicians withrespect to exercise prescription and exercise resources for peoplewith fibromyalgia Jones 2009 describes one strength study wheresubjects with fibromyalgia (n = 10) performed resistance trainingtwice per week for 16 weeks (Figueroa 2008) They were com-pared with a control group of sedentary health individuals (n = 9)and results showed people with fibromyalgia had perturbed heartrate variability (no further definition provided) however afterthe intervention the subjects with fibromyalgia improved in totalpower cardiac parasympathetic tone pain and muscle strength Interms of recommendations for resistance exercise for people withfibromyalgia Jones 2009 advises the importance of minimizing ec-centric loading in order to reduce unnecessary strain and possiblediscomfort for people with fibromyalgia (Gibson 2006 as cited byJones 2009) In addition Jones 2009 advise that strength trainingloads be less than 50 of one-repetition maximum using weightsthat are lighter than age-predicted norms and that loads be keptclose to midline and work done on a rsquoparallel planersquo with reducedrepetitive movements for smaller muscle groups They advise do-ing single sets of six repetitions to begin and increasing this slowlyIn our review all five included studies applied progressive resis-tance exercise starting at a lower level and progressing but Jones2002 probably started with low resistance and did not progress tointensity levels attained in the other studies Although all studies inthis review employed dynamic exercises Jones 2002 was the onlystudy in which the resistance exercises were modified to reducethe eccentric phase Our review does not support the Jones 2009recommendation regarding eccentric exercise Although avoidingthe eccentric phase could potentially minimize DOMS eccentriccontractions may have particular advantages for connective tissueand are specifically recommended in exercise regimens designed toprevent and manage tendonopathy (Crosier 2002 Hibbert 2008)In addition it should be noted that eccentric contractions are an



inherent component of most activities of daily livingOur group previously conducted a broad review of the effects ofexercise for fibromyalgia (Busch 2008) Although there were 34research publications included in this previous review only threeseparate investigations dealt specifically with resistance training forpeople with fibromyalgia (Hakkinen 2001 Jones 2002 Valkeinen2004) Analyses of these three studies resulted in the followingfindings in favor of resistance training large reductions in painthe number of TPs and depression large improvements in globalwell-being and moderate (non-significant) effects on objectivemeasures of physical function Results of the current review whichtook advantage of upgraded methodology and focused on sevenmajor outcomes similarly found favorable large effects for resis-tance training (versus control) on pain and patient-rated globalwell-being However the current analysis also revealed a small ef-fect for self reported physical function favoring resistance train-ing (over a control group) and large effects for muscle strengthand muscle power The current investigation included informa-tion about the effects of resistance training compared with aerobictraining and flexibility exercises which was not included in ourprevious review In addition the current study used the GRADEevaluation to rate included papers which was not available whenthe last review was publishedAs part of a scheduled update to the German S3 guidelines onfibromyalgia syndrome by the Association of the Scientific Medi-cal Societies (rsquoArbeitsgemeinschaft der Wissenschaftlichen Medi-zinischen Fachgesellschaftenrsquo) Winkelmann 2012 reviewed theeffectiveness of resistance training for fibromyalgia They identi-fied six RCTs (Altan 2009 Hakkinen 2001 Jones 2002 Kingsley2005 Rooks 2007 Valkeinen 2008) and generated the follow-ing recommendation Low- to moderate-intensity strength train-ing should be employed and indicated that there is evidence fora training frequency of 60 minutes twice a week Although wedo not dispute the recommendation the mismatch between ourincluded studies and those of Winkelmann 2012 is interestingAltan 2004 was excluded from our review because we determinedthat pilates are better classified as a mixed exercise because theycontain substantial aerobic and stretching components LikewiseRooks 2007 and Valkeinen 2008 had a substantial aerobic com-ponent included in the intervention All three studies have beenearmarked for a review on mixed exercise interventions which ourteam plans to conduct Kingsley 2005 was excluded because wewere unable to verify that a published criteria for the diagnosisof fibromyalgia had been used Our review included three studies(Bircan 2008 Kayo 2011 Valkeinen 2004) which were not in-cluded by Winkelmann 2012

A U T H O R S rsquo C O N C L U S I O N S

Implications for practice

We have found evidence in outcomes representing wellness symp-toms and physical fitness favoring resistance training over usualtreatment and over flexibility exercise and favoring aerobic train-ing over resistance training Despite large effect sizes for manyoutcomes the evidence has been decreased to low quality basedon small sample sizes small number of randomized clinical trials(RCTs) and the problems with description of study methods insome of the included studies

This review provides evidence that 16 to 21 weeks of moderate- tohigh-intensity supervised group resistance training using resistancemachines or free weights and body weight for resistance has severallarge and clinically important positive effects on wellness symp-toms and physical fitness of women with fibromyalgia There isevidence that eight weeks of aerobic exercise may be superior tomoderate-intensity resistance training for reducing pain and im-proving sleep in women with fibromyalgia There is evidence that12 weeks of low-intensity resistance training results in greater im-provements than flexibility exercise in women with fibromyalgiain multidimensional function pain fatigue and sleep There isevidence that women with fibromyalgia can tolerate and benefitfrom resistance training

Typically management of fibromyalgia is multidisciplinary In thestudies included in this review emphasis was placed on exerciseIn one study (Kayo 2011) exercise was administered as a sin-gle modality (medication use was discontinued during the study)Bircan 2008 and Valkeinen 2004 allowed participants to continuetheir medication at entry and Valkeinen 2004 also allowed partic-ipants to continue their normal daily activities and visit medicalprofessionals if needed In the two remaining studies no informa-tion was provided about co-interventions (Hakkinen 2001 Jones2002) Uncontrolled co-interventions act as a threat to validityin two ways - first the effects attributed to the experimental in-tervention may in fact be produced by the co-intervention andsecond the co-intervention may interact with the experimentalintervention to modify its effects It is hoped that the use of acontrol group helped to reduce the former and the consistency ofthe findings of Hakkinen 2001 Kayo 2011 and Valkeinen 2004provides reassurance that the exercise is an effective treatment withor without other co-interventions

Aside from very general recommendations we cannot make spe-cific recommendations about the optimal design of resistancetraining protocols (types of resistance intensities frequencies pro-gression schemes)

Implications for research

Several implications for further research arose from this reviewWe have used the EPICOT approach to describing implicationsfor future research (Brachaniec 2009)



Evidence There are insufficient high-quality studies to allow ad-equate meta-analysis of the effects of resistance training on symp-toms and physical function in individuals with fibromyalgia Abetter description of research procedures or training protocols orboth is needed in future research to address all aspects of potentialbias more adequately

Population The five studies included in this review recruitedonly women research is needed to clarify the effects of resistancetraining on males with fibromyalgia Researchers undertaking ex-ercise interventions are encouraged to describe physical fitness lev-els and physical activity participation of participants recruited tothese studies Population was mainly formed by middle-aged whitewomen living in developed countries (Europe n = 3 Brazil n = 1and US n=1) which make results difficult to generalize to otherpopulations and settings while at the same time brings awarenessof the need for studies coming from other parts of the world

Intervention More detail with respect to exercise frequency du-ration intensity and mode is needed to identify exercise volumemore precisely and to determine if the prescribed exercise proto-cols meet current recommendations

Comparators In this review resistance training was comparedwith aerobic exercise and flexibility exercise however there wasonly one study in each of these grouping More research of thistype is needed

Outcomes Improved documentation is needed in the area of ad-verse effects (injuries exacerbations of fibromyalgia and other as-sociated adverse effects) Assessment of adherence to frequency andintensity of exercise should be an integral part of the results sectionof all RCTs studying effects of exercise interventions Further re-search is needed to elucidate a dose-response relationship Formalfollow-up periods are needed to assess stability of responses Inaddition further work to validate a set of outcome measures forfibromyalgia research such as has been initiated by OMERACTis needed to allow comparisons across studies and elucidation ofthe more effective interventions Determination of the minimumclinically important difference (MCID) and responsiveness of thecore measures is also needed

Timestamp The need for an update of this review should bereviewed in three to five years

A C K N O W L E D G E M E N T S

We would like to acknowledge the following

bull Mary Brachaniec and Janet Gunderson for contributing toteam discussions reviewing outcome measures and drafting andreviewing the common language summary

bull Louise Falzon for help with the literature search

bull Christopher Ross for help with the manuscript data entryanalysis and administrative support for review team

bull Tanis Kershaw Joelle Harris and Saf Malleck foradministrative support for the review team

bull Beliz Acan for assistance with translations from Turkishwhich permitted screening and extraction for Yuruk 2008 (notused in this review)

bull Nora Chavarria for assistance translating a symptomchecklist (from German) used in Keel 1998

bull Patriacutecia Luciano Mancini for assistance with translationsfrom Portuguese which permitted screening of Matsutani 2012and Santana 2010 and data extraction for Hecker 2011 andMatsutani 2012 (not used in this review)

bull Winfried Hauser for assistance with translations fromGerman which permitted screening of Uhlemann 2007 Keel1990 and Hillebrand 1969

bull Silas Wieflspuett for assistance with translations fromGerman which permitted screening of Lange 2011 andSigl-Erkel 2011

bull Julia Bidonde for translation of Arcos-Carmona 2011Tomas-Carus 2007 Tomas-Carus 2007b Tomas-Carus 2007cand Sanudo 2010c from Spanish to English



R E F E R E N C E S

References to studies included in this review

Bircan 2008 published data only

Bircan C Karasel SA Akgun B El O Alper S Effectsof muscle strengthening versus aerobic exercise programin fibromyalgia Rheumatology International 200828(6)527ndash32

Hakkinen 2001 published data onlylowast Hakkinen A Hakkinen K Hannonen P Alen M Strengthtraining induced adaptations in neuromuscular function ofpremenopausal women with fibromyalgia comparison withhealthy women Annals of Rheumatic Diseases 200160(1)21ndash6Hakkinen K Pakarinen A Hannonen P Hakkinen AAiraksinen O Valkeinen H et alEffects of strengthtraining on muscle strength cross-sectional area maximalelectromyographic activity and serum hormones inpremenopausal women with fibromyalgia Journal of

Rheumatology 200229(6)1287ndash95

Jones 2002 published data only

Jones KD Burckhardt CS Clark SR Bennett RM PotempaKM A randomized controlled trial of muscle strengtheningversus flexibility training in fibromyalgia Journal of


Kayo 2011 published data only

Kayo AH Peccin MS Sanches CM Trevisani VFEffectiveness of physical activity in reducing pain in patientswith fibromyalgia a blinded randomized clinical trialRheumatology International 201132(8)2285ndash92

Valkeinen 2004 published data onlylowast Valkeinen H Alen M Hannonen P Hakkinen AAiraksinen O Hakkinen K Changes in knee extension andflexion force EMG and functional capacity during strengthtraining in older females with fibromyalgia and healthycontrols Rheumatology 200443(2)225ndash8Valkeinen H Hakkinen K Pakarinen A Hannonen PHakkinen A Airaksinen O et alMuscle hypertrophystrength development and serum hormones during strengthtraining in elderly women with fibromyalgia ScandinavianJournal of Rheumatology 2005 Vol 34 issue 4309ndash14

References to studies excluded from this review

Ahlgren 2001 published data only

Ahlgren C Waling K Kadi F Djupsjobacka M Thornell LSundelin G Effects on physical performance and pain fromthree dynamic training programs for women with work-related trapezius myalgia Journal of Rehabilitation Medicine

200133(4)162ndash9

Alentorn-Geli 2009 published data only

Alentorn-Geli E Moras G Padilla J Fernandez-Sola JBennett RM Lazaro-Haro C et alEffect of acute andchronic whole-body vibration exercise on serum insulin-like growth factor-1 levels in women with fibromyalgia

Journal of Alternative amp Complementary Medicine 200915

(5)573ndash8

Astin 2003 published data only

Astin JA Berman BM Bausel B Lee WL Hochberg MForys KL The efficacy of mindfulness meditation plusQigong movement therapy in the treatment of fibromyalgiaa randomized controlled trial Journal of Rheumatology

Journal of Rheumatology 200330(10)2257ndash62

Bailey 1999 published data only

Bailey A Starr L Alderson M Moreland J A comparativeevaluation of a fibromyalgia rehabilitation programArthritis Care amp Research 199912(5)336ndash40

Bakker 1995 published data only

Bakker C Rutten M van Santen-Hoeufft M BolwijnP van Doorslaer E van der Linden S Patient utilitiesin fibromyalgia and the association with other outcomemeasures Journal of Rheumatology 1995221536ndash43

Carbonell-Baeza 2011 published data only

Carbonell-Baeza A Ruiz JR Aparicio VA Ortega FBMunguiacutea-Izquierdo D Alvarez-Gallardo IC et alLand-and water-based exercise Intervention in women withfibromyalgia the Al-Andalus physical activity randomisedcontrol trial BMC Musculoskeletal Disorders 201218[DOI 1011861471-2474-13-18]

Casanueva-Fernandez 2012 published data only

Casanueva-Fernandez B Llorca J Rubio JBI Rodero-Fernandez B Gonzalez-Gay MA Efficacy of amultidisciplinary treatment program in patients with severefibromyalgia Rheumatology International 201232(8)2497ndash502

Dal 2011 published data only

Dal U Cimen OB Incel NA Adim M Dag F Erdogan ATet alFibromyalgia syndrome patients optimize the oxygencost of walking by preferring a lower walking speed Journal

of Musculoskeletal Pain 201119(4)212ndash7

da Silva 2007 published data only

da Silva GD Lorenzi-Filho G Lage LV Effects of yogaand the addition of Tui Na in patients with fibromyalgiaJournal of Alternative amp Complementary Medicine 200713

(10)1107ndash13

Dawson 2003 published data only

Dawson KA Tiidus PM Pierrynowski M CrawfordJP Trotter J Evaluation of a community-based exerciseprogram for diminishing symptoms of fibromyalgiaPhysiotherapy Canada 20035517ndash22

Finset 2004 published data only

Finset A Wigers SH Gotestam KG Depressed moodimpedes pain treatment response in patients withfibromyalgia Journal of Rheumatology 200431(5)976ndash80

Gandhi 2000 published data only

Gandhi N Effect of an Exercise Program on Quality of Life of

Women with Fibromyalgia Washington Washington StateUniversity 2000



Geel 2002 published data only

Geel SE Robergs RA The effect of graded resistance exerciseon fibromyalgia symptoms and muscle bioenergetics a pilotstudy Arthritis and Rheumatism 20024782ndash6

Gowans 2002 published data only

Gowans SE deHueck A Abbey SE Measuring exercise-induced mood changes in fibromyalgia a comparison ofseveral measures Arthritis and Rheumatism 200247603ndash9


Gowans SE deHueck A Voss S Silaj A Abbey SE Six-month and one-year followup of 23 weeks of aerobicexercise for individuals with fibromyalgia Arthritis Care amp

Research 200451(6)890ndash8

Guarino 2001 published data only

Guarino P Peduzzi P Donta ST Engel CC Clauw DJWilliams DA et alA multicenter two by two factorial trialof cognitive behavioral therapy and aerobic exercise forGulf War veteransrsquo illnesses design of a Veterans AffairsCooperative Study (CSP 470) Controlled Clinical Trials

200122310ndash32

Han 1998 published data only

Han SS Effects of a self-help program includingstretching exercise on symptom reduction in patients withfibromyalgia Taehan Kanho 19983778ndash80

Huyser 1997 published data only

Huyser B Buckelew SP Hewett JE Johnson JC Factorsaffecting adherence to rehabilitation interventions forindividuals with fibromyalgia Rehabilitation Psychology

19974275ndash91

Karper 2001 published data only

Karper WB Hopewell R Hodge M Exercise programeffects on women with fibromyalgia syndrome Clinical

Nurse Specialist 20011567ndash75

Kendall 2000 published data only

Kendall SA Brolin MK Soren B Gerdle B HenrikssonKG A pilot study of body awareness programs in thetreatment of fibromyalgia syndrome Arthritis Care and

Research 200013304ndash11

Khalsa 2009 published data only

Khalsa KPS Bodywork for fibromyalgia alternativetherapies soothe the pain Massage amp Bodywork 2009online

(MayJune)80

Kingsley 2005 published data only

Kingsley JD Panton LB Toole T Sirithienthad P MathisR McMillan V The effects of a 12-week strength-training program on strength and functionality in womenwith fibromyalgia Archives of Physical Medicine and

Rehabilitation 200586(9)1713ndash21

Lange 2011 published data only

Lange M Krohn-Grimberghe B Petermann F Medium-term effects of a multimodal therapy on patients withfibromyalgia Results of a controlled efficacy study[Mittelfristige Effekte einer multimodalen Behandlung beiPatienten mit Fibromyalgiesyndrom] Schmerz (BerlinGermany) 2011 Vol 25 issue 155ndash61

Lorig 2008 published data only

Lorig KR Ritter PL Laurent DD Plant K Lorig KR RitterPL The internet-based arthritis self-management programa one-year randomized trial for patients with arthritis orfibromyalgia Arthritis amp Rheumatism 200859(7)1009ndash17

Mannerkorpi 2002 published data only

Mannerkorpi K Ahlmen M Ekdahl C Six- and 24-monthfollow-up of pool exercise therapy and education for patientswith fibromyalgia Scandinavian Journal of Rheumatology

200231(5)306ndash10

Mason 1998 published data only

Mason LW Goolkasian P McCain GA Evaluation ofmultimodal treatment program for fibromyalgia Journal of

Behavioral Medicine 199821(2)163ndash78

McCain 1986 published data only

McCain GA Role of physical fitness training in thefibrositisfibromyalgia syndrome American Journal of

Medicine 198681(3A)73ndash7

Meiworm 2000 published data only

Meiworm L Jakob E Walker UA Peter HH Keul JPatients with fibromyalgia benefit from aerobic enduranceexercise Clinical Rheumatology 200019(4)253ndash7

Meyer 2000 published data only

Meyer BB Lemley KJ Utilizing exercise to affect thesymptomology of fibromyalgia a pilot study Medicine and

Science in Sports and Exercise 200032(10)1691ndash7

Mobily 2001 published data only

Mobily KE Verburg MD Aquatic therapy in community-based therapeutic recreation pain management in a caseof fibromyalgia Therapeutic Recreation Journal 20013557ndash69

Mutlu 2013 published data only

Mutlu B Paker N Bugdayci D Tekdos D KesiktasN Efficacy of supervised exercise combined withtranscutaneous electrical nerve stimulation in women withfibromyalgia a prospective controlled study Rheumatology

International 201333(3)649ndash55

Nielen 2000 published data only

Nielens H Boisset V Masquelier E Fitness and perceivedexertion in patients with fibromyalgia syndrome Clinical

Journal of Pain 200016209ndash13

Offenbacher 2000 published data only

Offenbacher M Stucki G Physical therapy in the treatmentof fibromyalgia Scandinavian Journal of Rheumatology

2000113(Suppl)78ndash85

Oncel 1994 published data only

Oncel A Eskiyurt N Leylabadi M The results obtainedby different therapeutic measures in the treatment ofgeneralized fibromyalgia syndrome Tip Fakultesi Mecmuasi

199457(4)45ndash9

Peters 2002 published data only

Peters S Stanley I Rose M Kaney S Salmon P Arandomized controlled trial of group aerobic exercise inprimary care patients with persistent unexplained physicalsymptoms Family Practice 200219665ndash74



Pfeiffer 2003 published data only

Pfeiffer AT Effects of a 15-day multidisciplinary outpatienttreatment program for fibromyalgia a pilot study American

Journal of Physical Medicine amp Rehabilitation 200382186ndash91

Piso 2001 published data only

Piso U Kuther G Gutenbrunner C Gehrke A Analgesiceffects of sauna in fibromyalgia [German] Physikalische

Medizin Rehabilitationsmedizin Kurortmedizin 200111(3)94ndash9

Rooks 2002 published data only

Rooks DS Silverman CB Kantrowitz FG The effectsof progressive strength training and aerobic exercise onmuscle strength and cardiovascular fitness in women withfibromyalgia a pilot study Arthritis and Rheumatism 20024722ndash8

Santana 2010 published data only

Santana JS Almeida AP Brandao PM The effect of Ai Chimethod in fibromyalgic patients [Os efeitos do meacutetodo AiChi em pacientes portadoras da siacutendrome fibromiaacutelgica]Ciecircncia amp Sauacutede Coletiva 201015 Suppl 11433ndash8

Sigl-Erkel 2011 published data only

Sigl-Erkel T A randomized trial of tai chi for fibromyalgia[Studienbesprechung zu tai chi (taiji) bei fibromyalgie]Chinesische Medizin 201126(2)ns

Thieme 2003 published data only

Thieme K Gronica-Ihle E Flor H Operant behavioraltreatment of fibromyalgia a controlled study Arthritis Care

amp Research Arthritis Care amp Research 200349314ndash20

Tiidus 1997 published data only

Tiidus PM Manual massage and recovery of musclefunction following exercise a literature review Journal of

Orthopaedic and Sports Physical Therapy 199725107ndash12

Uhlemann 2007 published data only

Uhlemann C Strobel I Muller-Ladner U Lange UProspective clinical trial about physical activity infibromyalgia Aktuelle Rheumatologie 200732(1)27ndash33

Vlaeyen1996 published data only

Vlaeyen JW Teeken-Gruben NJ Goossens ME Rutten-van Molken MP Pelt RA Van Eek H et alCognitive-educational treatment of fibromyalgia a randomizedclinical trial I Clinical effects Journal of Rheumatology

199623(7)1237ndash45

Williams 2010 published data only

Williams DA Kuper D Segar M Mohan N Sheth MClauw DJ Internet-enhanced management of fibromyalgiaa randomized controlled trial Pain 2010 Vol 151 issue 3694ndash702

Worrel 2001 published data only

Worrel LM Krahn LE Sletten CD Pond GR Treatingfibromyalgia with a brief interdisciplinary programinitial outcomes and predictors of response Mayo Clinic

Proceedings 200176384ndash90

References to studies awaiting assessment

Adsuar 2012 published data only

Adsuar JC Del Pozo-Cruz B Parraca JA Olivares PR GusiN Whole body vibration improves the single-leg stancestatic balance in women with fibromyalgia a randomizedcontrolled trial Journal of Sports Medicine amp Physical Fitness

201252(1)85ndash91

Amanollahi 2013 published data only

Amanollahi A Naghizadeh J Khatibi A Hollisaz MTShamseddini AR Saburi A Comparison of impacts offriction massage stretching exercises and analgesics on painrelief in primary fibromyalgia syndrome a randomizedclinical trial Tehran University Medical Journal 201370

(10)616ndash22

Aslan 2001 published data only

Aslan Ub Yuksel I Yazici M A comparison of classicalmassage and mobilization techniques treatment in primaryfibromyalgia Fizyoterapi Rehabilitasyon 200112(2)50ndash4

Bland 2010 published data only

Bland P Tai chi of benefit in fibromyalgia Practitioner

2010254(1735)8ndash10

Ekici 2008 published data only

Ekici G Yakut E Akbayrak T Effects of Pilates exercisesand connective tissue manipulation on pain and depressionin females with fibromyalgia a randomized controlled trialFizyoterapi Rehabilitasyon 200819(2)47ndash54

Thijssen 1992 published data only

Thijssen Ej de Klerk E Evaluatie van een zwemprogrammavoor patienten met fibromyalgie Nederlands Tijdschrift voor

Fysiotherapie 1992102(3)71ndash5

Wright 2012 published data only

Wright C Carson J Carson K Bennett R Mist S JonesK Yoga of awareness a randomized trial in fibromyalgiapost intervention and 3 month follow up results BMC

Complementary and Alternative Medicine 201212P249

Additional references

ACSM 2009a

American College of Sports Medicine ACSMrsquos Guidelines for

Exercise Testing and Prescription 8th Edition PhiladelphiaPA LippenWilliams and Wilkins 2009

ACSM 2009b

American College of Sports Medicine Progression modelsin resistance training for healthy adults Medicine amp Science

in Sports amp Exercise 200941(3)687ndash708

Alentorn-Geli 2008

Alentorn-Geli E Padilla J Moras G Lazaro Haro CFernandez-Sola J Six weeks of whole-body vibration exerciseimproves pain and fatigue in women with fibromyalgiaJournal of Alternative amp Complementary Medicine 200814

(8)975ndash81

Altan 2004

Altan L Bingol U Aykac M Koc Z Yurtkuran MInvestigation of the effects of pool-based exercise onfibromyalgia syndrome Rheumatology International 200424(5)272ndash7



Altan 2009

Altan L Korkmaz N Bingol U Gunay B Effect of pilatestraining on people with fibromyalgia syndrome a pilotstudy Archives of Physical Medicine and Rehabilitation 2009901983ndash8

Anderson 1995

Anderson KO Dowds BN Pelletz RE Edwards WTPeeters Asdourian C Development and initial validationof a scale to measure self-efficacy beliefs in patients withchronic pain Pain 199563(1)77ndash84

Arcos-Carmona 2011

Arcos-Carmona IM Castro-Sanchez AM Mataran-Penarrocha GA Gutierrez-Rubio AB Ramos-Gonzalez EMoreno-Lorenzo C Effects of aerobic exercise programand relaxation techniques on anxiety quality of sleepdepression and quality of life in patients with fibromyalgiaa randomized controlled trial Medicina Clinica 2011137

(9)398ndash491

Arnold 2008

Arnold LM Crofford LJ Mease PJ Burgess SM PalmerSC Abetz L et alPatient perspectives on the impact offibromyalgia Patient Education and Counseling 200873(1)114ndash20

Asikainen 2004

Asikainen TM Kukkonen-Harjula K Miilunpalo SExercise for health for early postmenopausal women asystematic review of randomised controlled trials Sports

Medicine 200434(11)753ndash78

Assis 2006

Assis MR Silva LE Alves AM Pessanha AP Valim VFeldman D et alA randomized controlled trial of deepwater running clinical effectiveness of aquatic exercise totreat fibromyalgia Arthritis and Rheumatology 200655(1)57ndash65

Baptista 2012

Baptista AS Villela AL Jones A Natour J Effectivenessof dance in patients with fibromyalgia a randomizedsingle-blind controlled study Clinical amp Experimental

Rheumatology 201230(6 Suppl 74)18ndash23

Bengtsson 1986a

Bengtsson A Henriksson KG Larsson J Musclebiopsy in primary fibromyalgia Light-microscopicaland histochemical findings Scandinavian Journal of


Bengtsson 1986b

Bengtsson A Henriksson KG Jorfeldt L Kagedal BLennmarken C Lindstrom F Primary fibromyalgia Aclinical and laboratory study of 55 patients Scandinavian


Bennett 1989

Bennett RM Clark SR Goldberg L Nelson D BonafedeRP Porter J et alAerobic fitness in patients with fibrositis Acontrolled study of respiratory gas exchange and 133xenonclearance from exercising muscle Arthritis amp Rheumatism

198932(4)454ndash60

Bennett 1999

Bennett RM Emerging concepts in the neurobiology ofchronic pain evidence of abnormal sensory processing infibromyalgia Mayo Clinic Proceedings 199974(4)385ndash98

Bennett 2009

Bennett RM Bushmakin AG Cappelleri JC ZlatevaG Sadosky AB Minimal clinically important differencein the Fibromyalgia Impact Questionnaire Journal of


Bernardy 2013

Bernardy K Klose P Busch AJ Choy EHS Haumluser WCognitive behavioural therapies for fibromyalgia Cochrane

Database of Systematic Reviews 2013 Issue 9 [DOI10100214651858CD009796pub2]

Birse 2012

Birse F Derry S Moore RA Phenytoin for neuropathicpain and fibromyalgia in adults Cochrane Database

of Systematic Reviews 2012 Issue 5 [DOI 10100214651858CD009485pub2]

Bojner Horwitz 2006

Bojner Horwitz E Kowalski J Theorell T Anderberg UMDancemovement therapy in fibromyalgia patients changesin self-figure drawings and their relation to verbal self-ratingscales Arts in Psychotherapy 200633(1)11ndash25

Boomershine 2012

Boomershine CS A comprehensive evaluation ofstandardized assessment tools in the diagnosis offibromyalgia and in the assessment of fibromyalgia severityPain Research and Treatment 20122012653714

Brachaniec 2009

Brachaniec M DePaul V Elliott M Moor L SherwinP Partnership in action an innovative knowledgetranslation approach to improve outcomes for persons withfibromyalgia (Editorial) Physiotherapy Canada 200961(3)123ndash7

Braith 2006

Braith RW Stewart KJ Resistance exercise training its rolein the prevention of cardiovascular disease Circulation

2006113(22)2642ndash50

Branco 2010

Branco JC Bannwarth B Failde I Abello Carbonell JBlotman F Spaeth M et alPrevalence of fibromyalgia asurvey in five European countries Seminars in Arthritis and

Rheumatism 201039(6)448ndash53

Bressan 2008

Bressan LR Matsutani LA Assumpcao A Marques APCabral CMN Effects of muscle stretching and physicalconditioning as physical therapy treatment for patientswith fibromyalgia [in Portuguese] Revista Brasileira de

FisioterapiaBrazilian Journal of Physical Therapy 200812

(2)88ndash93

Brosse 2002

Brosse AL Sheets ES Lett HS Blumenthal JA Exerciseand the treatment of clinical depression in adults recentfindings and future directions Sports Medicine 200232

(12)741ndash60



Brosseau 2008

Brosseau L Wells GA Tugwell P Egan M Wilson KGDubouloz CJ et alOttawa Panel evidence-based clinicalpractice guidelines for strengthening exercises in themanagement of fibromyalgia part 2 Physical Therapy

200888(7)873ndash86

Buchheld 2001

Buchheld N Grossman P Walach H Measuringmindfulness in insight meditation (Vipassana) andmeditation-based psychotherapy the development ofthe Freiburg Mindfulness Inventory (FMI) Journal for

Meditation and Meditation Research 20011(1)11ndash34

Buckelew 1998

Buckelew SP Conway R Parker J Deuser WE Read JWitty TE et alBiofeedbackrelaxation training and exerciseinterventions for fibromyalgia a prospective trial Arthritis

Care and Research 199811(3)196ndash209

Burckhardt 1993

Burckhardt CS Clark SR Bennett RM Fibromyalgiaand quality of life a comparative analysis Journal of

Rheumatology 199320475ndash9

Burckhardt 1994

Burckhardt CS Mannerkorpi K Hedenberg L Bjelle AA randomized controlled clinical trial of education andphysical training for women with fibromyalgia Journal of


Burckhardt 2005

Burckhardt CS Goldenberg D Crofford L Gerwin RDGowans SE Jackson K et alClinical Practice Guidelineguideline for the management of fibromyalgia syndromepain in adults and children American Pain Society (APS)Glenview (IL) American Pain Society 2005 issue 4109

Calandre 2009

Calandre EP Rodriguez-Claro ML Rico-VillademorosF Vilchez JS Hidalgo J Gado-Rodriguez A Effects ofpool-based exercise in fibromyalgia symptomatologyand sleep quality a prospective randomised comparisonbetween stretching and Ai Chi Clinical amp Experimental

Rheumatology 200927(5 Suppl 56)S21ndash8

Callahan 1988

Callahan LF Brooks RH Pincus T Further analysisof learned helplessness in rheumatoid arthritis using aldquoRheumatology Attitudes Indexrdquo Journal of Rheumatology

198815(3)418ndash26

Carson 2010

Carson JW Carson KM Jones KD Bennett RM WrightCL Mist SD A pilot randomized controlled trial ofthe Yoga of Awareness program in the management offibromyalgia Pain 2010 Vol 151 issue 2530ndash9

Carson 2012

Carson JW Carson KM Jones KD Mist SD Bennett RMFollow-up of Yoga of Awareness for Fibromyalgia resultsat 3 months and replication in the wait-list group Clinical

Journal of Pain 201228(9)804ndash13

Carville 2008

Carville SF Arendt-Nielsen S Bliddal H Blotman FBranco JC Buskila D et alEULAR evidence-basedrecommendations for the management of fibromyalgiasyndrome Annals of the Rheumatic Diseases 200867(4)536ndash41

Carville 2008a

Carville SF Choy EH Systematic review of discriminatingpower of outcome measures used in clinical trials offibromyalgia Journal of Rheumatology 200835(11)2094ndash105

Caspersen 1985

Caspersen CJ Powell KE Christenson GM Physicalactivity exercise and physical fitness definitions anddistinctions for health-related research Public Health

Reports 1985100(2)126ndash31

Cedraschi 2004

Cedraschi C Desmeules J Rapiti E Baumgartner E CohenP Finckh A et alFibromyalgia a randomised controlledtrial of a treatment programme based on self managementAnnals of Rheumatic Diseases 200463(3)290ndash6

Cheung 2003

Cheung K Hume P Maxwell L Delayed onset musclesoreness treatment strategies and performance factorsSports Medicine 200333(2)145ndash64

Chodzko-Zajko 2009

Chodzko-Zajko WJ Proctor DN Fiatarone Singh MAMinson CT Nigg CR Salem GJ et alAmerican Collegeof Sports Medicine position stand Exercise and physicalactivity for older adults Medicine and Science in Sports

Exercise 200941(7)1510ndash30

Choy 2009a

Choy EH Arnold LM Clauw DJ Crofford LJ GlassJM Simon LS et alContent and criterion validity of thepreliminary core dataset for clinical trials in fibromyalgiasyndrome Journal of Rheumatology 200936(10)2330ndash4

Choy 2009b

Choy EH Mease PJ Key symptom domains to be assessedin fibromyalgia (outcome measures in rheumatoid arthritisclinical trials) Rheumatic Diseases Clinics of North America

200935(2)329ndash37

Clauw 2011

Clauw DJ Arnold LM McCarberg BH The science offibromyalgia Mayo Clinic Proceedings 201186(9)907ndash11

Cohen 1988

Cohen J Statistical Power Analysis for the Behavioral Sciences2nd Edition Hillsdale NJ Lawrence Erlbaum Associates1988 [ ISBN 0 8058 0283 5]

Costill 1979

Costill DL Coyle EF Fink WF Lesmes GR Witzmann FAAdaptations in skeletal muscle following strength trainingJournal of Applied Physiology 197946(1)96ndash9

Crosier 2002

Crosier JL Forthomme B Namurois MH VanderthommeM Crielaard JM Hamstring muscle strain recurrence and



strength performance disorders American Journal of Sports


Da Costa 2005

Da Costa D Abrahamowicz M Lowensteyn I BernatskyS Dritsa M Fitzcharles MA et alA randomized clinicaltrial of an individualized home-based exercise programmefor women with fibromyalgia Rheumatology 200544(11)1422ndash7

Dadabhoy 2008

Dadabhoy D Crofford LJ Spaeth M Russell IJ ClauwDJ Biology and therapy of fibromyalgia Evidence-basedbiomarkers for fibromyalgia syndrome Arthritis Research amp

Therapy 200810(4)211

De Andrade 2008

De Andrade SC De Carvalho RFPP Soares AS DeAbreu Freitas RP De Madeiros Guerra LM Vilar MJThalassotherapy for fibromyalgia a randomized controlledtrial comparing aquatic exercises in sea water and waterpool Rheumatology International 200829(2)147ndash52

de Melo Vitorino 2006

de Melo Vitorino DF de Carvalho LBC do Prado GFHydrotherapy and conventional physiotherapy improvetotal sleep time and quality of life of fibromyalgia patientsrandomized clinical trial Sleep Medicine 20067(3)293ndash6

Demir-Gocmen 2013

Demir-Gocmen D Altan L Korkmaz N Arabaci R Effectof supervised exercise program including balance exerciseson the balance status and clinical signs in patients withfibromyalgia Rheumatology International 201333(3)743ndash50

Deschenes 2002

Deschenes MR Kraemer WJ Performance and physiologicadaptations to resistance training American Journal of

Physical Medicine amp Rehabilitation 200281(11 Suppl)S3ndash16

Desmeules 2003

Desmeules JA Cedraschi C Rapiti E Baumgartner EFinckh A Cohen P et alNeurophysiologic evidence for acentral sensitization in patients with fibromyalgia Arthritis

and Rheumatism 200348(5)1420ndash9

Dunn 2001

Dunn AL Trivedi MH OrsquoNeal HA Physical activity dose-response effects on outcomes of depression and anxietyMedicine amp Science in Sports amp Exercise 200133(6 Suppl)S587ndash97

Dworkin 2008

Dworkin RH Turk DC Wyrwich KW Beaton D CleelandCS Farrar JT et alInterpreting the clinical importanceof treatment outcomes in chronic pain clinical trialsIMMPACT recommendations Pain 20089(2)105ndash21

Elvin 2006

Elvin A Siosteen AK Nilsson A Kosek E Decreased muscleblood flow in fibromyalgia patients during standardisedmuscle exercise a contrast media enhanced colour Dopplerstudy European Journal of Pain 200610(2)137ndash44

Etnier 2009

Etnier JL Karper WB Gapin JI Barella LA Chang YKMurphy KJ Exercise fibromyalgia and fibrofog a pilotstudy Journal of Physical Activity amp Health 20096(2)239ndash46

Evcik 2008

Evcik D Yugit I Pusak H Kavuncu V Effectiveness ofaquatic therapy in the treatment of fibromyalgia syndromea randomized controlled open study Rheumatology


Faigenbaum 2009

Faigenbaum AD Kraemer WJ Blimkie CJ Jeffreys IMicheli LJ Nitka M et alYouth resistance trainingupdated position statement paper from the national strengthand conditioning association Journal of Strength and

Conditioning Research 200923(5 Suppl)S60ndash79

Field 2003

Field T Delage J Hernandez-Reif M Movement andmassage therapy reduce fibromyalgia pain Journal of

Bodywork and Movement Therapies 20037(1)49ndash52

Figueroa 2008

Figueroa A Kingsley JD McMillan V Panton LBResistance exercise training improves heart rate variabilityin women with fibromyalgia Clinical Physiology and

Functional Imaging 200828(1)49ndash54

FitzerGerald 2004

FitzerGerald SJ Barlow CE Kampert JB Morrow JRJr Jackson AW Blair SN Muscular fitness and all-causemortality prospective observations Journal of Physical

Activity and Health 200417ndash18

Fontaine 2007

Fontaine KR Haas S Effects of lifestyle physical activity onhealth status pain and function in adults with fibromyalgiasyndrome Journal of Musculoskeletal Pain 200715(1)3ndash9

Fontaine 2010

Fontaine KR Conn L Clauw DJ Effects of lifestyle physicalactivity on perceived symptoms and physical function inadults with fibromyalgia results of a randomized trialArthritis Research amp Therapy 201012(2)R55

Fontaine 2011

Fontaine KR Conn L Clauw DJ Effects of lifestyle physicalactivity in adults with fibromyalgia results at follow-upJournal of Clinical Rheumatology 201117(2)64ndash8

Garber 2011

Garber C Blissmer B Deschenes MR Franklin BALamonte MJ Lee IM et alQuantity and quality ofexercise for developing and maintaining cardiorespiratorymusculoskeletal and neuromotor fitness in apparentlyhealthy adults guidance for prescribing exercise Medicineand Science in Sports and Exercise 2011 Vol 43 issue 71334ndash59

Garcia-Martinez 2012

Garcia-Martinez AM De Paz JA Marquez S Effects ofan exercise programme on self-esteem self-concept andquality of life in women with fibromyalgia a randomized



controlled trial Rheumatology International 201232(7)1869ndash76

Genc 2002

Genc A Sagiroglu E Comparison of two different exerciseprograms in fibromyalgia treatment [in Turkish] Fizyoterapi

