Nordic walking in fibromyalgia: a means of promoting fitness that is easy for busy clinicians to recommend

A total of 67 women with fibromyalgia were recruited to an exercise study and were randomized to moderate-to-high-intensity Nordic walking (age 48 ± 7.8 years) or to a control group engaging in supervised low-intensity walking (age 50 ± 7.6 years). A total of 58 patients completed. Significantly greater improvement in the 6-minute walk test was found in the Nordic walking group (P = 0.009), compared with the low-intensity walking group. A significantly larger decrease in exercise heart rate (P = 0.020) and significantly improved scores on the Fibromyalgia Impact Questionnaire Physical function (P = 0.027) were found in the Nordic walking group as compared with the low-intensity walking group. No between-group difference was found for the Fibromyalgia Impact Questionnaire total or pain scores. The authors conclude that moderate-to-high intensity aerobic exercise by means of Nordic walking twice a week for 15 weeks was found to be a feasible mode of exercise, resulting in improved functional capacity and a decreased level of activity limitations.

Persons with fi bromyalgia can enjoy the same improvements in strength, fl exibility, aerobic capacity and perhaps postural control as can healthy persons. Symptom fl ares are commonly exacerbated, however, by exercise that is not modifi ed for fi bromyalgia. Specifi cally, aerobic activities that involve fast cycling, running, jumping, quick turns and certain dance moves may result in symptom fl ares, as can higher intensity exercise compared with lower intensity exercise [4,5].
What is less clear is how to design a 'start low and go slow' aerobic exercise protocol that is community based, of low cost, and does not require a high degree of specialized supervision. Moreover, the exercise should also provide signifi cant fi tness improvements without inducing a symptom fl are. Ideally, this intervention would improve not only fatigue, sleep, mood/distress and quality of life, but also pain. Lastly, it should be easy for busy clinicians to recommend as a specifi c modality.
Mannerkorpi and colleagues may have designed such a program in Sweden. Th ey randomized 67 women with fi bromyalgia to a 20-minute, twice-weekly, 15-week program of either moderate-to-high-intensity walking (13 to 15 Rated Perceived Exertion) out doors with Nordic walking poles or supervised low-intensity walking (9 to 11 Rated Perceived Exertion) without Nordic walking poles. Nordic walking poles activate muscles in the trunk and upper body while aiding balance. Th e poles also allow people to increase their stride length and employ a faster gait.
As expected, the group whose walking was supple mented with walking poles demonstrated signifi cant improvements in a 6-minute walk test (P = 0.009) and the Fibromyalgia Impact Questionnaire Physical function (P = 0.027) compared with the group who walked without poles. What was novel was that signifi cant fi tness gains were garnered without inducing a symptom fl are. In fact, both groups demonstrated clinically meaningful reductions in pain and fatigue. Nordic walking did not, however, produce greater symptom relief than lower intensity walking.

Abstract
A total of 67 women with fi bromyalgia were recruited to an exercise study and were randomized to moderate-to-high-intensity Nordic walking (age 48 ± 7.8 years) or to a control group engaging in supervised low-intensity walking (age 50 ± 7.6 years). A total of 58 patients completed. Signifi cantly greater improvement in the 6-minute walk test was found in the Nordic walking group (P = 0.009), compared with the low-intensity walking group. A signifi cantly larger decrease in exercise heart rate (P = 0.020) and signifi cantly improved scores on the Fibromyalgia Impact Questionnaire Physical function (P = 0.027) were found in the Nordic walking group as compared with the low-intensity walking group. No betweengroup diff erence was found for the Fibromyalgia Impact Questionnaire total or pain scores. The authors conclude that moderate-to-high intensity aerobic exercise by means of Nordic walking twice a week for 15 weeks was found to be a feasible mode of exercise, resulting in improved functional capacity and a decreased level of activity limitations.
So where are we now? We have a safe, communitybased intervention that will allow people with fi bromyalgia to walk outdoors without avoiding hills and increasing the fall risk. People with fi bromyalgia who walk with Nordic walking poles may experience greater fi tness gains than those walking without Nordic walking poles. Clinicians have a specifi c intervention they can easily recommend that does not require proximity to a specialized academic center with extensive expertise in fi bromyalgia exercise modifi cations. Patients have another form of exercise from which to choose that will help them regain signifi cant loss of aerobic fi tness while reducing fi bromyalgia symptoms.
Th e physiologic eff ects of more intense exercise in fi bromyalgia are being studied in an eff ort to better understand and manage exercise-induced symptom fl ares [6]. Of specifi c interest to an exercise program is how to modify exercise such that it reduces reducing peripheral pain generation from the muscle or myofascial trigger points within the muscle. Specifi cally, the milieu of myofascial trigger points have an acidic pH and contain elevated levels of bradykinin, calcitonin gene-related peptide, substance P, TNFα, IL-1β, serotonin, and norepinephrine [7]. It is further known that pain originating in the muscle, including latent or active myofascial trigger points, can induce or augment central sensitization in both healthy controls and persons with fi bromyalgia [7,8]. Th is is especially true if adequate rest periods are not incorporated into more intense exercise in persons with fi bromyalgia [9].
What is left to for clinicians to understand? Rarely can exercise alone adequately control fi bromyalgia symp toms, especially pain. Access to a combination of fi bromyalgiaspecifi c analgesics and modifi ed exercise are necessary to maximize functionality and symptom management [10]. Until the altered central and peripheral mechanisms in fi bromyalgia can more fully understood and mitigated, exercise will continue to need to be modifi ed for persons with fi bromyalgia. Nordic walking, as tested by Mannerkorpi and colleagues, represents such a modifi cation and off ers patients a safe and eff ective means of regaining functionality and physical fi tness. Abbreviations IL, interleukin; TNF, tumor necrosis factor.