Table 4.

Characteristics of the included studies.

Author/year	Participants	Intervention	Outcomes	Conclusions
Wigers, Stiles, and Vogel 199629	AE: 20 people with FM CG:20 people with FM	Intervention: AE Time was gradually increased up to, and decreased down from, four periods of high intensity training at 60–70% of maximum heart rate (altogether 18–20 min). The programme started with a 23 min music session, comprising warming up and two peaks of high intensity training, each of three–four min duration. This was followed by 15 min of aerobic ‘games’ (different types of tag, ball games etc.), representing two high intensity periods of five six min each, with four min of rest in between. The programme ended with warming down and thoroughly stretching out Comparison: treatment-as-usual (CG) Duration: 45 min three times a week for 14 weeks	Pain (VAS)	Compared to CG, AE induced short-term FM improvement in pain, depression and work capacity, but no obvious group differences in symptom severity were seen in the longer term
Jones et al. 200235	RE: 28 women with FM SE: 28 women with FM	Intervention: RE, The RE received a supervised, classroom based, progressive physical training programme with muscle strengthening exercises performed in the standing, sitting, and lying positions, without machine weights, initially with four to five repetitions (reps) and progressing to 12 reps by the end of the study Intervention: ST Supervised classes meet for 60 min twice per week for 12 weeks. Class began with a low intensity warmup of marching in place or rhythmic dance for 10 min, gentle stretching for 40 min, and guided imagery and relaxation for the concluding ten min Duration: twice a week, for 12 weeks	FIQ; Pain (VAS) Depression (BDI); QOL	The results revealed twice the number of significant improvements in the strengthening group compared to the stretching group. Effect size scores indicated that the magnitude of change was generally greater in the strengthening group than the stretching group
Richards and Scott 200241	AE: 67 people with FM CG: 69 people with FM	Intervention: AE An individualized AE programme was used, mostly walking on treadmills and cycling on exercise bicycles. Each individual was encouraged to increase the amount of exercise steadily as tolerated Comparison: relaxation therapy (CG) Duration: AE: Twice a week (12–50 min) for 12 weeks. CG: 2 days a week (60 min) for 12 weeks	FIQ SF-36	People in the exercise group also had greater reductions in tender point counts and in scores on the FIQ
Valim et al. 200333	AE: 32 women with FM SE: 28 women with FM	Intervention: AE The AE group underwent a walking programme monitored with frequency meters and supervised by a physiotherapist three times a week, of 45 min duration, for 20 weeks. The walking speed (training load) was determined by the training heart rate. Training heart rate was defined as the load beat immediately preceding the one in which the anaerobic threshold occurred. Each training session was preceded by a warmup period, where patients were instructed to walk freely and slowly for five to 10 min. After each session, the patients were placed in a circle and made rhythmic movements, to promote cooling off, for five min and ST. The ST programme consisted of three sessions a week of 45 min duration each and included 17 exercises using both muscles and joints in a general way, including face, cervical spine, trunk, and extremities. It lasted for the same 20 weeks. Each maximum position was sustained for 30 s. The exercises were chosen to provide for overall flexibility, without increasing heart rate Duration: AE: walking programme three times a week, of 45 min duration, for 20 weeks. SE: programme three sessions a week of 45 min duration 20 weeks	FIQ; SF36; Depression (BDI) Pain (VAS)	Aerobic exercise was superior to stretching in relation to depression, pain, and the emotional aspects and mental health domains of SF-36. Patients in the stretching group showed no improvement in depression, ‘role emotional’ and ‘mental health’
Sencan et al. 200442	AE: 20 people with FM PT: 20 people with FM CG: 20 people with FM	Intervention: AE AE were performed three times a week for six weeks and each exercise period lasted for 40 min; the first five min were spent for warm-up, the next 30 min for exercises and the last 5 min were spent cooling down Comparison: placebo treatment (CG) Duration: aerobic exercises on bicycle ergometer for 40 min, three times a week for six weeks	Pain (VAS) Depression (BDI)	This study shows that aerobic exercise had a better therapeutic effect when compared to the placebo group in terms of pain and depression
Bircan et al. 200836	AE: 13 women with FM RE: 13 women with FM	Intervention: AE AE for 20 min and increasing up to 30 min as the patient tolerated. Exercise intensity was adjusted to generate heart rates equivalent to 60–70% of age-adjusted maximum heart rate (220¡ age in years). Intervention: resistance exercise (RE) RE the upper and lower limb muscles and trunk muscles, initially with four-five reps and progressing to 12 reps gradually. Free weights and body weight were used for strengthening. Patients began with resistance levels they could do easily, and weight was gradually increased according to the patient’s tolerance. Exercise sessions began with a low intensity warm-up of marching in place and gentle stretching for five min, followed by 30 min of muscle strengthening, and concluded with five min of cool-down and stretching Duration: AE (20 min-30 min); RE (40 min)¸three times a week for eight weeks	Depression (HADS) SF-36 Pain (VAS)	AE and SE are similarly effective way to improving symptoms of depression and quality of life in FM