Rehabilitasyon 200213(2)90ndash5

Gibson 2006

Gibson W Arendt-Nielsen L Graven-Nielsen T Delayedonset muscle soreness at tendon-bone junction andmuscle tissue is associated with facilitated referred painExperimental Brain Research 2006174(2)351ndash60

Gowans 1999

Gowans SE de Hueck A Voss S Richardson M Arandomized controlled trial of exercise and education forindividuals with fibromyalgia Arthritis Care and Research

199912(2)120ndash8

Gowans 2001

Gowans SE de Hueck A Voss S Silaj A Abbey SEReynolds WJ Effect of a randomized controlled trial ofexercise on mood and physical function in individualswith fibromyalgia Arthritis and Rheumatism 200145(6)519ndash29

Gracely 2003

Gracely RH Grant MA Giesecke T Evoked painmeasures in fibromyalgia Best Practice amp Research Clinical


Gusi 2006

Gusi N Tomas-Carus P Hakkinen A Hakkinen K Ortega-Alonso A Exercise in waist-high warm water decreases painand improves health-related quality of life and strength inthe lower extremities in women with fibromyalgia Arthritis


Gusi 2008

Gusi N Tomas-Carus P Cost-utility of an 8-month aquatictraining for women with fibromyalgia a randomizedcontrolled trial Arthritis Research amp Therapy 200810(1)R24

Gusi 2010

Gusi N Parraca JA Olivares PR Leal A Adsuar JC Tiltvibratory exercise and the dynamic balance in fibromyalgiaa randomized controlled trial Arthritis Care amp Research

(Hoboken) 201062(8)1072ndash8

Hakkinen 2001 (Primary)

Hakkinen A Hakkinen K Hannonen P Alen M Strengthtraining induced adaptations in neuromuscular function ofpremenopausal women with fibromyalgia comparison withhealthy women Annals of Rheumatic Diseases 200160(1)21ndash6

Hakkinen 2002 (Secondary)

Hakkinen K Pakarinen A Hannonen P Hakkinen AAiraksinen O Valkeinen H et alEffects of strengthtraining on muscle strength cross-sectional area maximalelectromyographic activity and serum hormones inpremenopausal women with fibromyalgia Journal of


Hammond 2006

Hammond A Freeman K Community patient educationand exercise for people with fibromyalgia a parallel grouprandomized controlled trial Clinical Rehabilitation 200620(10)835ndash46

Hawley 1991

Hawley DJ Wolfe F Pain disability and paindisabilityrelationships in seven rheumatic disorders a study of 1522patients Journal of Rheumatology 199118(10)1552ndash7

Hecker 2011

Hecker CD Melo C Tomazoni SS Lopes-Martins RABLeal Junior ECP Analysis of effects of kinesiotherapyand hydrokinesiotherapy on the quality of patients withfibromyalgia - a randomized clinical trial [in Portuguese]Fisioterapia em Movimento 201124(1)57ndash64

Heyward 1998

Heyward VH Advanced fitness assessment and exercise

prescription 3 Champaign IL Human Kinetics 1998

Heyward 2010

Heyward VH Advanced Fitness Assessment and Exercise

Prescription 6th Edition Champaign IL Human Kinetics2010

Hibbert 2008

Hibbert O Cheong K Grant A Beers A Moizumi T Asystematic review of the effectiveness of eccentric strengthtraining in the prevention of hamstring muscle strains inotherwise healthy individuals North American Journal of

Sports Physical Therapy 20083(2)67ndash81

Higgins 2011a

Higgins JPT Green S (editors) Cochrane Handbookfor Systematic Reviews of Interventions Version 510[updated March 2011] The Cochrane Collaboration2011 Available from wwwcochrane-handbookorg

Higgins 2011b

Higgins JPT Altman DG Sterne JAC (editors) Chapter8 Assessing risk of bias in included studies In HigginsJPT Green S (editors) Cochrane Handbook for SystematicReviews of Interventions Version 510 [updated March2011] The Cochrane Collaboration 2011 Available fromwwwcochrane-handbookorg

Higgins 2011c

Higgins JPT Deeks JJ Altman DG (editors) Chapter16 Special topics in statistics In Higgins JPT Green S(editors) Cochrane Handbook for Systematic Reviewsof Interventions Version 510 [updated March 2011]The Cochrane Collaboration 2011 Available fromwwwcochrane-handbookorg

Holloszy 1984

Holloszy JO Coyle EF Adaptations of skeletal muscleto endurance exercise and their metabolic consequencesJournal of Applied Physiology Respiratory Environmental amp

Exercise Physiology 198456(4)831ndash8

Hooten 2012

Hooten WM Qu W Townsend CO Judd JW Effects ofstrength vs aerobic exercise on pain severity in adults with



fibromyalgia a randomized equivalence trial Pain 2012153(4)915ndash23

Howley 2001

Howley ET Type of activity resistance aerobic and leisureversus occupational physical activity Medicine and Science

in Sports and Exercise 200133(6 Suppl)S364ndash9

Hunt 2000

Hunt J Bogg J An evaluation of the impact of afibromyalgia self-management programme on patientmorbidity and coping Advancing in Physiotherapy 20002(4)168ndash75

Haumluser 2013

Haumluser W Urruacutetia G Tort S Uumlccedileyler N Walitt BSerotonin and noradrenaline reuptake inhibitors(SNRIs) for fibromyalgia syndrome Cochrane Database

of Systematic Reviews 2013 Issue 1 [DOI 10100214651858CD010292]

Ide 2008

Ide MR Laurindo LMM Rodrigues-Junior AL TanakaC Effect of aquatic respiratory exercise-based program inpatients with fibromyalgia APLAR Journal of Rheumatology

200811(2)131ndash40

Isomeri 1993

Isomeri R Mikkelsson M Latikka P Kammonen K Effectsof amitriptyline and cardiovascular fitness training onpain in patients with primary fibromyalgia Journal of

Musculoskeletal Pain 19931253ndash60

Jentoft 2001

Jentoft ES Kvalvik AG Mengshoel AM Effects of pool-based and land-based aerobic exercise on women withfibromyalgiachronic widespread muscle pain Arthritis and


Jones 2007

Jones KD Deodhar AA Burckhardt CS Perrin NAHanson GC Bennett RM A combination of 6 months oftreatment with pyridostigmine and triweekly exercise fails toimprove insulin-like growth factor-I levels in fibromyalgiadespite improvement in the acute growth hormone responseto exercise Journal of Rheumatology 200734(5)1103ndash11

Jones 2008

Jones KD Burckhardt CS Deodhar AA Perrin NAHanson GC Bennett RM A six-month randomizedcontrolled trial of exercise and pyridostigmine in thetreatment of fibromyalgia Arthritis and Rheumatism 200858(2)612ndash22

Jones 2009

Jones KD Liptan GL Exercise interventions infibromyalgia clinical applications from the evidenceRheumatics Diseases Clinics of North America 200935(2)373ndash91

Jones 2012

Jones K Sherman C Mist S Carson J Bennett R Li FA randomized controlled trial of 8-form Tai chi improvessymptoms and functional mobility in fibromyalgia patientsBMC Complementary and Alternative Medicine 2012121205ndash14

Joshi 2009

Joshi MN Joshi R Jain AP Effect of amitriptyline vsphysiotherapy in management of fibromyalgia syndromewhat predicts a clinical benefit Journal of Postgraduate


Jubrias 1994

Jubrias SA Bennett RM Klug GA Increased incidence ofa resonance in the phosphodiester region of 31P nuclearmagnetic resonance spectra in the skeletal muscle offibromyalgia patients Arthritis and Rheumatism 199437

(6)801ndash7

Katzmarzyk 2002

Katzmarzyk PT Craig CL Musculoskeletal fitness and riskof mortality Medicine and Science in Sports and Exercise

200234(5)740ndash4

Keel 1998

Keel PJ Bodoky C Gerhard U Muller W Comparison ofintegrated group therapy and group relaxation training forfibromyalgia Clinical Journal of Pain 199814(3)232ndash8

King 1997

King AC Oman RF Brassington GS Bliwise DL HaskellWL Moderate-intensity exercise and self-rated quality ofsleep in older adults A randomized controlled trial JAMA

1997277(1)32ndash7

King 2002

King SJ Wessel J Bhambhani Y Sholter D MaksymowychW The effects of exercise and education individuallyor combined in women with fibromyalgia Journal of


Kingsley 2009

Kingsley JD Panton LB McMillan V Figueroa ACardiovascular autonomic modulation after acute resistanceexercise in women with fibromyalgia Archives of Physical

Medicine and Rehabilitation 200990(9)1628ndash34

Kingsley 2011

Kingsley JD McMillan V Figueroa A Resistance exercisetraining does not affect postexercise hypotension and wavereflection in women with fibromyalgia Applied Physiology

Nutrition and Metabolism 201136(2)254ndash63

Knutzen 2007

Knutzen KM Pendergrast BA Lindsey B Brilla LR Theeffect of high resistance weight training on reported pain inolder adults Journal of Sports Science and Medicine 20076455ndash60

Koltyn 1998

Koltyn KF Arbogast RW Perception of pain after resistanceexercise British Journal of Sports Medicine 199832(1)20ndash4

Lefebvre 2011

Lefebvre C Manheimer E Glanville J Chapter 6 Searchingfor studies In Higgins JPT Green S (editors) CochraneHandbook for Systematic Reviews of Interventions Version510 [updated March 2011] The Cochrane Collaboration2011 Available from wwwcochrane-handbookorg

Lemstra 2005

Lemstra M Olszynski WP The effectiveness ofmultidisciplinary rehabilitation in the treatment of



fibromyalgia a randomized controlled trial Clinical Journal

of Pain 200521(2)166ndash74

Lewis 2012

Lewis PB Ruby D Bush-Joseph CA Muscle soreness anddelayed-onset muscle soreness Clinical Sports Medicine

201231(2)255ndash62

Liu 2012

Liu W Zahner L Cornell M Le T Ratner J Wang Y etalBenefit of Qigong exercise in patients with fibromyalgiaa pilot study International Journal of Neuroscience 2012122

(11)657ndash64

Lopez-Rodriguez 2012

Lopez-Rodriguez MM Castro-Sanchez AM Fernandez-Martinez M Mataran-Penarrocha GA Rodriguez-FerrerME Comparison between aquatic-biodanza and stretchingfor improving quality of life and pain in patients withfibromyalgia Atencion Primaria 201244(11)641ndash9

Lorig 1989

Lorig K Chastain RL Ung E Shoor S Holman HRDevelopment and evaluation of a scale to measureperceived self-efficacy in people with arthritis Arthritis and


Lund 1986

Lund N Bengtsson A Thorborg P Muscle tissue oxygenpressure in primary fibromyalgia Scandinavian Journal of


Lynch 2012

Lynch M Sawynok J Hiew C Marcon D A randomizedcontrolled trial of qigong for fibromyalgia Arthritis Research

and Therapy 201214(4)R178

Mannerkorpi 2000

Mannerkorpi K Nyberg B Ahlmen M Ekdahl C Poolexercise combined with an education program for patientswith fibromyalgia syndrome A prospective randomizedstudy Journal of Rheumatology 200027(10)2473ndash81

Mannerkorpi 2009

Mannerkorpi K Nordeman L Ericsson A Arndorw MPool exercise for patients with fibromyalgia or chronicwidespread pain a randomized controlled trial andsubgroup analyses Journal of Rehabilitation Medicine 200941(9)751ndash60

Mannerkorpi 2010

Mannerkorpi K Nordeman L Cider A Jonsson G Doesmoderate-to-high intensity Nordic walking improvefunctional capacity and pain in fibromyalgia A prospectiverandomized controlled trial Arthritis Research amp Therapy

201012(5)R189

Martin 1996

Martin L Nutting A MacIntosh BR Edworthy SMButterwick D Cook J An exercise program in the treatmentof fibromyalgia Journal of Rheumatology 199623(6)1050ndash3

Martin-Nogueras 2012

Martin-Nogueras AM Calvo-Arenillas JI Efficacy ofphysiotherapy treatment on pain and quality of life in

patients with fibromyalgia [in Spanish] Rehabilitacion

201246(3)199ndash206

Matsutani 2007

Matsutani LA Marques AP Ferreira EA Assumpcao A LageLV Casarotto RA et alEffectiveness of muscle stretchingexercises with and without laser therapy at tender pointsfor patients with fibromyalgia Clinical amp Experimental


Matsutani 2012

Matsutani LA Assumpcao A Marques AP Stretching andaerobic exercises in the treatment of fibromyalgia pilotstudy [in Portuguese] Fisioterapia em Movimento 201225

(2)411ndash8

McCain 1988

McCain GA Bell DA Mai FM Halliday PD A controlledstudy of the effects of a supervised cardiovascular fitnesstraining program on the manifestations of primaryfibromyalgia Arthritis and Rheumatism 198831(9)1135ndash41

McNalley 2006

McNalley JD Matheson DA Bakowshy VS Theepidemiology of self-reported fibromyalgia in CanadaChronic Diseases in Canada 200627(1)9ndash16

Mease 2005

Mease P Fibromyalgia syndrome review of clinicalpresentation pathogenesis outcome measures andtreatment Journal of Rheumatology - Supplement 2005756ndash21

Mease 2008

Mease PJ Arnold LM Crofford LJ Williams DA RussellIJ Humphrey L et alIdentifying the clinical domains offibromyalgia contributions from clinician and patientDelphi exercises Arthritis and Rheumatism 200859(7)952ndash60

Mease 2009

Mease P Arnold LM Choy EH Clauw DJ CroffordLJ Glass JM et alFibromyalgia syndrome module atOMERACT 9 domain construct Journal of Rheumatology

200936(10)2318ndash29

Mengshoel 1992

Mengshoel AM Komnaes HB Forre O The effects of 20weeks of physical fitness training in female patients withfibromyalgia Clinical amp Experimental Rheumatology 199210(4)345ndash9

Mengshoel 1993

Mengshoel AM Forre O Physical fitness training inpatients with fibromyalgia Musculoskeletal pain 19931(4)267ndash72

Merskey 1994

Merskey H Bogduk N Classifications of Chronic Pain

Descriptions and Definitions of Chronic Pain Syndromes and

Definitions of Pain Terms Seattle WA IASP 1994

Mitchell 2002

Mitchell M Engauge digitizer - digitizing softwaredigitizersourceforgenet 2002 Vol (accessed 20 October2013)



Mizelle 2011

Mizelle K Fontaine KR Exercise and physical activity forfibromyalgia Journal of Musculoskeletal Medicine 201128

(8)310ndash6

Moore 2012

Moore RA Derry S Aldington D Cole P Wiffen PJAmitriptyline for neuropathic pain and fibromyalgia inadults Cochrane Database of Systematic Reviews 2012 Issue12 [DOI 10100214651858CD008242pub2]

Morrissey 1995

Morrissey MC Harman EA Johnson MJ Resistancetraining modes specificity and effectiveness Medicine and


Munguia-Izquierdo 2007

Munguia-Izquierdo D Legaz-Arrese A Exercise in warmwater decreases pain and improves cognitive functionin middle-aged women with fibromyalgia Clinical amp

Experimental Rheumatology 200725(6)823ndash30


Munguia-Izquierdo D Legaz-Arrese A Assessment ofthe effects of aquatic therapy on global symptomatologyin patients with fibromyalgia syndrome a randomizedcontrolled trial Archives of Physical Medicine amp


Nelson 2007

Nelson ME Rejeski WJ Blair SN Duncan PW JudgeJO King AC et alPhysical activity and public health inolder adults recommendation from the American Collegeof Sports Medicine and the American Heart AssociationCirculation 2007116(9)1094ndash105

Nichols 1994

Nichols DS Glenn TM Effects of aerobic exercise on painperception affect and level of disability in individuals withfibromyalgia Physical Therapy 199474327ndash32

Norregaard 1997

Norregaard J Lykkegaard JJ Mehlsen J DanneskioldSamsoe B Exercise training in treatment of fibromyalgiaJournal of Musculoskeletal Pain 19975(1)71ndash9

Olivares 2011

Olivares PR Gusi N Parraca JA Adsuar JC Del Pozo-CruzB Tilting whole body vibration improves quality of life inwomen with fibromyalgia a randomized controlled trialJournal of Alternative and Complementary Medicine 201117

(8)723ndash8

Painter 1999

Painter P Stewart AL Carey S Physical functioningdefinitions measurement and expectations Advances in

Renal Replacement Therapy 19996(2)110ndash23

Park 1998

Park JH Phothimat P Oates CT Hernanz Schulman MOlsen NJ Use of P-31 magnetic resonance spectroscopy todetect metabolic abnormalities in muscles of patients withfibromyalgia Arthritis amp Rheumatism 199841(3)406ndash13

Park 2007

Park J Knudson S Medically unexplained physicalsymptoms Health Reports 200718(1)43ndash7

Philadelphia 2001

Philadelphia Panel Philadelphia Panel evidence-basedclinical practice guidelines on selected rehabilitationinterventions overview and methodology Physical Therapy

200181(10)1629ndash40

Raftery 2009

Raftery G Bridges M Heslop P Walker DJ Arefibromyalgia patients as inactive as they say they areClinical Rheumatology 200928(6)711ndash4

Ramsay 2000

Ramsay C Moreland J Ho M Joyce S Walker S PullarT An observer-blinded comparison of supervised andunsupervised aerobic exercise regimens in fibromyalgiaRheumatology 200039(5)501ndash5

RevMan 2012

The Nordic Cochrane Centre The Cochrane CollaborationReview Manager (RevMan) 52 Copenhagen The NordicCochrane Centre The Cochrane Collaboration 2012

Richards 2002

Richards SC Scott DL Prescribed exercise in people withfibromyalgia parallel group randomised controlled trialBMJ 2002325(7357)185

Rivera Redondo 2004

Rivera Redondo J Moratalla Justo C Valdepenas MoraledaF Garcia Velayos Y Oses Puche JJ Ruiz Zubero Jet alLong-term efficacy of therapy in patients withfibromyalgia a physical exercise-based program and acognitive-behavioral approach Arthritis and Rheumatism

200451(2)184ndash92

Rooks 2007

Rooks DS Gautam S Romeling M Cross ML StratigakisD Evans B et alGroup exercise education andcombination self-management in women with fibromyalgiaa randomized trial Archives of Internal Medicine 2007167

(20)2192ndash200

Sale 1987

Sale DG Influence of exercise and training on motor unitactivation Exercise and Sport Science Reviews 19871595ndash151

Sanudo 2010

Sanudo B de Hoyo M Carrasco L McVeigh JG Corral JCabeza R et alThe effect of 6-week exercise programmeand whole body vibration on strength and quality of life inwomen with fibromyalgia a randomised study Clinical amp

Experimental Rheumatology 201028(6 Suppl 63)S40ndash5

Sanudo 2010a

Sanudo B Galiano D Carrasco L Blagojevic M deHoyo M Saxton J Aerobic exercise versus combinedexercise therapy in women with fibromyalgia syndrome arandomized controlled trial Archives of Physical Medicine

and Rehabilitation 201091(12)1838ndash43



Sanudo 2010c

Sanudo Corrales B Galiano Orea D Carrasco PaezL Saxton J Autonomic nervous system response andquality of life on women with fibromyalgia after a long-term intervention with physical exercise [in Spanish]Rehabilitacion 201044(3)244ndash9

Sanudo 2011

Sanudo B Galiano D Carrasco L De Hoyo M McVeighJG Effects of a prolonged exercise program on key healthoutcomes in women with fibromyalgia a randomizedcontrolled trial Journal of Rehabilitation Medicine 201143

(6)521ndash6

Sanudo 2012

Sanudo B de Hoyo M Carrasco L Rodriguez-Blanco COliva-Pascual-Vaca A McVeigh JG Effect of whole-bodyvibration exercise on balance in women with fibromyalgiasyndrome a randomized controlled trial Journal of

Alternative and Complementary Medicine 201218(2)158ndash64

Schachter 2003

Schachter CL Busch AJ Peloso P Sheppard MS The effectsof short versus long bouts of aerobic exercise in sedentarywomen with fibromyalgia a randomized controlled trialPhysical Therapy 200383(4)340ndash58

Schmidt 2011

Schmidt S Grossman P Schwarzer B Jena S NaumannJ Walach H Treating fibromyalgia with mindfulness-based stress reduction Results from a 3-armed randomizedcontrolled trial Pain 2011152(2)1838ndash43

Schuumlnermann 2009

Schuumlnemann H Bro ek J Oxman A editors GRADEhandbook for grading quality of evidence and strength ofrecommendation Version 32 [updated March 2009] TheGRADE Working Group 2009 Available from wwwcc-imsnetgradepro

Seidel 2013

Seidel S Aigner M Ossege M Pernicka E Wildner BSycha T Antipsychotics for acute and chronic pain inadults Cochrane Database of Systematic Reviews 2013 Issue8 [DOI 10100214651858CD004844pub3]

Sencan 2004

Sencan S Ak S Karan A Muslumanoglu L Ozcan EBerker E A study to compare the therapeutic efficacy ofaerobic exercise and paroxetine in fibromyalgia syndromeJournal of Back amp Musculoskeletal Rehabilitation 200417(2)57ndash61

Singh 1997

Singh NA Clements KM Fiatarone MA A randomizedcontrolled trial of the effect of exercise on sleep Sleep 199720(2)95ndash101

Smythe 1981

Smythe HA Fibrositis and other diffuse musculoskeletalsyndromes In Kelley WN Harris ED Jr Ruddy SSledge CB editor(s) Textbook of Rheumatology 1st EditionOxford WB Saunders 1981

Tomas-Carus 2007

Tomas-Carus P Gusi N Leal A Garcia Y Orega-Alonso AThe fibromyalgia treatment with physical exercise in warmwater reduces the impact of the disease on female patientsrdquophysical and mental health [Spanish] Reumatologia Clinica

20073(1)33ndash7

Tomas-Carus 2007a

Tomas-Carus P Hakkinen A Gusi N Leal A Hakkinen KOrtega-Alonso A Aquatic training and detraining on fitnessand quality of life in fibromyalgia Medicine amp Science in

Sports amp Exercise 200739(7)1044ndash50

Tomas-Carus 2007b

Tomas-Carus P Raimundo A Adsuar JC Olivares P GusiN Effects of aquatic training and subsequent detrainingon the perception and intensity of pain and number [inSpanish] Apunts Medicina de lrsquoEsport 200715476ndash81

Tomas-Carus 2007c

Tomas-Carus P Raimundo A Timon R Gusi N Exercisein warm water decreases pain but no the number oftender points in women with fibromyalgia a randomizedcontrolled trial [in Spanish] Seleccion 200716(2)98ndash102

Tomas-Carus 2008

Tomas-Carus P Gusi N Hakkinen A Hakkinen K LealA Ortega-Alonso A Eight months of physical training inwarm water improves physical and mental health in womenwith fibromyalgia a randomized controlled trial Journal of

Rehabilitation Medicine 200840(4)248ndash52

Tort 2012

Tort S Urruacutetia G Nishishinya MB Walitt B Monoamineoxidase inhibitors (MAOIs) for fibromyalgia syndromeCochrane Database of Systematic Reviews 2012 Issue 4[DOI 10100214651858CD009807]

Trew 2005

Trew M Everett T Human Movement An Introductory Text5th Edition Edinburgh Elsevier Churchill Livingstone2005

Valencia 2009

Valencia M Alonso B Alvarez MJ Barrientos MJ AyanC Sanchez VM Effects of 2 physiotherapy programs onpain perception muscular flexibility and illness impactin women with fibromyalgia a pilot study Journal of

Manipulative and Physiological Therapeutics 200932(1)84ndash92

Valim 2003

Valim V Oliveira L Suda A Silva L de Assis M BarrosNeto T et alAerobic fitness effects in fibromyalgia Journal

of Rheumatology 200330(5)1060ndash9

Valkeinen 2004 (Primary)

Valkeinen H Alen M Hannonen P Hakkinen A AiraksinenO Hakkinen K Changes in knee extension and flexionforce EMG and functional capacity during strengthtraining in older females with fibromyalgia and healthycontrols Rheumatology 200443(2)225ndash8



Valkeinen 2005 (Secondary)

Valkeinen H Hakkinen K Pakarinen A Hannonen PHakkinen A Airaksinen O et alMuscle hypertrophystrength development and serum hormones during strengthtraining in elderly women with fibromyalgia ScandinavianJournal of Rheumatology 2005 Vol 34 issue 4309ndash14

Valkeinen 2008

Valkeinen H Alen M Hakkinen A Hannonen PKukkonen-Harjula K Hakkinen K Effects of concurrentstrength and endurance training on physical fitness andsymptoms in postmenopausal women with fibromyalgia arandomized controlled trial futures Archives of Physical and

Medical Rehabilitation 200889(9)1660ndash6

van Koulil 2007

van Koulil S Effting M Kraaimaat FW van LankveldW van Helmond T Cats H et alCognitive-behaviouraltherapies and exercise programmes for patients withfibromyalgia state of the art and future directions Annals

of the Rheumatic Diseases 200766(5)571ndash81

van Koulil 2010

van Koulil S van Lankveld W Kraaimaat FW van HelmondT Vedder A van Hoorn H et alTailored cognitive-behavioral therapy and exercise training for high-riskpatients with fibromyalgia Arthritis Care amp Research 201062(10)1377ndash85

van Tulder 2003

van Tulder MW Furlan A Bombardier C Bouter LUpdated method guidelines for systematic reviews in theCochrane Collaboration Back Review Group Spine 200328(12)1290ndash9

vanSanten 2002

vanSanten M Bolwijn P Landewe R Verstappen FBakker C Hidding A et alHigh or low intensity aerobicfitness training in fibromyalgia does it matter Journal of


vanSanten 2002a

vanSanten M Bolwijn P Verstappen F Bakker C HiddingA Houben H et alA randomized clinical trial comparingfitness and biofeedback training versus basic treatment inpatients with fibromyalgia Journal of Rheumatology 200229(3)575ndash81

Verstappen 1997

Verstappen FTJ Santen-Hoeuftt HMS Bolwijn PH vander Linden S Kuipers H Effects of a group activity programfor fibromyalgia patients on physical fitness and well beingJournal of Musculoskeletal Pain 19975(4)17ndash28

Wang 2010

Wang C Schmid CH Rones R Kalish R Yinh JGoldenberg DL et alA randomized trial of tai chi forfibromyalgia New England Journal of Medicine 2010363

(8)743ndash54

WHO 2012

World Health Organization Depression wwwwhointtopicsdepressionen (accessed 22 October 2013)

Wigers 1996

Wigers SH Stiles TC Vogel PA Effects of aerobic exerciseversus stress management treatment in fibromyalgiaA 45 year prospective study Scandinavian Journal of


Williams 2012

Williams AC Eccleston C Morley S Psychologicaltherapies for the management of chronic pain (excludingheadache) in adults Cochrane Database of Systematic Reviews

2012 Issue 11 [DOI 10100214651858CD007407]

Winkelmann 2012

Winkelmann A Hauser W Friedel E Moog-Egan MSeeger D Settan M et alPhysiotherapy and physicaltherapies for fibromyalgia syndrome systematic reviewmeta-analysis and guideline [in German] Schmerz 201226

(3)276ndash86

Wolfe 1990

Wolfe F Smythe HA Yunus MB Bennett RM BombardierC Goldenberg DL et alThe American College ofRheumatology 1990 criteria for the classification offibromyalgia Report of the Multicenter CriteriaCommittee Arthritis amp Rheumatism 199033(2)160ndash72

Wolfe 1995

Wolfe F Ross K Anderson J Russell IJ Hebert L Theprevalence and characteristics of fibromyalgia in the generalpopulation Arthritis amp Rheumatism 199538(1)19ndash28

Wolfe 2010

Wolfe F Clauw DJ Fitzcharles MA Goldenberg DL KatzRS Mease P et alThe American College of Rheumatologypreliminary diagnostic criteria for fibromyalgia andmeasurement of symptom severity Arthritis Care amp Research

201062(5)600ndash10

Wolfe 2011

Wolfe F Clauw DJ Fitzcharles MA Goldenberg DLHauser W Katz RS et alFibromyalgia Criteria andSeverity Scales for Clinical and Epidemiological Studies AModification of the ACR Preliminary Diagnostic Criteriafor Fibromyalgia Journal of Rheumatology 201138(6)1113ndash22

Yunus 1981

Yunus M Masi AT Calabro JJ Miller KA FeigenbaumSL Primary fibromyalgia (fibrositis) clinical study of50 patients with matched normal controls Seminars in

Arthritis and Rheumatism 198111151ndash71

Yunus 1982

Yunus M Masi AT Calabro JJ Shah IK Primaryfibromyalgia American Family Physician 198225(5)115ndash21

Yunus 1984

Yunus MB Primary fibromyalgia syndrome currentconcepts Comprehensive Therapy 19841021ndash8

Yuruk 2008

Yuruk OB Gultekin Z Comparison of two differentexercise programs in women with fibromyalgia syndrome[in Turkish] Fizyoterapi Rehabilitasyon 200819(1)15ndash23



Zeng 2008

Zeng QY Chen R Darmawan J Xiao ZY Chen SB WigleyR et alRheumatic diseases in China Arthritis Research amp

Therapy 200810(1)R17

References to other published versions of this review

Busch 2001

Busch AJ Schachter CL Peloso PM Fibromyalgia andexercise training a systematic review of randomized clinicaltrials Physical Therapy Review 20016287ndash306

Busch 2001a

Busch AJ Schachter CL Bombardier C Peloso P Exercisefor treating fibromyalgia syndrome (Protocol for a CochraneReview) Cochrane Database of Systematic Reviews 2001Issue 3 [DOI 10100214651858CD003786]

Busch 2002

Busch AJ Schachter CL Peloso P Bombardier C Exercisefor treating fibromyalgia syndrome Cochrane Database


Busch 2007

Busch AJ Barber KA Overend TJ Peloso PM SchachterCL Exercise for treating fibromyalgia syndrome Cochrane

Database of Systematic Reviews 2007 Issue 4 [DOI10100214651858CD003786]

Busch 2008

Busch AJ Schachter CL Overend TJ Peloso PM BarberKA Exercise for fibromyalgia a systematic review Journal

of Rheumatology 200835(6)1130ndash44lowast Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Bircan 2008

Methods Randomized trial 2 groups (aerobic exercise group resistance exercise group)LENGTH 8 wk

Participants FEMALEMALE = 260 AGE (yrs (SD)) 46 (85) to 483 (53)DURATION OF ILLNESS (yrs (SD)) 385 (331) to 462 (522)INCLUSION Women who met ACR 1990 diagnostic criteria for fibromyalgia (Wolfe1990)EXCLUSION Presence of serious cardiovascular pulmonary endocrine neurologic orrenal disease inflammatory rheumatic disease or participation in a physical therapy orexercise program in the last 6 months

Interventions 1) Resistance training group (randomized n = 15 completed and analyzed n = 13)frequency 3wk duration 40 min (30-min resistance exercise) intensity unspecified4-5 reps progressed to 12 reps method free weights or body weight resistance exercisein standing sitting and lying for upper and lower limb muscles and trunk muscles2) Aerobic training group (randomized n = 15 completed and analyzed n = 13)frequency 3wk duration 20 min progressing to 30 min intensity low to moderatemethod treadmill walking

Outcomes Measurements Pre- and post-intervention (8 wks) sleep disturbance (VAS) fatigue(VAS) tenderness (tender point count) cardio-respiratory function submaximal (6-min walk) anxiety (HAD Anxiety scale) depression (HAD Depression scale) self re-ported physical function (SF-36 Physical functioning scale) mental health (SF-36 Men-tal Health Scale) pain (VAS)

Congruence with ACSM Guidelines forResistance Training (yesno)

Guidelines for healthy adults No (frequency - yes type - yes rep - no starts too lowsets - unclear intensity - unclear progression - yes)Guidelines for older adults Unclear (frequency - yes type - yes rep - yes intensity -unclear progression - yes)

Notes Adverse effects page 529 ldquoNo patient experienced musculoskeletal injury or exacerba-tion of fibromyalgia related symptoms during the interventionrdquoAttrition Resistance training n = 2 (1333) aerobic training n = 2 (1333)Adherence Not specifiedCo-interventions Both groups ldquowere allowed to continue their medication at entryhowever treatment had to remain stable for 1 month prior to entry to the studyrdquo (p 528)Communication with author Correction to data in table 2 confirming data for painsleep fatigue are in centimeters (email 8 May 2013)Country Turkey (paper published in English)Funding conflict of interest No information was available

Risk of bias

Bias Authorsrsquo judgement Support for judgement



Bircan 2008 (Continued)

Random sequence generation (selectionbias)

Low risk ldquoParticipants were randomly assigned to anAE group or a SE grouprdquo (AE aerobic ex-ercise SE strengthening exercise) Bircan2008 (p 528) In email communicationwith the author (29 June 2012) the authorsclarified as follows ldquoThe patients were as-signed to groups by the random allocationrule As the sample size was planned to be30 special cards were prepared for eachtreatment (15 were labelled as A and 15as B) the cards were inserted into opaqueenvelopes and the envelopes were shuf-fled Patients were assigned to groups dur-ing the study by drawing lots among theseenvelopes after the initial evaluations weredonerdquo

Allocation concealment (selection bias) Low risk Although no information was provided inthe publication in email communicationwith the author (29 June 2012) we learnedthat ldquoThe patientrsquos group was determinedafter all initial evaluations of the patientwere done The investigators did not knowwhat the next treatment allocation wouldberdquo

Blinding (performance bias and detectionbias)All outcomes

High risk Although no information was provided inthe publication in email communicationwith the author (29 June 2012) we learnedldquoParticipants outcome assessors and peo-ple that delivered the intervention were notblind to study groupsrdquo

Blinding of outcome assessment (detectionbias)

High risk Only 1 variable was measured by an asses-sor (6-min walk) - in email communication(29 June 2012) we learned that this out-come was not blinded (see above)

Incomplete outcome data (attrition bias)All outcomes

Low risk Missing outcome data balanced in num-bers across intervention groups with simi-lar reasons for missing data across groupsIt is unclear why intention-to-treat analysiswas not used

Selective reporting (reporting bias) Low risk All outcomes specified on Bircan 2008page 528 appear in data tables Accordingto email communication with the authorsldquoThere were not any outcomes measuredbut not reported in the paperrdquo (29 June




2012)

Other bias Low risk Based on the data provided there is no in-dication that there are other important risksof bias

Hakkinen 2001

Methods Randomized trial 3 groups (fibromyalgia resistance exercise group fibromyalgia controlgroup healthy resistance training group) LENGTH 4-wk baseline control phase for allgroups followed by a 21-wk intervention phase

Participants FEMALEMALE = 330 AGE (yrs (SD)) 37 (6) to 39 (6)DURATION OF ILLNESS (yrs (SD)) 12 (4)INCLUSION Diagnosis fibromyalgia (ACR criteria Wolfe 1990) pre-menopausalwomenEXCLUSION Unspecified

Interventions 1) Fibromyalgia resistance training group (fibromyalgia n = 11) frequency 2wkduration duration of each session not provided intensity moderate-to-heavy progressiveresistance (15-20 reps at 40-60 of 1 RM progressing to 5-10 reps at 70-80 of 1 RMfrom wk 7 on 30 of leg exercise performed rapidly with 40-60 RM) method 6-8 dynamic resisted exercises using David 200 dynamometer to upper extremity lowerextremity and trunk muscle groups2) Fibromyalgia control group (fibromyalgia n = 10) Controls maintained their nor-mal low-intensity recreational physical activities but did not participate in the strengthtraining3) Healthy resistance training control group (healthy n = 12) A training group madeup of sedentary healthy women (without fibromyalgia) was also a part of this study Datafrom this group were not analyzed in this review

Outcomes Measurements 4 wks pre-intervention immediately pre-intervention immediatelypostintervention (21 wks) Patient-rated global well-being (VAS) pain (VAS) tenderness(tender point count) fatigue (VAS) muscle strength (maximum bilateral (1 RM) con-centric leg extension) sleep (VAS) self reported physical function (Health AssessmentQuestionnaire) muscle power (squat jump) muscle fiber activation (EMG) muscle size(cross-sectional area) depression (Beck Depression Index)


Guidelines for healthy adults Yes (frequency - yes type - yes reps - yes sets - yesintensity - yes progression - yes)Guidelines for older adults Yes (frequency - yes type - yes reps - yes intensity - yesprogression - yes)

Notes Adverse effects None reportedAttrition n = 0 (0) aerobic training n = 0 (0)Adherence to exercise protocol Not specifiedData for this study were extracted from 2 reports Hakkinen 2001 (Primary) Hakkinen2002 (Secondary) Additional data were obtained from the authors on the following



Hakkinen 2001 (Continued)

outcome measures maximum bilateral (1 RM) concentric leg extension squat jumpvertical and tender points The authors also clarified the timing of the assessmentsThe researcher reported that there were no dropouts The author attributed this tointensive process for habituating participants to the study methods and cultural valuesunique to Finland where the study took place (personal communication) Also of noteprior to entry into the study the ldquosubjects in all groups were habitually active (such aswalking swimming biking skiing) but they had no background in strength trainingrdquo(page 1288 Hakkinen 2002 (Secondary))Co-interventions No information was provided about co-interventionsCountry FinlandFunding conflict of interest As reported by the authors ldquoThis study was supportedin part by grants from Finnish Social Insurance Institution and the Yrjouml Jahnsson Foun-dationrdquo No information was available regarding conflict of interest

Risk of bias



Unclear risk No information regarding how participantswere randomized

Allocation concealment (selection bias) Unclear risk No procedure was described


High risk Insufficient information but it is unlikelythat participants and care providers wereblinded


Unclear risk No information on blinding of outcomeassessors was provided


Low risk No dropouts reported Table 1 in Hakkinen2001 showed the sample size for bothgroups We assume that these values areconsistent for before and after treatmentData on tenderness which was not avail-able in the research report was provided bythe study authors upon request

Selective reporting (reporting bias) Low risk Although the study protocol was unavail-able between the primary the companionpaper and the response from the authorsall the variables measured have been ac-counted for




Jones 2002

Methods Randomized trial 2 groups (resistance exercise group flexibility exercise group)LENGTH 12 wk

Participants FEMALEMALE = 560 AGE (yrs (SD) 464 (86) to 492 (63)DURATION OF ILLNESS (yrs (SD)) 69 (66) to 77 (55)INCLUSION Diagnosis fibromyalgia (ACR criteria Wolfe 1990) women only ages20-60 yrsEXCLUSION Current or past history of cardiovascular pulmonary neurologic en-docrine or renal disease that would preclude exercise program current use of medica-tions that would affect normal physiologic response to exercise current cigarette smok-ing score = 29 on Beck Depression Scale modified for fibromyalgia current participantin a regular exercise program

Interventions 1) Resistance exercise group (n = 28) frequency 2wk duration 60 min intensityprogressed from 4 to 12 reps method supervised dynamic resistance exercise for lowerand upper limbs and trunk using hand weight (1-3 lb (045-136 kg)) and elastic tubingminimization of eccentric work (a videotape to guide home practice of the strengtheningexercise regimen was provided to participants)2) Flexibility exercise group (n = 28) frequency 2wk duration 60 min flexibility forlower limbs and trunk intensity na method supervised static stretches (a videotape toguide home practice of the flexibility exercise regimen was provided to participants)

