Among the 53 patients who completed all assessments, the significant effects of LPA on physical activity, function, and pain found during the 12-week trial were not maintained at 6-and 12-month follow-up. The absence of sustained benefits at follow-up is consistent with the vast majority of studies on the effects of lifestyle intervention pertaining to, for example, weight loss and diabetes management.11,12
In FM exercise studies, attrition rates are relatively high, and adherence rates are relatively low,13
with patients reporting that pain and beliefs that exercise worsens their symptoms as primary impediments to maintaining an exercise regimen.14
Based on feedback from our study participants, the primary challenge of the LPA intervention was consistently (i.e., 5–7 d/wk) engaging in moderate-intensity physical activity, given the fluctuating nature of FM symptoms, particularly the fatigue and stiffness. That is, participants would have periods where their symptoms were quiescent so they could string together days of consistently elevated physical activity. However, during a period of increased symptoms, they found it difficult to adhere to the prescribed level of LPA. It is important to note, however, that although there was no statistically significant time or time × condition effect, the LPA group had an average daily step count at 12-month follow-up that represented a 44% increase from their baseline level of physical activity (the FME group, which did not receive information on the value of physical activity for FM until their last group session, increased their physical activity by 26% compared with their baseline level).
Interestingly, despite the absence of significant differences on outcomes at follow-up between the groups, the LPA participants perceived significantly greater improvement in their FM at each assessment compared with FME. It is possible that it is the result of developing a greater sense of self-efficacy as a function of participating in a trial that required tangible changes in behavior (e.g., self-monitoring of physical activity). This is conjecture, however, as self-efficacy was not assessed in this study.
Limitations of this study include the relatively small sample of participants who completed all follow-up assessments; the use of an education, as opposed to a nontreatment control group; and the use of pedometers to assess physical activity. Despite these limitations, the results of this study suggest that the effects of LPA are not well sustained over time. Given the evidence suggesting that exercise and physical activity can be beneficial for people with FM,13,14
additional strategies and innovative approaches need to be developed to assist these patients in staying physically active.
For example, we think the LPA program could be significantly improved by encouraging and promoting increased interaction between participants and between participants and study staff between group meetings and during follow-up. In particular, the use of a study-specific Web site, where patients could have additional access to resources and could communicate with study staff and other participants, might assist them in staying physically active. Participants could also enter their step counts on the Web site to track their levels of physical activity overtime. This form of interactive self-monitoring might facilitate greater adherence. Moreover, the use of prompts, words of encouragement, and tailored messages sent to patients’ e-mail accounts might be useful to help them stay as physically active as the waxing and waning of their FM symptoms allow. Finally, the Web site could facilitate social networking to allow the participants to interact with each other and share advice and provide social support. Indeed, one of the authors (D.J.C.) has been involved in the development of such a Web site (www.knowfibro.com
) to help patients better manage their FM15
(see also Lorig et al.16
). The incorporation of Internet-based technologies to both deliver treatment and facilitate its adherence have also been applied to obesity (e.g., see Funk et al.17
and Arem and Irwin18
), physical activity promotion,19,20
and smoking cessation,21
with some success. Innovative strategies such as these need to continue to be developed and refined to increase the chances that lifestyle modifications can be maintained in the intermediate and long term.