Bressan et al. 200846	SE: 8 women with FM CG: 7 women with FM	Intervention: ST The treatment was carried out for eight consecutive weeks and consisted of a 40–45 min weekly session. The participants in G1 underwent a treatment based on static muscular stretching of the triceps surae, isquiotibial, gluteal, paravertebral, latissimocondyloideus, pectoral, trapezius and respiratory muscles. Stretching was performed in dorsal decubitus or sitting. The exercises were performed in a series of five reps, remaining in the same position for 30 secs Comparison: physical condition programme (CG) Duration: ST was carried out for eight consecutive weeks and consisted of a 40–45 min weekly session	FIQ	Muscle stretching may have had a positive impact on FM, with reductions in morning tiredness and stiffness among the patients evaluated
Günendi et al. 200843	AE: 17 women with FM CG: 15 women with FM	Interventions: AE The study group performed submaximal aerobic exercise at 60–80% of maximal heart rate Comparison: normal daily activities (CG) Duration: AE on treadmill lasting 30 min, five times a week for four weeks. Submaximal AE was performed at 60–80% of maximal heart rate	Pain (VAS) Depression (HADS)	There were statistically significant improvements in the intensity of pain and depression
Panton et al. 200932	RE: 15 women with FM CG: 12 women with FM	Intervention: RE All participants performed one set of 8–12 reps twice a week on 10 exercises, using nine resistance machines. Participants began training at approximately 50% of their initial 1-RM measurement and were slowly progressed to approximately 100% of their initial 1-RM by the end of the 16 weeks. Once 12 reps were completed on two consecutive workouts, weights were increased by five to 10 pounds for upper and lower body, respectively Comparison: chiropractic treatment (CG) Duration: 16 weeks of RE consisting of 10 exercises performed twice per week	FIQ	In women with FM, resistance training improves strength, FM impact, and strength domains of functionality
Mannerkorpi et al. 201044	AE: 34 people with FM CG:33 people with FM	Intervention: moderate intensity AE The target was to achieve 20 min of moderate-to-high intensity exercise. Exercise intensity was based on the subjective perception of exertion, and patients were instructed as to how to rate exertion on the Borg´s Rating of Perceived Exertion (RPE) scale ranging from six to 20. RPE < 12 is considered to correspond to < 40% of the maximal heart rate, while 12 to 13 (moderate) corresponds to 40 to 60% and 14 to 16 (heavy) to 60 to 85% of the maximal heart rate. The groups started with light exercise for 10 min, ranging from nine (very light) to 11 (fairly light) on the RPE scale, after which they performed two-minute intervals of moderate-to-high intensity exercise, defined as exertion ranging from 13 to 15 on the RPE scale, alternated with two-minute low-intensity exercise, defined as 10 to 11 on the RPE scale. This means that the participants walked at different speeds in small groups, and the leaders alternated between them to provide individual instruction Comparison: aerobic exercise low intensity (CG) Duration: twice a week (10–20 min), 15 weeks	Pain (FIQ) FIQ	No between-group difference was found for the FIQ Pain and FIQ Total
Sañudo et al. 201045	AE: 22 women with FM CE: 21 women with FM CG: 20 women with FM	Interventions: AE Participants performed twice a week of 45 to 60 min duration. Each session included 10 min of warm-up activities (slow walks, easy, movements of progressive intensity); 15 to 20 min of steady-state AE at 60% to 65% of HRmax (calculated as 220-age of participant), including continuous walking with arm movements and jogging; 15 min of interval training at 75% to 80% HRmax (6 exercises for one min and half, resting for one minute between them) that included aerobic dance and jogging; and five to 10 min of cool-down activities (slow walks, easy movements, relaxation training) Comparison: normal daily activities (CG) Duration: twice a week (45–60 min). CE, twice a week (35–45 min) for 24 weeks	FIQ SF-36 Depression (BDI)	An improvement from baseline in total FIQ and SF-36 score was observed in the exercise groups and was accompanied by decreases in BDI scores relative to controls
Hooten et al. 201234	RE: 36 people with FM AE: 36 people with FM	Intervention: RE Study participants completed one set of 10 reps at individually specified weight loads where the initial weight loads for the upper and lower extremities generally ranged from 1–3 kg and 3–5 kg, respectively. All individuals were encouraged to increase weight loads by one kg per week during the course of the three-week study period and AE Therefore, the intensity and duration of AE was not advanced using a standardized protocol; rather, study participants were encouraged to gradually increase the intensity and duration of AE to achieve 70% to 75% of maximal heart rate based on age (220 bpm minus age). Study participants engaged in aerobic exercise up to 10 min daily during week 1 (50 min total week one), up to 15 min during week two (1.25 h total week two), and up to 20 to 30 min daily during week three (90 min to 150 min total week three) Duration:10–30 min each day for AE and 25–30 min for RE. Both for three weeks	Pain (MPI)	This study found that strength and aerobic exercise had equivalent effects on reducing pain severity among patients with FM