Outcomes Measurement pre- and post-intervention (12 wks) Multidimensional function (FIQ to-tal score) pain (FIQ VAS) tenderness (tender point count) fatigue (FIQ VAS) musclestrength (maximum isokinetic strength of nondominant knee extension) sleep (FIQVAS) musclejoint flexibility (hand-to-neck hand-to-scapula movement) depression(Beck Depression Inventory) anxiety (Beck Anxiety Inventory) copingself efficacy(Arthritis Self Efficacy Scale)


Guidelines for healthy adults No (F - yes type - yes reps - unclear sets - unclear I -no progression - unclear)Guidelines for older adults No (F- yes type - yes repetitions - unclear I - unclear)

Notes Adverse effects There were no occurrences of adverse events or injury during the inter-vention and incidence of worsening of pain or tenderness was the same in both groups(n = 3 in each group) (page 1045)Attrition Authors stated that they had a low attrition rate (9) (page 1045) howeverfollowing analysis of the data and communication with author (email 19 July 2010)the attrition from each group was not specified The data were 1268 (1764) eitherdropped out or did not meet adherence criteria for inclusion Resistance training n = 6(1764) flexibility training n = 6 (1764)Adherence to exercise protocol ldquoClass attendance records by the exercise instructorindicated that 85 of the participants (n = 58) attended 13 or more classesrdquo (page 1043) however ldquothe strengthening intervention was not monitored to assure that subjectsprogressively increased the load throughout the 12 weeks Instead participants wereencouraged to listen to their bodies and increase the intensity as they thought they couldtolerate itrdquo (pages 1045 1046)Co-interventions No information was provided about co-interventionsCountry US



Jones 2002 (Continued)

Communication with author Additional data were obtained from the authors to clarifythe content and delivery of the intervention (eg videotapes education the exercise levelat completion) the number randomized and specifics related to dropoutsFunding conflict of interest As reported by the authors ldquoSupported by an IndividualNational Research Service Award (1F31NR07337-01A1) from the National Institutesof Health a doctoral dissertation grant (2324938) from the Arthritis Foundationand funds from the Oregon Fibromyalgia Foundationrdquo No information was availableregarding conflict of interest

Risk of bias



Low risk ldquoRandomization was accomplished with acoin fliprdquo (page 1042)

Allocation concealment (selection bias) Unclear risk Insufficient information in the research re-port




Low risk ldquoData were collected by an exercise sciencetechnician (strength and body fat) or theprincipal investigator (all other measures) Both were blinded to group assignmentrdquo(Jones 2002 page 1042)


Low risk Reasons for missing outcome data unlikelyto be related to true outcome (for survivaldata censoring unlikely to be introducingbias)Authors stated that the participants whodropped out lived far from the fitness center(page 1045)

Selective reporting (reporting bias) Low risk The study protocol was not available butit was clear that the published reports in-cluded all expected outcomes includingthose that were prespecified

Other bias Low risk There may be a risk related to poor ad-herence to the exercise regimen ldquo85 ofthe participants attended only slightly morethan 50 of the 24 supervised sessionsrdquo(Jones 2002 page 1043) The low atten-dance may have contributed to low power(ie type 2 error)



Kayo 2011

Methods Randomized trial 3 groups (walking group strengthening exercise group control group) LENGTH 16 wks with follow-up for an additional 12 wks

Participants FEMALEMALE = 900 AGE (yrs (SD)) 461 (64) to 477 (53)DURATION OF ILLNESS (yrs (SD)) 4 (31) to 54 (35)INCLUSION women ages 30-55 yrs and agreed to participate in an exercise program3 timeswk for 16 wks and to discontinue medications for fibromyalgia 4 wks before thestart of the study and who had at least 4 yrs of schoolingEXCLUSION women with any contraindications to exercise on the basis for clinicalrheumatologic examination and those involved in cases of medical litigation

Interventions 1) Progressive aerobic exercise (n = 30) frequency 3 timeswk x 16 wks duration~ 60 min (warm-up (5-10 min) conditioning stimulus cool down (5 min) intensitymoderate to high intensity (40-50 to 60-70 heart rate reserve by wk 16) methodsupervised indoor or outdoor walking monitored using heart rate monitor2) Resistance exercise training (n = 30) frequency 3 timeswk x 16 wk duration ~60 min intensity high intensity (4 on 10-point Borg scale)b exercise load and intensitywere increased every 2 wks (reps - wks 1 + 2 3 sets of 10 reps with rest intervals of 1min between sets wks 3-16 load - wks 1-4 no load wks 5-16 load was included) ldquoThetraining load was individually and systematically adjusted every time the participantperformed more than 15 repetitions with successfullyrdquob M supervised exercise protocolconsisting of 11 free active exercises for upper and lower limbs and trunk muscles usingfree weights and body weight performed in the standing sitting and lying positions3) Control group (n = 30) control conditions not specified except authors statedparticipants in all 3 groups were asked to discontinue tricyclic antidepressants but wereallowed to use acetaminophen (paracetamol) for pain

Outcomes Measurement pre-intervention mid-intervention (8 wks) immediately post-interven-tion (16 wks) and follow-up (12 wks post-intervention) As reported in paper multidi-mensional function (FIQ total) pain (VAS)As provided by author on request fatigue (SF-36 - Vitality scale) tenderness (tenderpoint pain) self reported physical function (SF-36 Physical Function scale) mentalhealth (SF36 Mental Health)


Guidelines for healthy adults No (frequency - yes type - yes reps - no sets - yes inten-sity - yes according to description provided by authors regarding the scale progression- yes)Guidelines for older adults Yes (frequency - yes type - yes reps - yes intensity - yesprogression - yes)

Notes Adverse effects ldquoNo complications or adverse effects were observed during the studyperiod among patients who completed the treatment protocolsrdquoAttrition Aerobics training n = 1 (33) resistance training n = 5 (166) control n= 5 (166)Adherence to exercise protocol ldquoWe adopted Borg Scale (0-10) and the recommendedintensity was 4 (somewhat severe) and all participants compliedrdquo From email commu-nication (19 July 2012) 80 attendance rate - excluding those who dropped out forreasons of work or family illness with only 1 participant assigned to the resistance train-



Kayo 2011 (Continued)

ing group that did not meet the attendance requirements of the studyCo-interventions Exercise was administered in this study as a single modality thetiming of restarting medication was monitoredCountry BrazilFunding conflict of interest No information on funding of the study was found butthe authors stated there was no conflict of interest

Risk of bias



Low risk ldquoThe allocation sequence was based on arandom number list (GraphPad Statmateversion 10) which was organized by aninvestigator (MSP)rdquo (online page 2)

Allocation concealment (selection bias) Low risk Opaque sealed envelopes were used


Low risk No details provided in the report ldquoTherewas no contact among the groupsrdquob


Low risk The study authors stated ldquoall patients wereclinically examined by the same rheuma-tologist (CSM) who was blinded to groupassignment throughout the studyrdquo (onlinepage 2)


Low risk Intention-to-treat analysis was used

Selective reporting (reporting bias) High risk Outcome data for important variables (egtender points SF-36 Physical FunctioningSF-36 Vitality SF-36 Mental Health) werenot provided in the published report butthe study authors provided these on requestbAn important shortcoming was that therewere no performance tests for physicalfunction applied in this study

Other bias Low risk There did not appear to be any other se-rious sources of bias Although the re-searchers found differences between groupsin duration of disease at baseline (P value= 004 longer duration in control groupthan the intervention groups) no between-group differences were found in baselinelevels of age pain tenderness multidimen-




sional function SF-36 subscales so we didnot consider this a serious problem

Valkeinen 2004

Methods Randomized trial 3 groups (fibromyalgia resistance exercise group fibromyalgia controlgroup healthy resistance exercise control group) LENGTH 21 wk

Participants FEMALEMALE = 360 AGE (yrs (SD)) 591 (35) to 602 (25)DURATION OF ILLNESS (yrs (SD)) 85 (43) to 66 (41)INCLUSION Diagnosis fibromyalgia (ACR criteria Wolfe 1990) age = 55 yrs womenEXCLUSION No other diseases no injuries no experience of regular strength trainingexercises willingness to participate in study protocol

Interventions 1) Fibromyalgia resistance exercise group (fibromyalgia n = 13) frequency 2wkduration 60-90 min 80 strength 20 power I light- to high-intensity progressiveresistance from 3 sets of 15-20 reps at 40-60 1 RM to 3-5 sets of 5-10 reps at 70-80 1 RM for power (legs only) 2 sets of 8-12 reps at 40-50 1 RM method resisteddynamic exercise to knee extensors x 2 plus 5-6 exercises for other main muscle groupsof body (exercise equipment not specified)2) Fibromyalgia control group (fibromyalgia n = 13) Control conditions were treat-ment as usual and physical activity as usual3) Healthy resistance exercise control group (healthy n = 10) A group made up ofsedentary women without fibromyalgia (n = 12) who carried out the exercise protocolwas also a part of this study Data from this group were not analyzed in this review

Outcomes Measurements 4 wks pre-intervention immediately pre-intervention immediately post-intervention (21 wks) Tenderness (tender point count) muscle strength (Max concentricleg extension) self reported function (Health Assessment Questionnaire) muscle fiberactivation (EMG) muscle size (cross-sectional area)The study authors stated they measured 5 other variables (pain fatigue patient-ratedglobal depression and sleep) but the data were not available in the report and they didnot respond to our emails


Guidelines for healthy adults Yes (frequency - yes type - yes reps - yes sets - yesintensity - yes)Guidelines for older adults Yes (frequency - yes type - yes reps - yes intensity - yes)

Notes Adverse effects ldquoAfter the initial phase of training the patients did not complain ofany unusual exercise-induced pain or muscle sorenessrdquo (Valkeinen 2004 (Primary) page227)Attrition Fibromyalgia resistance training n = 0 (0) fibromyalgia control n = 0 (0) healthy resistance training n = 0 (0)Adherence to exercise protocol The researchers did not specify if or how adherenceto the exercise protocol was monitored however muscular function was measured at 714 and 21 wks They did state all fibromyalgia subjects ldquocompleted trainingrdquoCo-interventions ldquoAll subjects were allowed to continue their normal daily activitiesto use their normal medication and to visit medical professionals if neededrdquo (page



Valkeinen 2004 (Continued)

226)Country FinlandData for this study was extracted from 2 reports Valkeinen 2004 (Primary) Valkeinen2005 (Secondary)Funding conflict of interest As reported by the authors ldquoThis study was supported inpart by grants from the Central Hospital of Central Finland Kuopio University HospitalPeurunka-Medical Rehabilitation Foundation and The Ministry of Education FinlandrdquoNo information was available regarding conflict of interest

Risk of bias



Low risk Described on page 225 Valkeinen 2004ldquoAfter inclusion the fibromyalgia patientswere randomly allocated by draw rdquo

Allocation concealment (selection bias) Unclear risk No mention of allocation concealment




Unclear risk No information available


Low risk Missing outcome data balanced in num-bers across interventions groups with sim-ilar reasons for missing data across groups

Selective reporting (reporting bias) High risk Outcome of statistical analyses are reportedfor pain fatigue sleep depression per-ceived health (all non-significant) but pointestimates for these outcome measures werenot reported


a intention-to-treat analysisb based on email communication with the study authorACR American College of Rheumatology EMG electromyography FIQ Fibromyalgia Impact Questionnaire HAD Hospital Anxietyand Depression min minute rep repetition RM repetition maximum SD standard deviation SF Short Form VAS visual analogscale wk week yr year



Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Ahlgren 2001 Diagnosis - trapezius myalgia

Alentorn-Geli 2009 The study did not provide data on outcomes used in this review - focus was on serum insulin-likegrowth factor

Astin 2003 Did not meet exercise criteria (QiGong)

Bailey 1999 Not an RCT (1 group design)

Bakker 1995 Between-group analysis not done

Carbonell-Baeza 2011 A study proposal (no data)

Casanueva-Fernandez 2012 Insufficient exercise component (treadmill 5 min cycle ergometer 5 min oncewk 8 weeks)

da Silva 2007 This study did not present data allowing isolation of effects of physical activity - focus of study was ona manipulative intervention called Tui Na

Dal 2011 Not an RCT

Dawson 2003 Not randomized A 1-group before-after design

Finset 2004 This report did not provide data for parallel groups

Gandhi 2000 Not randomized 3-group design (1) non-exercising control (n = 12) (2) hospital-based exercise group(n = 10) (3) home-based videotaped exercise program (n = 10)

Geel 2002 Not randomized

Gowans 2002 Focused on measurement issues of selected variables already reported in an included study new variablesdid not include standard deviations

Gowans 2004 This report described an uncontrolled follow-up of a physical activity intervention

Guarino 2001 Diagnosis - Gulf War syndrome

Han 1998 Not randomized (geographic control)

Huyser 1997 Not an RCT

Karper 2001 Not randomized (program evaluation)

Kendall 2000 Did not meet exercise criteria (body awareness)

Khalsa 2009 Not an RCT



(Continued)

Kingsley 2005 Diagnosis of fibromyalgia made by physician or rheumatologist but when contacted the authors didnot verify the use of published criteria (eg ACR criteria Wolfe 1990)

Lange 2011 Not randomized

Lorig 2008 Arthritis Self-Management Program internet-based instruction Content included exercise design butno explanation was given

Mannerkorpi 2002 Not an RCT

Mason 1998 Not randomized (subjects enrolled in a multimodal treatment compared with subjects who were unableto participate due to insurance reasons)

McCain 1986 This study appears to present preliminary results of the McCain 1988 study and was thereforeexcluded

Meiworm 2000 Not randomized (subjects self selected their group)

Meyer 2000 Problem with implementation of study design - randomization lost

Mobily 2001 Not an RCT (a case study)

Mutlu 2013 Study compared exercise + Transcutaneous electrical nerve stimulation (TENS) versus exercise effectsof exercise cannot be isolated in this RCT

Nielen 2000 Not randomized (cross-sectional case-control study of fitness)

Offenbacher 2000 Non-experimental - narrative review

Oncel 1994 Insufficient description of exercise (1 group received ldquomedical therapy and exerciserdquo no further infor-mation about the exercise intervention given)

Peters 2002 Diagnosis - persistent unexplained symptoms

Pfeiffer 2003 Not an RCT (1 group before-and-after design)

Piso 2001 Not randomized - our translator reported ldquoThe authors wrote only how they recruited nine of thepatients They wrote nothing about if and how the patients were allocated to the two groupsrdquo Wewere unsuccessful on several attempts to contact the authors for clarification

Rooks 2002 Not an RCT (1-group design)

Santana 2010 Could not confirm that diagnosis was made using published criteria

Sigl-Erkel 2011 A commentary on research by other investigators



(Continued)

Thieme 2003 Did not meet exercise criteria (passive physical therapy with light movement in water - the activeexercise was too small a component not described or quantified sufficiently)

Tiidus 1997 Not an RCT (1 group repeated measures design)

Uhlemann 2007 Not an RCT (cross-over design - no parallel data reported)

Vlaeyen1996 Insufficient description of the mode of exercise ldquoEach session ended with a physical exercise such asswimming or bicycling excluding systematic physical or fitness trainingrdquo

Williams 2010 The study did not present data allowing isolation of effects of physical activity - focused on internet-based management system to increase adherence

Worrel 2001 Not an RCT (1-group design)

RCT randomized clinical trial wk week

Characteristics of studies awaiting assessment [ordered by study ID]

Adsuar 2012

Methods Unknown

Participants

Interventions Vibration exercise versus control

Outcomes

Notes Awaiting acquisition of full-text article

Amanollahi 2013

Methods Unknown

Participants

Interventions Ibuprofen versus massage versus stretching

Outcomes

Notes Awaiting translation



Aslan 2001

Methods RCT

Participants 14 people with fibromyalgia

Interventions Classical massage combined with superficial heating and exercise in KMG

Outcomes Visual analog scale (VAS) number of trigger points and Neck Pain and Disability (NPAD) VAS

Notes In Turkish - awaiting translation

Bland 2010

Methods

Participants

Interventions

Outcomes

Notes

Ekici 2008

Methods RCT

Participants 51 women with fibromyalgia (ACR criteria Wolfe 1990)

Interventions Pilates versus connective tissue massage

Outcomes Pain depression


Thijssen 1992

Methods Unknown

Participants Patienten met fibromyalgie (people with fibromyalgia)

Interventions Zwemprogramma

Outcomes Unknown

Notes In Dutch - awaiting acquisition



Wright 2012

Methods

Participants

Interventions

Outcomes

Notes

ACR American College of Rheumatology RCT randomized clinical trial



D A T A A N D A N A L Y S E S

Comparison 1 Resistance training versus control

Outcome or subgroup titleNo of

studies

No of

participants Statistical method Effect size

1 Multidimensional function 1 Mean Difference (IV Fixed 95 CI) Totals not selected2 Physical function 3 107 Mean Difference (IV Fixed 95 CI) -629 [-1045 -213]3 Pain 2 81 Mean Difference (IV Random 95 CI) -330 [-635 -026]4 Tenderness 3 107 Mean Difference (IV Fixed 95 CI) -184 [-260 -108]

5 Muscle strength max concentricleg extension

2 47 Mean Difference (IV Random 95 CI) 2732 [1828 3636]

6 Fatigue 2 81 Mean Difference (IV Fixed 95 CI) -1466 [-2055 -877]

7 Patient-rated global 1 Mean Difference (IV Fixed 95 CI) Totals not selected8 Mental health 1 Mean Difference (IV Fixed 95 CI) Totals not selected9 Depression 1 Mean Difference (IV Fixed 95 CI) Totals not selected10 Sleep 1 Mean Difference (IV Fixed 95 CI) Totals not selected11 Muscle power 1 Mean Difference (IV Fixed 95 CI) Totals not selected12 Muscle size 2 47 Std Mean Difference (IV Fixed 95 CI) 048 [-011 106]13 Muscle activation 2 47 Mean Difference (IV Random 95 CI) 4092 [3350 4834]14 All-cause attrition 3 107 Risk Ratio (M-H Fixed 95 CI) 35 [079 1549]

Comparison 2 Resistance versus aerobic training


studies

No of


1 Multidimensional Function 1 Mean Difference (IV Fixed 95 CI) Totals not selected2 Self reported physical function 2 86 Mean Difference (IV Fixed 95 CI) -148 [-669 374]3 Pain 2 86 Mean Difference (IV Fixed 95 CI) 099 [031 167]4 Tenderness 2 86 Std Mean Difference (IV Fixed 95 CI) -013 [-055 030]5 Fatigue 2 86 Mean Difference (IV Fixed 95 CI) 150 [-414 713]6 Mental health 2 86 Mean Difference (IV Fixed 95 CI) 096 [-497 690]7 Sleep 1 Mean Difference (IV Fixed 95 CI) Totals not selected8 Depression 1 Mean Difference (IV Fixed 95 CI) Totals not selected9 Anxiety 1 Mean Difference (IV Fixed 95 CI) Totals not selected10 Cardio respiratory submax 1 Mean Difference (IV Fixed 95 CI) Totals not selected11 All-cause attrition 2 90 Peto Odds Ratio (Peto Fixed 95 CI) 10 [024 423]



Comparison 3 Resistance versus flexibility exercise


studies

No of


1 Multidimensional function 1 Mean Difference (IV Fixed 95 CI) Totals not selected2 Pain 1 Mean Difference (IV Fixed 95 CI) Totals not selected3 Tenderness 1 Mean Difference (IV Fixed 95 CI) Totals not selected4 Strength 1 Mean Difference (IV Fixed 95 CI) Totals not selected5 Self efficacy 1 Mean Difference (IV Fixed 95 CI) Totals not selected6 Fatigue 1 Std Mean Difference (IV Fixed 95 CI) Totals not selected7 Sleep 1 Mean Difference (IV Fixed 95 CI) Totals not selected8 Depression 1 Mean Difference (IV Fixed 95 CI) Totals not selected9 Anxiety 1 Mean Difference (IV Fixed 95 CI) Totals not selected10 Musclejoint flexibility 1 Mean Difference (IV Fixed 95 CI) Totals not selected11 All-cause attrition 1 Risk Ratio (M-H Fixed 95 CI) Totals not selected

Comparison 4 Acceptability - Attrition


studies

No of


1 Attrition 5 253 Odds Ratio (M-H Fixed 95 CI) 094 [049 183]11 RT vs control 3 107 Odds Ratio (M-H Fixed 95 CI) 10 [030 331]12 RT vs AE 2 90 Odds Ratio (M-H Fixed 95 CI) 087 [031 243]13 RT vs flexibility 1 56 Odds Ratio (M-H Fixed 95 CI) 10 [028 358]

Comparison 5 Follow-up resistance training versus control


studies

No of


1 Multidimensional function 1 180 Mean Difference (IV Fixed 95 CI) -1243 [-1625 -861]

11 8 weeks (wk) 1 60 Mean Difference (IV Fixed 95 CI) -987 [-1607 -367]

12 16 wk 1 60 Mean Difference (IV Fixed 95 CI) -1675 [-2331 -1019]


2 Physical function 1 180 Mean Difference (IV Fixed 95 CI) -064 [-411 283]21 8 wk 1 60 Mean Difference (IV Fixed 95 CI) -067 [-663 529]22 16 wk 1 60 Mean Difference (IV Fixed 95 CI) -224 [-826 378]23 28 wk 1 60 Mean Difference (IV Fixed 95 CI) 10 [-504 704]

3 Pain 1 180 Mean Difference (IV Fixed 95 CI) -112 [-165 -058]31 8 wk 1 60 Mean Difference (IV Fixed 95 CI) -068 [-162 026]32 16 wk 1 60 Mean Difference (IV Fixed 95 CI) -179 [-270 -088]



33 28 wk 1 60 Mean Difference (IV Fixed 95 CI) -085 [-177 007]4 Tenderness 1 180 Mean Difference (IV Fixed 95 CI) -182 [-437 074]

41 8 wk 1 60 Mean Difference (IV Fixed 95 CI) -026 [-421 369]42 16 wk 1 60 Mean Difference (IV Fixed 95 CI) -369 [-811 073]43 28 wk 1 60 Mean Difference (IV Fixed 95 CI) -192 [-706 322]

5 Fatigue 1 180 Mean Difference (IV Fixed 95 CI) -653 [-1047 -259]51 8 wk 1 60 Mean Difference (IV Fixed 95 CI) 165 [-496 826]


53 28 wk 1 60 Mean Difference (IV Fixed 95 CI) -911 [-1618 -204]6 Mental health 1 180 Mean Difference (IV Fixed 95 CI) -095 [-521 332]

61 8 wk 1 60 Mean Difference (IV Fixed 95 CI) -054 [-769 661]62 16 wk 1 60 Mean Difference (IV Fixed 95 CI) -286 [-1035 463]63 28 wk 1 60 Mean Difference (IV Fixed 95 CI) 054 [-701 809]

Comparison 6 Follow-up resistance training versus aerobic training


studies

No of


1 Multidimensional function 1 180 Mean Difference (IV Fixed 95 CI) 482 [069 895]11 8 weeks (wk) 1 60 Mean Difference (IV Fixed 95 CI) 548 [-092 1188]12 16 wk 1 60 Mean Difference (IV Fixed 95 CI) 139 [-602 880]13 28 wk 1 60 Mean Difference (IV Fixed 95 CI) 771 [-019 1561]

2 Physical function 1 180 Mean Difference (IV Fixed 95 CI) 522 [161 883]21 8 wk 1 60 Mean Difference (IV Fixed 95 CI) 283 [-325 891]22 16 wk 1 60 Mean Difference (IV Fixed 95 CI) 443 [-176 1062]23 28 wk 1 60 Mean Difference (IV Fixed 95 CI) 883 [233 1533]

3 Pain 1 180 Mean Difference (IV Fixed 95 CI) 028 [-028 085]31 8 wk 1 60 Mean Difference (IV Fixed 95 CI) 067 [-028 162]32 16 wk 1 60 Mean Difference (IV Fixed 95 CI) -067 [-167 033]33 28 wk 1 60 Mean Difference (IV Fixed 95 CI) 083 [-018 184]

4 Tenderness 1 180 Mean Difference (IV Fixed 95 CI) 064 [-223 351]41 8 wk 1 60 Mean Difference (IV Fixed 95 CI) 047 [-422 516]42 16 wk 1 60 Mean Difference (IV Fixed 95 CI) -136 [-648 376]43 28 wk 1 60 Mean Difference (IV Fixed 95 CI) 284 [-228 796]

5 Fatigue 1 180 Mean Difference (IV Fixed 95 CI) -047 [-427 333]51 8 wk 1 60 Mean Difference (IV Fixed 95 CI) 038 [-594 670]52 16 wk 1 60 Mean Difference (IV Fixed 95 CI) -356 [-1030 318]53 28 wk 1 60 Mean Difference (IV Fixed 95 CI) 162 [-508 832]

6 Mental health 1 180 Mean Difference (IV Fixed 95 CI) 438 [-003 878]61 8 wk 1 60 Mean Difference (IV Fixed 95 CI) -027 [-773 719]62 16 wk 1 60 Mean Difference (IV Fixed 95 CI) 474 [-303 1251]63 28 wk 1 60 Mean Difference (IV Fixed 95 CI) 894 [126 1662]



Analysis 11 Comparison 1 Resistance training versus control Outcome 1 Multidimensional function

Review Resistance exercise training for fibromyalgia


Outcome 1 Multidimensional function

Study or subgroup Resistance exercise ControlMean

DifferenceMean

Difference

NMean(SD)[FIQ

Total] NMean(SD)[FIQ

Total] IVFixed95 CI IVFixed95 CI

Kayo 2011 30 -2491 (1534) 30 -816 (1005) -1675 [ -2331 -1019 ]

-20 -10 0 10 20

Favors exercise Favors control

Analysis 12 Comparison 1 Resistance training versus control Outcome 2 Physical function



Outcome 2 Physical function


Difference WeightMean

Difference

N Mean(SD)[HAQSF36]N Mean(SD)[HAQSF36] IVFixed95 CI IVFixed95 CI

Hakkinen 2001 11 -10 (126491) 10 0 (802773) 215 -1000 [ -1898 -102 ]

Valkeinen 2004 13 -6667 (8944) 13 333 (10541) 307 -1000 [ -1751 -249 ]

Kayo 2011 30 -724 (1197) 30 -5 (1181) 478 -224 [ -826 378 ]

Total (95 CI) 54 53 1000 -629 [ -1045 -213 ]

Heterogeneity Chi2 = 333 df = 2 (P = 019) I2 =40

Test for overall effect Z = 296 (P = 00031)

Test for subgroup differences Not applicable

-100 -50 0 50 100




Analysis 13 Comparison 1 Resistance training versus control Outcome 3 Pain



Outcome 3 Pain



Difference

N Mean(SD)[cm] N Mean(SD)[cm] IVRandom95 CI IVRandom95 CI

Hakkinen 2001 11 -24 (1503) 10 25 (1641) 487 -490 [ -625 -355 ]

Kayo 2011 30 -394 (202) 30 -215 (156) 513 -179 [ -270 -088 ]

Total (95 CI) 41 40 1000 -330 [ -635 -026 ]

Heterogeneity Tau2 = 449 Chi2 = 1398 df = 1 (P = 000018) I2 =93



-10 -5 0 5 10


Analysis 14 Comparison 1 Resistance training versus control Outcome 4 Tenderness



Outcome 4 Tenderness



Difference

N Mean(SD)[TPs] N Mean(SD)[TPs] IVFixed95 CI IVFixed95 CI

Hakkinen 2001 11 -1 (2683) 10 1 (1265) 185 -200 [ -377 -023 ]

Valkeinen 2004 13 -19 (151) 13 02 (114) 547 -210 [ -313 -107 ]

Kayo 2011 30 -507 (316) 30 -387 (263) 268 -120 [ -267 027 ]

Total (95 CI) 54 53 1000 -184 [ -260 -108 ]


Test for overall effect Z = 474 (P lt 000001)


-100 -50 0 50 100




Analysis 15 Comparison 1 Resistance training versus control Outcome 5 Muscle strength max concentric

leg extension



Outcome 5 Muscle strength max concentric leg extension



Difference

N Mean(SD)[Kg] N Mean(SD)[Kg] IVRandom95 CI IVRandom95 CI

Hakkinen 2001 11 25 (1399) 10 1 (1726) 447 2400 [ 1048 3752 ]

Valkeinen 2004 13 30 (1844) 13 0 (1264) 553 3000 [ 1785 4215 ]

Total (95 CI) 24 23 1000 2732 [ 1828 3636 ]




-100 -50 0 50 100

Favors control Favors exercise



Analysis 16 Comparison 1 Resistance training versus control Outcome 6 Fatigue



Outcome 6 Fatigue



Difference

N Mean(SD)[mm] N Mean(SD)[mm] IVFixed95 CI IVFixed95 CI

Hakkinen 2001 11 -19 (1513) 10 1 (1881) 254 -2000 [ -3169 -831 ]

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 746 -1285 [ -1967 -603 ]

Total (95 CI) 41 40 1000 -1466 [ -2055 -877 ]




-20 -10 0 10 20


Analysis 17 Comparison 1 Resistance training versus control Outcome 7 Patient-rated global



Outcome 7 Patient-rated global


DifferenceMean

Difference


Hakkinen 2001 11 -26 (1565) 10 14 (1762) -4000 [ -5431 -2569 ]

-100 -50 0 50 100




Analysis 18 Comparison 1 Resistance training versus control Outcome 8 Mental health



Outcome 8 Mental health


DifferenceMean

Difference

N Mean(SD) N Mean(SD) IVFixed95 CI IVFixed95 CI

Kayo 2011 30 -873 (161) 30 -587 (1338) -286 [ -1035 463 ]

-100 -50 0 50 100


Analysis 19 Comparison 1 Resistance training versus control Outcome 9 Depression



Outcome 9 Depression


DifferenceMean

Difference

N Mean(SD)[BDI] N Mean(SD)[BDI] IVFixed95 CI IVFixed95 CI

Hakkinen 2001 11 -28 (313) 10 09 (31) -370 [ -637 -103 ]

-100 -50 0 50 100




Analysis 110 Comparison 1 Resistance training versus control Outcome 10 Sleep



Outcome 10 Sleep


DifferenceMean

Difference


Hakkinen 2001 11 -10 (1448) 10 -3 (1744) -700 [ -2079 679 ]

-100 -50 0 50 100


Analysis 111 Comparison 1 Resistance training versus control Outcome 11 Muscle power



Outcome 11 Muscle power


DifferenceMean

Difference

NMean(SD)[m

(jump)] NMean(SD)[m

(jump)] IVFixed95 CI IVFixed95 CI

Hakkinen 2001 11 0015 (0009) 10 -001 (00054) 002 [ 001 003 ]

-01 -005 0 005 01




Analysis 112 Comparison 1 Resistance training versus control Outcome 12 Muscle size



Outcome 12 Muscle size

Study or subgroup Resistance exercise Control

StdMean

Difference Weight

StdMean

Difference

NMean(SD)[cmˆ2

(CSA)] NMean(SD)[cmˆ2

(CSA)] IVFixed95 CI IVFixed95 CI

Hakkinen 2001 11 406 (298318) 10 139 (364077) 427 077 [ -012 167 ]

Valkeinen 2004 13 268 (434497) 13 151 (439434) 573 026 [ -051 103 ]

Total (95 CI) 24 23 1000 048 [ -011 106 ]




-100 -50 0 50 100


Analysis 113 Comparison 1 Resistance training versus control Outcome 13 Muscle activation



Outcome 13 Muscle activation



Difference

N Mean(SD)[EMG] N Mean(SD)[EMG] IVRandom95 CI IVRandom95 CI

Hakkinen 2001 11 2958 (1082) 10 -1071 (779) 857 4029 [ 3228 4830 ]

Valkeinen 2004 13 5663 (2835) 13 1191 (2239) 143 4472 [ 2508 6436 ]

Total (95 CI) 24 23 1000 4092 [ 3350 4834 ]




-50 -25 0 25 50




Analysis 114 Comparison 1 Resistance training versus control Outcome 14 All-cause attrition



Outcome 14 All-cause attrition

Study or subgroup Resistance exercise Control Risk Ratio Risk Ratio

nN nN M-HFixed95 CI M-HFixed95 CI

Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 230 350 [ 079 1549 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Total (95 CI) 54 53 350 [ 079 1549 ]

Total events 7 (Resistance exercise) 2 (Control)




0001 001 01 1 10 100 1000


Analysis 21 Comparison 2 Resistance versus aerobic training Outcome 1 Multidimensional Function



Outcome 1 Multidimensional Function

Study or subgroup Resistance exercise Aerobic exerciseMean

DifferenceMean

Difference

N Mean(SD)[FIQ˙Total] N Mean(SD)[FIQ˙Total] IVFixed95 CI IVFixed95 CI

Kayo 2011 30 -1585 (125) 30 -2133 (1279) 548 [ -092 1188 ]

-20 -10 0 10 20

Favors RE Favors AE



Analysis 22 Comparison 2 Resistance versus aerobic training Outcome 2 Self reported physical function



Outcome 2 Self reported physical function



Difference

NMean(SD)[SF36

PF] NMean(SD)[SF36

PF] IVFixed95 CI IVFixed95 CI

Bircan 2008 13 1231 (1345) 13 10 (1297) 264 231 [ -785 1247 ]

Kayo 2011 30 117 (1213) 30 4 (1188) 736 -283 [ -891 325 ]

Total (95 CI) 43 43 1000 -148 [ -669 374 ]




-20 -10 0 10 20

Favors RE Favors AE

Analysis 23 Comparison 2 Resistance versus aerobic training Outcome 3 Pain



Outcome 3 Pain



Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm

(VAS)] IVFixed95 CI IVFixed95 CI

Bircan 2008 13 -256 (135) 13 -388 (1183) 488 132 [ 034 230 ]

Kayo 2011 30 -277 (195) 30 -344 (181) 512 067 [ -028 162 ]

Total (95 CI) 43 43 1000 099 [ 031 167 ]




-4 -2 0 2 4

Favors RE Favors AE



Analysis 24 Comparison 2 Resistance versus aerobic training Outcome 4 Tenderness




Study or subgroup Resistance exercise Aerobic exercise

StdMean

Difference Weight

StdMean

Difference


Bircan 2008 13 -616 (135) 13 -538 (137) 293 -056 [ -134 023 ]

Kayo 2011 30 -98 (792) 30 -1027 (1046) 707 005 [ -046 056 ]

Total (95 CI) 43 43 1000 -013 [ -055 030 ]




-2 -1 0 1 2

Favors RE Favors AE

Analysis 25 Comparison 2 Resistance versus aerobic training Outcome 5 Fatigue



Outcome 5 Fatigue



Difference


Bircan 2008 13 -281 (1736) 13 -339 (148) 206 580 [ -660 1820 ]

Kayo 2011 30 -828 (1271) 30 -866 (1228) 794 038 [ -594 670 ]

Total (95 CI) 43 43 1000 150 [ -414 713 ]




-20 -10 0 10 20

Favors RE Favors AE



Analysis 26 Comparison 2 Resistance versus aerobic training Outcome 6 Mental health






Difference

NMean(SD)[SF-

36 MH] NMean(SD)[SF-

36 MH] IVFixed95 CI IVFixed95 CI

Bircan 2008 13 1201 (13135) 13 893 (12328) 367 308 [ -671 1287 ]

Kayo 2011 30 -587 (1488) 30 -56 (1461) 633 -027 [ -773 719 ]

Total (95 CI) 43 43 1000 096 [ -497 690 ]




-10 -5 0 5 10

Favors AE Favors RE

Analysis 27 Comparison 2 Resistance versus aerobic training Outcome 7 Sleep



Outcome 7 Sleep


DifferenceMean

Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -188 (188) 13 -335 (121) 147 [ 025 269 ]

-4 -2 0 2 4

Favors RE Favors AE



Analysis 28 Comparison 2 Resistance versus aerobic training Outcome 8 Depression





DifferenceMean

Difference

NMean(SD)[HAD

dep] NMean(SD)[HAD

dep] IVFixed95 CI IVFixed95 CI

Bircan 2008 13 -254 (273) 13 -2 (246) -054 [ -254 146 ]

-4 -2 0 2 4

Favors RE Favors AE

Analysis 29 Comparison 2 Resistance versus aerobic training Outcome 9 Anxiety



Outcome 9 Anxiety


DifferenceMean

Difference

NMean(SD)[HAD

anx] NMean(SD)[HAD

anx] IVFixed95 CI IVFixed95 CI

Bircan 2008 13 -054 (275) 13 -115 (268) 061 [ -148 270 ]

-20 -10 0 10 20

Favors RE Favors AE



Analysis 210 Comparison 2 Resistance versus aerobic training Outcome 10 Cardio respiratory submax



Outcome 10 Cardio respiratory submax


DifferenceMean

Difference

NMean(SD)[6MWT (m)] N

Mean(SD)[6MWT (m)] IVFixed95 CI IVFixed95 CI

Bircan 2008 13 7661 (4704) 13 4085 (5963) 3576 [ -553 7705 ]

-100 -50 0 50 100

Favors AE Favors RE

Analysis 211 Comparison 2 Resistance versus aerobic training Outcome 11 All-cause attrition




Study or subgroup Resistance exercise Aerobic exercisePeto

Odds Ratio WeightPeto

Odds Ratio

nN nN PetoFixed95 CI PetoFixed95 CI

Bircan 2008 215 215 486 100 [ 013 792 ]

Kayo 2011 230 230 514 100 [ 013 748 ]

Total (95 CI) 45 45 1000 100 [ 024 423 ]

Total events 4 (Resistance exercise) 4 (Aerobic exercise)




0005 01 1 10 200

Favors resistance Favors aerobic



Analysis 31 Comparison 3 Resistance versus flexibility exercise Outcome 1 Multidimensional function




Study or subgroup Resistance exercise Flexibility exerciseMean

DifferenceMean

Difference

N Mean(SD)[FIQ] N Mean(SD)[FIQ] IVFixed95 CI IVFixed95 CI

Jones 2002 28 -1027 (1032) 28 -378 (1276) -649 [ -1257 -041 ]

-20 -10 0 10 20

Favors RE Favors FX

Analysis 32 Comparison 3 Resistance versus flexibility exercise Outcome 2 Pain



Outcome 2 Pain


DifferenceMean

Difference

N Mean(SD)[cm] N Mean(SD)[cm] IVFixed95 CI IVFixed95 CI

Jones 2002 28 -189 (131) 28 -101 (131) -088 [ -157 -019 ]

-2 -1 0 1 2

Favors RE Favors FX



Analysis 33 Comparison 3 Resistance versus flexibility exercise Outcome 3 Tenderness





DifferenceMean

Difference

N Mean(SD)[ TPs] N Mean(SD)[ TPs] IVFixed95 CI IVFixed95 CI

Jones 2002 28 -146 (193) 28 -1 (224) -046 [ -156 064 ]

-4 -2 0 2 4

Favors RE Favors FX

Analysis 34 Comparison 3 Resistance versus flexibility exercise Outcome 4 Strength



Outcome 4 Strength


DifferenceMean

Difference

N Mean(SD)[ft lb] N Mean(SD)[ft lb] IVFixed95 CI IVFixed95 CI

Jones 2002 28 1447 (1399) 28 97 (1336) 477 [ -240 1194 ]

-20 -10 0 10 20

Favors FX Favors RE



Analysis 35 Comparison 3 Resistance versus flexibility exercise Outcome 5 Self efficacy



