Date sent: Sat, 3 Aug 2002 the full text of this article can be found at: http://bmj.com/cgi/content/full/325/7357/185 Below you will find four electronic responses to this article. Electronic responses to: ".. Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial..." Selwyn C M Richards and David L Scott, BMJ 2002; 325: 185 The Findings of Selwyn, et al., --------------------------------------------- May Be Due to Increased DHEA 27 July 2002 James M. Howard 1037 North Woolsey Avenue, Fayetteville, Arkansas 72701-2046,U.S.A. Email James M. Howard: jmhoward@arkansas.net Selwyn, et al., found that exercise ameliorates symptoms of fibromyalgia. This may be due to increased DHEA. DHEA is low in fibromyalgia (Pain 1999 Nov;83(2):313-9) and exercise increases DHEA (Eur J Appl Physiol Occup Physiol 1998 Oct;78(5):466-71). To paraphrase Selwyn, et al., "[DHEA could be] a simple, cheap, effective, and potentially widely available treatment for fibromyalgia." ~~~~~~~~~~~~~~~~~~~~~~~~~~ Our experience with fibromyalgia ---------------------------------------------- 28 July 2002 Shiju Majeed, Postgraduate student in orthopedics Medical College Trivandrum , India 695011 Email Shiju Majeed: shiju1690@yahoo.com Occasionally, patients with fibromyalgia present to our faculty. These are mostly patients who have been wrongly diagnosed to have some vague pain or mental disorders. We have found that infiltration of local steroids with local anaesthetics can considerably increase their well being in addition to graded aerobic exercises. Some of these patients are prescribed yoga and they do well ~~~~~~~~~~~~~~~~~~~~~~ Fibromyalgia put on the front page ----------------------------------------------- 30 July 2002 Martin Westby, director 7 Ashbourne Road, Bournemouth, Dorset, BH5 2JS Email Martin Westby: admin@ukfibromyalgia.com Dear Editor, I applaud the BMJ not just for publishing Richards and Scott's paper on the treatment of Fibromyalgia, but also for putting it on your front cover. Fibromyalgia is still seen by some doctors as a non-disease, and many sufferers are denied adequate treatment and support. Treatment options are limited, but successive studies have shown that a graded exercise program, combined with an element of CBT, can greatly reduce disability. Long-term studies are still lacking, but with the advent of "exercise prescription" schemes and healthy living centres, there is some hope that effective interventions may be offered to more of the 1 to 2% of the population who suffer from this condition. Our website works with local groups to support sufferers and has been publishing a self-help exercise guide for some time. We have also been lobbying the government to achieve a higher profile for the condition, and more funds for research. Thank you for raising the profile for Fibromyalgia. We hope that through your intervention, more doctors will be able to adequately treat and support their patients in the future. Yours truly, Martin Westby ~~~~~~~~~~~~~~~~~~~~~~~ Missing data and compliance with oversimplification ------------------------------------------------------------------------ 1 August 2002 A Chaudhuri, Clinical Senior Lecturer in Neurology University of Glasgow Email A Chaudhuri: ac54p@udcf.gla.ac.uk Prescribing exercise for fibromyalgia is a tempting option, and the BMJ's cover picture offers an example of exercise that surely many would wish to undertake. There are a few points though that may be worth noting. Firstly, the study recruited patients diagnosed between January 1997 and June 1998 but when published three years after the study was finished, it did not offer any data on the follow up period beyond the first year. Secondly, the authors did not provide any explanation as to why the comparative benefit of graded exercise is largely limited to the improvement in the quality of life questionnaire responses and did not influence McGill pain score, fibromyalgia impact questionnaires or fatigue severity. I would hesitate to accept an improvement in "tender point" counts as of much relevance because there is controversy regarding the nature of these pressure points and the validity of methods used to elicit them, and of course, mechanical dolorimetry suggests that these patients have a reduced tolerance of pain at all sites. Thirdly, given the fact that over two thirds of patients in each of the arms (48 and 47) fulfilled the full definition of chronic fatigue syndrome (CFS), I fail to understand why the authors have not provided us with any data on this important subgroup in terms of their outcome measures. I am also surprised why the data on fatigue measures in the two groups were not even presented in the paper given the fact that CFS and fibromyalgia are considered to be overlap disorders. Was this because graded exercise (as compared to relaxation) was not particularly effective for fatigue and the authors were instructed not to give importance to the fatigue outcome in this study since it would undermine the precriptions of graded exercise for CFS frequently advocated by the BMJ in the past year? Fourthly, there is almost an over-reiteration of fibromyalgia as a "medically unexplained symptom". In reality, fibromyalgia does not represent a single symptom and authors should have taken note of an authoratitive text before submitting to this naive paradigm.[1] Finally, it has been suggested that cognitive behaviour therapy (CBT) would improve patient's compliance to graded exercise. This is a new and untested hypothesis. Having done a post-doctoral thesis some time ago on patient compliance to long term anti-epileptic drug therapy, I have some reservations in accepting that compliance to "prescriptions" would be specifically enhanced by CBT over and above other measures. Infact, the term "compliance" itself is very contentious since it is defined as the extent to which a patient's behaviour coincides with the doctor's advice. Thus, the term compliance, even when used in the context of medical therapy, has been objected to as having overtones of obsolete, arrogant attitudes, implying obedience to the doctor's orders [2]. The suggested alternative is adherence. Whilst no one would question that physical exercise improves quality of life both in health and diseases in general, recommending graded exercise as a specific prescription for complex disorders like fibromyalgia and CFS is a gross oversimplication of science. The BMJ headlines of graded exercise in fibromyalgia and CFS however keep reminding me of an old text that I had come across sometime back in an antique book shop. This book was written by Frenkel who was the medical superintendent of the Freihoff Sanatorium in Switzerland and one of the first to recommend extensive physiotherapy for neurologic diseases with his introduction of exercises for tabetic ataxia in 1890. Frenkel's book ("The treatment of tabetic ataxia by means of systematic exercise") suggest to me that learning history is as important as precribing exercises even if we are treating only the "non-diseases". Last but not the least, I hugely appreciate the efforts of the authors in researching this difficult area. References 1. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. Philadelphia: Lippincott Williams & Wilkins 2001. 2. Lawrence DR, Bennet PN. Clinical Pharmacology. Edinburgh: Churchill Livingstone 1987. ~~~~~~~~~~~~~~~~~~~~