Physical Leisure Activity Level and Physical Fitness amongWomen with Fibromyalgia

BÔrd Natvig, Dag Bruusgaard, and Willy Eriksen

Institute of general practice and community medicine, University of Oslo, Norway

To determine selfreported physical leisure activity level and physical ¢tness in women with ¢bromyalgia we sent questionnaires to the femalemembers of a local ¢bromyalgia association and the same questionnaire to the women in a population based cohort study. The ¢bromyalgiapatients had higher physical leisure activity level, but lower physical ¢tness than the women in the population survey. The di¡erence in physicalleisure activity persisted even after controlling for a series of possible confounders, including employment status and work load in a logisticregression analysis.

Key words: ¢bromyalgia, population survey, physical leisure activity level, physical ¢tness, COOP/WONCA Chart

Women with ¢bromyalgia are markedly below averagein physical performance abilities when measured byclinical tests (1) and when assessed by measures offunctional limitation in performing daily activities (2).

Many patients with ¢bromyalgia ¢nd that exerciseaggravate their pain (3). In 1989 Bennett et al. foundthat a majority of patients with ¢bromyalgia wereaerobically un¢t, and `reluctant to exercise, due totheir symptoms' (4). They suggested that the `detrain-ing phenomenon' might be relevant to the aetiologyof ¢bromyalgia.

Exercise programs have positive short-term symp-tomatic e¡ects in ¢bromyalgia (5 ^ 8), and an ade-quate level of regular physical exercise correlateshighly with low symptom intensity in ¢bromyalgia(9). Research projects have been based on theassumption that patients with ¢bromyalgia are lessphysically active than the average healthy person (3),and persons with rheumatic conditions including¢bromyalgia report to participate less in leisure-timephysical activity than the average American (10).

However, we do not know whether reduced physi-cal ¢tness in women with ¢bromyalgia is a result oflow level of physical leisure activity.

In this study we compared a group of women with¢bromyalgia with a population based sample, withrespect to self-reported physical leisure activity leveland self-reported physical ¢tness.

Our main hypothesis was that women with ¢bro-myalgia are less physically active in their leisure timethan women in the general population.

We also compared the two groups according tophysical ¢tness, and assessed the correlation between

physical leisure activity level and physical ¢tness. Wealso explored factors associated with a high level ofphysical leisure activity.

Materials and methods

Sample and setting

Romerike is a region north-east of Oslo, Norway,with 190,000 inhabitants in 1994. Ullensaker, a muni-cipality with 18,500 inhabitants, is a part of Romer-ike. The Romerike Fibromyalgia Association had588 members in 1994. To become a member a doctormust verify the diagnosis of ¢bromyalgia.

In late autumn 1994 a postal questionnaire aboutmusculoskeletal complaints was sent to all membersof the Romerike Fibromyalgia Association, and toall inhabitants of Ullensaker belonging to six birthcohorts: 24 ^ 26 years, 34 ^ 36 years, 44 ^ 46 years,54 ^ 56 years, 64 ^ 66 years, and 74 ^ 76 years.

The participation rate in the Association was 78%(457 responders). A majority of the respondents fromthe Association were women between 30 and 70 yearsof age (82%, n~374). As we wanted to comparewomen with ¢bromyalgia with the most relevantgroup in the population according to physical leisureactivity level and physical ¢tness, we excluded men,women of unknown age, as well as the youngest andoldest age cohorts in the population study. Eightywomen aged 30 ^ 70 years in the Ullensaker popula-tion who responded yes to the question `Do you have¢bromyalgia?' were analysed separately. The partici-pation rate in the four age-cohorts of women inUllen-saker was 72.6% (n~1043).