Outcome 5 Self efficacy


DifferenceMean

Difference

N Mean(SD)[ASES] N Mean(SD)[ASES] IVFixed95 CI IVFixed95 CI

Jones 2002 28 3445 (10992) 28 661 (1062) -3165 [ -8826 2496 ]

-200 -100 0 100 200

Favors FX Favors RE

Analysis 36 Comparison 3 Resistance versus flexibility exercise Outcome 6 Fatigue



Outcome 6 Fatigue

Study or subgroup Resistance exercise Flexibility exercise

StdMean

Difference

StdMean

Difference


Jones 2002 28 -243 (125) 28 -068 (148) -126 [ -184 -068 ]

-4 -2 0 2 4

Favors RE Favors FX



Analysis 37 Comparison 3 Resistance versus flexibility exercise Outcome 7 Sleep



Outcome 7 Sleep


DifferenceMean

Difference


Jones 2002 28 -23 (165) 28 -053 (161) -177 [ -262 -092 ]

-4 -2 0 2 4

Favors RE Favors FX

Analysis 38 Comparison 3 Resistance versus flexibility exercise Outcome 8 Depression





DifferenceMean

Difference


Jones 2002 28 -367 (423) 28 -184 (403) -183 [ -399 033 ]

-10 -5 0 5 10

Favors RE Favors FX



Analysis 39 Comparison 3 Resistance versus flexibility exercise Outcome 9 Anxiety



Outcome 9 Anxiety


DifferenceMean

Difference

N Mean(SD)[BAI] N Mean(SD)[BAI] IVFixed95 CI IVFixed95 CI

Jones 2002 28 -25 (584) 28 07 (645) -320 [ -642 002 ]

-10 -5 0 5 10

Favors RE Favors FX

Analysis 310 Comparison 3 Resistance versus flexibility exercise Outcome 10 Musclejoint flexibility



Outcome 10 Musclejoint flexibility


DifferenceMean

Difference

NMean(SD)[4-

pt scale] NMean(SD)[4-

pt scale] IVFixed95 CI IVFixed95 CI

Jones 2002 28 -115 (051) 28 -145 (06) 030 [ 001 059 ]

-2 -1 0 1 2

Favors RE Favors FX



Analysis 311 Comparison 3 Resistance versus flexibility exercise Outcome 11 All-cause attrition




Study or subgroup Resistance exercise Flexibility exercise Risk Ratio Risk Ratio


Jones 2002 628 628 100 [ 037 273 ]

01 02 05 1 2 5 10

Favors RT Favors FX

Analysis 41 Comparison 4 Acceptability - Attrition Outcome 1 Attrition



Outcome 1 Attrition

Study or subgroup Experimental Control Odds Ratio Odds Ratio


1 RT vs control

Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 730 100 [ 030 331 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Subtotal (95 CI) 54 53 100 [ 030 331 ]

Total events 7 (Experimental) 7 (Control)



2 RT vs AE

Bircan 2008 215 215 100 [ 012 821 ]

Kayo 2011 730 830 084 [ 026 270 ]

Subtotal (95 CI) 45 45 087 [ 031 243 ]


002 01 1 10 50

Favors RT Favors Comparator

(Continued )



( Continued)Study or subgroup Experimental Control Odds Ratio Odds Ratio




3 RT vs flexibility

Jones 2002 628 628 100 [ 028 358 ]

Subtotal (95 CI) 28 28 100 [ 028 358 ]


Heterogeneity not applicable


Total (95 CI) 127 126 094 [ 049 183 ]




Test for subgroup differences Chi2 = 004 df = 2 (P = 098) I2 =00

002 01 1 10 50




Analysis 51 Comparison 5 Follow-up resistance training versus control Outcome 1 Multidimensional

function




Study or subgroup RT ControlMean


Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -598 (1199) 380 -987 [ -1607 -367 ]

Subtotal (95 CI) 30 30 380 -987 [ -1607 -367 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -816 (1005) 339 -1675 [ -2331 -1019 ]

Subtotal (95 CI) 30 30 339 -1675 [ -2331 -1019 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -619 (1117) 281 -1067 [ -1788 -346 ]

Subtotal (95 CI) 30 30 281 -1067 [ -1788 -346 ]



Total (95 CI) 90 90 1000 -1243 [ -1625 -861 ]




-100 -50 0 50 100

Favors experimental Favors control



Analysis 52 Comparison 5 Follow-up resistance training versus control Outcome 2 Physical function






Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -05 (1142) 338 -067 [ -663 529 ]

Subtotal (95 CI) 30 30 338 -067 [ -663 529 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -5 (1181) 332 -224 [ -826 378 ]

Subtotal (95 CI) 30 30 332 -224 [ -826 378 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -517 (119) 330 100 [ -504 704 ]

Subtotal (95 CI) 30 30 330 100 [ -504 704 ]



Total (95 CI) 90 90 1000 -064 [ -411 283 ]




-100 -50 0 50 100




Analysis 53 Comparison 5 Follow-up resistance training versus control Outcome 3 Pain



Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -209 (176) 321 -068 [ -162 026 ]

Subtotal (95 CI) 30 30 321 -068 [ -162 026 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -215 (156) 340 -179 [ -270 -088 ]

Subtotal (95 CI) 30 30 340 -179 [ -270 -088 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -189 (168) 339 -085 [ -177 007 ]

Subtotal (95 CI) 30 30 339 -085 [ -177 007 ]



Total (95 CI) 90 90 1000 -112 [ -165 -058 ]




-100 -50 0 50 100




Analysis 54 Comparison 5 Follow-up resistance training versus control Outcome 4 Tenderness






Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -954 (769) 418 -026 [ -421 369 ]

Subtotal (95 CI) 30 30 418 -026 [ -421 369 ]



2 16 wk

Kayo 2011 30 -1529 (949) 30 -116 (79) 334 -369 [ -811 073 ]

Subtotal (95 CI) 30 30 334 -369 [ -811 073 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -1064 (951) 247 -192 [ -706 322 ]

Subtotal (95 CI) 30 30 247 -192 [ -706 322 ]



Total (95 CI) 90 90 1000 -182 [ -437 074 ]




-100 -50 0 50 100




Analysis 55 Comparison 5 Follow-up resistance training versus control Outcome 5 Fatigue



Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -993 (1339) 356 165 [ -496 826 ]

Subtotal (95 CI) 30 30 356 165 [ -496 826 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 334 -1285 [ -1967 -603 ]

Subtotal (95 CI) 30 30 334 -1285 [ -1967 -603 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -277 (1313) 311 -911 [ -1618 -204 ]

Subtotal (95 CI) 30 30 311 -911 [ -1618 -204 ]



Total (95 CI) 90 90 1000 -653 [ -1047 -259 ]




-100 -50 0 50 100




Analysis 56 Comparison 5 Follow-up resistance training versus control Outcome 6 Mental health






Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -533 (1334) 356 -054 [ -769 661 ]

Subtotal (95 CI) 30 30 356 -054 [ -769 661 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -587 (1338) 324 -286 [ -1035 463 ]

Subtotal (95 CI) 30 30 324 -286 [ -1035 463 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -547 (1409) 320 054 [ -701 809 ]

Subtotal (95 CI) 30 30 320 054 [ -701 809 ]



Total (95 CI) 90 90 1000 -095 [ -521 332 ]




-100 -50 0 50 100




Analysis 61 Comparison 6 Follow-up resistance training versus aerobic training Outcome 1

Multidimensional function




Study or subgroup RT AEMean


Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -2133 (1279) 416 548 [ -092 1188 ]

Subtotal (95 CI) 30 30 416 548 [ -092 1188 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -263 (139) 311 139 [ -602 880 ]

Subtotal (95 CI) 30 30 311 139 [ -602 880 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -2457 (1434) 273 771 [ -019 1561 ]

Subtotal (95 CI) 30 30 273 771 [ -019 1561 ]



Total (95 CI) 90 90 1000 482 [ 069 895 ]




-20 -10 0 10 20

Favors AE Favors RT



Analysis 62 Comparison 6 Follow-up resistance training versus aerobic training Outcome 2 Physical

function






Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -4 (1188) 353 283 [ -325 891 ]

Subtotal (95 CI) 30 30 353 283 [ -325 891 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -1167 (125) 339 443 [ -176 1062 ]

Subtotal (95 CI) 30 30 339 443 [ -176 1062 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -13 (1367) 308 883 [ 233 1533 ]

Subtotal (95 CI) 30 30 308 883 [ 233 1533 ]



Total (95 CI) 90 90 1000 522 [ 161 883 ]




-20 -10 0 10 20

Favors AE Favors RT



Analysis 63 Comparison 6 Follow-up resistance training versus aerobic training Outcome 3 Pain



Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -344 (181) 357 067 [ -028 162 ]

Subtotal (95 CI) 30 30 357 067 [ -028 162 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -327 (192) 326 -067 [ -167 033 ]

Subtotal (95 CI) 30 30 326 -067 [ -167 033 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -357 (206) 317 083 [ -018 184 ]

Subtotal (95 CI) 30 30 317 083 [ -018 184 ]



Total (95 CI) 90 90 1000 028 [ -028 085 ]




-2 -1 0 1 2

Favors AE Favors RT



Analysis 64 Comparison 6 Follow-up resistance training versus aerobic training Outcome 4 Tenderness






Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -1027 (1046) 373 047 [ -422 516 ]

Subtotal (95 CI) 30 30 373 047 [ -422 516 ]



2 16 wk

Kayo 2011 30 -152 (949) 30 -1384 (1072) 313 -136 [ -648 376 ]

Subtotal (95 CI) 30 30 313 -136 [ -648 376 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -154 (941) 314 284 [ -228 796 ]

Subtotal (95 CI) 30 30 314 284 [ -228 796 ]



Total (95 CI) 90 90 1000 064 [ -223 351 ]




-20 -10 0 10 20

Favors AE Favors RT



Analysis 65 Comparison 6 Follow-up resistance training versus aerobic training Outcome 5 Fatigue



Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -866 (1228) 361 038 [ -594 670 ]

Subtotal (95 CI) 30 30 361 038 [ -594 670 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -1256 (1143) 318 -356 [ -1030 318 ]

Subtotal (95 CI) 30 30 318 -356 [ -1030 318 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -135 (1152) 321 162 [ -508 832 ]

Subtotal (95 CI) 30 30 321 162 [ -508 832 ]



Total (95 CI) 90 90 1000 -047 [ -427 333 ]




-10 -5 0 5 10

Favors AE Favors RT



Analysis 66 Comparison 6 Follow-up resistance training versus aerobic training Outcome 6 Mental health






Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -56 (1461) 349 -027 [ -773 719 ]

Subtotal (95 CI) 30 30 349 -027 [ -773 719 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -1347 (1457) 322 474 [ -303 1251 ]

Subtotal (95 CI) 30 30 322 474 [ -303 1251 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -1387 (1463) 330 894 [ 126 1662 ]

Subtotal (95 CI) 30 30 330 894 [ 126 1662 ]



Total (95 CI) 90 90 1000 438 [ -003 878 ]




-20 -10 0 10 20

Favors AE Favors RT

A D D I T I O N A L T A B L E S

Table 1 Glossary of terms

Term Definition

Allodynia A painful response to a normally innocuous stimulus

Endurance 2 forms of endurance that refer to health-related physical fitness are (1)cardiorespiratory endurance (also known as cardiovascular enduranceaerobic fitness aerobic endurance exercise tolerance) which rdquorelates tothe ability of the circulatory and respiratory systems to supply fuel during



Table 1 Glossary of terms (Continued)

sustained physical activity and to eliminate waste products after supplyingfuelldquo and (2) muscle endurance which relates to the ability of musclegroups to exert external force for many repetitionsrdquo (Caspersen 1985)

Exercise Planned structured and repetitive activities designed to improve ormaintain strength or fitness

Hyperalgesia An increased response to a painful stimulus

Maximum voluntary contraction (MVC) A measure of muscle strength the maximum muscle contraction that aperson can generate voluntarily as measured in units of force (poundskilograms Newtons) or as a moment around a joint (eg Newton-meterfoot-pounds kilograms-meters)

Mental health 1 score derived from set of questions or questionnaire that attempts tosummarize the individualrsquos level of psychologic well-being or an absenceof a mental disorder

Multidimensional function (health-related quality of life) 1 score derived from either a general health questionnaire (eg Short-Form(SF)-36 EuroQol 5D) or a disease-specific questionnaire (FibromyalgiaImpact Questionnaire) that attempts to summarize the many compo-nents of health

Muscle strength A physical test of the amount of force a muscle can generate

Paresthesia Abnormal sensory symptoms such as pins and needles burning andtingling

Physical activity Any bodily movement produced by skeletal muscles that results in energyexpenditure (ie active work housework gardening leisure or hobbies)

Repetition maximum (1 RM) The maximum amount of weight one can lift in 1 repetition for a givenexercise

Sleep disturbance A score derived from a questionnaire that measures sleep quantity andquality The Medical Outcomes Survey Sleep Scale measures 6 dimen-sions of sleep (initiation staying asleep quantity adequacy drowsinessshortness of breath and snoring)

Somatosensory Of or relating to the perception of sensory stimuli from the skin andinternal organs

Tenderness Pain evoked by tactile pressure



Table 2 RCTs of exercise interventions screened out of resistance training review

Study (primary and secondary citations)

Number of groups Interventions

Alentorn-Geli 2008 3 MX Comp (Vib+MX) Control

Altan 2004 2 AQ-MX Bal

Altan 2009 2 MX Relax+FX

Arcos-Carmona 2011 2 AQ+LD MX Control (placebo magnet therapy)

Assis 2006 2 AE AQ-AE

Astin 2003 2 Mindfulness Meditation Control

Baptista 2012 2 Dance Wait List Control

Bojner Horwitz 2006 2 DanceMovement Control

Bressan 2008 2 2 groups FX AE

Buckelew 1998 4 4 groups Biof+Relax MX Comp (Biof+Relax+MX) Control(EducAttention)

Burckhardt 1994 3 Comp (ED+MX) ED Control (Delayed treatment)

Calandre 2009 2 FX AiChi

Carson 2010 Carson 2012 2 COMP (Yoga meditation breathing exercises ED) Control(Wait List)

Cedraschi 2004 2 Comp (AQ+Land AE Relax ED) Control

Demir-Gocmen 2013 2 MX (FX+Coord)HPrg (FX)

Da Costa 2005 2 AQ+LD MX Control (TAU)

De Andrade 2008 2 AQ-(AE) AQ-(AE) SPA

de Melo Vitorino 2006 2 AQ-MX LD-MX

Etnier 2009 2 MX Control - Delayed Entry

Evcik 2008 2 AQ-MX MX

Field 2003 2 COMP (Self Massage+FX) Relax



Table 2 RCTs of exercise interventions screened out of resistance training review (Continued)

Fontaine 2007 2 LPA (likely mostly aerobic) ED

Fontaine 2010 Fontaine 2011 2 LPA (likely mostly aerobic) ED

Garcia-Martinez 2012 2 MX (AE+ST+FX) Control

Genc 2002 2 MX COMP (Non ex intervention Remedial Ex Relax Mobil)

Gowans 1999 2 Comp (AQ-AE+ED) Control (Wait List)

Gowans 2001 Gowans 2002 2 AQ-AE+LD AE Control (TAU)

Gusi 2010 Olivares 2011 2 VIB Control (TAU)

Gusi 2006 Tomas-Carus 2007a Tomas-Carus 2007b Tomas-Carus 2007

2 AQ-MX Control

Hammond 2006 2 COMP (Educ+SMP+MX) Relax

Hecker 2011 2 AQ MX MX

Hooten 2012 2 COMP (MX+pain prg) COMP (MX+pain prg)

Hunt 2000 2 MX Control

Ide 2008 2 AQ-COMP (AE+Relax) Control (Supervised ~PA RecreationalActivities)

Isomeri 1993 3 AE ST+Meds AE+Meds

Jentoft 2001 2 AQ-MX MX

Jones 2007 Jones 2008 4 Comp Meds+MX Meds+Placebo (Diet Recall) PlaceboMed+MX Control Placebo Med+Placebo Diet Recall

Jones 2012 2 Tai Chi Educ

Joshi 2009 2 MX Med

Keel 1998 2 Comp (MX ED Relax) Relax

King 2002 4 AE (AQ plusmn LD) ED Comp (AE AQ plusmn LD+ED) Control

Lemstra 2005 2 Comp (MX+Educ+SMP+Massage) Control

Liu 2012 2 Qi Gongsham QiGong




Lopez-Rodriguez 2012 2 AQ Biodance

Lynch 2012 2 Qi GongWait List Control

Mannerkorpi 2000 2 AQ-MX Edu

Mannerkorpi 2009 2 COMP AQ-MX+ED ED

Mannerkorpi 2010 2 AE (moderate intensity) AE (low intensity)

Martin 1996 2 MX Relax

Martin-Nogueras 2012 2 MX (FX+FX+Relax)Control

Matsutani 2007 2 COMP (Educ+Laser+FX) COMP (Educ+FX)

Matsutani 2012 2 AE FX

McCain 1988 2 AE FX

Mengshoel 1992 Mengshoel 1993 2 AE-Dance Control

Munguia-Izquierdo 2007Munguia-Izquierdo 2008

3 AQ-MX Control (fibromyalgia) Control (Healthy)

Nichols 1994 2 AE Control

Norregaard 1997 2 AE MX Thermotherapy

Ramsay 2000 2 AE AE (CV)

Richards 2002 2 AE Comp Relax+FX

Rivera Redondo 2004 2 AQ+LD MX CBT

Rooks 2007 4 MX1 MX2 FSHC FSHC+MX

Sanudo 2010 2 MX Comp (MX+Vib)

Sanudo 2010a 3 AE MX Control (TAU)

Sanudo 2010c 2 AE Control

Sanudo 2011 2 MX Control (TAU AAU)

Sanudo 2012 2 MX (Vib+AE+ST+FX) MX (AE+ST+FX)




Schachter 2003 3 AE - long bout AE - short bout Control (TAU)

Schmidt 2011 3 Comp (Meditation Yoga) Comp (Relax+FX) Control (Wait List)

Sencan 2004 3 AE Meds Control

Tomas-Carus 2008 Tomas-Carus 2007cGusi 2008

2 AQ-MX Control

Valencia 2009 2 COMP (Relax+MX) FX (Meziere Method)

Valim 2003 2 AE FX

Valkeinen 2008 2 MX C (AAU)

van Koulil 2010 2 Comp CBT1 + AQLD MX Comp CBT2 + AQLD MX

vanSanten 2002a 3 MX Biofeedback Control

vanSanten 2002 2 MX (self selected intensity) AE (moderate to vigorous intensity)

Verstappen 1997 2 MX Control

Wang 2010 2 Tai Chi Comp (FX + ED)

Wigers 1996 3 AE SMT Control (TAU)

Yuruk 2008 2 MX1 MX2

AAU activity as usual AE aerobics AQ aquatics Biof biofeedback spa balneotherapy CBT cognitive behavior therapy Compcomposite ED education FX flexibility LD land LPA leisure time physical activity LifePA lifestyle physical activity Medsmedication Multi multidisciplinary program ~ not or non MX mixed exercise Relax relaxation SMP self management programST strength SM stress management Spa thelassotherapy TAU treatment as usual TENS transcutaneous electrical stimulationVib whole body vibration

Seven trials had more than one publication In total there were 73 trials with 14 additional publications



A P P E N D I C E S

Appendix 1 2011 American College of Sports Medicine (ACSM) position stand guidance forprescribing exercise

The following recommendations are from Garber 2011

Recommendations for cardiorespiratory fitness

bull Moderate-intensity cardiorespiratory exercise training for ge 30 minutesday on ge five daysweek for a total of ge 150 minutesweek vigorous-intensity cardiorespiratory exercise training for ge 20 minutesday on ge three daysweek (ge 75 minutesweek) or acombination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ge 500-1000 MET (metabolicenergy) minuteweek

Recommendations for muscular fitness

bull On two to three daysweek adults should also perform resistance exercises for each of the major muscle groups and neuromotorexercise involving balance agility and coordination

bull Two to four sets of resistance exercise per muscle group are recommended but even one set of exercise may significantly improvemuscle strength and size

bull Rest interval between sets if more than one set is performed two to three minutesbull Resistance equivalent of 60 to 80 of one repetition max (1 RM) effort For novices 60 to 70 of 1 RM is recommended

for experienced exercises ge 80 may be appropriatebull The selected resistance should permit the completion of 8 to 12 repetitions per set or the number needed to induce muscle

fatigue but not exhaustionbull For people who wish to focus on improving muscular endurance a lower intensity (lt 50 of 1 RM) can be used with 15 to 25

repetitions in no more than two sets

Recommendations for flexibility

bull A series of flexibility exercises for each the major muscle-tendon groups with a total of 60 seconds per exercise on ge two daysweek is recommended A series of exercises targeting the major muscle-tendon units of the shoulder girdle chest neck trunk lowerback hops posterior and anterior legs and ankles are recommended For most individuals this routine can be completed within 10minutes

bull Stretches should be held for 1 to 30 seconds at the point of tightness or slight discomfort Older people may realize greaterimprovements in range of motion with longer durations (30-60 seconds) of stretching A 20 to 75 maximum contraction held forthree to six seconds followed by a 10- to 30-second assisted stretch is recommended for proprioceptive neuromuscular facilitation(PNF) techniques

bull Repeating each flexibility exercise two to four times is effective

Appendix 2 MEDLINE (Ovid) search strategy

1 Fibromyalgia2 Fibromyalgi$tw3 fibrositistw4 or1-35 exp Exercise6 Physical Exertion7 Physical Fitness8 exp Physical Endurance9 exp Sports10 Pliability11 exertion$tw



12 exercis$tw13 sport$tw14 ((physical or motion) adj5 (fitness or therapy or therapies))tw15 (physical$ adj2 endur$)tw16 manipulat$tw17 (skate$ or skating)tw18 jog$tw19 swim$tw20 bicycl$tw21 (cycle$ or cycling)tw22 walk$tw23 (row or rows or rowing)tw24 weight train$tw25 muscle strength$tw26 exp Yoga27 yogatw28 exp Tai Ji29 tai chitw30 Ai Chitw31 exp Vibration32 vibrationtw33 pilatestw34 or5-3335 4 and 34

Appendix 3 EMBASE (Ovid) search strategy

1 FIBROMYALGIA2 fibromyalgi$tw3 fibrositistw4 or1-35 exp exercise6 fitness7 exercise tolerance8 exp sport9 pliability10 exertion$tw11 exercis$tw12 sport$tw13 ((physical or motion) adj5 (fitness or therapy or therapies))tw14 (physical$ adj2 endur$)tw15 manipulat$tw16 (skate$ or skating)tw17 jog$tw18 swim$tw19 bicycl$tw20 (cycle$ or cycling)tw21 walk$tw22 (row or rows or rowing)tw23 weight train$tw24 muscle strength$tw



Appendix 4 The Cochrane Library search strategy

1 MeSH descriptor Fibromyalgia explode all trees2 fibromyalgia3 fibrositis4 (1 OR 2 OR 3)5 MeSH descriptor Exercise explode all trees6 MeSH descriptor Physical Exertion explode all trees7 MeSH descriptor Physical Fitness explode all trees8 MeSH descriptor Exercise Tolerance explode all trees9 MeSH descriptor Sports explode all trees10 MeSH descriptor Pliability explode all trees11 exertion12 exercis13 sport14 (physical or motion) near5 (fitness or therapy or therapies)15 physical near2 endur16 manipulat17 skate or skating18 jog19 swim20 bicycl21 cycle22 walk23 row or rows or rowing24 weight next train25 muscle next strength26 MeSH descriptor Yoga explode all trees27 yoga28 tai chi29 MeSH descriptor Tai Ji explode all trees30 MeSH descriptor Vibration explode all trees31 vibration32 pilates33 (5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR ( AND 27 ) OR 28 OR 29 OR 30 OR 31 OR 32)34 (33 AND 4)

Appendix 5 CINAHL (EbscoHost) search strategy

S41 (S27 and (S28 or S40)S40 S31 or S32 or S33 or S34 or S35 or S36 or S37 or S38 or S39S39 TX vibrationS38 (MH ldquoVibrationrdquo)S37 (MH ldquoPilatesrdquo) OR ldquopilatesrdquoS36 TX pilatesS35 TX tai jiS34 (MM ldquoTai Chirdquo)S33 TX tai chiS32 TX yogaS31 (MH ldquoYoga Poserdquo) OR (MH ldquoYogardquo)S30 S27 and S28S29 S27 and S28



S28 S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 orS23 or S24 or S25 or S26S27 S1 or S2 or S3S26 TI manipulat or AB manipulatS25 TI muscle strength or AB muscle strengthS24 TI weight train or AB weight trainS23 TI ( row or rows or rowing ) or AB ( row or rows or rowing )S22 TI walk or AB walkS21 TI ( (cycle or cycling) ) or AB ( (cycle or cycling) )S20 TI bicycl or AB bicyclS19 TI swim or AB swimS18 jog or AB jogS17 ( skate or skating ) or AB ( skate or skating )S16 TI physical N2 endur or AB physical N2 endurS15 TI motion N5 fitness or TI motion N5 therapy or TI motion N5 therapies or AB motion N5 fitness or AB motion N5 therapyor AB motion N5 therapiesS14 TI physical N5 fitness or TI physical N5 therapy or TI physical N5 therapies or AB physical N5 fitness or AB physical N5 therapyor AB physical N5 therapiesS13 TI sport or AB sportS12 TI exercis or AB exercisS11 TI exertion or AB exertionS10 (MH ldquoPhysical Endurance+rdquo)S9 (MH ldquoPliabilityrdquo)S8 (MH ldquoSports+rdquo)S7 (MH ldquoExercise Test+rdquo)S6 (MH ldquoPhysical Fitnessrdquo)S5 (MH ldquoExertion+rdquo)S4 (MH ldquoExercise+rdquo)S3 TI fibrositis or AB fibrositisS2 TI fibromyalgia or AB fibromyalgiaS1 (MH ldquoFibromyalgiardquo)

Appendix 6 PEDro Physiotherapy Evidence Database (wwwpedroorgau) search strategy

Terms searched1 fibromyalg AND fitness training2 fibromyalg AND strength training3 fibrositis

Appendix 7 Dissertation Abstracts (ProQuest) search strategy

Terms searched fibromyalg or fibrositis (in citation or abstract)



Appendix 8 Current Controlled Trials (wwwcontrolled-trialscom) search strategy

Terms searched fibromyalg or fibrositis

Appendix 9 WHO International Clinical Trials Registry Platform (wwwwhointictrpen) searchstrategy

Terms searched fibromyalg or fibrositis in Condition

Appendix 10 AMED (Ovid) Allied and Complementary Medicine search strategy

Ovid AMED (Allied and Complementary Medicine) lt1985 to Jan 2012gt

Search strategy--------------------------------------------------------------------------------1 Fibromyalgia (1453)2 Fibromyalgi$tw (1626)3 fibrositistw (20)4 or1-3 (1631)5 exp Exercise (7293)6 Physical Fitness (1655)7 exp Physical Endurance (747)8 exp Sports (3576)9 Pliability (32)10 exertion$tw (1129)11 exercis$tw (18675)12 sport$tw (4952)13 ((physical or motion) adj5 (fitness or therapy or therapies))tw (8773)14 (physical$ adj2 endur$)tw (629)15 manipulat$tw (4038)16 (skate$ or skating)tw (81)17 jog$tw (158)18 swim$tw (552)19 bicycl$tw (972)20 (cycle$ or cycling)tw (3530)21 walk$tw (7139)22 (row or rows or rowing)tw (174)23 weight train$tw (149)24 muscle strength$tw (5651)25 exp pilates (22)26 exp Yoga (345)27 exp Tai chi (204)28 Tai jitw (6)29 yogatw (448)30 (hatha or kundalini or ashtunga or bikram)tw (26)31 pilatestw (62)32 exp Exercise therapy (4945)33 or5-32 (43624)34 4 and 33 (328)



Appendix 11 Selection criteria

Level one screen

Based solely on the title of the report1 Does the study deal exclusively with fibromyalgia No - exclude Yes or uncertain - go to step two2 Does it include exercise No - exclude Yes or uncertain - go to step three3 Does the study deal exclusively with adults No - exclude Yes or uncertain - go to step four4 Is it an RCT No - exclude Yes or uncertain - Include

Level two screen

Based solely on the abstract of the report1 Does the study deal exclusively with fibromyalgia No - exclude Yes or uncertain - go to step two2 Does it include exercise No - exclude Yes or uncertain - go to step three3 Does the study deal exclusively with adults No - exclude Yes or uncertain - go to step four4 Is it an RCT No - exclude Yes or uncertain - Include

Level three screen

Based on the full text of the report1 Does the study deal exclusively with fibromyalgia No - exclude Yes - go to step two Uncertain - add to list of questions for

author and proceed to step two2 Is the diagnosis of fibromyalgia based on published criteria No - exclude Yes - go to step three Uncertain - add to list of

questions for author and proceed to step three3 Does the study deal exclusively with adults No - exclude Yes - go onto step four Uncertain - add to list of questions for author

and proceed to step four4 Is it an RCT (the study uses terms such as ldquorandomrdquo ldquorandomizedrdquo ldquoRCTrdquo or ldquorandomizationrdquo to describe the study design or

assignment of subjects to groups) No - exclude Yes - go onto step five Uncertain - add to list of questions for author and proceed tostep five

5 Does it include at least one physical activity or exercise intervention No - exclude Yes - go onto step six Uncertain - add to listof questions for author and proceed to step six

6 Is between group data provided for the outcomes No (the study does not contain ONLY fibromyalgia or results are reportedsuch that effects on fibromyalgia cannot be isolated) - exclude Yes - include the study Uncertain about one or more of steps 1 - 5 -reserve judgment until authors are contactedLevel four screen (classification of interventions in the included studies)

1 Classification of designi) Number of interventions

ii) Type of comparisonsa) Head to head comparisonb) Exercise to controlc) Composite to control

2 Control groupi) Classify type of control

3 Exercisei) Enter the type of exercise interventions used in the study

ii) Complete the naming of the intervention groups



W H A T rsquo S N E W

Last assessed as up-to-date 5 March 2013

Date Event Description

25 February 2013 Amended Update and restructuring of the Exercise for treating fibromyalgia review The Exercise for treatingfibromyalgia review has been split into several reviews each focusing on a particular type of exercisetraining or physical activity This review addresses resistance exercise trainingThe others are- Aquatic exercise training for fibromyalgia- Aerobic exercise for fibromyalgia- Composite exercise for fibromyalgia- Flexibility exercise for fibromyalgia- Mixed exercise for fibromyalgia- Whole body vibration exercise for fibromyalgia

H I S T O R Y

Review first published Issue 12 2013


14 June 2008 Amended Converted to new review format CMSG ID C036-R

17 August 2007 New citation required and conclusions have changed Substantive amendment See published notes for details

C O N T R I B U T I O N S O F A U T H O R S

AJB Designing and reviewing protocol for review screening data extraction methodologic analysis and writing and reviewingmanuscript

SW Participating in discussion regarding methods screening studies data extraction methodologic analysis and writing and reviewingmanuscript

RR Participating in discussion regarding methods screening studies data extraction methodologic analysis and writing and reviewingmanuscript

JB Participating in discussion regarding methods screening studies data extraction methodologic analysis writing and reviewingdrafts and approving the final manuscript

LS Participating in discussion regarding methods screening studies data extraction reviewing drafts and approving the final draft ofthe manuscript

AD Participating in discussion regarding methods screening studies data extraction reviewing drafts and approving the final draftof the manuscript

AS Participating in discussion regarding methods screening studies data extraction reviewing drafts and approving the final draft ofthe manuscript



VDBH Participating in discussion regarding methods screening studies data extraction reviewing drafts and approving the finaldraft of the manuscript

TR Designing and implementing the search strategy designing the study selection protocol writing the clay text summary reviewingdrafts and approving the final draft of the manuscript

CLS Designing and reviewing protocol for review screening studies data extraction providing expert opinion on exercise physiologyreviewing drafts and approving the final draft of the manuscript

TO Designing and reviewing protocol for review screening studies data extraction providing expert opinion on exercise physiologyreviewing drafts and approving the final draft of the manuscript

D E C L A R A T I O N S O F I N T E R E S T

We confirm that any present or past affiliations or other involvement in any organization or entity with an interest in the review thatmight lead us to have a real or perceived conflict of interest are listed below

bull None known

S O U R C E S O F S U P P O R T

Internal sources

bull School of Physical Therapy University of Saskatchewan Canadabull Department of Medicine University of Saskatchewan Canadabull Institute of Health and Outcomes Research University of Saskatchewan Canadabull Institute for Work and Health Canada

External sources

bull No sources of support supplied

N O T E S

This review is a major update of the previous reviews completed in 2002 and 2007 Methodologic differences between the 2007 reviewand this update included

bull small revisions to the search terms

bull changes in the membership of the review team (addition of new review authors and two consumers)

bull use of the rsquoRisk of biasrsquo tool (Higgins 2011b) to assess the quality of the evidence instead of the van Tulder 2003 methodologiccriteria that were used in the earlier version of the review

bull revisions to Cochrane methods described in Version 510 of the Cochrane Handbook for Systematic Reviews of Interventions(Higgins 2011a) including Summary of findings Grade

bull use of electronic data extraction methods (Google docs) as opposed to paper-based methods used in earlier versions of the review



T A B L E O F C O N T E N T S

1HEADER 1ABSTRACT 2PLAIN LANGUAGE SUMMARY 5SUMMARY OF FINDINGS FOR THE MAIN COMPARISON 8BACKGROUND 9OBJECTIVES

10METHODS Figure 1 15

16RESULTS Figure 2 17Figure 3 19Figure 4 20

23ADDITIONAL SUMMARY OF FINDINGS 30DISCUSSION 33AUTHORSrsquo CONCLUSIONS 34ACKNOWLEDGEMENTS 35REFERENCES 47CHARACTERISTICS OF STUDIES 63DATA AND ANALYSES

Analysis 11 Comparison 1 Resistance training versus control Outcome 1 Multidimensional function 66Analysis 12 Comparison 1 Resistance training versus control Outcome 2 Physical function 66Analysis 13 Comparison 1 Resistance training versus control Outcome 3 Pain 67Analysis 14 Comparison 1 Resistance training versus control Outcome 4 Tenderness 67Analysis 15 Comparison 1 Resistance training versus control Outcome 5 Muscle strength max concentric leg extension 68Analysis 16 Comparison 1 Resistance training versus control Outcome 6 Fatigue 69Analysis 17 Comparison 1 Resistance training versus control Outcome 7 Patient-rated global 69Analysis 18 Comparison 1 Resistance training versus control Outcome 8 Mental health 70Analysis 19 Comparison 1 Resistance training versus control Outcome 9 Depression 70Analysis 110 Comparison 1 Resistance training versus control Outcome 10 Sleep 71Analysis 111 Comparison 1 Resistance training versus control Outcome 11 Muscle power 71Analysis 112 Comparison 1 Resistance training versus control Outcome 12 Muscle size 72Analysis 113 Comparison 1 Resistance training versus control Outcome 13 Muscle activation 72Analysis 114 Comparison 1 Resistance training versus control Outcome 14 All-cause attrition 73Analysis 21 Comparison 2 Resistance versus aerobic training Outcome 1 Multidimensional Function 73Analysis 22 Comparison 2 Resistance versus aerobic training Outcome 2 Self reported physical function 74Analysis 23 Comparison 2 Resistance versus aerobic training Outcome 3 Pain 74Analysis 24 Comparison 2 Resistance versus aerobic training Outcome 4 Tenderness 75Analysis 25 Comparison 2 Resistance versus aerobic training Outcome 5 Fatigue 75Analysis 26 Comparison 2 Resistance versus aerobic training Outcome 6 Mental health 76Analysis 27 Comparison 2 Resistance versus aerobic training Outcome 7 Sleep 76Analysis 28 Comparison 2 Resistance versus aerobic training Outcome 8 Depression 77Analysis 29 Comparison 2 Resistance versus aerobic training Outcome 9 Anxiety 77Analysis 210 Comparison 2 Resistance versus aerobic training Outcome 10 Cardio respiratory submax 78Analysis 211 Comparison 2 Resistance versus aerobic training Outcome 11 All-cause attrition 78Analysis 31 Comparison 3 Resistance versus flexibility exercise Outcome 1 Multidimensional function 79Analysis 32 Comparison 3 Resistance versus flexibility exercise Outcome 2 Pain 79Analysis 33 Comparison 3 Resistance versus flexibility exercise Outcome 3 Tenderness 80Analysis 34 Comparison 3 Resistance versus flexibility exercise Outcome 4 Strength 80Analysis 35 Comparison 3 Resistance versus flexibility exercise Outcome 5 Self efficacy 81Analysis 36 Comparison 3 Resistance versus flexibility exercise Outcome 6 Fatigue 81Analysis 37 Comparison 3 Resistance versus flexibility exercise Outcome 7 Sleep 82

iResistance exercise training for fibromyalgia (Review)














A B S T R A C T

Background


Objectives


Search methods


Selection criteria






Main results









Research question






















Tenderness




Muscle strength










Quality of evidence










Comparison Control


(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion

FIQ Total Score

Scale 0-100 (lower


health)

Follow-up 16 weeks




trol group was

-816 FIQ units1





-2491 FIQ units1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD -127 (95 CI -183

to -072)8



31 to -1019)



cise group7

NNTB 2 (95 CI 1 to 3)


function

Health Assessment





better health)





control groups was

-201 units1





-767 units1

- 107

(3 studies2)

oplusopluscopycopy

low910

SMD -05 (95 CI -089

to -011) 11


units (95 CI -1045 to -

213)


1448 (95 CI 49 to


groups

NNTB 5 (95 CI 3 to 22)

5R

esista

nce

exerc

isetra

inin

gfo

rfi

bro

myalg

ia(R

evie

w)

Co

pyrig

ht

copy2013

Th

eC

och

ran

eC

olla

bo

ratio

nP

ub

lished

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Pain

Visual analog scale






control groups was

-099 cm1




-353 cm1

81

(2 studies2)

oplusopluscopycopy

low91012

SMD -189 (95 CI -386

to 007)8


cm (95 CI -635 to -0

26)


446 (95 CI 35 to


groups7

NNTB 2 (95 CI 1 to 34)

Tenderness


myalgic scores




derness)





-20 tender points1

The estimated mean



vention groups was

-35 tender points1

- 107

(3 studies2)

oplusopluscopycopy

low91012SMD -073 (95 CI -112

to -033)8



6 to -108)


128 (95 CI 749 to


cise groups

NNTB 4 (95 CI 3 to 7)

Muscle strength



in kg)

Follow-up 21 weeks




was 044 kg1




tion groups was

2771 kg1

- 47

(2 studies2)

oplusopluscopycopy

low91012

SMD 167 (95 CI 098

to 235)8


kg (95 CI 1828 to 36

36)


25 (95 CI 17 to


groups7

NNTB 2 (95 CI 1 to 3)





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studies)

All-cause attrition

Dropout rates


39 per 1000 134 per 1000

(95 CI 30 to 439)

RR 350 (079 to 1549) 107

(3 studies2)

oplusopluscopycopy

low9


(95 CI -2 to 20)