Kayo et al. 201237	AE: 30 women with FM RE: 30 women with FM CG: 30 women with FM	Interventions: AE Walking was performed either outdoors or indoors in a gymnasium, depending on the weather. Each session consisted of a warm-up period, stretching (five-10 min), conditioning stimulus, and a cool down period (five min). Every four weeks, walking duration was increased (25–30 min to 50 min), as well as the intensity of the conditioning stimulus [began at 40–50% and progressed to 60–70% of the heart rate reserve by week and RE group followed an exercise protocol consisting of 11 free active exercises, using free weights and body weight performed in the standing, sitting, and lying positions to improve the muscle strength of the upper and lower limbs and trunk muscles. On average, the exercise load and intensity were increased every two weeks, according to the patient’s tolerance and by following the Borg Scale Comparison: conventional treatment (CG) Duration: AE and RE practice three days a week (60 min) for 16 weeks	Pain (VAS) FIQ SF-36	Patients in the AE and RE groups reported higher scores (better health status) than controls in almost all SF-36 subscales. RE was as effective in reducing pain regarding all study variables; however, the management of symptoms during the follow-up period was more efficient in the AE group
Gavi et al. 201438	RE: 35 women with FM SE: 31 women with FM	Intervention: RE Supervised progressive training in the standing and sitting positions using weight machines. The intensity was moderate, with an overload of 45% of the estimated 1RM. Three sets of 12 reps Comparison: ST Duration: 45 min twice a week, for 16 weeks	Pain (VAS) FIQ SF-36	ST showed greater and more rapid improvements in pain and strength than flexibility exercises
Larson et al. 201539	RE: 67 women with FM CG: 63 women with FM	Intervention: RE The group was initiated at low loads (based in 1-RM), and possibilities for progressions of loads were evaluated every three-four weeks. When the participant was not ready to increase exercise loads, she continued exercising at the same load until she was ready to do so Comparison: relaxation therapy (CG) Duration: resistance exercise two days a week (60 min) for 15 weeks. CG two days a week (25 min) four weeks	FIQ SF-36 Pain (VAS)	Significantly greater improvement was observed in: health status (FIQ total score); pain intensity (VAS); significantly greater improvement were observed in the health related quality of life (SF-36 PCS)
Ericsson et al. 201640	RE: 67 women with FM CG: 63 women with FM	Intervention: RE The RE was initiated at 40% of 1 repetition maximum (RM) and progressed up to 80% of 1-RM during the 15 weeks. Possibilities for progression of loads were evaluated every three-four weeks Comparison: relaxation therapy (CG) Duration: twice a week (60 min) for 15 weeks	Depression (HADS)   Pain (PCS)	No significant changes during the study period were found in HADS dimensions (anxiety or depression)
Assumpção et al. 201830	SE: 14 women with FM RE: 16 women with FM CG: 14 women with FM	Interventions: ST 12-week supervised exercise programme of 40-min sessions performed twice a week, as suggested by the American College of Sports Medicine and RE Comparison: normal daily activities (CG) Duration: ST and RE, 12-week 40-min sessions performed twice a week	Pain (VAS) FIQ SF-36	The ST group showed significant improvements in pain, impact on FM symptoms measured by the FIQ total score and quality of life measured by SF-36 physical function, bodily pain, vitality and mental health. After the intervention, the RE group had significant improvements in pain threshold; number of tender points, impact on FM symptoms and quality of life measured by SF-36, as well as better physical function, vitality and mental health compared with baseline
Silva et al. 201831	RE 30 women with FM CG: 30 women with FM	Interventions: RE A resistance training programme using weight training for calculating one repetition maximum (1-RM), twice a week for 40 min for a period of 12 weeks. The exercise programme is described: three sets of 12 reps, with an interval of one to two min for recovery; between one set to another, alternating lower limbs. Loads with 60% of 1-RM in the first month, 70% of a new 1-RM test in the second month, and 80% of a new 1-RM test in the third month. Patients were re-evaluated at the end of every four weeks for their load progression Comparison: sophrology group (SG) who participated in a relaxation programme based on sophrology Duration: RG performed a resistance training programme using weight training twice a week for 40 min for a period of 12 weeks	Pain (VAS) FIQ SF-36	RE led to statistically significant decreases in pain. No differences in pain were found between the groups. RE was more effective than sophrology in improving strength and functional capacity in women with FM