Measurements

Physical leisure activity level was registered by thequestion: `How much do you use your body (so hard

BÔrd Natvig, Department of General Practice and CommunityMedicine, University of Oslo, P.O. Box 1130 Blindern, N-0318 Oslo,Norway

Received 15 December 1997Accepted 3 April 1998

Scand J Rheumatol 1998;27:337^41

337# 1998 Scandinavian University Press on license from Scandinavian Rheumatology Research Foundation

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that you sweat and/or breathe heavily) in your leisuretime?', with the answer possibilities: none, less than 2hours a week, 2 ^ 4 hours a week, and more than 4hours a week).

Physical ¢tness was registered by the COOP-WONCA Chart `Physical ¢tness' (11), using the o¤-cial Norwegian translation (12). The respondentswere asked to rate their physical ¢tness on a ¢ve-pointscale, and each level was illustrated pictorially,numerically, and verbally. The question was `Duringthe past 2 weeks ... . What was the hardest physicalactivity you could do for at least 2 minutes?'. Theoptional answers were: Very heavy, for example runat a fast pace (score 1); heavy, for example jog at aslow pace (score 2); moderate, for example walk at afast pace (score 3); light, for example walk at a med-ium pace (score 4) and very light, for example walk ata slow pace or not able to walk (score 5).

Three dimensions of pain were used as variables inthe logistic regression. Pain intensity was registeredby an optional COOP-WONCA-chart `pain' withthe question `During the past two weeks... How muchbodily pain have you generally had?'. The optionalanswers were: No pain (score 1); very mild pain (score2); mild pain (score 3); moderate pain (score 4), andsevere pain (score 5). Pain duration was registered bythe question `For how many years have you had mus-culoskeletal pain?' The optional answers were: nocomplaints, less than a year, one to ¢ve years, six toten years, and more than ten years. Widespreadnessof pain was registered by the Nordic Questionnaire(13). We added headache as an extra category, result-ing in ten possible areas, marked on a body map. Inthis study we used the number of areas with muscu-loskeletal pain during the last week.

Statistical analysis

In comparing di¡erences between the two groups weused the Mann-Whitney rank sum test for ordinal

data and the chi-square test for categorical data. Cor-relation between physical leisure activity level andphysical ¢tness was measured by 2-tailed Spearmanrank correlation coe¤cient (rho).

We dichotomised physical leisure activity level (atleast two hours a week or less than two hours a week).We searched for di¡erences in subgroups between thepopulation and the ¢bromyalgia patients in their ten-dency to report more than two hours physical leisureactivity a week. Then we entered a variety of variableswe expected could be associated with physical leisureactivity level in a logistic regression model. We usedphysical leisure activity as dependent variable. In thislogistic regression model we analysed the populationand the ¢bromyalgia association together, with age,civil status, pain characteristics (intensity, duration,widespreadness), employment status, hours of salar-ied work a day, hours of total work a day, subjectivework load, sleep quality, and Body Mass Index(BMI)as independent variables. Pain intensity and durationwere entered as categorical variables in the logisticregression, while widespreadness was used as a conti-nous variable.

The statistics were performed with the SPSS 7.5Statistical Package (14). The project was approvedby the regional committee of medical ethics.

Results

54.1% of the women in the Fibromyalgia Associationreported a physical leisure activity of more than twohours a week, compared to 41.5% in the population(table I).

The tendency for women with ¢bromyalgia toreport a higher physical leisure activity level was pre-sent in most subgroups. Only in women aged 61 ^ 70years there was a non-signi¢cant tendency in theopposite direction (table II).

While 54.4% in the population study reportedbeing able to do heavy or very heavy physical activity,only 23.0% of the ¢bromyalgia patients reported thesame (table III).

High physical leisure activity was signi¢cantly, butweakly, correlated with better physical ¢tness, withcorrelation coe¤cients of 0.18 (pv0.01) in the Asso-ciation and 0.16 (pv0.01) in the population.

In the group of 80 women from the population whoanswered `yes' to having ¢bromyalgia, the resultswere similar to those of the Association, with thesame proportion doing more than two hours leisurephysical activity (53.8%), and with similar tendenciesin the subgroups in table III compared with the popu-lation data (data not shown).