250 (95 CI -21 to

1449)


cant




difference









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B A C K G R O U N D














O B J E C T I V E S







M E T H O D S


Types of studies






































adaptation













Major outcomes



Minor outcomes












Electronic searches















Review team






















Data synthesis

















R E S U L T S










Included studies



Excluded studies







study





Allocation


Blinding




Selective reporting



































(95 CI)

No of Participants

(studies)


(GRADE)

Comments7




tion




Follow-up 8 weeks





-2133 FIQ units1





was

-1585 FIQ units 1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD 043 (95 CI -008

to 094)6



to 1188)


cant


function




greater health)

Follow-up 8 weeks





was

581 SF-36 units 1





was

454 SF-36 units 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -011 (95 CI -053

to 031) 6



69 to 374)6


cant

Pain



indicate less pain)

Follow-up 8 weeks




was

-357 cm12




was

-27 cm 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD 053 (95 CI 010

to 097)8


cm (95 CI 031 to 167)


24

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nce

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7 129 (95 CI 405



NNTB 5 (95 CI 3 to 24)

Tenderness



converted to tender



derness)

Follow-up 8 weeks




groups was

-515 tender points1




groups was

-49 tender points 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -013 (95 CI -055

to 03)6



68 to 033)


cant







studies)

All-cause attrition

Dropout rates

Follow-up 8 weeks

89 per 1000 89 per 1000

(22 to 296)

Peto OR 1

(024 to 423)

90

(2 studies2)

oplusopluscopycopy

low


(95 CI -12 to 12)


0


cant









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26

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Settings USA




(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion



greater health)

Follow-up 12 weeks




-378 FIQ units 1




group was

-1027 units 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -055 (95 CI -109

to -002) 6



57 to -041)



tance group


cant

Pain

VAS 0-10 cm (lower


Follow-up 12 weeks




-101 cm 1




was

-189 cm 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -066 (95 CI -12

to -012)6


cm (95 CI -157 to -0

19)12


14 (95 CI 30 to 24


tance group


cant27

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Tenderness

Tender point count

scores 0-18 (lower


derness)

Follow-up 12 weeks



group was

-1 tender points 1



training group was


- 56

(1 study)

oplusopluscopycopy

low23

SMD -022 (95 CI -074

to 031)7



56 to 064)


cant

Strength

Maximal isokinetic



in foot-pounds8

Follow-up 12 weeks

The mean change in


group was

97 foot-pounds 1

The mean change in


training group was

1447 foot-pounds 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD 034 (95 CI -018

to 087)7



40 to 1194)


cant



All-cause attrition

Dropout rates

Follow-up 12 weeks

214 per 1000 214 per 1000 RR 100 (037 to 273) 56

(1 study)

oplusopluscopycopy

low23



0


cant










8R

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29

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D I S C U S S I O N

























































R E F E R E N C E S















200133(4)162ndash9




(5)573ndash8

















(10)1107ndash13



















200122310ndash32





19974275ndash91









(MayJune)80










200231(5)306ndash10

























199457(4)45ndash9



























199623(7)1237ndash45









201252(1)85ndash91



(10)616ndash22





2010254(1735)8ndash10










ACSM 2009a



ACSM 2009b



Alentorn-Geli 2008


(8)975ndash81

Altan 2004




Altan 2009


Anderson 1995


Arcos-Carmona 2011


(9)398ndash491

Arnold 2008


Asikainen 2004



Assis 2006


Baptista 2012



Bengtsson 1986a



Bengtsson 1986b



Bennett 1989


198932(4)454ndash60

Bennett 1999


Bennett 2009



Bernardy 2013



Birse 2012



Bojner Horwitz 2006


Boomershine 2012


Brachaniec 2009


Braith 2006


2006113(22)2642ndash50

Branco 2010



Bressan 2008



(2)88ndash93

Brosse 2002


(12)741ndash60



Brosseau 2008


200888(7)873ndash86

Buchheld 2001



Buckelew 1998



Burckhardt 1993



Burckhardt 1994



Burckhardt 2005


Calandre 2009



Callahan 1988


198815(3)418ndash26

Carson 2010


Carson 2012



Carville 2008


Carville 2008a


Caspersen 1985



Cedraschi 2004


Cheung 2003


Chodzko-Zajko 2009



Choy 2009a


Choy 2009b


200935(2)329ndash37

Clauw 2011


Cohen 1988


Costill 1979


Crosier 2002






Da Costa 2005


Dadabhoy 2008


Therapy 200810(4)211

De Andrade 2008




Demir-Gocmen 2013


Deschenes 2002



Desmeules 2003



Dunn 2001


Dworkin 2008


Elvin 2006


Etnier 2009


Evcik 2008



Faigenbaum 2009



Field 2003



Figueroa 2008



FitzerGerald 2004



Fontaine 2007


Fontaine 2010


Fontaine 2011


Garber 2011







Genc 2002



Gibson 2006


Gowans 1999


199912(2)120ndash8

Gowans 2001


Gracely 2003



Gusi 2006



Gusi 2008


Gusi 2010








Hammond 2006


Hawley 1991


Hecker 2011


Heyward 1998



Heyward 2010



Hibbert 2008



Higgins 2011a


Higgins 2011b


Higgins 2011c


Holloszy 1984



Hooten 2012





Howley 2001



Hunt 2000


Haumluser 2013



Ide 2008


200811(2)131ndash40

Isomeri 1993



Jentoft 2001



Jones 2007


Jones 2008


Jones 2009


Jones 2012


Joshi 2009



Jubrias 1994


(6)801ndash7

Katzmarzyk 2002


200234(5)740ndash4

Keel 1998


King 1997


1997277(1)32ndash7

King 2002



Kingsley 2009



Kingsley 2011



Knutzen 2007


Koltyn 1998


Lefebvre 2011


Lemstra 2005






Lewis 2012


201231(2)255ndash62

Liu 2012


(11)657ndash64



Lorig 1989



Lund 1986



Lynch 2012



Mannerkorpi 2000


Mannerkorpi 2009


Mannerkorpi 2010


201012(5)R189

Martin 1996





201246(3)199ndash206

Matsutani 2007



Matsutani 2012


(2)411ndash8

McCain 1988


McNalley 2006


Mease 2005


Mease 2008


Mease 2009


200936(10)2318ndash29

Mengshoel 1992


Mengshoel 1993


Merskey 1994




Mitchell 2002




Mizelle 2011


(8)310ndash6

Moore 2012


Morrissey 1995









Nelson 2007


Nichols 1994


Norregaard 1997


Olivares 2011


(8)723ndash8

Painter 1999



Park 1998


Park 2007


Philadelphia 2001


200181(10)1629ndash40

Raftery 2009


Ramsay 2000


RevMan 2012


Richards 2002


Rivera Redondo 2004


200451(2)184ndash92

Rooks 2007


(20)2192ndash200

Sale 1987


Sanudo 2010



Sanudo 2010a





Sanudo 2010c


Sanudo 2011


(6)521ndash6

Sanudo 2012



Schachter 2003


Schmidt 2011


Schuumlnermann 2009


Seidel 2013


Sencan 2004


Singh 1997


Smythe 1981


Tomas-Carus 2007


20073(1)33ndash7

Tomas-Carus 2007a



Tomas-Carus 2007b


Tomas-Carus 2007c


Tomas-Carus 2008



Tort 2012


Trew 2005


Valencia 2009



Valim 2003









Valkeinen 2008



van Koulil 2007



van Koulil 2010


van Tulder 2003


vanSanten 2002



vanSanten 2002a


Verstappen 1997


Wang 2010


(8)743ndash54

WHO 2012


Wigers 1996



Williams 2012


2012 Issue 11 [DOI 10100214651858CD007407]

Winkelmann 2012


(3)276ndash86

Wolfe 1990


Wolfe 1995


Wolfe 2010


201062(5)600ndash10

Wolfe 2011


Yunus 1981



Yunus 1982


Yunus 1984


Yuruk 2008




Zeng 2008




Busch 2001


Busch 2001a


Busch 2002



Busch 2007



Busch 2008







Bircan 2008








Risk of bias


















2012)


Hakkinen 2001












Risk of bias















Jones 2002












Risk of bias















Kayo 2011












Risk of bias

















Valkeinen 2004












Risk of bias


























Dal 2011 Not an RCT















(Continued)






















(Continued)









Adsuar 2012

Methods Unknown

Participants


Outcomes


Amanollahi 2013

Methods Unknown

Participants


Outcomes




Aslan 2001

Methods RCT





Bland 2010

Methods

Participants

Interventions

Outcomes

Notes

Ekici 2008

Methods RCT





Thijssen 1992

Methods Unknown



Outcomes Unknown




Wright 2012

Methods

Participants

Interventions

Outcomes

Notes







studies

No of









studies

No of







studies

No of





studies

No of





studies

No of


















studies

No of















DifferenceMean

Difference

NMean(SD)[FIQ



Kayo 2011 30 -2491 (1534) 30 -816 (1005) -1675 [ -2331 -1019 ]

-20 -10 0 10 20








Difference


Hakkinen 2001 11 -10 (126491) 10 0 (802773) 215 -1000 [ -1898 -102 ]

Valkeinen 2004 13 -6667 (8944) 13 333 (10541) 307 -1000 [ -1751 -249 ]

Kayo 2011 30 -724 (1197) 30 -5 (1181) 478 -224 [ -826 378 ]

Total (95 CI) 54 53 1000 -629 [ -1045 -213 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


Hakkinen 2001 11 -24 (1503) 10 25 (1641) 487 -490 [ -625 -355 ]

Kayo 2011 30 -394 (202) 30 -215 (156) 513 -179 [ -270 -088 ]

Total (95 CI) 41 40 1000 -330 [ -635 -026 ]




-10 -5 0 5 10








Difference


Hakkinen 2001 11 -1 (2683) 10 1 (1265) 185 -200 [ -377 -023 ]

Valkeinen 2004 13 -19 (151) 13 02 (114) 547 -210 [ -313 -107 ]

Kayo 2011 30 -507 (316) 30 -387 (263) 268 -120 [ -267 027 ]

Total (95 CI) 54 53 1000 -184 [ -260 -108 ]




-100 -50 0 50 100





leg extension






Difference


Hakkinen 2001 11 25 (1399) 10 1 (1726) 447 2400 [ 1048 3752 ]

Valkeinen 2004 13 30 (1844) 13 0 (1264) 553 3000 [ 1785 4215 ]

Total (95 CI) 24 23 1000 2732 [ 1828 3636 ]




-100 -50 0 50 100







Outcome 6 Fatigue



Difference


Hakkinen 2001 11 -19 (1513) 10 1 (1881) 254 -2000 [ -3169 -831 ]

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 746 -1285 [ -1967 -603 ]

Total (95 CI) 41 40 1000 -1466 [ -2055 -877 ]




-20 -10 0 10 20







DifferenceMean

Difference


Hakkinen 2001 11 -26 (1565) 10 14 (1762) -4000 [ -5431 -2569 ]

-100 -50 0 50 100









DifferenceMean

Difference


Kayo 2011 30 -873 (161) 30 -587 (1338) -286 [ -1035 463 ]

-100 -50 0 50 100







DifferenceMean

Difference


Hakkinen 2001 11 -28 (313) 10 09 (31) -370 [ -637 -103 ]

-100 -50 0 50 100







Outcome 10 Sleep


DifferenceMean

Difference


Hakkinen 2001 11 -10 (1448) 10 -3 (1744) -700 [ -2079 679 ]

-100 -50 0 50 100







DifferenceMean

Difference

NMean(SD)[m

(jump)] NMean(SD)[m


Hakkinen 2001 11 0015 (0009) 10 -001 (00054) 002 [ 001 003 ]

-01 -005 0 005 01









StdMean

Difference Weight

StdMean

Difference

NMean(SD)[cmˆ2



Hakkinen 2001 11 406 (298318) 10 139 (364077) 427 077 [ -012 167 ]

Valkeinen 2004 13 268 (434497) 13 151 (439434) 573 026 [ -051 103 ]

Total (95 CI) 24 23 1000 048 [ -011 106 ]




-100 -50 0 50 100








Difference


Hakkinen 2001 11 2958 (1082) 10 -1071 (779) 857 4029 [ 3228 4830 ]

Valkeinen 2004 13 5663 (2835) 13 1191 (2239) 143 4472 [ 2508 6436 ]

Total (95 CI) 24 23 1000 4092 [ 3350 4834 ]




-50 -25 0 25 50










Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 230 350 [ 079 1549 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Total (95 CI) 54 53 350 [ 079 1549 ]





0001 001 01 1 10 100 1000







DifferenceMean

Difference


Kayo 2011 30 -1585 (125) 30 -2133 (1279) 548 [ -092 1188 ]

-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF36

PF] NMean(SD)[SF36


Bircan 2008 13 1231 (1345) 13 10 (1297) 264 231 [ -785 1247 ]

Kayo 2011 30 117 (1213) 30 4 (1188) 736 -283 [ -891 325 ]

Total (95 CI) 43 43 1000 -148 [ -669 374 ]




-20 -10 0 10 20

Favors RE Favors AE




Outcome 3 Pain



Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -256 (135) 13 -388 (1183) 488 132 [ 034 230 ]

Kayo 2011 30 -277 (195) 30 -344 (181) 512 067 [ -028 162 ]

Total (95 CI) 43 43 1000 099 [ 031 167 ]




-4 -2 0 2 4

Favors RE Favors AE








StdMean

Difference Weight

StdMean

Difference


Bircan 2008 13 -616 (135) 13 -538 (137) 293 -056 [ -134 023 ]

Kayo 2011 30 -98 (792) 30 -1027 (1046) 707 005 [ -046 056 ]

Total (95 CI) 43 43 1000 -013 [ -055 030 ]




-2 -1 0 1 2

Favors RE Favors AE




Outcome 5 Fatigue



Difference


Bircan 2008 13 -281 (1736) 13 -339 (148) 206 580 [ -660 1820 ]

Kayo 2011 30 -828 (1271) 30 -866 (1228) 794 038 [ -594 670 ]

Total (95 CI) 43 43 1000 150 [ -414 713 ]




-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF-



Bircan 2008 13 1201 (13135) 13 893 (12328) 367 308 [ -671 1287 ]

Kayo 2011 30 -587 (1488) 30 -56 (1461) 633 -027 [ -773 719 ]

Total (95 CI) 43 43 1000 096 [ -497 690 ]




-10 -5 0 5 10

Favors AE Favors RE




Outcome 7 Sleep


DifferenceMean

Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -188 (188) 13 -335 (121) 147 [ 025 269 ]

-4 -2 0 2 4

Favors RE Favors AE








DifferenceMean

Difference

NMean(SD)[HAD

dep] NMean(SD)[HAD


Bircan 2008 13 -254 (273) 13 -2 (246) -054 [ -254 146 ]

-4 -2 0 2 4

Favors RE Favors AE




Outcome 9 Anxiety


DifferenceMean

Difference

NMean(SD)[HAD

anx] NMean(SD)[HAD


Bircan 2008 13 -054 (275) 13 -115 (268) 061 [ -148 270 ]

-20 -10 0 10 20

Favors RE Favors AE








DifferenceMean

Difference



Bircan 2008 13 7661 (4704) 13 4085 (5963) 3576 [ -553 7705 ]

-100 -50 0 50 100

Favors AE Favors RE







Odds Ratio


Bircan 2008 215 215 486 100 [ 013 792 ]

Kayo 2011 230 230 514 100 [ 013 748 ]

Total (95 CI) 45 45 1000 100 [ 024 423 ]





0005 01 1 10 200









DifferenceMean

Difference


Jones 2002 28 -1027 (1032) 28 -378 (1276) -649 [ -1257 -041 ]

-20 -10 0 10 20

Favors RE Favors FX




Outcome 2 Pain


DifferenceMean

Difference


Jones 2002 28 -189 (131) 28 -101 (131) -088 [ -157 -019 ]

-2 -1 0 1 2

Favors RE Favors FX








DifferenceMean

Difference


Jones 2002 28 -146 (193) 28 -1 (224) -046 [ -156 064 ]

-4 -2 0 2 4

Favors RE Favors FX




Outcome 4 Strength


DifferenceMean

Difference


Jones 2002 28 1447 (1399) 28 97 (1336) 477 [ -240 1194 ]

-20 -10 0 10 20

Favors FX Favors RE








DifferenceMean

Difference


Jones 2002 28 3445 (10992) 28 661 (1062) -3165 [ -8826 2496 ]

-200 -100 0 100 200

Favors FX Favors RE




Outcome 6 Fatigue


StdMean

Difference

StdMean

Difference


Jones 2002 28 -243 (125) 28 -068 (148) -126 [ -184 -068 ]

-4 -2 0 2 4

Favors RE Favors FX






Outcome 7 Sleep


DifferenceMean

Difference


Jones 2002 28 -23 (165) 28 -053 (161) -177 [ -262 -092 ]

-4 -2 0 2 4

Favors RE Favors FX






DifferenceMean

Difference


Jones 2002 28 -367 (423) 28 -184 (403) -183 [ -399 033 ]

-10 -5 0 5 10

Favors RE Favors FX






Outcome 9 Anxiety


DifferenceMean

Difference


Jones 2002 28 -25 (584) 28 07 (645) -320 [ -642 002 ]

-10 -5 0 5 10

Favors RE Favors FX






DifferenceMean

Difference

NMean(SD)[4-



Jones 2002 28 -115 (051) 28 -145 (06) 030 [ 001 059 ]

-2 -1 0 1 2

Favors RE Favors FX









Jones 2002 628 628 100 [ 037 273 ]

01 02 05 1 2 5 10

Favors RT Favors FX




Outcome 1 Attrition



1 RT vs control

Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 730 100 [ 030 331 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Subtotal (95 CI) 54 53 100 [ 030 331 ]




2 RT vs AE

Bircan 2008 215 215 100 [ 012 821 ]

Kayo 2011 730 830 084 [ 026 270 ]

Subtotal (95 CI) 45 45 087 [ 031 243 ]


002 01 1 10 50


(Continued )







3 RT vs flexibility

Jones 2002 628 628 100 [ 028 358 ]

Subtotal (95 CI) 28 28 100 [ 028 358 ]




Total (95 CI) 127 126 094 [ 049 183 ]





002 01 1 10 50





function






Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -598 (1199) 380 -987 [ -1607 -367 ]

Subtotal (95 CI) 30 30 380 -987 [ -1607 -367 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -816 (1005) 339 -1675 [ -2331 -1019 ]

Subtotal (95 CI) 30 30 339 -1675 [ -2331 -1019 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -619 (1117) 281 -1067 [ -1788 -346 ]

Subtotal (95 CI) 30 30 281 -1067 [ -1788 -346 ]



Total (95 CI) 90 90 1000 -1243 [ -1625 -861 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -05 (1142) 338 -067 [ -663 529 ]

Subtotal (95 CI) 30 30 338 -067 [ -663 529 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -5 (1181) 332 -224 [ -826 378 ]

Subtotal (95 CI) 30 30 332 -224 [ -826 378 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -517 (119) 330 100 [ -504 704 ]

Subtotal (95 CI) 30 30 330 100 [ -504 704 ]



Total (95 CI) 90 90 1000 -064 [ -411 283 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -209 (176) 321 -068 [ -162 026 ]

Subtotal (95 CI) 30 30 321 -068 [ -162 026 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -215 (156) 340 -179 [ -270 -088 ]

Subtotal (95 CI) 30 30 340 -179 [ -270 -088 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -189 (168) 339 -085 [ -177 007 ]

Subtotal (95 CI) 30 30 339 -085 [ -177 007 ]



Total (95 CI) 90 90 1000 -112 [ -165 -058 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -954 (769) 418 -026 [ -421 369 ]

Subtotal (95 CI) 30 30 418 -026 [ -421 369 ]



2 16 wk

Kayo 2011 30 -1529 (949) 30 -116 (79) 334 -369 [ -811 073 ]

Subtotal (95 CI) 30 30 334 -369 [ -811 073 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -1064 (951) 247 -192 [ -706 322 ]

Subtotal (95 CI) 30 30 247 -192 [ -706 322 ]



Total (95 CI) 90 90 1000 -182 [ -437 074 ]




-100 -50 0 50 100







Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -993 (1339) 356 165 [ -496 826 ]

Subtotal (95 CI) 30 30 356 165 [ -496 826 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 334 -1285 [ -1967 -603 ]

Subtotal (95 CI) 30 30 334 -1285 [ -1967 -603 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -277 (1313) 311 -911 [ -1618 -204 ]

Subtotal (95 CI) 30 30 311 -911 [ -1618 -204 ]



Total (95 CI) 90 90 1000 -653 [ -1047 -259 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -533 (1334) 356 -054 [ -769 661 ]

Subtotal (95 CI) 30 30 356 -054 [ -769 661 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -587 (1338) 324 -286 [ -1035 463 ]

Subtotal (95 CI) 30 30 324 -286 [ -1035 463 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -547 (1409) 320 054 [ -701 809 ]

Subtotal (95 CI) 30 30 320 054 [ -701 809 ]



Total (95 CI) 90 90 1000 -095 [ -521 332 ]




-100 -50 0 50 100











Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -2133 (1279) 416 548 [ -092 1188 ]

Subtotal (95 CI) 30 30 416 548 [ -092 1188 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -263 (139) 311 139 [ -602 880 ]

Subtotal (95 CI) 30 30 311 139 [ -602 880 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -2457 (1434) 273 771 [ -019 1561 ]

Subtotal (95 CI) 30 30 273 771 [ -019 1561 ]



Total (95 CI) 90 90 1000 482 [ 069 895 ]




-20 -10 0 10 20

Favors AE Favors RT




function






Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -4 (1188) 353 283 [ -325 891 ]

Subtotal (95 CI) 30 30 353 283 [ -325 891 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -1167 (125) 339 443 [ -176 1062 ]

Subtotal (95 CI) 30 30 339 443 [ -176 1062 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -13 (1367) 308 883 [ 233 1533 ]

Subtotal (95 CI) 30 30 308 883 [ 233 1533 ]



Total (95 CI) 90 90 1000 522 [ 161 883 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -344 (181) 357 067 [ -028 162 ]

Subtotal (95 CI) 30 30 357 067 [ -028 162 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -327 (192) 326 -067 [ -167 033 ]

Subtotal (95 CI) 30 30 326 -067 [ -167 033 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -357 (206) 317 083 [ -018 184 ]

Subtotal (95 CI) 30 30 317 083 [ -018 184 ]



Total (95 CI) 90 90 1000 028 [ -028 085 ]




-2 -1 0 1 2

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -1027 (1046) 373 047 [ -422 516 ]

Subtotal (95 CI) 30 30 373 047 [ -422 516 ]



2 16 wk

Kayo 2011 30 -152 (949) 30 -1384 (1072) 313 -136 [ -648 376 ]

Subtotal (95 CI) 30 30 313 -136 [ -648 376 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -154 (941) 314 284 [ -228 796 ]

Subtotal (95 CI) 30 30 314 284 [ -228 796 ]



Total (95 CI) 90 90 1000 064 [ -223 351 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -866 (1228) 361 038 [ -594 670 ]

Subtotal (95 CI) 30 30 361 038 [ -594 670 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -1256 (1143) 318 -356 [ -1030 318 ]

Subtotal (95 CI) 30 30 318 -356 [ -1030 318 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -135 (1152) 321 162 [ -508 832 ]

Subtotal (95 CI) 30 30 321 162 [ -508 832 ]



Total (95 CI) 90 90 1000 -047 [ -427 333 ]




-10 -5 0 5 10

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -56 (1461) 349 -027 [ -773 719 ]

Subtotal (95 CI) 30 30 349 -027 [ -773 719 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -1347 (1457) 322 474 [ -303 1251 ]

Subtotal (95 CI) 30 30 322 474 [ -303 1251 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -1387 (1463) 330 894 [ 126 1662 ]

Subtotal (95 CI) 30 30 330 894 [ 126 1662 ]



Total (95 CI) 90 90 1000 438 [ -003 878 ]




-20 -10 0 10 20

Favors AE Favors RT



Term Definition
























































2 AQ-MX Control










Joshi 2009 2 MX Med

















McCain 1988 2 AE FX






















2 AQ-MX Control


Valim 2003 2 AE FX













A P P E N D I C E S
















































Level one screen


Level two screen


Level three screen



















H I S T O R Y





















bull None known


Internal sources


External sources


N O T E S





















A B S T R A C T

Background


Objectives


Search methods


Selection criteria






Main results









Research question






















Tenderness




Muscle strength










Quality of evidence










Comparison Control


(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion

FIQ Total Score

Scale 0-100 (lower


health)

Follow-up 16 weeks




trol group was

-816 FIQ units1





-2491 FIQ units1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD -127 (95 CI -183

to -072)8



31 to -1019)



cise group7

NNTB 2 (95 CI 1 to 3)


function

Health Assessment





better health)





control groups was

-201 units1





-767 units1

- 107

(3 studies2)

oplusopluscopycopy

low910

SMD -05 (95 CI -089

to -011) 11


units (95 CI -1045 to -

213)


1448 (95 CI 49 to


groups

NNTB 5 (95 CI 3 to 22)

5R

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Pain

Visual analog scale






control groups was

-099 cm1




-353 cm1

81

(2 studies2)

oplusopluscopycopy

low91012

SMD -189 (95 CI -386

to 007)8


cm (95 CI -635 to -0

26)


446 (95 CI 35 to


groups7

NNTB 2 (95 CI 1 to 34)

Tenderness


myalgic scores




derness)





-20 tender points1

The estimated mean



vention groups was

-35 tender points1

- 107

(3 studies2)

oplusopluscopycopy

low91012SMD -073 (95 CI -112

to -033)8



6 to -108)


128 (95 CI 749 to


cise groups

NNTB 4 (95 CI 3 to 7)

Muscle strength



in kg)

Follow-up 21 weeks




was 044 kg1




tion groups was

2771 kg1

- 47

(2 studies2)

oplusopluscopycopy

low91012

SMD 167 (95 CI 098

to 235)8


kg (95 CI 1828 to 36

36)


25 (95 CI 17 to


groups7

NNTB 2 (95 CI 1 to 3)





6R

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studies)

All-cause attrition

Dropout rates


39 per 1000 134 per 1000

(95 CI 30 to 439)

RR 350 (079 to 1549) 107

(3 studies2)

oplusopluscopycopy

low9


(95 CI -2 to 20)


250 (95 CI -21 to

1449)


cant




difference









7R

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B A C K G R O U N D














O B J E C T I V E S







M E T H O D S


Types of studies






































adaptation













Major outcomes



Minor outcomes












Electronic searches















Review team






















Data synthesis

















R E S U L T S










Included studies



Excluded studies







study





Allocation


Blinding




Selective reporting



































(95 CI)

No of Participants

(studies)


(GRADE)

Comments7




tion




Follow-up 8 weeks





-2133 FIQ units1





was

-1585 FIQ units 1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD 043 (95 CI -008

to 094)6



to 1188)


cant


function




greater health)

Follow-up 8 weeks





was

581 SF-36 units 1





was

454 SF-36 units 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -011 (95 CI -053

to 031) 6



69 to 374)6


cant

Pain



indicate less pain)

Follow-up 8 weeks




was

-357 cm12




was

-27 cm 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD 053 (95 CI 010

to 097)8


cm (95 CI 031 to 167)


24

Resista

nce

exerc

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7 129 (95 CI 405



NNTB 5 (95 CI 3 to 24)

Tenderness



converted to tender



derness)

Follow-up 8 weeks




groups was

-515 tender points1




groups was

-49 tender points 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -013 (95 CI -055

to 03)6



68 to 033)


cant







studies)

All-cause attrition

Dropout rates

Follow-up 8 weeks

89 per 1000 89 per 1000

(22 to 296)

Peto OR 1

(024 to 423)

90

(2 studies2)

oplusopluscopycopy

low


(95 CI -12 to 12)


0


cant









Resista

nce

exerc

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26

Resista

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Settings USA




(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion



greater health)

Follow-up 12 weeks




-378 FIQ units 1




group was

-1027 units 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -055 (95 CI -109

to -002) 6



57 to -041)



tance group


cant

Pain

VAS 0-10 cm (lower


Follow-up 12 weeks




-101 cm 1




was

-189 cm 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -066 (95 CI -12

to -012)6


cm (95 CI -157 to -0

19)12


14 (95 CI 30 to 24


tance group


cant27

Resista

nce

exerc

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Tenderness

Tender point count

scores 0-18 (lower


derness)

Follow-up 12 weeks



group was

-1 tender points 1



training group was


- 56

(1 study)

oplusopluscopycopy

low23

SMD -022 (95 CI -074

to 031)7



56 to 064)


cant

Strength

Maximal isokinetic



in foot-pounds8

Follow-up 12 weeks

The mean change in


group was

97 foot-pounds 1

The mean change in


training group was

1447 foot-pounds 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD 034 (95 CI -018

to 087)7



40 to 1194)


cant



All-cause attrition

Dropout rates

Follow-up 12 weeks

214 per 1000 214 per 1000 RR 100 (037 to 273) 56

(1 study)

oplusopluscopycopy

low23



0


cant










8R

esista

nce

exerc

isetra

inin

gfo

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29

Resista

nce

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D I S C U S S I O N

























































R E F E R E N C E S















200133(4)162ndash9




(5)573ndash8

















(10)1107ndash13



















200122310ndash32





19974275ndash91









(MayJune)80










200231(5)306ndash10

























199457(4)45ndash9



























199623(7)1237ndash45









201252(1)85ndash91



(10)616ndash22





2010254(1735)8ndash10










ACSM 2009a



ACSM 2009b



Alentorn-Geli 2008


(8)975ndash81

Altan 2004




Altan 2009


Anderson 1995


Arcos-Carmona 2011


(9)398ndash491

Arnold 2008


Asikainen 2004



Assis 2006


Baptista 2012



Bengtsson 1986a



Bengtsson 1986b



Bennett 1989


198932(4)454ndash60

Bennett 1999


Bennett 2009



Bernardy 2013



Birse 2012



Bojner Horwitz 2006


Boomershine 2012


Brachaniec 2009


Braith 2006


2006113(22)2642ndash50

Branco 2010



Bressan 2008



(2)88ndash93

Brosse 2002


(12)741ndash60



Brosseau 2008


200888(7)873ndash86

Buchheld 2001



Buckelew 1998



Burckhardt 1993



Burckhardt 1994



Burckhardt 2005


Calandre 2009



Callahan 1988


198815(3)418ndash26

Carson 2010


Carson 2012



Carville 2008


Carville 2008a


Caspersen 1985



Cedraschi 2004


Cheung 2003


Chodzko-Zajko 2009



Choy 2009a


Choy 2009b


200935(2)329ndash37

Clauw 2011


Cohen 1988


Costill 1979


Crosier 2002






Da Costa 2005


Dadabhoy 2008


Therapy 200810(4)211

De Andrade 2008




Demir-Gocmen 2013


Deschenes 2002



Desmeules 2003



Dunn 2001


Dworkin 2008


Elvin 2006


Etnier 2009


Evcik 2008



Faigenbaum 2009



Field 2003



Figueroa 2008



FitzerGerald 2004



Fontaine 2007


Fontaine 2010


Fontaine 2011


Garber 2011







Genc 2002



Gibson 2006


Gowans 1999


199912(2)120ndash8

Gowans 2001


Gracely 2003



Gusi 2006



Gusi 2008


Gusi 2010








Hammond 2006


Hawley 1991


Hecker 2011


Heyward 1998



Heyward 2010



Hibbert 2008



Higgins 2011a


Higgins 2011b


Higgins 2011c


Holloszy 1984



Hooten 2012





Howley 2001



Hunt 2000


Haumluser 2013



Ide 2008


200811(2)131ndash40

Isomeri 1993



Jentoft 2001



Jones 2007


Jones 2008


Jones 2009


Jones 2012


Joshi 2009



Jubrias 1994


(6)801ndash7

Katzmarzyk 2002


200234(5)740ndash4

Keel 1998


King 1997


1997277(1)32ndash7

King 2002



Kingsley 2009



Kingsley 2011



Knutzen 2007


Koltyn 1998


Lefebvre 2011


Lemstra 2005






Lewis 2012


201231(2)255ndash62

Liu 2012


(11)657ndash64



Lorig 1989



Lund 1986



Lynch 2012



Mannerkorpi 2000


Mannerkorpi 2009


Mannerkorpi 2010


201012(5)R189

Martin 1996





201246(3)199ndash206

Matsutani 2007



Matsutani 2012


(2)411ndash8

McCain 1988


McNalley 2006


Mease 2005


Mease 2008


Mease 2009


200936(10)2318ndash29

Mengshoel 1992


Mengshoel 1993


Merskey 1994




Mitchell 2002




Mizelle 2011


(8)310ndash6

Moore 2012


Morrissey 1995









Nelson 2007


Nichols 1994


Norregaard 1997


Olivares 2011


(8)723ndash8

Painter 1999



Park 1998


Park 2007


Philadelphia 2001


200181(10)1629ndash40

Raftery 2009


Ramsay 2000


RevMan 2012


Richards 2002


Rivera Redondo 2004


200451(2)184ndash92

Rooks 2007


(20)2192ndash200

Sale 1987


Sanudo 2010



Sanudo 2010a





Sanudo 2010c


Sanudo 2011


(6)521ndash6

Sanudo 2012



Schachter 2003


Schmidt 2011


Schuumlnermann 2009


Seidel 2013


Sencan 2004


Singh 1997


Smythe 1981


Tomas-Carus 2007


20073(1)33ndash7

Tomas-Carus 2007a



Tomas-Carus 2007b


Tomas-Carus 2007c


Tomas-Carus 2008



Tort 2012


Trew 2005


Valencia 2009



Valim 2003









Valkeinen 2008



van Koulil 2007



van Koulil 2010


van Tulder 2003


vanSanten 2002



vanSanten 2002a


Verstappen 1997


Wang 2010


(8)743ndash54

WHO 2012


Wigers 1996



Williams 2012


2012 Issue 11 [DOI 10100214651858CD007407]

Winkelmann 2012


(3)276ndash86

Wolfe 1990


Wolfe 1995


Wolfe 2010


201062(5)600ndash10

Wolfe 2011


Yunus 1981



Yunus 1982


Yunus 1984


Yuruk 2008




Zeng 2008




Busch 2001


Busch 2001a


Busch 2002



Busch 2007



Busch 2008







Bircan 2008








Risk of bias


















2012)


Hakkinen 2001












Risk of bias















Jones 2002












Risk of bias















Kayo 2011












Risk of bias

















Valkeinen 2004












Risk of bias


























Dal 2011 Not an RCT















(Continued)






















(Continued)









Adsuar 2012

Methods Unknown

Participants


Outcomes


Amanollahi 2013

Methods Unknown

Participants


Outcomes




Aslan 2001

Methods RCT





Bland 2010

Methods

Participants

Interventions

Outcomes

Notes

Ekici 2008

Methods RCT





Thijssen 1992

Methods Unknown



Outcomes Unknown




Wright 2012

Methods

Participants

Interventions

Outcomes

Notes







studies

No of









studies

No of







studies

No of





studies

No of





studies

No of


















studies

No of















DifferenceMean

Difference

NMean(SD)[FIQ



Kayo 2011 30 -2491 (1534) 30 -816 (1005) -1675 [ -2331 -1019 ]

-20 -10 0 10 20








Difference


Hakkinen 2001 11 -10 (126491) 10 0 (802773) 215 -1000 [ -1898 -102 ]

Valkeinen 2004 13 -6667 (8944) 13 333 (10541) 307 -1000 [ -1751 -249 ]

Kayo 2011 30 -724 (1197) 30 -5 (1181) 478 -224 [ -826 378 ]

Total (95 CI) 54 53 1000 -629 [ -1045 -213 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


Hakkinen 2001 11 -24 (1503) 10 25 (1641) 487 -490 [ -625 -355 ]

Kayo 2011 30 -394 (202) 30 -215 (156) 513 -179 [ -270 -088 ]

Total (95 CI) 41 40 1000 -330 [ -635 -026 ]




-10 -5 0 5 10








Difference


Hakkinen 2001 11 -1 (2683) 10 1 (1265) 185 -200 [ -377 -023 ]

Valkeinen 2004 13 -19 (151) 13 02 (114) 547 -210 [ -313 -107 ]

Kayo 2011 30 -507 (316) 30 -387 (263) 268 -120 [ -267 027 ]

Total (95 CI) 54 53 1000 -184 [ -260 -108 ]




-100 -50 0 50 100





leg extension






Difference


Hakkinen 2001 11 25 (1399) 10 1 (1726) 447 2400 [ 1048 3752 ]

Valkeinen 2004 13 30 (1844) 13 0 (1264) 553 3000 [ 1785 4215 ]

Total (95 CI) 24 23 1000 2732 [ 1828 3636 ]




-100 -50 0 50 100







Outcome 6 Fatigue



Difference


Hakkinen 2001 11 -19 (1513) 10 1 (1881) 254 -2000 [ -3169 -831 ]

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 746 -1285 [ -1967 -603 ]

Total (95 CI) 41 40 1000 -1466 [ -2055 -877 ]




-20 -10 0 10 20







DifferenceMean

Difference


Hakkinen 2001 11 -26 (1565) 10 14 (1762) -4000 [ -5431 -2569 ]

-100 -50 0 50 100









DifferenceMean

Difference


Kayo 2011 30 -873 (161) 30 -587 (1338) -286 [ -1035 463 ]

-100 -50 0 50 100







DifferenceMean

Difference


Hakkinen 2001 11 -28 (313) 10 09 (31) -370 [ -637 -103 ]

-100 -50 0 50 100







Outcome 10 Sleep


DifferenceMean

Difference


Hakkinen 2001 11 -10 (1448) 10 -3 (1744) -700 [ -2079 679 ]

-100 -50 0 50 100







DifferenceMean

Difference

NMean(SD)[m

(jump)] NMean(SD)[m


Hakkinen 2001 11 0015 (0009) 10 -001 (00054) 002 [ 001 003 ]

-01 -005 0 005 01









StdMean

Difference Weight

StdMean

Difference

NMean(SD)[cmˆ2



Hakkinen 2001 11 406 (298318) 10 139 (364077) 427 077 [ -012 167 ]

Valkeinen 2004 13 268 (434497) 13 151 (439434) 573 026 [ -051 103 ]

Total (95 CI) 24 23 1000 048 [ -011 106 ]




-100 -50 0 50 100








Difference


Hakkinen 2001 11 2958 (1082) 10 -1071 (779) 857 4029 [ 3228 4830 ]

Valkeinen 2004 13 5663 (2835) 13 1191 (2239) 143 4472 [ 2508 6436 ]

Total (95 CI) 24 23 1000 4092 [ 3350 4834 ]




-50 -25 0 25 50










Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 230 350 [ 079 1549 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Total (95 CI) 54 53 350 [ 079 1549 ]





0001 001 01 1 10 100 1000







DifferenceMean

Difference


Kayo 2011 30 -1585 (125) 30 -2133 (1279) 548 [ -092 1188 ]

-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF36

PF] NMean(SD)[SF36


Bircan 2008 13 1231 (1345) 13 10 (1297) 264 231 [ -785 1247 ]

Kayo 2011 30 117 (1213) 30 4 (1188) 736 -283 [ -891 325 ]

Total (95 CI) 43 43 1000 -148 [ -669 374 ]




-20 -10 0 10 20

Favors RE Favors AE




Outcome 3 Pain



Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -256 (135) 13 -388 (1183) 488 132 [ 034 230 ]

Kayo 2011 30 -277 (195) 30 -344 (181) 512 067 [ -028 162 ]

