Exercise is highly recommended as an adjunct therapy in fibromyalgia. We’re not talking about pounding the pavement, however.

tired young woman

Intense aerobic exercise is not recommended for fibromyalgia

A 2010 review of exercise studies found that ‘slight to moderate’ intensity aerobic exercise sessions done two to three times a week worked best, and that appropriate levels of exercise result in improved fitness but only modestly improved pain. Another review that warned not to overdo on exercise stated that “the latest findings…. indicate the fundamental importance of assigning workloads (i.e. exercise) that do not exacerbate post-exercise pain.”

Something is stopping many FM patients and almost all ME/CFS patients from participating in intense exercise. Four studies suggest that that “something” in ME/CFS involves a damaged aerobic energy production process.

Health Rising hasn’t covered exercise in FM before, but guess what some FM studies suggest the same issue is present in FM. The aerobic energy production system doesn’t appear to be doing well at all in FM.

Déjà vu All Over Again – the Fibromyalgia Exercise Studies

Several FM studies have found problems with exercise. A 2013 study found reduced oxygen consumption both during a submaximal and a maximal exercise test. A 2011 finding  of reduced oxygen consumption (VO2 max), reduced heart rates during exercise, and delayed heart rate recovery suggested a familiar pattern of autonomic nervous dysfunction (increased sympathetic nervous system activation/decreased parasympathetic nervous system activity) was responsible.

The authors pointed out that 57% of FM patients met the criteria for chronotropic incompetence (an inability to get the heart up to speed during exercise). The same problem may be found in ME/CFS.


Defying expectations, the stress response is on at rest in FM (and ME/CFS) and then poops out when stressful situations occur

They also noted FM patients demonstrate ‘sustained sympathetic hyperactivity’ during rest (the stress response is on during rest), and a hypoactive or poor response to stress. This suggests that the stress response in FM is “on” when it should be “off”(at rest), and then tends to poop out when faced with work (such as intense exercise). (People with lupus have a similar response to exercise.)

A 2002 study finding of reduced oxygen uptake (VO2 max), ventilatory anaerobic threshold, and heart rate during a maximal exercise test in FM again suggested problems with aerobic energy production were present.  These authors proposed that dysregulation of the autonomic nervous system (dysautonomia) causing the exercise issues in FM.  They also noted that resistance training was able to improve some aspects of autonomic nervous system functioning.

These findings suggest that, whatever the differences in their ability to exercise, FM and ME/CFS patients have very similar problems with aerobic energy production and autonomic dysfunction.

The Study

Pain severity is associated with muscle strength and peak oxygen uptake in adults with fibromyalgia. Hooten WM, Smith JM, Eldrige JS, Olsen DA, Mauck WD, Moeschler SM. J Pain Res. 2014 May 3;7:237-42. doi: 10.2147/JPR.S61312. eCollection 2014.

These researchers wanted to know if reduced aerobic energy production (low VO2 max) was associated with reduced strength and increased pain. They had their FM patients exercise to exhaustion while measuring their oxygen uptake and then did a separate muscle strength test.

It turned out that the FM patients with reduced aerobic energy production were significantly weaker and in more pain than FM patients with higher aerobic energy production.

Simply being in pain can inhibit muscle recruitment - making you weaker.

Simply being in pain can inhibit muscle recruitment – making you weaker.

The Triad: Energy Production, Strength and Pain

What’s causing this energy production-pain association? Studies have illuminated a number of possibilities.

  1. Simply the presence of pain could be reducing the muscle contraction needed to exercise properly. It turns out that activated pain receptors in the joints actually tell the motor neurons in the brain not to turn on the muscles. Even the anticipation of pain can reduce the efficiency of motor neuron activity. (An April 2014  study indicating that trigger point injections increased handgrip strength in women with FM and/or myofascial pain syndrome suggested pain may be reducing strength. )
  2.  Indeed, some research suggests the normal muscle recruitment is not occurring in FM. Because stimulating the same muscle unit again and again puts it into a contracted painful state, more and more muscle units need to become activated as we continue to exercise. Reduced muscle recruitment, then, could contribute to the painful, contracted feeling of muscles found in FM.
  3. Blood flows are critical not just to meet the oxygen demands of exercising tissues but to remove the toxins created during exercise. The reduced capillary density and blood flows been found in FM could cause problems removing those toxins. At least as early as 2006, researchers suggested that muscle ischemia (low blood flows) both during and after exercise could be causing pain in FM and driving the central sensitization found. Problems with the microcirculation could, therefore, be contributing to the aerobic energy problems, pain, and weakness found in FM.
Problems with the microcirculation could explain much in both FM and M/CFS

Problems with the microcirculation could explain much in both FM and ME/CFS

The authors argued that next step is to determine what happens to capillary blood flows during during exercise. Given the overlap in both exercise and muscle study results in ME/CFS and FM, those results could very well apply to ME/CFS as well.

This study also suggests finding an appropriate exercise regimen could be helpful. FM studies have suggested that greater muscle strength is associated with better mental and emotional well-being and reduced oxidative stress.


An interesting jumble of energy production and muscle problems have showed up in ME/CFS and FM.

Low blood volume – obviously potentially a critical factor in getting blood to the tissues – is acknowledged in ME/CFS but is hardly considered in FM but perhaps should be given the issues shown in the this study.

Increased levels of oxidative stress, mitochondrial problems, muscle fiber issues, increased muscle levels of the toxins pyruvate and lactate, and reduced microcirculation in the muscles have all been found in FM.

Newton’s studies found poor pH handling and increased muscle acidosis in ME/CFS. Reduced muscle ATP production has also been found in ME/CFS. Studies suggest the muscles in both ME/CFS and FM patients suffer from reduced oxygen uptake.

A 2014 study finding normal blood flows but increased muscle and blood glutamate and lactic acid levels in the people with chronic widespread muscle pain suggested normal blood flows may not be enough to remove the toxic byproducts produced.

The similar muscle and energy problems in ME/CFS and FM suggest a research collaboration could be helpful.

The similar muscle and energy problems in ME/CFS and FM suggest a research collaboration could be helpful.

The ME/CFS and FM fields remain stubbornly separate with few studies  incorporating both types of patients. For the most part FM researchers research FM and ME/CFS researchers research  ME/CFS.

The energy production and muscle study results appear to be strikingly similar, however, in both diseases, and findings from either disease could end up informing the other. With neither disorder getting  much  in the way of  federal funding working together might be a good  idea.

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