From 57 of the 80 women with ¢bromyalgia inUllensaker we have reports about physical leisureactivity from a survey four years earlier (15), and 2/

Table I. Selfreported physical leisure activity level in a population ofwomen aged 30 ^70 years, and in female members of a ¢bromyalgiaassociation of the same age.

Physical leisure Population Membersactivity level n~918 Fibromyalgia(hours a week) Association

n~357% %

None 17.3 14.3Some, less than 2 hours 41.2 31.7Between 2 and 4 hours 31.4 37.0More than 4 hours 10.1 17.1

Two-tailed pv0.001 (Mann-Whitney test).

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3 of them (38) reported increased physical leisureactivity level in 1994 compared to 1990.

Being a member of the Fibromyalgia Associationwas the only variable that was signi¢cantly relatedto physical leisure activity level in our logistic regres-sion model after controlling for age, civil status, paincharacteristics (intensity, duration and widespread-ness), employment status, hours of salaried work aday, hours of total work a day, subjective work load,sleep quality, and BMI. The odds ratio for physicalleisure activity higher than two hours per week was

1.98 (95% con¢dence interval 1.27 ^ 3.10) for themembers compared with the women in the Ullensakerpopulation.

Discussion

Unexpectedly, female patients with ¢bromyalgiareported higher physical leisure activity level, but atthe same time lower physical ¢tness than a femalepopulation.

Methodological considerations

The participation rate in the two samples was fairlygood. We do not have information about sex or ageof non-responders from the Association. Even if therespondents are reasonably representative for theAssociation, we do not know how representative themembers of the Association are for the entire groupof patients with ¢bromyalgia. It is not unlikely thatmembers of a patient organisation are more resource-ful and active than non-members with the same pro-blem. However, the similarity in results between the80 women with ¢bromyalgia in Ullensaker and therespondents from the Association gives reason to

Table II. Percentage reporting more than two hours physical leisure activity pr. week in subgroups of a population women 30^70 years compared tofemale members of a ¢bromyalgia association of the same age.

Population Members Pearson's chi-square,% Fibromyalgia di¡erence between

Association groups% p

All 41.5 54.1 v0.0131^40 years 40.8 49.3 0.2141^50 years 46.9 60.2 0.0151^60 years 35.5 54.2 v0.0161^70 years 39.7 38.2 0.88Married/cohabiting 40.5 54.0 v0.01All others 45.6 54.2 0.25Salaried employed 40.7 52.1 0.01All others 43.6 55.3 0.01v6 hour employment a day 45.8 57.3 0.02w6 hour employment a day 40.5 52.0 0.030 ^4 areas with pain 43.6 ^ ^5 ^10 areas with pain 37.9 54.1 v0.01BMI v20 45.7 55.6 0.44BMI 20^25 42.4 57.1 v0.01BMI 25^30 39.2 48.2 0.12BMI w30 39.0 55.2 0.18Too low workload 40.4 ^ ^Suitable workload 46.3 58.0 0.01Too high workload 36.1 53.6No complaints or not so bad 46.9 ^ ^Medium complaints 37.8 51.6 0.04Bad or very bad complaints 41.6 55.5 v0.01Good sleepers 43.4 58.6 0.11Medium sleepers 38.1 45.1 0.15Poor sleepers 42.5 60.7 0.01

Table III. Physical ¢tness in a population of women aged 30 ^70 years,and in female members of a ¢bromyalgia association of the same age.

How hard Population Membersphysical activity n~908 Fibromyalgiahave you been % Associationable to do during n~362the last 14 days? %

Very heavy 20.4 9.7Heavy 34.0 13.3Moderate 30.6 36.5Easy 11.5 31.5Very easy 3.5 9.1

Two-tailed pv0.001 (Mann-Whitney test).

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believe that the members are fairly representative forall patients with ¢bromyalgia in our region.