Total (95 CI) 43 43 1000 099 [ 031 167 ]




-4 -2 0 2 4

Favors RE Favors AE








StdMean

Difference Weight

StdMean

Difference


Bircan 2008 13 -616 (135) 13 -538 (137) 293 -056 [ -134 023 ]

Kayo 2011 30 -98 (792) 30 -1027 (1046) 707 005 [ -046 056 ]

Total (95 CI) 43 43 1000 -013 [ -055 030 ]




-2 -1 0 1 2

Favors RE Favors AE




Outcome 5 Fatigue



Difference


Bircan 2008 13 -281 (1736) 13 -339 (148) 206 580 [ -660 1820 ]

Kayo 2011 30 -828 (1271) 30 -866 (1228) 794 038 [ -594 670 ]

Total (95 CI) 43 43 1000 150 [ -414 713 ]




-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF-



Bircan 2008 13 1201 (13135) 13 893 (12328) 367 308 [ -671 1287 ]

Kayo 2011 30 -587 (1488) 30 -56 (1461) 633 -027 [ -773 719 ]

Total (95 CI) 43 43 1000 096 [ -497 690 ]




-10 -5 0 5 10

Favors AE Favors RE




Outcome 7 Sleep


DifferenceMean

Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -188 (188) 13 -335 (121) 147 [ 025 269 ]

-4 -2 0 2 4

Favors RE Favors AE








DifferenceMean

Difference

NMean(SD)[HAD

dep] NMean(SD)[HAD


Bircan 2008 13 -254 (273) 13 -2 (246) -054 [ -254 146 ]

-4 -2 0 2 4

Favors RE Favors AE




Outcome 9 Anxiety


DifferenceMean

Difference

NMean(SD)[HAD

anx] NMean(SD)[HAD


Bircan 2008 13 -054 (275) 13 -115 (268) 061 [ -148 270 ]

-20 -10 0 10 20

Favors RE Favors AE








DifferenceMean

Difference



Bircan 2008 13 7661 (4704) 13 4085 (5963) 3576 [ -553 7705 ]

-100 -50 0 50 100

Favors AE Favors RE







Odds Ratio


Bircan 2008 215 215 486 100 [ 013 792 ]

Kayo 2011 230 230 514 100 [ 013 748 ]

Total (95 CI) 45 45 1000 100 [ 024 423 ]





0005 01 1 10 200









DifferenceMean

Difference


Jones 2002 28 -1027 (1032) 28 -378 (1276) -649 [ -1257 -041 ]

-20 -10 0 10 20

Favors RE Favors FX




Outcome 2 Pain


DifferenceMean

Difference


Jones 2002 28 -189 (131) 28 -101 (131) -088 [ -157 -019 ]

-2 -1 0 1 2

Favors RE Favors FX








DifferenceMean

Difference


Jones 2002 28 -146 (193) 28 -1 (224) -046 [ -156 064 ]

-4 -2 0 2 4

Favors RE Favors FX




Outcome 4 Strength


DifferenceMean

Difference


Jones 2002 28 1447 (1399) 28 97 (1336) 477 [ -240 1194 ]

-20 -10 0 10 20

Favors FX Favors RE








DifferenceMean

Difference


Jones 2002 28 3445 (10992) 28 661 (1062) -3165 [ -8826 2496 ]

-200 -100 0 100 200

Favors FX Favors RE




Outcome 6 Fatigue


StdMean

Difference

StdMean

Difference


Jones 2002 28 -243 (125) 28 -068 (148) -126 [ -184 -068 ]

-4 -2 0 2 4

Favors RE Favors FX






Outcome 7 Sleep


DifferenceMean

Difference


Jones 2002 28 -23 (165) 28 -053 (161) -177 [ -262 -092 ]

-4 -2 0 2 4

Favors RE Favors FX






DifferenceMean

Difference


Jones 2002 28 -367 (423) 28 -184 (403) -183 [ -399 033 ]

-10 -5 0 5 10

Favors RE Favors FX






Outcome 9 Anxiety


DifferenceMean

Difference


Jones 2002 28 -25 (584) 28 07 (645) -320 [ -642 002 ]

-10 -5 0 5 10

Favors RE Favors FX






DifferenceMean

Difference

NMean(SD)[4-



Jones 2002 28 -115 (051) 28 -145 (06) 030 [ 001 059 ]

-2 -1 0 1 2

Favors RE Favors FX









Jones 2002 628 628 100 [ 037 273 ]

01 02 05 1 2 5 10

Favors RT Favors FX




Outcome 1 Attrition



1 RT vs control

Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 730 100 [ 030 331 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Subtotal (95 CI) 54 53 100 [ 030 331 ]




2 RT vs AE

Bircan 2008 215 215 100 [ 012 821 ]

Kayo 2011 730 830 084 [ 026 270 ]

Subtotal (95 CI) 45 45 087 [ 031 243 ]


002 01 1 10 50


(Continued )







3 RT vs flexibility

Jones 2002 628 628 100 [ 028 358 ]

Subtotal (95 CI) 28 28 100 [ 028 358 ]




Total (95 CI) 127 126 094 [ 049 183 ]





002 01 1 10 50





function






Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -598 (1199) 380 -987 [ -1607 -367 ]

Subtotal (95 CI) 30 30 380 -987 [ -1607 -367 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -816 (1005) 339 -1675 [ -2331 -1019 ]

Subtotal (95 CI) 30 30 339 -1675 [ -2331 -1019 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -619 (1117) 281 -1067 [ -1788 -346 ]

Subtotal (95 CI) 30 30 281 -1067 [ -1788 -346 ]



Total (95 CI) 90 90 1000 -1243 [ -1625 -861 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -05 (1142) 338 -067 [ -663 529 ]

Subtotal (95 CI) 30 30 338 -067 [ -663 529 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -5 (1181) 332 -224 [ -826 378 ]

Subtotal (95 CI) 30 30 332 -224 [ -826 378 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -517 (119) 330 100 [ -504 704 ]

Subtotal (95 CI) 30 30 330 100 [ -504 704 ]



Total (95 CI) 90 90 1000 -064 [ -411 283 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -209 (176) 321 -068 [ -162 026 ]

Subtotal (95 CI) 30 30 321 -068 [ -162 026 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -215 (156) 340 -179 [ -270 -088 ]

Subtotal (95 CI) 30 30 340 -179 [ -270 -088 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -189 (168) 339 -085 [ -177 007 ]

Subtotal (95 CI) 30 30 339 -085 [ -177 007 ]



Total (95 CI) 90 90 1000 -112 [ -165 -058 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -954 (769) 418 -026 [ -421 369 ]

Subtotal (95 CI) 30 30 418 -026 [ -421 369 ]



2 16 wk

Kayo 2011 30 -1529 (949) 30 -116 (79) 334 -369 [ -811 073 ]

Subtotal (95 CI) 30 30 334 -369 [ -811 073 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -1064 (951) 247 -192 [ -706 322 ]

Subtotal (95 CI) 30 30 247 -192 [ -706 322 ]



Total (95 CI) 90 90 1000 -182 [ -437 074 ]




-100 -50 0 50 100







Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -993 (1339) 356 165 [ -496 826 ]

Subtotal (95 CI) 30 30 356 165 [ -496 826 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 334 -1285 [ -1967 -603 ]

Subtotal (95 CI) 30 30 334 -1285 [ -1967 -603 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -277 (1313) 311 -911 [ -1618 -204 ]

Subtotal (95 CI) 30 30 311 -911 [ -1618 -204 ]



Total (95 CI) 90 90 1000 -653 [ -1047 -259 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -533 (1334) 356 -054 [ -769 661 ]

Subtotal (95 CI) 30 30 356 -054 [ -769 661 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -587 (1338) 324 -286 [ -1035 463 ]

Subtotal (95 CI) 30 30 324 -286 [ -1035 463 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -547 (1409) 320 054 [ -701 809 ]

Subtotal (95 CI) 30 30 320 054 [ -701 809 ]



Total (95 CI) 90 90 1000 -095 [ -521 332 ]




-100 -50 0 50 100











Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -2133 (1279) 416 548 [ -092 1188 ]

Subtotal (95 CI) 30 30 416 548 [ -092 1188 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -263 (139) 311 139 [ -602 880 ]

Subtotal (95 CI) 30 30 311 139 [ -602 880 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -2457 (1434) 273 771 [ -019 1561 ]

Subtotal (95 CI) 30 30 273 771 [ -019 1561 ]



Total (95 CI) 90 90 1000 482 [ 069 895 ]




-20 -10 0 10 20

Favors AE Favors RT




function






Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -4 (1188) 353 283 [ -325 891 ]

Subtotal (95 CI) 30 30 353 283 [ -325 891 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -1167 (125) 339 443 [ -176 1062 ]

Subtotal (95 CI) 30 30 339 443 [ -176 1062 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -13 (1367) 308 883 [ 233 1533 ]

Subtotal (95 CI) 30 30 308 883 [ 233 1533 ]



Total (95 CI) 90 90 1000 522 [ 161 883 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -344 (181) 357 067 [ -028 162 ]

Subtotal (95 CI) 30 30 357 067 [ -028 162 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -327 (192) 326 -067 [ -167 033 ]

Subtotal (95 CI) 30 30 326 -067 [ -167 033 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -357 (206) 317 083 [ -018 184 ]

Subtotal (95 CI) 30 30 317 083 [ -018 184 ]



Total (95 CI) 90 90 1000 028 [ -028 085 ]




-2 -1 0 1 2

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -1027 (1046) 373 047 [ -422 516 ]

Subtotal (95 CI) 30 30 373 047 [ -422 516 ]



2 16 wk

Kayo 2011 30 -152 (949) 30 -1384 (1072) 313 -136 [ -648 376 ]

Subtotal (95 CI) 30 30 313 -136 [ -648 376 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -154 (941) 314 284 [ -228 796 ]

Subtotal (95 CI) 30 30 314 284 [ -228 796 ]



Total (95 CI) 90 90 1000 064 [ -223 351 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -866 (1228) 361 038 [ -594 670 ]

Subtotal (95 CI) 30 30 361 038 [ -594 670 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -1256 (1143) 318 -356 [ -1030 318 ]

Subtotal (95 CI) 30 30 318 -356 [ -1030 318 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -135 (1152) 321 162 [ -508 832 ]

Subtotal (95 CI) 30 30 321 162 [ -508 832 ]



Total (95 CI) 90 90 1000 -047 [ -427 333 ]




-10 -5 0 5 10

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -56 (1461) 349 -027 [ -773 719 ]

Subtotal (95 CI) 30 30 349 -027 [ -773 719 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -1347 (1457) 322 474 [ -303 1251 ]

Subtotal (95 CI) 30 30 322 474 [ -303 1251 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -1387 (1463) 330 894 [ 126 1662 ]

Subtotal (95 CI) 30 30 330 894 [ 126 1662 ]



Total (95 CI) 90 90 1000 438 [ -003 878 ]




-20 -10 0 10 20

Favors AE Favors RT



Term Definition
























































2 AQ-MX Control










Joshi 2009 2 MX Med

















McCain 1988 2 AE FX






















2 AQ-MX Control


Valim 2003 2 AE FX













A P P E N D I C E S
















































Level one screen


Level two screen


Level three screen



















H I S T O R Y





















bull None known


Internal sources


External sources


N O T E S

















A B S T R A C T

Background


Objectives


Search methods


Selection criteria






Main results









Research question






















Tenderness




Muscle strength










Quality of evidence










Comparison Control


(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion

FIQ Total Score

Scale 0-100 (lower


health)

Follow-up 16 weeks




trol group was

-816 FIQ units1





-2491 FIQ units1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD -127 (95 CI -183

to -072)8



31 to -1019)



cise group7

NNTB 2 (95 CI 1 to 3)


function

Health Assessment





better health)





control groups was

-201 units1





-767 units1

- 107

(3 studies2)

oplusopluscopycopy

low910

SMD -05 (95 CI -089

to -011) 11


units (95 CI -1045 to -

213)


1448 (95 CI 49 to


groups

NNTB 5 (95 CI 3 to 22)

5R

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Pain

Visual analog scale






control groups was

-099 cm1




-353 cm1

81

(2 studies2)

oplusopluscopycopy

low91012

SMD -189 (95 CI -386

to 007)8


cm (95 CI -635 to -0

26)


446 (95 CI 35 to


groups7

NNTB 2 (95 CI 1 to 34)

Tenderness


myalgic scores




derness)





-20 tender points1

The estimated mean



vention groups was

-35 tender points1

- 107

(3 studies2)

oplusopluscopycopy

low91012SMD -073 (95 CI -112

to -033)8



6 to -108)


128 (95 CI 749 to


cise groups

NNTB 4 (95 CI 3 to 7)

Muscle strength



in kg)

Follow-up 21 weeks




was 044 kg1




tion groups was

2771 kg1

- 47

(2 studies2)

oplusopluscopycopy

low91012

SMD 167 (95 CI 098

to 235)8


kg (95 CI 1828 to 36

36)


25 (95 CI 17 to


groups7

NNTB 2 (95 CI 1 to 3)





6R

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studies)

All-cause attrition

Dropout rates


39 per 1000 134 per 1000

(95 CI 30 to 439)

RR 350 (079 to 1549) 107

(3 studies2)

oplusopluscopycopy

low9


(95 CI -2 to 20)


250 (95 CI -21 to

1449)


cant




difference









7R

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B A C K G R O U N D














O B J E C T I V E S







M E T H O D S


Types of studies






































adaptation













Major outcomes



Minor outcomes












Electronic searches















Review team






















Data synthesis

















R E S U L T S










Included studies



Excluded studies







study





Allocation


Blinding




Selective reporting



































(95 CI)

No of Participants

(studies)


(GRADE)

Comments7




tion




Follow-up 8 weeks





-2133 FIQ units1





was

-1585 FIQ units 1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD 043 (95 CI -008

to 094)6



to 1188)


cant


function




greater health)

Follow-up 8 weeks





was

581 SF-36 units 1





was

454 SF-36 units 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -011 (95 CI -053

to 031) 6



69 to 374)6


cant

Pain



indicate less pain)

Follow-up 8 weeks




was

-357 cm12




was

-27 cm 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD 053 (95 CI 010

to 097)8


cm (95 CI 031 to 167)


24

Resista

nce

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7 129 (95 CI 405



NNTB 5 (95 CI 3 to 24)

Tenderness



converted to tender



derness)

Follow-up 8 weeks




groups was

-515 tender points1




groups was

-49 tender points 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -013 (95 CI -055

to 03)6



68 to 033)


cant







studies)

All-cause attrition

Dropout rates

Follow-up 8 weeks

89 per 1000 89 per 1000

(22 to 296)

Peto OR 1

(024 to 423)

90

(2 studies2)

oplusopluscopycopy

low


(95 CI -12 to 12)


0


cant









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26

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Settings USA




(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion



greater health)

Follow-up 12 weeks




-378 FIQ units 1




group was

-1027 units 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -055 (95 CI -109

to -002) 6



57 to -041)



tance group


cant

Pain

VAS 0-10 cm (lower


Follow-up 12 weeks




-101 cm 1




was

-189 cm 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -066 (95 CI -12

to -012)6


cm (95 CI -157 to -0

19)12


14 (95 CI 30 to 24


tance group


cant27

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Tenderness

Tender point count

scores 0-18 (lower


derness)

Follow-up 12 weeks



group was

-1 tender points 1



training group was


- 56

(1 study)

oplusopluscopycopy

low23

SMD -022 (95 CI -074

to 031)7



56 to 064)


cant

Strength

Maximal isokinetic



in foot-pounds8

Follow-up 12 weeks

The mean change in


group was

97 foot-pounds 1

The mean change in


training group was

1447 foot-pounds 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD 034 (95 CI -018

to 087)7



40 to 1194)


cant



All-cause attrition

Dropout rates

Follow-up 12 weeks

214 per 1000 214 per 1000 RR 100 (037 to 273) 56

(1 study)

oplusopluscopycopy

low23



0


cant










8R

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nce

exerc

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29

Resista

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D I S C U S S I O N

























































R E F E R E N C E S















200133(4)162ndash9




(5)573ndash8

















(10)1107ndash13



















200122310ndash32





19974275ndash91









(MayJune)80










200231(5)306ndash10

























199457(4)45ndash9



























199623(7)1237ndash45









201252(1)85ndash91



(10)616ndash22





2010254(1735)8ndash10










ACSM 2009a



ACSM 2009b



Alentorn-Geli 2008


(8)975ndash81

Altan 2004




Altan 2009


Anderson 1995


Arcos-Carmona 2011


(9)398ndash491

Arnold 2008


Asikainen 2004



Assis 2006


Baptista 2012



Bengtsson 1986a



Bengtsson 1986b



Bennett 1989


198932(4)454ndash60

Bennett 1999


Bennett 2009



Bernardy 2013



Birse 2012



Bojner Horwitz 2006


Boomershine 2012


Brachaniec 2009


Braith 2006


2006113(22)2642ndash50

Branco 2010



Bressan 2008



(2)88ndash93

Brosse 2002


(12)741ndash60



Brosseau 2008


200888(7)873ndash86

Buchheld 2001



Buckelew 1998



Burckhardt 1993



Burckhardt 1994



Burckhardt 2005


Calandre 2009



Callahan 1988


198815(3)418ndash26

Carson 2010


Carson 2012



Carville 2008


Carville 2008a


Caspersen 1985



Cedraschi 2004


Cheung 2003


Chodzko-Zajko 2009



Choy 2009a


Choy 2009b


200935(2)329ndash37

Clauw 2011


Cohen 1988


Costill 1979


Crosier 2002






Da Costa 2005


Dadabhoy 2008


Therapy 200810(4)211

De Andrade 2008




Demir-Gocmen 2013


Deschenes 2002



Desmeules 2003



Dunn 2001


Dworkin 2008


Elvin 2006


Etnier 2009


Evcik 2008



Faigenbaum 2009



Field 2003



Figueroa 2008



FitzerGerald 2004



Fontaine 2007


Fontaine 2010


Fontaine 2011


Garber 2011







Genc 2002



Gibson 2006


Gowans 1999


199912(2)120ndash8

Gowans 2001


Gracely 2003



Gusi 2006



Gusi 2008


Gusi 2010








Hammond 2006


Hawley 1991


Hecker 2011


Heyward 1998



Heyward 2010



Hibbert 2008



Higgins 2011a


Higgins 2011b


Higgins 2011c


Holloszy 1984



Hooten 2012





Howley 2001



Hunt 2000


Haumluser 2013



Ide 2008


200811(2)131ndash40

Isomeri 1993



Jentoft 2001



Jones 2007


Jones 2008


Jones 2009


Jones 2012


Joshi 2009



Jubrias 1994


(6)801ndash7

Katzmarzyk 2002


200234(5)740ndash4

Keel 1998


King 1997


1997277(1)32ndash7

King 2002



Kingsley 2009



Kingsley 2011



Knutzen 2007


Koltyn 1998


Lefebvre 2011


Lemstra 2005






Lewis 2012


201231(2)255ndash62

Liu 2012


(11)657ndash64



Lorig 1989



Lund 1986



Lynch 2012



Mannerkorpi 2000


Mannerkorpi 2009


Mannerkorpi 2010


201012(5)R189

Martin 1996





201246(3)199ndash206

Matsutani 2007



Matsutani 2012


(2)411ndash8

McCain 1988


McNalley 2006


Mease 2005


Mease 2008


Mease 2009


200936(10)2318ndash29

Mengshoel 1992


Mengshoel 1993


Merskey 1994




Mitchell 2002




Mizelle 2011


(8)310ndash6

Moore 2012


Morrissey 1995









Nelson 2007


Nichols 1994


Norregaard 1997


Olivares 2011


(8)723ndash8

Painter 1999



Park 1998


Park 2007


Philadelphia 2001


200181(10)1629ndash40

Raftery 2009


Ramsay 2000


RevMan 2012


Richards 2002


Rivera Redondo 2004


200451(2)184ndash92

Rooks 2007


(20)2192ndash200

Sale 1987


Sanudo 2010



Sanudo 2010a





Sanudo 2010c


Sanudo 2011


(6)521ndash6

Sanudo 2012



Schachter 2003


Schmidt 2011


Schuumlnermann 2009


Seidel 2013


Sencan 2004


Singh 1997


Smythe 1981


Tomas-Carus 2007


20073(1)33ndash7

Tomas-Carus 2007a



Tomas-Carus 2007b


Tomas-Carus 2007c


Tomas-Carus 2008



Tort 2012


Trew 2005


Valencia 2009



Valim 2003









Valkeinen 2008



van Koulil 2007



van Koulil 2010


van Tulder 2003


vanSanten 2002



vanSanten 2002a


Verstappen 1997


Wang 2010


(8)743ndash54

WHO 2012


Wigers 1996



Williams 2012


2012 Issue 11 [DOI 10100214651858CD007407]

Winkelmann 2012


(3)276ndash86

Wolfe 1990


Wolfe 1995


Wolfe 2010


201062(5)600ndash10

Wolfe 2011


Yunus 1981



Yunus 1982


Yunus 1984


Yuruk 2008




Zeng 2008




Busch 2001


Busch 2001a


Busch 2002



Busch 2007



Busch 2008







Bircan 2008








Risk of bias


















2012)


Hakkinen 2001












Risk of bias















Jones 2002












Risk of bias















Kayo 2011












Risk of bias

















Valkeinen 2004












Risk of bias


























Dal 2011 Not an RCT















(Continued)






















(Continued)









Adsuar 2012

Methods Unknown

Participants


Outcomes


Amanollahi 2013

Methods Unknown

Participants


Outcomes




Aslan 2001

Methods RCT





Bland 2010

Methods

Participants

Interventions

Outcomes

Notes

Ekici 2008

Methods RCT





Thijssen 1992

Methods Unknown



Outcomes Unknown




Wright 2012

Methods

Participants

Interventions

Outcomes

Notes







studies

No of









studies

No of







studies

No of





studies

No of





studies

No of


















studies

No of















DifferenceMean

Difference

NMean(SD)[FIQ



Kayo 2011 30 -2491 (1534) 30 -816 (1005) -1675 [ -2331 -1019 ]

-20 -10 0 10 20








Difference


Hakkinen 2001 11 -10 (126491) 10 0 (802773) 215 -1000 [ -1898 -102 ]

Valkeinen 2004 13 -6667 (8944) 13 333 (10541) 307 -1000 [ -1751 -249 ]

Kayo 2011 30 -724 (1197) 30 -5 (1181) 478 -224 [ -826 378 ]

Total (95 CI) 54 53 1000 -629 [ -1045 -213 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


Hakkinen 2001 11 -24 (1503) 10 25 (1641) 487 -490 [ -625 -355 ]

Kayo 2011 30 -394 (202) 30 -215 (156) 513 -179 [ -270 -088 ]

Total (95 CI) 41 40 1000 -330 [ -635 -026 ]




-10 -5 0 5 10








Difference


Hakkinen 2001 11 -1 (2683) 10 1 (1265) 185 -200 [ -377 -023 ]

Valkeinen 2004 13 -19 (151) 13 02 (114) 547 -210 [ -313 -107 ]

Kayo 2011 30 -507 (316) 30 -387 (263) 268 -120 [ -267 027 ]

Total (95 CI) 54 53 1000 -184 [ -260 -108 ]




-100 -50 0 50 100





leg extension






Difference


Hakkinen 2001 11 25 (1399) 10 1 (1726) 447 2400 [ 1048 3752 ]

Valkeinen 2004 13 30 (1844) 13 0 (1264) 553 3000 [ 1785 4215 ]

Total (95 CI) 24 23 1000 2732 [ 1828 3636 ]




-100 -50 0 50 100







Outcome 6 Fatigue



Difference


Hakkinen 2001 11 -19 (1513) 10 1 (1881) 254 -2000 [ -3169 -831 ]

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 746 -1285 [ -1967 -603 ]

Total (95 CI) 41 40 1000 -1466 [ -2055 -877 ]




-20 -10 0 10 20







DifferenceMean

Difference


Hakkinen 2001 11 -26 (1565) 10 14 (1762) -4000 [ -5431 -2569 ]

-100 -50 0 50 100









DifferenceMean

Difference


Kayo 2011 30 -873 (161) 30 -587 (1338) -286 [ -1035 463 ]

-100 -50 0 50 100







DifferenceMean

Difference


Hakkinen 2001 11 -28 (313) 10 09 (31) -370 [ -637 -103 ]

-100 -50 0 50 100







Outcome 10 Sleep


DifferenceMean

Difference


Hakkinen 2001 11 -10 (1448) 10 -3 (1744) -700 [ -2079 679 ]

-100 -50 0 50 100







DifferenceMean

Difference

NMean(SD)[m

(jump)] NMean(SD)[m


Hakkinen 2001 11 0015 (0009) 10 -001 (00054) 002 [ 001 003 ]

-01 -005 0 005 01









StdMean

Difference Weight

StdMean

Difference

NMean(SD)[cmˆ2



Hakkinen 2001 11 406 (298318) 10 139 (364077) 427 077 [ -012 167 ]

Valkeinen 2004 13 268 (434497) 13 151 (439434) 573 026 [ -051 103 ]

Total (95 CI) 24 23 1000 048 [ -011 106 ]




-100 -50 0 50 100








Difference


Hakkinen 2001 11 2958 (1082) 10 -1071 (779) 857 4029 [ 3228 4830 ]

Valkeinen 2004 13 5663 (2835) 13 1191 (2239) 143 4472 [ 2508 6436 ]

Total (95 CI) 24 23 1000 4092 [ 3350 4834 ]




-50 -25 0 25 50










Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 230 350 [ 079 1549 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Total (95 CI) 54 53 350 [ 079 1549 ]





0001 001 01 1 10 100 1000







DifferenceMean

Difference


Kayo 2011 30 -1585 (125) 30 -2133 (1279) 548 [ -092 1188 ]

-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF36

PF] NMean(SD)[SF36


Bircan 2008 13 1231 (1345) 13 10 (1297) 264 231 [ -785 1247 ]

Kayo 2011 30 117 (1213) 30 4 (1188) 736 -283 [ -891 325 ]

Total (95 CI) 43 43 1000 -148 [ -669 374 ]




-20 -10 0 10 20

Favors RE Favors AE




Outcome 3 Pain



Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -256 (135) 13 -388 (1183) 488 132 [ 034 230 ]

Kayo 2011 30 -277 (195) 30 -344 (181) 512 067 [ -028 162 ]

Total (95 CI) 43 43 1000 099 [ 031 167 ]




-4 -2 0 2 4

Favors RE Favors AE








StdMean

Difference Weight

StdMean

Difference


Bircan 2008 13 -616 (135) 13 -538 (137) 293 -056 [ -134 023 ]

Kayo 2011 30 -98 (792) 30 -1027 (1046) 707 005 [ -046 056 ]

Total (95 CI) 43 43 1000 -013 [ -055 030 ]




-2 -1 0 1 2

Favors RE Favors AE




Outcome 5 Fatigue



Difference


Bircan 2008 13 -281 (1736) 13 -339 (148) 206 580 [ -660 1820 ]

Kayo 2011 30 -828 (1271) 30 -866 (1228) 794 038 [ -594 670 ]

Total (95 CI) 43 43 1000 150 [ -414 713 ]




-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF-



Bircan 2008 13 1201 (13135) 13 893 (12328) 367 308 [ -671 1287 ]

Kayo 2011 30 -587 (1488) 30 -56 (1461) 633 -027 [ -773 719 ]

Total (95 CI) 43 43 1000 096 [ -497 690 ]




-10 -5 0 5 10

Favors AE Favors RE




Outcome 7 Sleep


DifferenceMean

Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -188 (188) 13 -335 (121) 147 [ 025 269 ]

-4 -2 0 2 4

Favors RE Favors AE








DifferenceMean

Difference

NMean(SD)[HAD

dep] NMean(SD)[HAD


Bircan 2008 13 -254 (273) 13 -2 (246) -054 [ -254 146 ]

-4 -2 0 2 4

Favors RE Favors AE




Outcome 9 Anxiety


DifferenceMean

Difference

NMean(SD)[HAD

anx] NMean(SD)[HAD


Bircan 2008 13 -054 (275) 13 -115 (268) 061 [ -148 270 ]

-20 -10 0 10 20

Favors RE Favors AE








DifferenceMean

Difference



Bircan 2008 13 7661 (4704) 13 4085 (5963) 3576 [ -553 7705 ]

-100 -50 0 50 100

Favors AE Favors RE







Odds Ratio


Bircan 2008 215 215 486 100 [ 013 792 ]

Kayo 2011 230 230 514 100 [ 013 748 ]

Total (95 CI) 45 45 1000 100 [ 024 423 ]





0005 01 1 10 200









DifferenceMean

Difference


Jones 2002 28 -1027 (1032) 28 -378 (1276) -649 [ -1257 -041 ]

-20 -10 0 10 20

Favors RE Favors FX




Outcome 2 Pain


DifferenceMean

Difference


Jones 2002 28 -189 (131) 28 -101 (131) -088 [ -157 -019 ]

-2 -1 0 1 2

Favors RE Favors FX








DifferenceMean

Difference


Jones 2002 28 -146 (193) 28 -1 (224) -046 [ -156 064 ]

-4 -2 0 2 4

Favors RE Favors FX




Outcome 4 Strength


DifferenceMean

Difference


Jones 2002 28 1447 (1399) 28 97 (1336) 477 [ -240 1194 ]

-20 -10 0 10 20

Favors FX Favors RE








DifferenceMean

Difference


Jones 2002 28 3445 (10992) 28 661 (1062) -3165 [ -8826 2496 ]

-200 -100 0 100 200

Favors FX Favors RE




Outcome 6 Fatigue


StdMean

Difference

StdMean

Difference


Jones 2002 28 -243 (125) 28 -068 (148) -126 [ -184 -068 ]

-4 -2 0 2 4

Favors RE Favors FX






Outcome 7 Sleep


DifferenceMean

Difference


Jones 2002 28 -23 (165) 28 -053 (161) -177 [ -262 -092 ]

-4 -2 0 2 4

Favors RE Favors FX






DifferenceMean

Difference


Jones 2002 28 -367 (423) 28 -184 (403) -183 [ -399 033 ]

-10 -5 0 5 10

Favors RE Favors FX






Outcome 9 Anxiety


DifferenceMean

Difference


Jones 2002 28 -25 (584) 28 07 (645) -320 [ -642 002 ]

-10 -5 0 5 10

Favors RE Favors FX






DifferenceMean

Difference

NMean(SD)[4-



Jones 2002 28 -115 (051) 28 -145 (06) 030 [ 001 059 ]

-2 -1 0 1 2

Favors RE Favors FX









Jones 2002 628 628 100 [ 037 273 ]

01 02 05 1 2 5 10

Favors RT Favors FX




Outcome 1 Attrition



1 RT vs control

Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 730 100 [ 030 331 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Subtotal (95 CI) 54 53 100 [ 030 331 ]




2 RT vs AE

Bircan 2008 215 215 100 [ 012 821 ]

Kayo 2011 730 830 084 [ 026 270 ]

Subtotal (95 CI) 45 45 087 [ 031 243 ]


002 01 1 10 50


(Continued )







3 RT vs flexibility

Jones 2002 628 628 100 [ 028 358 ]

Subtotal (95 CI) 28 28 100 [ 028 358 ]




Total (95 CI) 127 126 094 [ 049 183 ]





002 01 1 10 50





function






Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -598 (1199) 380 -987 [ -1607 -367 ]

Subtotal (95 CI) 30 30 380 -987 [ -1607 -367 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -816 (1005) 339 -1675 [ -2331 -1019 ]

Subtotal (95 CI) 30 30 339 -1675 [ -2331 -1019 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -619 (1117) 281 -1067 [ -1788 -346 ]

Subtotal (95 CI) 30 30 281 -1067 [ -1788 -346 ]



Total (95 CI) 90 90 1000 -1243 [ -1625 -861 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -05 (1142) 338 -067 [ -663 529 ]

Subtotal (95 CI) 30 30 338 -067 [ -663 529 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -5 (1181) 332 -224 [ -826 378 ]

Subtotal (95 CI) 30 30 332 -224 [ -826 378 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -517 (119) 330 100 [ -504 704 ]

Subtotal (95 CI) 30 30 330 100 [ -504 704 ]



Total (95 CI) 90 90 1000 -064 [ -411 283 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -209 (176) 321 -068 [ -162 026 ]

Subtotal (95 CI) 30 30 321 -068 [ -162 026 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -215 (156) 340 -179 [ -270 -088 ]

Subtotal (95 CI) 30 30 340 -179 [ -270 -088 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -189 (168) 339 -085 [ -177 007 ]

Subtotal (95 CI) 30 30 339 -085 [ -177 007 ]



Total (95 CI) 90 90 1000 -112 [ -165 -058 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -954 (769) 418 -026 [ -421 369 ]

Subtotal (95 CI) 30 30 418 -026 [ -421 369 ]



2 16 wk

Kayo 2011 30 -1529 (949) 30 -116 (79) 334 -369 [ -811 073 ]

Subtotal (95 CI) 30 30 334 -369 [ -811 073 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -1064 (951) 247 -192 [ -706 322 ]

Subtotal (95 CI) 30 30 247 -192 [ -706 322 ]



Total (95 CI) 90 90 1000 -182 [ -437 074 ]




-100 -50 0 50 100







Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -993 (1339) 356 165 [ -496 826 ]

Subtotal (95 CI) 30 30 356 165 [ -496 826 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 334 -1285 [ -1967 -603 ]

Subtotal (95 CI) 30 30 334 -1285 [ -1967 -603 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -277 (1313) 311 -911 [ -1618 -204 ]

Subtotal (95 CI) 30 30 311 -911 [ -1618 -204 ]



Total (95 CI) 90 90 1000 -653 [ -1047 -259 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -533 (1334) 356 -054 [ -769 661 ]

Subtotal (95 CI) 30 30 356 -054 [ -769 661 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -587 (1338) 324 -286 [ -1035 463 ]

Subtotal (95 CI) 30 30 324 -286 [ -1035 463 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -547 (1409) 320 054 [ -701 809 ]

Subtotal (95 CI) 30 30 320 054 [ -701 809 ]



Total (95 CI) 90 90 1000 -095 [ -521 332 ]




-100 -50 0 50 100











Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -2133 (1279) 416 548 [ -092 1188 ]

Subtotal (95 CI) 30 30 416 548 [ -092 1188 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -263 (139) 311 139 [ -602 880 ]

Subtotal (95 CI) 30 30 311 139 [ -602 880 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -2457 (1434) 273 771 [ -019 1561 ]

Subtotal (95 CI) 30 30 273 771 [ -019 1561 ]



Total (95 CI) 90 90 1000 482 [ 069 895 ]




-20 -10 0 10 20

Favors AE Favors RT




function






Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -4 (1188) 353 283 [ -325 891 ]

Subtotal (95 CI) 30 30 353 283 [ -325 891 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -1167 (125) 339 443 [ -176 1062 ]

Subtotal (95 CI) 30 30 339 443 [ -176 1062 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -13 (1367) 308 883 [ 233 1533 ]

Subtotal (95 CI) 30 30 308 883 [ 233 1533 ]



Total (95 CI) 90 90 1000 522 [ 161 883 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -344 (181) 357 067 [ -028 162 ]

Subtotal (95 CI) 30 30 357 067 [ -028 162 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -327 (192) 326 -067 [ -167 033 ]

Subtotal (95 CI) 30 30 326 -067 [ -167 033 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -357 (206) 317 083 [ -018 184 ]

Subtotal (95 CI) 30 30 317 083 [ -018 184 ]



Total (95 CI) 90 90 1000 028 [ -028 085 ]




-2 -1 0 1 2

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -1027 (1046) 373 047 [ -422 516 ]

Subtotal (95 CI) 30 30 373 047 [ -422 516 ]



2 16 wk

Kayo 2011 30 -152 (949) 30 -1384 (1072) 313 -136 [ -648 376 ]

Subtotal (95 CI) 30 30 313 -136 [ -648 376 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -154 (941) 314 284 [ -228 796 ]

Subtotal (95 CI) 30 30 314 284 [ -228 796 ]



Total (95 CI) 90 90 1000 064 [ -223 351 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -866 (1228) 361 038 [ -594 670 ]

Subtotal (95 CI) 30 30 361 038 [ -594 670 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -1256 (1143) 318 -356 [ -1030 318 ]

Subtotal (95 CI) 30 30 318 -356 [ -1030 318 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -135 (1152) 321 162 [ -508 832 ]

Subtotal (95 CI) 30 30 321 162 [ -508 832 ]



Total (95 CI) 90 90 1000 -047 [ -427 333 ]




-10 -5 0 5 10

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -56 (1461) 349 -027 [ -773 719 ]

Subtotal (95 CI) 30 30 349 -027 [ -773 719 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -1347 (1457) 322 474 [ -303 1251 ]

Subtotal (95 CI) 30 30 322 474 [ -303 1251 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -1387 (1463) 330 894 [ 126 1662 ]

Subtotal (95 CI) 30 30 330 894 [ 126 1662 ]



Total (95 CI) 90 90 1000 438 [ -003 878 ]




-20 -10 0 10 20

Favors AE Favors RT



Term Definition
























































2 AQ-MX Control










Joshi 2009 2 MX Med

















McCain 1988 2 AE FX






















2 AQ-MX Control


Valim 2003 2 AE FX













A P P E N D I C E S
















































Level one screen


Level two screen


Level three screen



















H I S T O R Y





















bull None known


Internal sources


External sources


N O T E S











Main results









Research question






















Tenderness




Muscle strength










Quality of evidence










Comparison Control


(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion

FIQ Total Score

Scale 0-100 (lower


health)

Follow-up 16 weeks




trol group was

-816 FIQ units1





-2491 FIQ units1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD -127 (95 CI -183

to -072)8



31 to -1019)



cise group7

NNTB 2 (95 CI 1 to 3)


function

Health Assessment





better health)





control groups was

-201 units1





-767 units1

- 107

(3 studies2)

oplusopluscopycopy

low910

SMD -05 (95 CI -089

to -011) 11


units (95 CI -1045 to -

213)


1448 (95 CI 49 to


groups

NNTB 5 (95 CI 3 to 22)

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Pain

Visual analog scale






control groups was

-099 cm1




-353 cm1

81

(2 studies2)

oplusopluscopycopy

low91012

SMD -189 (95 CI -386

to 007)8


cm (95 CI -635 to -0

26)


446 (95 CI 35 to


groups7

NNTB 2 (95 CI 1 to 34)

Tenderness


myalgic scores




derness)





-20 tender points1

The estimated mean



vention groups was

-35 tender points1

- 107

(3 studies2)

oplusopluscopycopy

low91012SMD -073 (95 CI -112

to -033)8



6 to -108)


128 (95 CI 749 to


cise groups

NNTB 4 (95 CI 3 to 7)

Muscle strength



in kg)

Follow-up 21 weeks




was 044 kg1




tion groups was

2771 kg1

- 47

(2 studies2)

oplusopluscopycopy

low91012

SMD 167 (95 CI 098

to 235)8


kg (95 CI 1828 to 36

36)


25 (95 CI 17 to


groups7

NNTB 2 (95 CI 1 to 3)





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studies)

All-cause attrition

Dropout rates


39 per 1000 134 per 1000

(95 CI 30 to 439)

RR 350 (079 to 1549) 107

(3 studies2)

oplusopluscopycopy

low9


(95 CI -2 to 20)


250 (95 CI -21 to

1449)


cant




difference









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B A C K G R O U N D














O B J E C T I V E S







M E T H O D S


Types of studies






































adaptation













Major outcomes



Minor outcomes












Electronic searches















Review team






















Data synthesis

















R E S U L T S










Included studies



Excluded studies







study





Allocation


Blinding




Selective reporting



































(95 CI)

No of Participants

(studies)


(GRADE)

Comments7




tion




Follow-up 8 weeks





-2133 FIQ units1





was

-1585 FIQ units 1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD 043 (95 CI -008

to 094)6



to 1188)


cant


function




greater health)

Follow-up 8 weeks





was

581 SF-36 units 1





was

454 SF-36 units 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -011 (95 CI -053

to 031) 6



69 to 374)6


cant

Pain



indicate less pain)

Follow-up 8 weeks




was

-357 cm12




was

-27 cm 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD 053 (95 CI 010

to 097)8


cm (95 CI 031 to 167)


24

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7 129 (95 CI 405



NNTB 5 (95 CI 3 to 24)

Tenderness



converted to tender



derness)

Follow-up 8 weeks




groups was

-515 tender points1




groups was

-49 tender points 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -013 (95 CI -055

to 03)6



68 to 033)


cant







studies)

All-cause attrition

Dropout rates

Follow-up 8 weeks

89 per 1000 89 per 1000

(22 to 296)

Peto OR 1

(024 to 423)

90

(2 studies2)

oplusopluscopycopy

low


(95 CI -12 to 12)


0


cant









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26

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Settings USA




(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion



greater health)

Follow-up 12 weeks




-378 FIQ units 1




group was

-1027 units 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -055 (95 CI -109

to -002) 6



57 to -041)



tance group


cant

Pain

VAS 0-10 cm (lower


Follow-up 12 weeks




-101 cm 1




was

-189 cm 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -066 (95 CI -12

to -012)6


cm (95 CI -157 to -0

19)12


14 (95 CI 30 to 24


tance group


cant27

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Joh

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on

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td

Tenderness

Tender point count

scores 0-18 (lower


derness)

Follow-up 12 weeks



group was

-1 tender points 1



training group was


- 56

(1 study)

oplusopluscopycopy

low23

SMD -022 (95 CI -074

to 031)7



56 to 064)


cant

Strength

Maximal isokinetic



in foot-pounds8

Follow-up 12 weeks

The mean change in


group was

97 foot-pounds 1

The mean change in


training group was

1447 foot-pounds 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD 034 (95 CI -018

to 087)7



40 to 1194)


cant



All-cause attrition

Dropout rates

Follow-up 12 weeks

214 per 1000 214 per 1000 RR 100 (037 to 273) 56

(1 study)

oplusopluscopycopy

low23



0


cant










8R

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nce

exerc

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by

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29

Resista

nce

exerc

isetra

inin

gfo

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D I S C U S S I O N

























































R E F E R E N C E S















200133(4)162ndash9




(5)573ndash8

















(10)1107ndash13



















200122310ndash32





19974275ndash91









(MayJune)80










200231(5)306ndash10

























199457(4)45ndash9



























199623(7)1237ndash45









201252(1)85ndash91



(10)616ndash22





2010254(1735)8ndash10










ACSM 2009a



ACSM 2009b



Alentorn-Geli 2008


(8)975ndash81

Altan 2004




Altan 2009


Anderson 1995


Arcos-Carmona 2011


(9)398ndash491

Arnold 2008


Asikainen 2004



Assis 2006


Baptista 2012



Bengtsson 1986a



Bengtsson 1986b



Bennett 1989


198932(4)454ndash60

Bennett 1999


Bennett 2009



Bernardy 2013



Birse 2012



Bojner Horwitz 2006


Boomershine 2012


Brachaniec 2009


Braith 2006


2006113(22)2642ndash50

Branco 2010



Bressan 2008



(2)88ndash93

Brosse 2002


(12)741ndash60



Brosseau 2008


200888(7)873ndash86

Buchheld 2001



Buckelew 1998



Burckhardt 1993



Burckhardt 1994



Burckhardt 2005


Calandre 2009



Callahan 1988


198815(3)418ndash26

Carson 2010


Carson 2012



Carville 2008


Carville 2008a


Caspersen 1985



Cedraschi 2004


Cheung 2003


Chodzko-Zajko 2009



Choy 2009a


Choy 2009b


200935(2)329ndash37

Clauw 2011


Cohen 1988


Costill 1979


Crosier 2002






Da Costa 2005


Dadabhoy 2008


Therapy 200810(4)211

De Andrade 2008




Demir-Gocmen 2013


Deschenes 2002



Desmeules 2003



Dunn 2001


Dworkin 2008


Elvin 2006


Etnier 2009


Evcik 2008



Faigenbaum 2009



Field 2003



Figueroa 2008



FitzerGerald 2004



Fontaine 2007


Fontaine 2010


Fontaine 2011


Garber 2011







Genc 2002



Gibson 2006


Gowans 1999


199912(2)120ndash8

Gowans 2001


Gracely 2003



Gusi 2006



Gusi 2008


Gusi 2010








Hammond 2006


Hawley 1991


Hecker 2011


Heyward 1998



Heyward 2010



Hibbert 2008



Higgins 2011a


Higgins 2011b


Higgins 2011c


Holloszy 1984



Hooten 2012





Howley 2001



Hunt 2000


Haumluser 2013



Ide 2008


200811(2)131ndash40

Isomeri 1993



Jentoft 2001



Jones 2007


Jones 2008


Jones 2009


Jones 2012


Joshi 2009



Jubrias 1994


(6)801ndash7

Katzmarzyk 2002


200234(5)740ndash4

Keel 1998


King 1997


1997277(1)32ndash7

King 2002



Kingsley 2009



Kingsley 2011



Knutzen 2007


Koltyn 1998


Lefebvre 2011


Lemstra 2005






Lewis 2012


201231(2)255ndash62

Liu 2012


(11)657ndash64



Lorig 1989



Lund 1986



Lynch 2012



Mannerkorpi 2000


Mannerkorpi 2009


Mannerkorpi 2010


201012(5)R189

Martin 1996





201246(3)199ndash206

Matsutani 2007



Matsutani 2012


(2)411ndash8

McCain 1988


McNalley 2006


Mease 2005


Mease 2008


Mease 2009


200936(10)2318ndash29

Mengshoel 1992


Mengshoel 1993


Merskey 1994




Mitchell 2002




Mizelle 2011


(8)310ndash6

Moore 2012


Morrissey 1995









Nelson 2007


Nichols 1994


Norregaard 1997


Olivares 2011


(8)723ndash8

Painter 1999



Park 1998


Park 2007


Philadelphia 2001


200181(10)1629ndash40

Raftery 2009


Ramsay 2000


RevMan 2012


Richards 2002


Rivera Redondo 2004


200451(2)184ndash92

Rooks 2007


(20)2192ndash200

Sale 1987


Sanudo 2010



Sanudo 2010a





Sanudo 2010c


Sanudo 2011


(6)521ndash6

Sanudo 2012



Schachter 2003


Schmidt 2011


Schuumlnermann 2009


Seidel 2013


Sencan 2004


Singh 1997


Smythe 1981


Tomas-Carus 2007


20073(1)33ndash7

Tomas-Carus 2007a



Tomas-Carus 2007b


Tomas-Carus 2007c


Tomas-Carus 2008



Tort 2012


Trew 2005


Valencia 2009



Valim 2003









Valkeinen 2008



van Koulil 2007



van Koulil 2010


van Tulder 2003


vanSanten 2002



vanSanten 2002a


Verstappen 1997


Wang 2010


(8)743ndash54

WHO 2012


Wigers 1996



Williams 2012


2012 Issue 11 [DOI 10100214651858CD007407]

Winkelmann 2012


(3)276ndash86

Wolfe 1990


Wolfe 1995


Wolfe 2010


201062(5)600ndash10

Wolfe 2011


Yunus 1981



Yunus 1982


Yunus 1984


Yuruk 2008




Zeng 2008




Busch 2001


Busch 2001a


Busch 2002



Busch 2007



Busch 2008







Bircan 2008








Risk of bias


















2012)


Hakkinen 2001












Risk of bias















Jones 2002












Risk of bias















Kayo 2011












Risk of bias

















Valkeinen 2004












Risk of bias


























Dal 2011 Not an RCT















(Continued)






















(Continued)









Adsuar 2012

Methods Unknown

Participants


Outcomes


Amanollahi 2013

Methods Unknown

Participants


Outcomes




Aslan 2001

Methods RCT





Bland 2010

Methods

Participants

Interventions

Outcomes

Notes

Ekici 2008

Methods RCT





Thijssen 1992

Methods Unknown



Outcomes Unknown




Wright 2012

Methods

Participants

Interventions

Outcomes

Notes







studies

No of









studies

No of







studies

No of





studies

No of





studies

No of


















studies

No of















DifferenceMean

Difference

NMean(SD)[FIQ



Kayo 2011 30 -2491 (1534) 30 -816 (1005) -1675 [ -2331 -1019 ]

-20 -10 0 10 20








Difference


Hakkinen 2001 11 -10 (126491) 10 0 (802773) 215 -1000 [ -1898 -102 ]

Valkeinen 2004 13 -6667 (8944) 13 333 (10541) 307 -1000 [ -1751 -249 ]

Kayo 2011 30 -724 (1197) 30 -5 (1181) 478 -224 [ -826 378 ]

Total (95 CI) 54 53 1000 -629 [ -1045 -213 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


Hakkinen 2001 11 -24 (1503) 10 25 (1641) 487 -490 [ -625 -355 ]

Kayo 2011 30 -394 (202) 30 -215 (156) 513 -179 [ -270 -088 ]

Total (95 CI) 41 40 1000 -330 [ -635 -026 ]




-10 -5 0 5 10








Difference


Hakkinen 2001 11 -1 (2683) 10 1 (1265) 185 -200 [ -377 -023 ]

Valkeinen 2004 13 -19 (151) 13 02 (114) 547 -210 [ -313 -107 ]

Kayo 2011 30 -507 (316) 30 -387 (263) 268 -120 [ -267 027 ]

Total (95 CI) 54 53 1000 -184 [ -260 -108 ]




-100 -50 0 50 100





leg extension






Difference


Hakkinen 2001 11 25 (1399) 10 1 (1726) 447 2400 [ 1048 3752 ]

Valkeinen 2004 13 30 (1844) 13 0 (1264) 553 3000 [ 1785 4215 ]

Total (95 CI) 24 23 1000 2732 [ 1828 3636 ]




-100 -50 0 50 100







Outcome 6 Fatigue



Difference


Hakkinen 2001 11 -19 (1513) 10 1 (1881) 254 -2000 [ -3169 -831 ]

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 746 -1285 [ -1967 -603 ]

Total (95 CI) 41 40 1000 -1466 [ -2055 -877 ]




-20 -10 0 10 20







DifferenceMean

Difference


Hakkinen 2001 11 -26 (1565) 10 14 (1762) -4000 [ -5431 -2569 ]

-100 -50 0 50 100









DifferenceMean

Difference


Kayo 2011 30 -873 (161) 30 -587 (1338) -286 [ -1035 463 ]

-100 -50 0 50 100







DifferenceMean

Difference


Hakkinen 2001 11 -28 (313) 10 09 (31) -370 [ -637 -103 ]

-100 -50 0 50 100







Outcome 10 Sleep


DifferenceMean

Difference


Hakkinen 2001 11 -10 (1448) 10 -3 (1744) -700 [ -2079 679 ]

-100 -50 0 50 100







DifferenceMean

Difference

NMean(SD)[m

(jump)] NMean(SD)[m


Hakkinen 2001 11 0015 (0009) 10 -001 (00054) 002 [ 001 003 ]

-01 -005 0 005 01









StdMean

Difference Weight

StdMean

Difference

NMean(SD)[cmˆ2



Hakkinen 2001 11 406 (298318) 10 139 (364077) 427 077 [ -012 167 ]

Valkeinen 2004 13 268 (434497) 13 151 (439434) 573 026 [ -051 103 ]

Total (95 CI) 24 23 1000 048 [ -011 106 ]




-100 -50 0 50 100








Difference


Hakkinen 2001 11 2958 (1082) 10 -1071 (779) 857 4029 [ 3228 4830 ]

Valkeinen 2004 13 5663 (2835) 13 1191 (2239) 143 4472 [ 2508 6436 ]

Total (95 CI) 24 23 1000 4092 [ 3350 4834 ]




-50 -25 0 25 50










Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 230 350 [ 079 1549 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Total (95 CI) 54 53 350 [ 079 1549 ]





0001 001 01 1 10 100 1000







DifferenceMean

Difference


Kayo 2011 30 -1585 (125) 30 -2133 (1279) 548 [ -092 1188 ]

-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF36

PF] NMean(SD)[SF36


Bircan 2008 13 1231 (1345) 13 10 (1297) 264 231 [ -785 1247 ]

Kayo 2011 30 117 (1213) 30 4 (1188) 736 -283 [ -891 325 ]

Total (95 CI) 43 43 1000 -148 [ -669 374 ]




-20 -10 0 10 20

Favors RE Favors AE




Outcome 3 Pain



Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -256 (135) 13 -388 (1183) 488 132 [ 034 230 ]

Kayo 2011 30 -277 (195) 30 -344 (181) 512 067 [ -028 162 ]

Total (95 CI) 43 43 1000 099 [ 031 167 ]




-4 -2 0 2 4

Favors RE Favors AE








StdMean

Difference Weight

StdMean

Difference


Bircan 2008 13 -616 (135) 13 -538 (137) 293 -056 [ -134 023 ]

Kayo 2011 30 -98 (792) 30 -1027 (1046) 707 005 [ -046 056 ]

Total (95 CI) 43 43 1000 -013 [ -055 030 ]




-2 -1 0 1 2

Favors RE Favors AE




Outcome 5 Fatigue



Difference


Bircan 2008 13 -281 (1736) 13 -339 (148) 206 580 [ -660 1820 ]

Kayo 2011 30 -828 (1271) 30 -866 (1228) 794 038 [ -594 670 ]

Total (95 CI) 43 43 1000 150 [ -414 713 ]




-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF-



Bircan 2008 13 1201 (13135) 13 893 (12328) 367 308 [ -671 1287 ]

Kayo 2011 30 -587 (1488) 30 -56 (1461) 633 -027 [ -773 719 ]

Total (95 CI) 43 43 1000 096 [ -497 690 ]




-10 -5 0 5 10

Favors AE Favors RE




Outcome 7 Sleep


DifferenceMean

Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -188 (188) 13 -335 (121) 147 [ 025 269 ]

-4 -2 0 2 4

Favors RE Favors AE








DifferenceMean

Difference

NMean(SD)[HAD

dep] NMean(SD)[HAD


Bircan 2008 13 -254 (273) 13 -2 (246) -054 [ -254 146 ]

-4 -2 0 2 4

Favors RE Favors AE




Outcome 9 Anxiety


DifferenceMean

Difference

NMean(SD)[HAD

anx] NMean(SD)[HAD


Bircan 2008 13 -054 (275) 13 -115 (268) 061 [ -148 270 ]

-20 -10 0 10 20

Favors RE Favors AE








DifferenceMean

Difference



Bircan 2008 13 7661 (4704) 13 4085 (5963) 3576 [ -553 7705 ]

-100 -50 0 50 100

Favors AE Favors RE







Odds Ratio


Bircan 2008 215 215 486 100 [ 013 792 ]

Kayo 2011 230 230 514 100 [ 013 748 ]

Total (95 CI) 45 45 1000 100 [ 024 423 ]





0005 01 1 10 200









DifferenceMean

Difference


Jones 2002 28 -1027 (1032) 28 -378 (1276) -649 [ -1257 -041 ]

-20 -10 0 10 20

Favors RE Favors FX




Outcome 2 Pain


DifferenceMean

Difference


Jones 2002 28 -189 (131) 28 -101 (131) -088 [ -157 -019 ]

-2 -1 0 1 2

Favors RE Favors FX








DifferenceMean

Difference


Jones 2002 28 -146 (193) 28 -1 (224) -046 [ -156 064 ]

-4 -2 0 2 4

Favors RE Favors FX




Outcome 4 Strength


DifferenceMean

Difference


Jones 2002 28 1447 (1399) 28 97 (1336) 477 [ -240 1194 ]

-20 -10 0 10 20

Favors FX Favors RE








DifferenceMean

Difference


Jones 2002 28 3445 (10992) 28 661 (1062) -3165 [ -8826 2496 ]

-200 -100 0 100 200

Favors FX Favors RE




Outcome 6 Fatigue


StdMean

Difference

StdMean

Difference


Jones 2002 28 -243 (125) 28 -068 (148) -126 [ -184 -068 ]

-4 -2 0 2 4

Favors RE Favors FX






Outcome 7 Sleep


DifferenceMean

Difference


Jones 2002 28 -23 (165) 28 -053 (161) -177 [ -262 -092 ]

-4 -2 0 2 4

Favors RE Favors FX






DifferenceMean

Difference


Jones 2002 28 -367 (423) 28 -184 (403) -183 [ -399 033 ]

-10 -5 0 5 10

Favors RE Favors FX






Outcome 9 Anxiety


DifferenceMean

Difference


Jones 2002 28 -25 (584) 28 07 (645) -320 [ -642 002 ]

-10 -5 0 5 10

Favors RE Favors FX






DifferenceMean

Difference

NMean(SD)[4-



Jones 2002 28 -115 (051) 28 -145 (06) 030 [ 001 059 ]

-2 -1 0 1 2

Favors RE Favors FX









Jones 2002 628 628 100 [ 037 273 ]

01 02 05 1 2 5 10

Favors RT Favors FX




Outcome 1 Attrition



1 RT vs control

Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 730 100 [ 030 331 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Subtotal (95 CI) 54 53 100 [ 030 331 ]




2 RT vs AE

Bircan 2008 215 215 100 [ 012 821 ]

Kayo 2011 730 830 084 [ 026 270 ]

Subtotal (95 CI) 45 45 087 [ 031 243 ]


002 01 1 10 50


(Continued )







3 RT vs flexibility

Jones 2002 628 628 100 [ 028 358 ]

Subtotal (95 CI) 28 28 100 [ 028 358 ]




Total (95 CI) 127 126 094 [ 049 183 ]





002 01 1 10 50





function






Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -598 (1199) 380 -987 [ -1607 -367 ]

Subtotal (95 CI) 30 30 380 -987 [ -1607 -367 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -816 (1005) 339 -1675 [ -2331 -1019 ]

Subtotal (95 CI) 30 30 339 -1675 [ -2331 -1019 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -619 (1117) 281 -1067 [ -1788 -346 ]

Subtotal (95 CI) 30 30 281 -1067 [ -1788 -346 ]



Total (95 CI) 90 90 1000 -1243 [ -1625 -861 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -05 (1142) 338 -067 [ -663 529 ]

Subtotal (95 CI) 30 30 338 -067 [ -663 529 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -5 (1181) 332 -224 [ -826 378 ]

Subtotal (95 CI) 30 30 332 -224 [ -826 378 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -517 (119) 330 100 [ -504 704 ]

Subtotal (95 CI) 30 30 330 100 [ -504 704 ]



Total (95 CI) 90 90 1000 -064 [ -411 283 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -209 (176) 321 -068 [ -162 026 ]

Subtotal (95 CI) 30 30 321 -068 [ -162 026 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -215 (156) 340 -179 [ -270 -088 ]

Subtotal (95 CI) 30 30 340 -179 [ -270 -088 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -189 (168) 339 -085 [ -177 007 ]

Subtotal (95 CI) 30 30 339 -085 [ -177 007 ]



Total (95 CI) 90 90 1000 -112 [ -165 -058 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -954 (769) 418 -026 [ -421 369 ]

Subtotal (95 CI) 30 30 418 -026 [ -421 369 ]



2 16 wk

Kayo 2011 30 -1529 (949) 30 -116 (79) 334 -369 [ -811 073 ]

Subtotal (95 CI) 30 30 334 -369 [ -811 073 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -1064 (951) 247 -192 [ -706 322 ]

Subtotal (95 CI) 30 30 247 -192 [ -706 322 ]



Total (95 CI) 90 90 1000 -182 [ -437 074 ]




-100 -50 0 50 100







Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -993 (1339) 356 165 [ -496 826 ]

Subtotal (95 CI) 30 30 356 165 [ -496 826 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 334 -1285 [ -1967 -603 ]

Subtotal (95 CI) 30 30 334 -1285 [ -1967 -603 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -277 (1313) 311 -911 [ -1618 -204 ]

Subtotal (95 CI) 30 30 311 -911 [ -1618 -204 ]



Total (95 CI) 90 90 1000 -653 [ -1047 -259 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -533 (1334) 356 -054 [ -769 661 ]

Subtotal (95 CI) 30 30 356 -054 [ -769 661 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -587 (1338) 324 -286 [ -1035 463 ]

Subtotal (95 CI) 30 30 324 -286 [ -1035 463 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -547 (1409) 320 054 [ -701 809 ]

Subtotal (95 CI) 30 30 320 054 [ -701 809 ]



Total (95 CI) 90 90 1000 -095 [ -521 332 ]




-100 -50 0 50 100











Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -2133 (1279) 416 548 [ -092 1188 ]

Subtotal (95 CI) 30 30 416 548 [ -092 1188 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -263 (139) 311 139 [ -602 880 ]

Subtotal (95 CI) 30 30 311 139 [ -602 880 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -2457 (1434) 273 771 [ -019 1561 ]

Subtotal (95 CI) 30 30 273 771 [ -019 1561 ]



Total (95 CI) 90 90 1000 482 [ 069 895 ]




-20 -10 0 10 20

Favors AE Favors RT




function






Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -4 (1188) 353 283 [ -325 891 ]

Subtotal (95 CI) 30 30 353 283 [ -325 891 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -1167 (125) 339 443 [ -176 1062 ]

Subtotal (95 CI) 30 30 339 443 [ -176 1062 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -13 (1367) 308 883 [ 233 1533 ]

Subtotal (95 CI) 30 30 308 883 [ 233 1533 ]



Total (95 CI) 90 90 1000 522 [ 161 883 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -344 (181) 357 067 [ -028 162 ]

Subtotal (95 CI) 30 30 357 067 [ -028 162 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -327 (192) 326 -067 [ -167 033 ]

Subtotal (95 CI) 30 30 326 -067 [ -167 033 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -357 (206) 317 083 [ -018 184 ]

Subtotal (95 CI) 30 30 317 083 [ -018 184 ]



Total (95 CI) 90 90 1000 028 [ -028 085 ]




-2 -1 0 1 2

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -1027 (1046) 373 047 [ -422 516 ]

Subtotal (95 CI) 30 30 373 047 [ -422 516 ]



2 16 wk

Kayo 2011 30 -152 (949) 30 -1384 (1072) 313 -136 [ -648 376 ]

Subtotal (95 CI) 30 30 313 -136 [ -648 376 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -154 (941) 314 284 [ -228 796 ]

Subtotal (95 CI) 30 30 314 284 [ -228 796 ]



Total (95 CI) 90 90 1000 064 [ -223 351 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -866 (1228) 361 038 [ -594 670 ]

Subtotal (95 CI) 30 30 361 038 [ -594 670 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -1256 (1143) 318 -356 [ -1030 318 ]

Subtotal (95 CI) 30 30 318 -356 [ -1030 318 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -135 (1152) 321 162 [ -508 832 ]

Subtotal (95 CI) 30 30 321 162 [ -508 832 ]



Total (95 CI) 90 90 1000 -047 [ -427 333 ]




-10 -5 0 5 10

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -56 (1461) 349 -027 [ -773 719 ]

Subtotal (95 CI) 30 30 349 -027 [ -773 719 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -1347 (1457) 322 474 [ -303 1251 ]

Subtotal (95 CI) 30 30 322 474 [ -303 1251 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -1387 (1463) 330 894 [ 126 1662 ]

Subtotal (95 CI) 30 30 330 894 [ 126 1662 ]



Total (95 CI) 90 90 1000 438 [ -003 878 ]




-20 -10 0 10 20

Favors AE Favors RT



Term Definition
























































2 AQ-MX Control










Joshi 2009 2 MX Med

















McCain 1988 2 AE FX






















2 AQ-MX Control


Valim 2003 2 AE FX













A P P E N D I C E S
















































Level one screen


Level two screen


Level three screen



















H I S T O R Y





















bull None known


Internal sources


External sources


N O T E S




























Tenderness




Muscle strength










Quality of evidence










Comparison Control


(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion

FIQ Total Score

Scale 0-100 (lower


health)

Follow-up 16 weeks




trol group was

-816 FIQ units1





-2491 FIQ units1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD -127 (95 CI -183

to -072)8



31 to -1019)



cise group7

NNTB 2 (95 CI 1 to 3)


function

Health Assessment





better health)





control groups was

-201 units1





-767 units1

- 107

(3 studies2)

oplusopluscopycopy

low910

SMD -05 (95 CI -089

to -011) 11


units (95 CI -1045 to -

213)


1448 (95 CI 49 to


groups

NNTB 5 (95 CI 3 to 22)

5R

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nce

exerc

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gfo

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Pain

Visual analog scale






control groups was

-099 cm1




-353 cm1

81

(2 studies2)

oplusopluscopycopy

low91012

SMD -189 (95 CI -386

to 007)8


cm (95 CI -635 to -0

26)


446 (95 CI 35 to


groups7

NNTB 2 (95 CI 1 to 34)

Tenderness


myalgic scores




derness)





-20 tender points1

The estimated mean



vention groups was

-35 tender points1

- 107

(3 studies2)

oplusopluscopycopy

low91012SMD -073 (95 CI -112

to -033)8



6 to -108)


128 (95 CI 749 to


cise groups

NNTB 4 (95 CI 3 to 7)

Muscle strength



in kg)

Follow-up 21 weeks




was 044 kg1




tion groups was

2771 kg1

- 47

(2 studies2)

oplusopluscopycopy

low91012

SMD 167 (95 CI 098

to 235)8


kg (95 CI 1828 to 36

36)


25 (95 CI 17 to


groups7

NNTB 2 (95 CI 1 to 3)





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studies)

All-cause attrition

Dropout rates


39 per 1000 134 per 1000

(95 CI 30 to 439)

RR 350 (079 to 1549) 107

(3 studies2)

oplusopluscopycopy

low9


(95 CI -2 to 20)


250 (95 CI -21 to

1449)


cant




difference









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B A C K G R O U N D














O B J E C T I V E S







M E T H O D S


Types of studies






































adaptation













Major outcomes



Minor outcomes












Electronic searches















Review team






















Data synthesis

















R E S U L T S










Included studies



Excluded studies







study





Allocation


Blinding




Selective reporting



































(95 CI)

No of Participants

(studies)


(GRADE)

Comments7




tion




Follow-up 8 weeks





-2133 FIQ units1





was

-1585 FIQ units 1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD 043 (95 CI -008

to 094)6



to 1188)


cant


function




greater health)

Follow-up 8 weeks





was

581 SF-36 units 1





was

454 SF-36 units 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -011 (95 CI -053

to 031) 6



69 to 374)6


cant

Pain



indicate less pain)

Follow-up 8 weeks




was

-357 cm12




was

-27 cm 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD 053 (95 CI 010

to 097)8


cm (95 CI 031 to 167)


24

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7 129 (95 CI 405



NNTB 5 (95 CI 3 to 24)

Tenderness



converted to tender



derness)

Follow-up 8 weeks




groups was

-515 tender points1




groups was

-49 tender points 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -013 (95 CI -055

to 03)6



68 to 033)


cant







studies)

All-cause attrition

Dropout rates

Follow-up 8 weeks

89 per 1000 89 per 1000

(22 to 296)

Peto OR 1

(024 to 423)

90

(2 studies2)

oplusopluscopycopy

low


(95 CI -12 to 12)


0


cant









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26

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Settings USA




(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion



greater health)

Follow-up 12 weeks




-378 FIQ units 1




group was

-1027 units 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -055 (95 CI -109

to -002) 6



57 to -041)



tance group


cant

Pain

VAS 0-10 cm (lower


Follow-up 12 weeks




-101 cm 1




was

-189 cm 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -066 (95 CI -12

to -012)6


cm (95 CI -157 to -0

19)12


14 (95 CI 30 to 24


tance group


cant27

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Tenderness

Tender point count

scores 0-18 (lower


derness)

Follow-up 12 weeks



group was

-1 tender points 1



training group was


- 56

(1 study)

oplusopluscopycopy

low23

SMD -022 (95 CI -074

to 031)7



56 to 064)


cant

Strength

Maximal isokinetic



in foot-pounds8

Follow-up 12 weeks

The mean change in


group was

97 foot-pounds 1

The mean change in


training group was

1447 foot-pounds 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD 034 (95 CI -018

to 087)7



40 to 1194)


cant



All-cause attrition

Dropout rates

Follow-up 12 weeks

214 per 1000 214 per 1000 RR 100 (037 to 273) 56

(1 study)

oplusopluscopycopy

low23



0


cant










8R

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29

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D I S C U S S I O N

























































R E F E R E N C E S















200133(4)162ndash9




(5)573ndash8

















(10)1107ndash13



















200122310ndash32





19974275ndash91









(MayJune)80










200231(5)306ndash10

























199457(4)45ndash9



























199623(7)1237ndash45









201252(1)85ndash91



(10)616ndash22





2010254(1735)8ndash10










ACSM 2009a



ACSM 2009b



Alentorn-Geli 2008


(8)975ndash81

Altan 2004




Altan 2009


Anderson 1995


Arcos-Carmona 2011


(9)398ndash491

Arnold 2008


Asikainen 2004



Assis 2006


Baptista 2012



Bengtsson 1986a



Bengtsson 1986b



Bennett 1989


198932(4)454ndash60

Bennett 1999


Bennett 2009



Bernardy 2013



Birse 2012



Bojner Horwitz 2006


Boomershine 2012


Brachaniec 2009


Braith 2006


2006113(22)2642ndash50

Branco 2010



Bressan 2008



(2)88ndash93

Brosse 2002


(12)741ndash60



Brosseau 2008


200888(7)873ndash86

Buchheld 2001



Buckelew 1998



Burckhardt 1993



Burckhardt 1994



Burckhardt 2005


Calandre 2009



Callahan 1988


198815(3)418ndash26

Carson 2010


Carson 2012



Carville 2008


Carville 2008a


Caspersen 1985



Cedraschi 2004


Cheung 2003


Chodzko-Zajko 2009



Choy 2009a


Choy 2009b


200935(2)329ndash37

Clauw 2011


Cohen 1988


Costill 1979


Crosier 2002






Da Costa 2005


Dadabhoy 2008


Therapy 200810(4)211

De Andrade 2008




Demir-Gocmen 2013


Deschenes 2002



Desmeules 2003



Dunn 2001


Dworkin 2008


Elvin 2006


Etnier 2009


Evcik 2008



Faigenbaum 2009



Field 2003



Figueroa 2008



FitzerGerald 2004



Fontaine 2007


Fontaine 2010


Fontaine 2011


Garber 2011







Genc 2002



Gibson 2006


Gowans 1999


199912(2)120ndash8

Gowans 2001


Gracely 2003



Gusi 2006



Gusi 2008


Gusi 2010








Hammond 2006


Hawley 1991


Hecker 2011


Heyward 1998



Heyward 2010



Hibbert 2008



Higgins 2011a


Higgins 2011b


Higgins 2011c


Holloszy 1984



Hooten 2012





Howley 2001



Hunt 2000


Haumluser 2013



Ide 2008


200811(2)131ndash40

Isomeri 1993



Jentoft 2001



Jones 2007


Jones 2008


Jones 2009


Jones 2012


Joshi 2009



Jubrias 1994


(6)801ndash7

Katzmarzyk 2002


200234(5)740ndash4

Keel 1998


King 1997


1997277(1)32ndash7

King 2002



Kingsley 2009



Kingsley 2011



Knutzen 2007


Koltyn 1998


Lefebvre 2011


Lemstra 2005






Lewis 2012


201231(2)255ndash62

Liu 2012


(11)657ndash64



Lorig 1989



Lund 1986



Lynch 2012



Mannerkorpi 2000


Mannerkorpi 2009


Mannerkorpi 2010


201012(5)R189

Martin 1996





201246(3)199ndash206

Matsutani 2007



Matsutani 2012


(2)411ndash8

McCain 1988


McNalley 2006


Mease 2005


Mease 2008


Mease 2009


200936(10)2318ndash29

Mengshoel 1992


Mengshoel 1993


Merskey 1994




Mitchell 2002




Mizelle 2011


(8)310ndash6

Moore 2012


Morrissey 1995









Nelson 2007


Nichols 1994


Norregaard 1997


Olivares 2011


(8)723ndash8

Painter 1999



Park 1998


Park 2007


Philadelphia 2001


200181(10)1629ndash40

Raftery 2009


Ramsay 2000


RevMan 2012


Richards 2002


Rivera Redondo 2004


200451(2)184ndash92

Rooks 2007


(20)2192ndash200

Sale 1987


Sanudo 2010



Sanudo 2010a





Sanudo 2010c


Sanudo 2011


(6)521ndash6

Sanudo 2012



Schachter 2003


Schmidt 2011


Schuumlnermann 2009


Seidel 2013


Sencan 2004


Singh 1997


Smythe 1981


Tomas-Carus 2007


20073(1)33ndash7

Tomas-Carus 2007a



Tomas-Carus 2007b


Tomas-Carus 2007c


Tomas-Carus 2008



Tort 2012


Trew 2005


Valencia 2009



Valim 2003









Valkeinen 2008



van Koulil 2007



van Koulil 2010


van Tulder 2003


vanSanten 2002



vanSanten 2002a


Verstappen 1997


Wang 2010


(8)743ndash54

WHO 2012


Wigers 1996



Williams 2012


2012 Issue 11 [DOI 10100214651858CD007407]

Winkelmann 2012


(3)276ndash86

Wolfe 1990


Wolfe 1995


Wolfe 2010


201062(5)600ndash10

Wolfe 2011


Yunus 1981



Yunus 1982


Yunus 1984


Yuruk 2008




Zeng 2008




Busch 2001


Busch 2001a


Busch 2002



Busch 2007



Busch 2008







Bircan 2008








Risk of bias


















2012)


Hakkinen 2001












Risk of bias















Jones 2002












Risk of bias















Kayo 2011












Risk of bias

















Valkeinen 2004












Risk of bias


























Dal 2011 Not an RCT















(Continued)






















(Continued)









Adsuar 2012

Methods Unknown

Participants


Outcomes


Amanollahi 2013

Methods Unknown

Participants


Outcomes




Aslan 2001

Methods RCT





Bland 2010

Methods

Participants

Interventions

Outcomes

Notes

Ekici 2008

Methods RCT





Thijssen 1992

Methods Unknown



Outcomes Unknown




Wright 2012

Methods

Participants

Interventions

Outcomes

Notes







studies

No of









studies

No of







studies

No of





studies

No of





studies

No of


















studies

No of















DifferenceMean

Difference

NMean(SD)[FIQ



Kayo 2011 30 -2491 (1534) 30 -816 (1005) -1675 [ -2331 -1019 ]

-20 -10 0 10 20








Difference


Hakkinen 2001 11 -10 (126491) 10 0 (802773) 215 -1000 [ -1898 -102 ]

Valkeinen 2004 13 -6667 (8944) 13 333 (10541) 307 -1000 [ -1751 -249 ]

Kayo 2011 30 -724 (1197) 30 -5 (1181) 478 -224 [ -826 378 ]

Total (95 CI) 54 53 1000 -629 [ -1045 -213 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


Hakkinen 2001 11 -24 (1503) 10 25 (1641) 487 -490 [ -625 -355 ]

Kayo 2011 30 -394 (202) 30 -215 (156) 513 -179 [ -270 -088 ]

Total (95 CI) 41 40 1000 -330 [ -635 -026 ]




-10 -5 0 5 10








Difference


Hakkinen 2001 11 -1 (2683) 10 1 (1265) 185 -200 [ -377 -023 ]

Valkeinen 2004 13 -19 (151) 13 02 (114) 547 -210 [ -313 -107 ]

Kayo 2011 30 -507 (316) 30 -387 (263) 268 -120 [ -267 027 ]

Total (95 CI) 54 53 1000 -184 [ -260 -108 ]




-100 -50 0 50 100





leg extension






Difference


Hakkinen 2001 11 25 (1399) 10 1 (1726) 447 2400 [ 1048 3752 ]

Valkeinen 2004 13 30 (1844) 13 0 (1264) 553 3000 [ 1785 4215 ]

Total (95 CI) 24 23 1000 2732 [ 1828 3636 ]




-100 -50 0 50 100







Outcome 6 Fatigue



Difference


Hakkinen 2001 11 -19 (1513) 10 1 (1881) 254 -2000 [ -3169 -831 ]

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 746 -1285 [ -1967 -603 ]

Total (95 CI) 41 40 1000 -1466 [ -2055 -877 ]




-20 -10 0 10 20







DifferenceMean

Difference


Hakkinen 2001 11 -26 (1565) 10 14 (1762) -4000 [ -5431 -2569 ]

-100 -50 0 50 100









DifferenceMean

Difference


Kayo 2011 30 -873 (161) 30 -587 (1338) -286 [ -1035 463 ]

-100 -50 0 50 100







DifferenceMean

Difference


Hakkinen 2001 11 -28 (313) 10 09 (31) -370 [ -637 -103 ]

-100 -50 0 50 100







Outcome 10 Sleep


DifferenceMean

Difference


Hakkinen 2001 11 -10 (1448) 10 -3 (1744) -700 [ -2079 679 ]

-100 -50 0 50 100







DifferenceMean

Difference

NMean(SD)[m

(jump)] NMean(SD)[m


Hakkinen 2001 11 0015 (0009) 10 -001 (00054) 002 [ 001 003 ]

-01 -005 0 005 01









StdMean

Difference Weight

StdMean

Difference

NMean(SD)[cmˆ2



Hakkinen 2001 11 406 (298318) 10 139 (364077) 427 077 [ -012 167 ]

Valkeinen 2004 13 268 (434497) 13 151 (439434) 573 026 [ -051 103 ]

Total (95 CI) 24 23 1000 048 [ -011 106 ]




-100 -50 0 50 100








Difference


Hakkinen 2001 11 2958 (1082) 10 -1071 (779) 857 4029 [ 3228 4830 ]

Valkeinen 2004 13 5663 (2835) 13 1191 (2239) 143 4472 [ 2508 6436 ]

Total (95 CI) 24 23 1000 4092 [ 3350 4834 ]




-50 -25 0 25 50










Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 230 350 [ 079 1549 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Total (95 CI) 54 53 350 [ 079 1549 ]





0001 001 01 1 10 100 1000







DifferenceMean

Difference


Kayo 2011 30 -1585 (125) 30 -2133 (1279) 548 [ -092 1188 ]

-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF36

PF] NMean(SD)[SF36


Bircan 2008 13 1231 (1345) 13 10 (1297) 264 231 [ -785 1247 ]

Kayo 2011 30 117 (1213) 30 4 (1188) 736 -283 [ -891 325 ]

Total (95 CI) 43 43 1000 -148 [ -669 374 ]




-20 -10 0 10 20

Favors RE Favors AE




Outcome 3 Pain



Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -256 (135) 13 -388 (1183) 488 132 [ 034 230 ]

Kayo 2011 30 -277 (195) 30 -344 (181) 512 067 [ -028 162 ]