As Ullensaker is part of Romerike, some of the per-sons with ¢bromyalgia in the Ullensaker populationmight also be members of the Romerike FibromyalgiaAssociation. If we assume that members in the asso-ciation are evenly distributed in the population ofRomerike, this might be in the range of 10 ^ 15 per-sons, causing minor methodological problems.

The two groups of women were not age-matched.In the population they were more evenly distributedon the range 30 ^ 70 years, while most associationmembers were 40 ^ 50 years. As we found no obvioustrend in physical leisure activity level according toage, we would not expect this to in£uence the conclu-sions.

The COOP/WONCA-charts are international,easy to use, and fairly well validated charts for simplefunctional assessment in general practice (16). Thequestion used for registration of physical leisureactivity attempts to get reports on leisure activitieshard enough to give gainful e¡ects on endurance andstrength. This question has been used in several Nor-wegian population studies, and it has a reasonableface validity, but has not been further validated.

The tendency for low physical ¢tness in patientswith ¢bromyalgia is well known. The importance ofa high physical leisure activity level for patients with¢bromyalgia has been emphasised both by the Asso-ciation, by media, and by local health personnel. Thismight lead to overrating of physical leisure activityamong these patients. Clark et al. (17) found that asubset of patients with ¢bromyalgia perceived theirrate of exertion too high, and did not reach theiranaerobic threshold under testing. Our design cannotrule out the possibility that ¢bromyalgia-patientsreport a higher physical leisure activity level than theyactually have.

Physical ¢tness

Fibromyalgia symptoms are known to have severeconsequences on the activities of everyday life (18).The aerobic ¢tness in patients with ¢bromyalgia islow (4). Our results con¢rm that persons with ¢bro-myalgia have strongly reduced physical ¢tness com-pared to a population sample, on the other hand,physical leisure activity level was only weakly corre-lated with physical ¢tness.

Physical leisure activity

In a follow-up study of patients with ¢bromyalgia(19), 57% reported that they were physically lessactive during their leisure time than before, eventhough half the group exercised twice a week or more.

Combined with the experience of many patientswith ¢bromyalgia, that exercise induce pain (3), weexpected the members of the Association to report alower physical leisure activity level than the women ofthe same age in the Ullensaker population. There wasa signi¢cant di¡erence, but in the opposite direction.The female ¢bromyalgia members reported a higherphysical leisure activity level than the female popula-tion.

One likely explanation was that patients with ¢bro-myalgia, with reduced employment activity, havemore leisure time to spend on physical activity. How-ever, neither employment status nor hours per day inwork outside the home could explain the variation inphysical leisure activity in the logistic regressionmodel.

Alternatively one could speculate that physicaltraining is used as treatment or rehabilitation in ¢bro-myalgia. This theory is supported by the tendencytowards reporting a higher physical leisure activitylevel in 1994 than in 1990 in the group reporting tohave ¢bromyalgia in the Ullensaker population. Thisis further in accordance with an interview study with20 American and 20 Swedish women with ¢bromyal-gia; regular, suitable, light exercises were often men-tioned as a strategy in living with continuousmuscular pain (20). It is also possible that personswith ¢bromyalgia spend more time on doing physicalleisure activities because they perform these activitiesat a slower pace with reduced e¡ect on endurance orstrength (19). A need for slow pace could perhaps alsoexplain the apparent contradiction that most ¢bro-myalgia patients reported that they were unable todo hard work, but at the same time were participatingin physical leisure activities, hard enough to causesweating or increased respiration.

In our cross-sectional study we cannot conclude onthe causality between low physical leisure activitylevel and the reduced physical ¢tness seen in patientswith ¢bromyalgia.

The results suggest however, that causes other thanlow physical leisure activity level are important forthe reduced physical ¢tness seen in persons with wide-spread chronic pain, diagnosed as ¢bromyalgia.

Acknowledgments

The study was ¢nanced by the Norwegian Research Council, theUniversity of Oslo, the Norwegian Fibromyalgia Association, andthe Trygve Gythfeldt fund.

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