Total (95 CI) 43 43 1000 099 [ 031 167 ]




-4 -2 0 2 4

Favors RE Favors AE








StdMean

Difference Weight

StdMean

Difference


Bircan 2008 13 -616 (135) 13 -538 (137) 293 -056 [ -134 023 ]

Kayo 2011 30 -98 (792) 30 -1027 (1046) 707 005 [ -046 056 ]

Total (95 CI) 43 43 1000 -013 [ -055 030 ]




-2 -1 0 1 2

Favors RE Favors AE




Outcome 5 Fatigue



Difference


Bircan 2008 13 -281 (1736) 13 -339 (148) 206 580 [ -660 1820 ]

Kayo 2011 30 -828 (1271) 30 -866 (1228) 794 038 [ -594 670 ]

Total (95 CI) 43 43 1000 150 [ -414 713 ]




-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF-



Bircan 2008 13 1201 (13135) 13 893 (12328) 367 308 [ -671 1287 ]

Kayo 2011 30 -587 (1488) 30 -56 (1461) 633 -027 [ -773 719 ]

Total (95 CI) 43 43 1000 096 [ -497 690 ]




-10 -5 0 5 10

Favors AE Favors RE




Outcome 7 Sleep


DifferenceMean

Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -188 (188) 13 -335 (121) 147 [ 025 269 ]

-4 -2 0 2 4

Favors RE Favors AE








DifferenceMean

Difference

NMean(SD)[HAD

dep] NMean(SD)[HAD


Bircan 2008 13 -254 (273) 13 -2 (246) -054 [ -254 146 ]

-4 -2 0 2 4

Favors RE Favors AE




Outcome 9 Anxiety


DifferenceMean

Difference

NMean(SD)[HAD

anx] NMean(SD)[HAD


Bircan 2008 13 -054 (275) 13 -115 (268) 061 [ -148 270 ]

-20 -10 0 10 20

Favors RE Favors AE








DifferenceMean

Difference



Bircan 2008 13 7661 (4704) 13 4085 (5963) 3576 [ -553 7705 ]

-100 -50 0 50 100

Favors AE Favors RE







Odds Ratio


Bircan 2008 215 215 486 100 [ 013 792 ]

Kayo 2011 230 230 514 100 [ 013 748 ]

Total (95 CI) 45 45 1000 100 [ 024 423 ]





0005 01 1 10 200









DifferenceMean

Difference


Jones 2002 28 -1027 (1032) 28 -378 (1276) -649 [ -1257 -041 ]

-20 -10 0 10 20

Favors RE Favors FX




Outcome 2 Pain


DifferenceMean

Difference


Jones 2002 28 -189 (131) 28 -101 (131) -088 [ -157 -019 ]

-2 -1 0 1 2

Favors RE Favors FX








DifferenceMean

Difference


Jones 2002 28 -146 (193) 28 -1 (224) -046 [ -156 064 ]

-4 -2 0 2 4

Favors RE Favors FX




Outcome 4 Strength


DifferenceMean

Difference


Jones 2002 28 1447 (1399) 28 97 (1336) 477 [ -240 1194 ]

-20 -10 0 10 20

Favors FX Favors RE








DifferenceMean

Difference


Jones 2002 28 3445 (10992) 28 661 (1062) -3165 [ -8826 2496 ]

-200 -100 0 100 200

Favors FX Favors RE




Outcome 6 Fatigue


StdMean

Difference

StdMean

Difference


Jones 2002 28 -243 (125) 28 -068 (148) -126 [ -184 -068 ]

-4 -2 0 2 4

Favors RE Favors FX






Outcome 7 Sleep


DifferenceMean

Difference


Jones 2002 28 -23 (165) 28 -053 (161) -177 [ -262 -092 ]

-4 -2 0 2 4

Favors RE Favors FX






DifferenceMean

Difference


Jones 2002 28 -367 (423) 28 -184 (403) -183 [ -399 033 ]

-10 -5 0 5 10

Favors RE Favors FX






Outcome 9 Anxiety


DifferenceMean

Difference


Jones 2002 28 -25 (584) 28 07 (645) -320 [ -642 002 ]

-10 -5 0 5 10

Favors RE Favors FX






DifferenceMean

Difference

NMean(SD)[4-



Jones 2002 28 -115 (051) 28 -145 (06) 030 [ 001 059 ]

-2 -1 0 1 2

Favors RE Favors FX









Jones 2002 628 628 100 [ 037 273 ]

01 02 05 1 2 5 10

Favors RT Favors FX




Outcome 1 Attrition



1 RT vs control

Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 730 100 [ 030 331 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Subtotal (95 CI) 54 53 100 [ 030 331 ]




2 RT vs AE

Bircan 2008 215 215 100 [ 012 821 ]

Kayo 2011 730 830 084 [ 026 270 ]

Subtotal (95 CI) 45 45 087 [ 031 243 ]


002 01 1 10 50


(Continued )







3 RT vs flexibility

Jones 2002 628 628 100 [ 028 358 ]

Subtotal (95 CI) 28 28 100 [ 028 358 ]




Total (95 CI) 127 126 094 [ 049 183 ]





002 01 1 10 50





function






Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -598 (1199) 380 -987 [ -1607 -367 ]

Subtotal (95 CI) 30 30 380 -987 [ -1607 -367 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -816 (1005) 339 -1675 [ -2331 -1019 ]

Subtotal (95 CI) 30 30 339 -1675 [ -2331 -1019 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -619 (1117) 281 -1067 [ -1788 -346 ]

Subtotal (95 CI) 30 30 281 -1067 [ -1788 -346 ]



Total (95 CI) 90 90 1000 -1243 [ -1625 -861 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -05 (1142) 338 -067 [ -663 529 ]

Subtotal (95 CI) 30 30 338 -067 [ -663 529 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -5 (1181) 332 -224 [ -826 378 ]

Subtotal (95 CI) 30 30 332 -224 [ -826 378 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -517 (119) 330 100 [ -504 704 ]

Subtotal (95 CI) 30 30 330 100 [ -504 704 ]



Total (95 CI) 90 90 1000 -064 [ -411 283 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -209 (176) 321 -068 [ -162 026 ]

Subtotal (95 CI) 30 30 321 -068 [ -162 026 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -215 (156) 340 -179 [ -270 -088 ]

Subtotal (95 CI) 30 30 340 -179 [ -270 -088 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -189 (168) 339 -085 [ -177 007 ]

Subtotal (95 CI) 30 30 339 -085 [ -177 007 ]



Total (95 CI) 90 90 1000 -112 [ -165 -058 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -954 (769) 418 -026 [ -421 369 ]

Subtotal (95 CI) 30 30 418 -026 [ -421 369 ]



2 16 wk

Kayo 2011 30 -1529 (949) 30 -116 (79) 334 -369 [ -811 073 ]

Subtotal (95 CI) 30 30 334 -369 [ -811 073 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -1064 (951) 247 -192 [ -706 322 ]

Subtotal (95 CI) 30 30 247 -192 [ -706 322 ]



Total (95 CI) 90 90 1000 -182 [ -437 074 ]




-100 -50 0 50 100







Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -993 (1339) 356 165 [ -496 826 ]

Subtotal (95 CI) 30 30 356 165 [ -496 826 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 334 -1285 [ -1967 -603 ]

Subtotal (95 CI) 30 30 334 -1285 [ -1967 -603 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -277 (1313) 311 -911 [ -1618 -204 ]

Subtotal (95 CI) 30 30 311 -911 [ -1618 -204 ]



Total (95 CI) 90 90 1000 -653 [ -1047 -259 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -533 (1334) 356 -054 [ -769 661 ]

Subtotal (95 CI) 30 30 356 -054 [ -769 661 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -587 (1338) 324 -286 [ -1035 463 ]

Subtotal (95 CI) 30 30 324 -286 [ -1035 463 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -547 (1409) 320 054 [ -701 809 ]

Subtotal (95 CI) 30 30 320 054 [ -701 809 ]



Total (95 CI) 90 90 1000 -095 [ -521 332 ]




-100 -50 0 50 100











Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -2133 (1279) 416 548 [ -092 1188 ]

Subtotal (95 CI) 30 30 416 548 [ -092 1188 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -263 (139) 311 139 [ -602 880 ]

Subtotal (95 CI) 30 30 311 139 [ -602 880 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -2457 (1434) 273 771 [ -019 1561 ]

Subtotal (95 CI) 30 30 273 771 [ -019 1561 ]



Total (95 CI) 90 90 1000 482 [ 069 895 ]




-20 -10 0 10 20

Favors AE Favors RT




function






Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -4 (1188) 353 283 [ -325 891 ]

Subtotal (95 CI) 30 30 353 283 [ -325 891 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -1167 (125) 339 443 [ -176 1062 ]

Subtotal (95 CI) 30 30 339 443 [ -176 1062 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -13 (1367) 308 883 [ 233 1533 ]

Subtotal (95 CI) 30 30 308 883 [ 233 1533 ]



Total (95 CI) 90 90 1000 522 [ 161 883 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -344 (181) 357 067 [ -028 162 ]

Subtotal (95 CI) 30 30 357 067 [ -028 162 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -327 (192) 326 -067 [ -167 033 ]

Subtotal (95 CI) 30 30 326 -067 [ -167 033 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -357 (206) 317 083 [ -018 184 ]

Subtotal (95 CI) 30 30 317 083 [ -018 184 ]



Total (95 CI) 90 90 1000 028 [ -028 085 ]




-2 -1 0 1 2

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -1027 (1046) 373 047 [ -422 516 ]

Subtotal (95 CI) 30 30 373 047 [ -422 516 ]



2 16 wk

Kayo 2011 30 -152 (949) 30 -1384 (1072) 313 -136 [ -648 376 ]

Subtotal (95 CI) 30 30 313 -136 [ -648 376 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -154 (941) 314 284 [ -228 796 ]

Subtotal (95 CI) 30 30 314 284 [ -228 796 ]



Total (95 CI) 90 90 1000 064 [ -223 351 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -866 (1228) 361 038 [ -594 670 ]

Subtotal (95 CI) 30 30 361 038 [ -594 670 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -1256 (1143) 318 -356 [ -1030 318 ]

Subtotal (95 CI) 30 30 318 -356 [ -1030 318 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -135 (1152) 321 162 [ -508 832 ]

Subtotal (95 CI) 30 30 321 162 [ -508 832 ]



Total (95 CI) 90 90 1000 -047 [ -427 333 ]




-10 -5 0 5 10

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -56 (1461) 349 -027 [ -773 719 ]

Subtotal (95 CI) 30 30 349 -027 [ -773 719 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -1347 (1457) 322 474 [ -303 1251 ]

Subtotal (95 CI) 30 30 322 474 [ -303 1251 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -1387 (1463) 330 894 [ 126 1662 ]

Subtotal (95 CI) 30 30 330 894 [ 126 1662 ]



Total (95 CI) 90 90 1000 438 [ -003 878 ]




-20 -10 0 10 20

Favors AE Favors RT



Term Definition
























































2 AQ-MX Control










Joshi 2009 2 MX Med

















McCain 1988 2 AE FX






















2 AQ-MX Control


Valim 2003 2 AE FX













A P P E N D I C E S
















































Level one screen


Level two screen


Level three screen



















H I S T O R Y





















bull None known


Internal sources


External sources


N O T E S













Quality of evidence










Comparison Control


(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion

FIQ Total Score

Scale 0-100 (lower


health)

Follow-up 16 weeks




trol group was

-816 FIQ units1





-2491 FIQ units1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD -127 (95 CI -183

to -072)8



31 to -1019)



cise group7

NNTB 2 (95 CI 1 to 3)


function

Health Assessment





better health)





control groups was

-201 units1





-767 units1

- 107

(3 studies2)

oplusopluscopycopy

low910

SMD -05 (95 CI -089

to -011) 11


units (95 CI -1045 to -

213)


1448 (95 CI 49 to


groups

NNTB 5 (95 CI 3 to 22)

5R

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Pain

Visual analog scale






control groups was

-099 cm1




-353 cm1

81

(2 studies2)

oplusopluscopycopy

low91012

SMD -189 (95 CI -386

to 007)8


cm (95 CI -635 to -0

26)


446 (95 CI 35 to


groups7

NNTB 2 (95 CI 1 to 34)

Tenderness


myalgic scores




derness)





-20 tender points1

The estimated mean



vention groups was

-35 tender points1

- 107

(3 studies2)

oplusopluscopycopy

low91012SMD -073 (95 CI -112

to -033)8



6 to -108)


128 (95 CI 749 to


cise groups

NNTB 4 (95 CI 3 to 7)

Muscle strength



in kg)

Follow-up 21 weeks




was 044 kg1




tion groups was

2771 kg1

- 47

(2 studies2)

oplusopluscopycopy

low91012

SMD 167 (95 CI 098

to 235)8


kg (95 CI 1828 to 36

36)


25 (95 CI 17 to


groups7

NNTB 2 (95 CI 1 to 3)





6R

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studies)

All-cause attrition

Dropout rates


39 per 1000 134 per 1000

(95 CI 30 to 439)

RR 350 (079 to 1549) 107

(3 studies2)

oplusopluscopycopy

low9


(95 CI -2 to 20)


250 (95 CI -21 to

1449)


cant




difference









7R

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B A C K G R O U N D














O B J E C T I V E S







M E T H O D S


Types of studies






































adaptation













Major outcomes



Minor outcomes












Electronic searches















Review team






















Data synthesis

















R E S U L T S










Included studies



Excluded studies







study





Allocation


Blinding




Selective reporting



































(95 CI)

No of Participants

(studies)


(GRADE)

Comments7




tion




Follow-up 8 weeks





-2133 FIQ units1





was

-1585 FIQ units 1

- 60

(1 study2)

oplusopluscopycopy

low34

SMD 043 (95 CI -008

to 094)6



to 1188)


cant


function




greater health)

Follow-up 8 weeks





was

581 SF-36 units 1





was

454 SF-36 units 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -011 (95 CI -053

to 031) 6



69 to 374)6


cant

Pain



indicate less pain)

Follow-up 8 weeks




was

-357 cm12




was

-27 cm 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD 053 (95 CI 010

to 097)8


cm (95 CI 031 to 167)


24

Resista

nce

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7 129 (95 CI 405



NNTB 5 (95 CI 3 to 24)

Tenderness



converted to tender



derness)

Follow-up 8 weeks




groups was

-515 tender points1




groups was

-49 tender points 1

- 86

(2 studies2)

oplusopluscopycopy

low4

SMD -013 (95 CI -055

to 03)6



68 to 033)


cant







studies)

All-cause attrition

Dropout rates

Follow-up 8 weeks

89 per 1000 89 per 1000

(22 to 296)

Peto OR 1

(024 to 423)

90

(2 studies2)

oplusopluscopycopy

low


(95 CI -12 to 12)


0


cant









Resista

nce

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26

Resista

nce

exerc

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Settings USA




(95 CI)

No of Participants

(studies)


(GRADE)

Comments




tion



greater health)

Follow-up 12 weeks




-378 FIQ units 1




group was

-1027 units 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -055 (95 CI -109

to -002) 6



57 to -041)



tance group


cant

Pain

VAS 0-10 cm (lower


Follow-up 12 weeks




-101 cm 1




was

-189 cm 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD -066 (95 CI -12

to -012)6


cm (95 CI -157 to -0

19)12


14 (95 CI 30 to 24


tance group


cant27

Resista

nce

exerc

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Tenderness

Tender point count

scores 0-18 (lower


derness)

Follow-up 12 weeks



group was

-1 tender points 1



training group was


- 56

(1 study)

oplusopluscopycopy

low23

SMD -022 (95 CI -074

to 031)7



56 to 064)


cant

Strength

Maximal isokinetic



in foot-pounds8

Follow-up 12 weeks

The mean change in


group was

97 foot-pounds 1

The mean change in


training group was

1447 foot-pounds 1

- 56

(1 study)

oplusopluscopycopy

low23

SMD 034 (95 CI -018

to 087)7



40 to 1194)


cant



All-cause attrition

Dropout rates

Follow-up 12 weeks

214 per 1000 214 per 1000 RR 100 (037 to 273) 56

(1 study)

oplusopluscopycopy

low23



0


cant










8R

esista

nce

exerc

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inin

gfo

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29

Resista

nce

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D I S C U S S I O N

























































R E F E R E N C E S















200133(4)162ndash9




(5)573ndash8

















(10)1107ndash13



















200122310ndash32





19974275ndash91









(MayJune)80










200231(5)306ndash10

























199457(4)45ndash9



























199623(7)1237ndash45









201252(1)85ndash91



(10)616ndash22





2010254(1735)8ndash10










ACSM 2009a



ACSM 2009b



Alentorn-Geli 2008


(8)975ndash81

Altan 2004




Altan 2009


Anderson 1995


Arcos-Carmona 2011


(9)398ndash491

Arnold 2008


Asikainen 2004



Assis 2006


Baptista 2012



Bengtsson 1986a



Bengtsson 1986b



Bennett 1989


198932(4)454ndash60

Bennett 1999


Bennett 2009



Bernardy 2013



Birse 2012



Bojner Horwitz 2006


Boomershine 2012


Brachaniec 2009


Braith 2006


2006113(22)2642ndash50

Branco 2010



Bressan 2008



(2)88ndash93

Brosse 2002


(12)741ndash60



Brosseau 2008


200888(7)873ndash86

Buchheld 2001



Buckelew 1998



Burckhardt 1993



Burckhardt 1994



Burckhardt 2005


Calandre 2009



Callahan 1988


198815(3)418ndash26

Carson 2010


Carson 2012



Carville 2008


Carville 2008a


Caspersen 1985



Cedraschi 2004


Cheung 2003


Chodzko-Zajko 2009



Choy 2009a


Choy 2009b


200935(2)329ndash37

Clauw 2011


Cohen 1988


Costill 1979


Crosier 2002






Da Costa 2005


Dadabhoy 2008


Therapy 200810(4)211

De Andrade 2008




Demir-Gocmen 2013


Deschenes 2002



Desmeules 2003



Dunn 2001


Dworkin 2008


Elvin 2006


Etnier 2009


Evcik 2008



Faigenbaum 2009



Field 2003



Figueroa 2008



FitzerGerald 2004



Fontaine 2007


Fontaine 2010


Fontaine 2011


Garber 2011







Genc 2002



Gibson 2006


Gowans 1999


199912(2)120ndash8

Gowans 2001


Gracely 2003



Gusi 2006



Gusi 2008


Gusi 2010








Hammond 2006


Hawley 1991


Hecker 2011


Heyward 1998



Heyward 2010



Hibbert 2008



Higgins 2011a


Higgins 2011b


Higgins 2011c


Holloszy 1984



Hooten 2012





Howley 2001



Hunt 2000


Haumluser 2013



Ide 2008


200811(2)131ndash40

Isomeri 1993



Jentoft 2001



Jones 2007


Jones 2008


Jones 2009


Jones 2012


Joshi 2009



Jubrias 1994


(6)801ndash7

Katzmarzyk 2002


200234(5)740ndash4

Keel 1998


King 1997


1997277(1)32ndash7

King 2002



Kingsley 2009



Kingsley 2011



Knutzen 2007


Koltyn 1998


Lefebvre 2011


Lemstra 2005






Lewis 2012


201231(2)255ndash62

Liu 2012


(11)657ndash64



Lorig 1989



Lund 1986



Lynch 2012



Mannerkorpi 2000


Mannerkorpi 2009


Mannerkorpi 2010


201012(5)R189

Martin 1996





201246(3)199ndash206

Matsutani 2007



Matsutani 2012


(2)411ndash8

McCain 1988


McNalley 2006


Mease 2005


Mease 2008


Mease 2009


200936(10)2318ndash29

Mengshoel 1992


Mengshoel 1993


Merskey 1994




Mitchell 2002




Mizelle 2011


(8)310ndash6

Moore 2012


Morrissey 1995









Nelson 2007


Nichols 1994


Norregaard 1997


Olivares 2011


(8)723ndash8

Painter 1999



Park 1998


Park 2007


Philadelphia 2001


200181(10)1629ndash40

Raftery 2009


Ramsay 2000


RevMan 2012


Richards 2002


Rivera Redondo 2004


200451(2)184ndash92

Rooks 2007


(20)2192ndash200

Sale 1987


Sanudo 2010



Sanudo 2010a





Sanudo 2010c


Sanudo 2011


(6)521ndash6

Sanudo 2012



Schachter 2003


Schmidt 2011


Schuumlnermann 2009


Seidel 2013


Sencan 2004


Singh 1997


Smythe 1981


Tomas-Carus 2007


20073(1)33ndash7

Tomas-Carus 2007a



Tomas-Carus 2007b


Tomas-Carus 2007c


Tomas-Carus 2008



Tort 2012


Trew 2005


Valencia 2009



Valim 2003









Valkeinen 2008



van Koulil 2007



van Koulil 2010


van Tulder 2003


vanSanten 2002



vanSanten 2002a


Verstappen 1997


Wang 2010


(8)743ndash54

WHO 2012


Wigers 1996



Williams 2012


2012 Issue 11 [DOI 10100214651858CD007407]

Winkelmann 2012


(3)276ndash86

Wolfe 1990


Wolfe 1995


Wolfe 2010


201062(5)600ndash10

Wolfe 2011


Yunus 1981



Yunus 1982


Yunus 1984


Yuruk 2008




Zeng 2008




Busch 2001


Busch 2001a


Busch 2002



Busch 2007



Busch 2008







Bircan 2008








Risk of bias


















2012)


Hakkinen 2001












Risk of bias















Jones 2002












Risk of bias















Kayo 2011












Risk of bias

















Valkeinen 2004












Risk of bias


























Dal 2011 Not an RCT















(Continued)






















(Continued)









Adsuar 2012

Methods Unknown

Participants


Outcomes


Amanollahi 2013

Methods Unknown

Participants


Outcomes




Aslan 2001

Methods RCT





Bland 2010

Methods

Participants

Interventions

Outcomes

Notes

Ekici 2008

Methods RCT





Thijssen 1992

Methods Unknown



Outcomes Unknown




Wright 2012

Methods

Participants

Interventions

Outcomes

Notes







studies

No of









studies

No of







studies

No of





studies

No of





studies

No of


















studies

No of















DifferenceMean

Difference

NMean(SD)[FIQ



Kayo 2011 30 -2491 (1534) 30 -816 (1005) -1675 [ -2331 -1019 ]

-20 -10 0 10 20








Difference


Hakkinen 2001 11 -10 (126491) 10 0 (802773) 215 -1000 [ -1898 -102 ]

Valkeinen 2004 13 -6667 (8944) 13 333 (10541) 307 -1000 [ -1751 -249 ]

Kayo 2011 30 -724 (1197) 30 -5 (1181) 478 -224 [ -826 378 ]

Total (95 CI) 54 53 1000 -629 [ -1045 -213 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


Hakkinen 2001 11 -24 (1503) 10 25 (1641) 487 -490 [ -625 -355 ]

Kayo 2011 30 -394 (202) 30 -215 (156) 513 -179 [ -270 -088 ]

Total (95 CI) 41 40 1000 -330 [ -635 -026 ]




-10 -5 0 5 10








Difference


Hakkinen 2001 11 -1 (2683) 10 1 (1265) 185 -200 [ -377 -023 ]

Valkeinen 2004 13 -19 (151) 13 02 (114) 547 -210 [ -313 -107 ]

Kayo 2011 30 -507 (316) 30 -387 (263) 268 -120 [ -267 027 ]

Total (95 CI) 54 53 1000 -184 [ -260 -108 ]




-100 -50 0 50 100





leg extension






Difference


Hakkinen 2001 11 25 (1399) 10 1 (1726) 447 2400 [ 1048 3752 ]

Valkeinen 2004 13 30 (1844) 13 0 (1264) 553 3000 [ 1785 4215 ]

Total (95 CI) 24 23 1000 2732 [ 1828 3636 ]




-100 -50 0 50 100







Outcome 6 Fatigue



Difference


Hakkinen 2001 11 -19 (1513) 10 1 (1881) 254 -2000 [ -3169 -831 ]

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 746 -1285 [ -1967 -603 ]

Total (95 CI) 41 40 1000 -1466 [ -2055 -877 ]




-20 -10 0 10 20







DifferenceMean

Difference


Hakkinen 2001 11 -26 (1565) 10 14 (1762) -4000 [ -5431 -2569 ]

-100 -50 0 50 100









DifferenceMean

Difference


Kayo 2011 30 -873 (161) 30 -587 (1338) -286 [ -1035 463 ]

-100 -50 0 50 100







DifferenceMean

Difference


Hakkinen 2001 11 -28 (313) 10 09 (31) -370 [ -637 -103 ]

-100 -50 0 50 100







Outcome 10 Sleep


DifferenceMean

Difference


Hakkinen 2001 11 -10 (1448) 10 -3 (1744) -700 [ -2079 679 ]

-100 -50 0 50 100







DifferenceMean

Difference

NMean(SD)[m

(jump)] NMean(SD)[m


Hakkinen 2001 11 0015 (0009) 10 -001 (00054) 002 [ 001 003 ]

-01 -005 0 005 01









StdMean

Difference Weight

StdMean

Difference

NMean(SD)[cmˆ2



Hakkinen 2001 11 406 (298318) 10 139 (364077) 427 077 [ -012 167 ]

Valkeinen 2004 13 268 (434497) 13 151 (439434) 573 026 [ -051 103 ]

Total (95 CI) 24 23 1000 048 [ -011 106 ]




-100 -50 0 50 100








Difference


Hakkinen 2001 11 2958 (1082) 10 -1071 (779) 857 4029 [ 3228 4830 ]

Valkeinen 2004 13 5663 (2835) 13 1191 (2239) 143 4472 [ 2508 6436 ]

Total (95 CI) 24 23 1000 4092 [ 3350 4834 ]




-50 -25 0 25 50










Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 230 350 [ 079 1549 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Total (95 CI) 54 53 350 [ 079 1549 ]





0001 001 01 1 10 100 1000







DifferenceMean

Difference


Kayo 2011 30 -1585 (125) 30 -2133 (1279) 548 [ -092 1188 ]

-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF36

PF] NMean(SD)[SF36


Bircan 2008 13 1231 (1345) 13 10 (1297) 264 231 [ -785 1247 ]

Kayo 2011 30 117 (1213) 30 4 (1188) 736 -283 [ -891 325 ]

Total (95 CI) 43 43 1000 -148 [ -669 374 ]




-20 -10 0 10 20

Favors RE Favors AE




Outcome 3 Pain



Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -256 (135) 13 -388 (1183) 488 132 [ 034 230 ]

Kayo 2011 30 -277 (195) 30 -344 (181) 512 067 [ -028 162 ]

Total (95 CI) 43 43 1000 099 [ 031 167 ]




-4 -2 0 2 4

Favors RE Favors AE








StdMean

Difference Weight

StdMean

Difference


Bircan 2008 13 -616 (135) 13 -538 (137) 293 -056 [ -134 023 ]

Kayo 2011 30 -98 (792) 30 -1027 (1046) 707 005 [ -046 056 ]

Total (95 CI) 43 43 1000 -013 [ -055 030 ]




-2 -1 0 1 2

Favors RE Favors AE




Outcome 5 Fatigue



Difference


Bircan 2008 13 -281 (1736) 13 -339 (148) 206 580 [ -660 1820 ]

Kayo 2011 30 -828 (1271) 30 -866 (1228) 794 038 [ -594 670 ]

Total (95 CI) 43 43 1000 150 [ -414 713 ]




-20 -10 0 10 20

Favors RE Favors AE









Difference

NMean(SD)[SF-



Bircan 2008 13 1201 (13135) 13 893 (12328) 367 308 [ -671 1287 ]

Kayo 2011 30 -587 (1488) 30 -56 (1461) 633 -027 [ -773 719 ]

Total (95 CI) 43 43 1000 096 [ -497 690 ]




-10 -5 0 5 10

Favors AE Favors RE




Outcome 7 Sleep


DifferenceMean

Difference

NMean(SD)[cm

(VAS)] NMean(SD)[cm


Bircan 2008 13 -188 (188) 13 -335 (121) 147 [ 025 269 ]

-4 -2 0 2 4

Favors RE Favors AE








DifferenceMean

Difference

NMean(SD)[HAD

dep] NMean(SD)[HAD


Bircan 2008 13 -254 (273) 13 -2 (246) -054 [ -254 146 ]

-4 -2 0 2 4

Favors RE Favors AE




Outcome 9 Anxiety


DifferenceMean

Difference

NMean(SD)[HAD

anx] NMean(SD)[HAD


Bircan 2008 13 -054 (275) 13 -115 (268) 061 [ -148 270 ]

-20 -10 0 10 20

Favors RE Favors AE








DifferenceMean

Difference



Bircan 2008 13 7661 (4704) 13 4085 (5963) 3576 [ -553 7705 ]

-100 -50 0 50 100

Favors AE Favors RE







Odds Ratio


Bircan 2008 215 215 486 100 [ 013 792 ]

Kayo 2011 230 230 514 100 [ 013 748 ]

Total (95 CI) 45 45 1000 100 [ 024 423 ]





0005 01 1 10 200









DifferenceMean

Difference


Jones 2002 28 -1027 (1032) 28 -378 (1276) -649 [ -1257 -041 ]

-20 -10 0 10 20

Favors RE Favors FX




Outcome 2 Pain


DifferenceMean

Difference


Jones 2002 28 -189 (131) 28 -101 (131) -088 [ -157 -019 ]

-2 -1 0 1 2

Favors RE Favors FX








DifferenceMean

Difference


Jones 2002 28 -146 (193) 28 -1 (224) -046 [ -156 064 ]

-4 -2 0 2 4

Favors RE Favors FX




Outcome 4 Strength


DifferenceMean

Difference


Jones 2002 28 1447 (1399) 28 97 (1336) 477 [ -240 1194 ]

-20 -10 0 10 20

Favors FX Favors RE








DifferenceMean

Difference


Jones 2002 28 3445 (10992) 28 661 (1062) -3165 [ -8826 2496 ]

-200 -100 0 100 200

Favors FX Favors RE




Outcome 6 Fatigue


StdMean

Difference

StdMean

Difference


Jones 2002 28 -243 (125) 28 -068 (148) -126 [ -184 -068 ]

-4 -2 0 2 4

Favors RE Favors FX






Outcome 7 Sleep


DifferenceMean

Difference


Jones 2002 28 -23 (165) 28 -053 (161) -177 [ -262 -092 ]

-4 -2 0 2 4

Favors RE Favors FX






DifferenceMean

Difference


Jones 2002 28 -367 (423) 28 -184 (403) -183 [ -399 033 ]

-10 -5 0 5 10

Favors RE Favors FX






Outcome 9 Anxiety


DifferenceMean

Difference


Jones 2002 28 -25 (584) 28 07 (645) -320 [ -642 002 ]

-10 -5 0 5 10

Favors RE Favors FX






DifferenceMean

Difference

NMean(SD)[4-



Jones 2002 28 -115 (051) 28 -145 (06) 030 [ 001 059 ]

-2 -1 0 1 2

Favors RE Favors FX









Jones 2002 628 628 100 [ 037 273 ]

01 02 05 1 2 5 10

Favors RT Favors FX




Outcome 1 Attrition



1 RT vs control

Hakkinen 2001 011 010 00 [ 00 00 ]

Kayo 2011 730 730 100 [ 030 331 ]

Valkeinen 2004 013 013 00 [ 00 00 ]

Subtotal (95 CI) 54 53 100 [ 030 331 ]




2 RT vs AE

Bircan 2008 215 215 100 [ 012 821 ]

Kayo 2011 730 830 084 [ 026 270 ]

Subtotal (95 CI) 45 45 087 [ 031 243 ]


002 01 1 10 50


(Continued )







3 RT vs flexibility

Jones 2002 628 628 100 [ 028 358 ]

Subtotal (95 CI) 28 28 100 [ 028 358 ]




Total (95 CI) 127 126 094 [ 049 183 ]





002 01 1 10 50





function






Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -598 (1199) 380 -987 [ -1607 -367 ]

Subtotal (95 CI) 30 30 380 -987 [ -1607 -367 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -816 (1005) 339 -1675 [ -2331 -1019 ]

Subtotal (95 CI) 30 30 339 -1675 [ -2331 -1019 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -619 (1117) 281 -1067 [ -1788 -346 ]

Subtotal (95 CI) 30 30 281 -1067 [ -1788 -346 ]



Total (95 CI) 90 90 1000 -1243 [ -1625 -861 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -05 (1142) 338 -067 [ -663 529 ]

Subtotal (95 CI) 30 30 338 -067 [ -663 529 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -5 (1181) 332 -224 [ -826 378 ]

Subtotal (95 CI) 30 30 332 -224 [ -826 378 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -517 (119) 330 100 [ -504 704 ]

Subtotal (95 CI) 30 30 330 100 [ -504 704 ]



Total (95 CI) 90 90 1000 -064 [ -411 283 ]




-100 -50 0 50 100







Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -209 (176) 321 -068 [ -162 026 ]

Subtotal (95 CI) 30 30 321 -068 [ -162 026 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -215 (156) 340 -179 [ -270 -088 ]

Subtotal (95 CI) 30 30 340 -179 [ -270 -088 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -189 (168) 339 -085 [ -177 007 ]

Subtotal (95 CI) 30 30 339 -085 [ -177 007 ]



Total (95 CI) 90 90 1000 -112 [ -165 -058 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -954 (769) 418 -026 [ -421 369 ]

Subtotal (95 CI) 30 30 418 -026 [ -421 369 ]



2 16 wk

Kayo 2011 30 -1529 (949) 30 -116 (79) 334 -369 [ -811 073 ]

Subtotal (95 CI) 30 30 334 -369 [ -811 073 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -1064 (951) 247 -192 [ -706 322 ]

Subtotal (95 CI) 30 30 247 -192 [ -706 322 ]



Total (95 CI) 90 90 1000 -182 [ -437 074 ]




-100 -50 0 50 100







Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -993 (1339) 356 165 [ -496 826 ]

Subtotal (95 CI) 30 30 356 165 [ -496 826 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -327 (1178) 334 -1285 [ -1967 -603 ]

Subtotal (95 CI) 30 30 334 -1285 [ -1967 -603 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -277 (1313) 311 -911 [ -1618 -204 ]

Subtotal (95 CI) 30 30 311 -911 [ -1618 -204 ]



Total (95 CI) 90 90 1000 -653 [ -1047 -259 ]




-100 -50 0 50 100










Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -533 (1334) 356 -054 [ -769 661 ]

Subtotal (95 CI) 30 30 356 -054 [ -769 661 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -587 (1338) 324 -286 [ -1035 463 ]

Subtotal (95 CI) 30 30 324 -286 [ -1035 463 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -547 (1409) 320 054 [ -701 809 ]

Subtotal (95 CI) 30 30 320 054 [ -701 809 ]



Total (95 CI) 90 90 1000 -095 [ -521 332 ]




-100 -50 0 50 100











Difference


1 8 weeks (wk)

Kayo 2011 30 -1585 (125) 30 -2133 (1279) 416 548 [ -092 1188 ]

Subtotal (95 CI) 30 30 416 548 [ -092 1188 ]



2 16 wk

Kayo 2011 30 -2491 (1534) 30 -263 (139) 311 139 [ -602 880 ]

Subtotal (95 CI) 30 30 311 139 [ -602 880 ]



3 28 wk

Kayo 2011 30 -1686 (1677) 30 -2457 (1434) 273 771 [ -019 1561 ]

Subtotal (95 CI) 30 30 273 771 [ -019 1561 ]



Total (95 CI) 90 90 1000 482 [ 069 895 ]




-20 -10 0 10 20

Favors AE Favors RT




function






Difference


1 8 wk

Kayo 2011 30 -117 (1213) 30 -4 (1188) 353 283 [ -325 891 ]

Subtotal (95 CI) 30 30 353 283 [ -325 891 ]



2 16 wk

Kayo 2011 30 -724 (1197) 30 -1167 (125) 339 443 [ -176 1062 ]

Subtotal (95 CI) 30 30 339 443 [ -176 1062 ]



3 28 wk

Kayo 2011 30 -417 (1196) 30 -13 (1367) 308 883 [ 233 1533 ]

Subtotal (95 CI) 30 30 308 883 [ 233 1533 ]



Total (95 CI) 90 90 1000 522 [ 161 883 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 3 Pain



Difference


1 8 wk

Kayo 2011 30 -277 (195) 30 -344 (181) 357 067 [ -028 162 ]

Subtotal (95 CI) 30 30 357 067 [ -028 162 ]



2 16 wk

Kayo 2011 30 -394 (202) 30 -327 (192) 326 -067 [ -167 033 ]

Subtotal (95 CI) 30 30 326 -067 [ -167 033 ]



3 28 wk

Kayo 2011 30 -274 (193) 30 -357 (206) 317 083 [ -018 184 ]

Subtotal (95 CI) 30 30 317 083 [ -018 184 ]



Total (95 CI) 90 90 1000 028 [ -028 085 ]




-2 -1 0 1 2

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -98 (792) 30 -1027 (1046) 373 047 [ -422 516 ]

Subtotal (95 CI) 30 30 373 047 [ -422 516 ]



2 16 wk

Kayo 2011 30 -152 (949) 30 -1384 (1072) 313 -136 [ -648 376 ]

Subtotal (95 CI) 30 30 313 -136 [ -648 376 ]



3 28 wk

Kayo 2011 30 -1256 (1076) 30 -154 (941) 314 284 [ -228 796 ]

Subtotal (95 CI) 30 30 314 284 [ -228 796 ]



Total (95 CI) 90 90 1000 064 [ -223 351 ]




-20 -10 0 10 20

Favors AE Favors RT






Outcome 5 Fatigue



Difference


1 8 wk

Kayo 2011 30 -828 (1271) 30 -866 (1228) 361 038 [ -594 670 ]

Subtotal (95 CI) 30 30 361 038 [ -594 670 ]



2 16 wk

Kayo 2011 30 -1612 (1497) 30 -1256 (1143) 318 -356 [ -1030 318 ]

Subtotal (95 CI) 30 30 318 -356 [ -1030 318 ]



3 28 wk

Kayo 2011 30 -1188 (1476) 30 -135 (1152) 321 162 [ -508 832 ]

Subtotal (95 CI) 30 30 321 162 [ -508 832 ]



Total (95 CI) 90 90 1000 -047 [ -427 333 ]




-10 -5 0 5 10

Favors AE Favors RT









Difference


1 8 wk

Kayo 2011 30 -587 (1488) 30 -56 (1461) 349 -027 [ -773 719 ]

Subtotal (95 CI) 30 30 349 -027 [ -773 719 ]



2 16 wk

Kayo 2011 30 -873 (161) 30 -1347 (1457) 322 474 [ -303 1251 ]

Subtotal (95 CI) 30 30 322 474 [ -303 1251 ]



3 28 wk

Kayo 2011 30 -493 (1569) 30 -1387 (1463) 330 894 [ 126 1662 ]

Subtotal (95 CI) 30 30 330 894 [ 126 1662 ]



Total (95 CI) 90 90 1000 438 [ -003 878 ]




-20 -10 0 10 20

Favors AE Favors RT



Term Definition
























































2 AQ-MX Control










Joshi 2009 2 MX Med

















McCain 1988 2 AE FX






















2 AQ-MX Control


Valim 2003 2 AE FX













A P P E N D I C E S
















































Level one screen


Level two screen


Level three screen



















H I S T O R Y





















bull None known


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Resistance exercise training for fibromyalgia