Rev. Bras. Reumatol. vol.55 número2

rev bras reumatol.2015;55(2):167–173

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Review

article

Effects

of

muscle

stretching

exercises

in

the

treatment

of

fibromyalgia:

a

systematic

review

夽

Suélem

Barros

de

Lorena

_,

_Maria

_do

_Carmo

_Correia

_de

_Lima,

_Aline

_Ranzolin,

Ângela

Luiza

Branco

Pinto

Duarte

UniversidadeFederaldePernambuco,Recife,PE,Brazil

a

r

t

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c

l

e

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n

f

o

Articlehistory:

Received16March2014

Accepted17August2014

Availableonline6January2015

Keywords:

Fibromyalgia Stretching Physiotherapy

a

b

s

t

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c

t

Objective:thisstudyhastheobjectivetosystematizescientificevidencesabouttheuseof

musclestretchingexercisesinthetreatmentofFM.

Methodology:itwasperformedfromretrospectiveresearchwithoutchronologicaland

lin-guisticlimits,atdatabasesofMEDLINE,LILACS,SciELOandPEDro,aswellasatPubMed

searchtool.DatacollectionwasperformedbytwoindependentreviewersinOctober2012,

withthesearchstrategyformulatedbycrossingdescriptorsandrelevanttermstothetopic

inEnglish,PortugueseandSpanishlanguages.Randomizedclinicaltrials,onlywithpatients

withaclinicaldiagnosisoffibromyalgiaandmusclestretchingexercisesasatherapeutic

measureatleastinoneoftheinterventiongroupswereincluded.Includedstudieswere

assessed formethodological qualityusingPEDroscaleandtheirreferences analyzedto

highlightadditionalsources.Thesearchamountedtoanaverageof6,794items.Onlyfive

articleswereselected,onebeingexcludedbecauseofitslowmethodologicalquality.Pain

wasassessedunanimously.Themethodandtimingofinterventionsvariedwidely,there

waspoormentionoftheparametersusedinthestretchesandabsenceofspecificphysical

examinations.

Results:therewassignificantimprovementinallstudiesregardingpain,besidesasrelated

toqualityoflifeandphysicalcondition.

Conclusion: itiscleartheimportanceofmusclestretchinginthetreatmentofFM,however,

thereisaneedforfurtherstudiestoestablishtherealbenefitsofthetechnique,because

themajorityofpublishedstudiesshowslowmethodologicalqualityandthereisalackof

standardizationregardingtheuseofthisresource.

©2014ElsevierEditoraLtda.Allrightsreserved.

夽

Institution:Post-GraduatePrograminHealthSciences,UniversidadeFederaldePernambuco,Recife,PE,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](S.B.d.Lorena).

http://dx.doi.org/10.1016/j.rbre.2014.08.014

168

Efeitos

dos

exercícios

de

alongamento

muscular

no

tratamento

da

fibromialgia:

uma

revisão

sistemática

Palavras-chave:

Fibromialgia Alongamento Fisioterapia

r

e

s

u

m

o

Objetivo: opresentetrabalhotemcomoobjetivosistematizarevidênciascientíficassobrea

utilizac¸ãodosexercíciosdealongamentomuscularnotratamentodafibromialgia(FM).

Metodologia: foirealizadoapartirdeconsultaretrospectiva,semlimitecronológicoe

lin-guístico,àsbasesdedadosMedLine,LILACS,SciELOePEDro,alémdaferramentadebusca

PubMed.Acoletafoirealizadapordoisrevisoresindependentes,emoutubrode2012,sendo

aestratégiadebuscaformuladapormeiodocruzamentodedescritoresetermosrelevantes

paraotemanosidiomasinglês,portuguêseespanhol.Foramincluídosensaiosclínicos

randomizados(ECRs)compostosapenasporpacientescomdiagnósticoclínicodeFMecom

exercíciosdealongamentomuscularcomomedidaterapêuticaempelomenosumdos

gru-posdeintervenc¸ão.Osestudosincluídosforamavaliadosquantoàqualidademetodológica

pormeiodaescalaPEDro,esuasreferênciasbibliográficas,analisadas,parasedestacar

fontesadicionais.Abuscatotalizou6.794artigos.Cincoartigosforamselecionados,sendo

um delesexcluídoporapresentarbaixaqualidademetodológica.Ador foiavaliadapor

unanimidade.Ométodoeotempodasintervenc¸õesvariaramamplamente,houvefalta

demenc¸ãodeparâmetrosnautilizac¸ãodosalongamentoseausênciadeexamesfísicos

específicos.

Resultados: houvemelhorasignificativaemtodososestudosquantoàdor,alémdeaspectos

relacionadosaqualidadedevidaecondic¸ãofísica.

Conclusão:éevidenteaimportânciadoalongamentomuscularnotratamentodaFM,porém

observa-seanecessidadedenovosestudosparaseestabelecerosreaisbenefíciosdatécnica,

vistoqueamaioriadostrabalhospublicadosapresentabaixaqualidademetodológicae

ausênciadepadronizac¸ãoquantoaousodesserecurso.

©2014ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Fibromyalgia(FM)isarheumaticsyndromeofunknown

etiol-ogythatoccurspredominantlyinwomenaged30-55years.1

Itis characterizedbya chronic, widespread

musculoskele-talpain, withgreater than threemonthsduration,causing

physicalandemotionalproblemsinterferingdirectlyin

func-tional capacityand quality oflife.2 _{The diagnosis isbased}

on the clinical condition of the patient,3 _{and the}

treat-ment advocates pain control through global strategies of

an interdisciplinary approach, with interventions in

phys-ical,pharmacological, cognitive-behavioraland educational

spheres.1,4

Acting directly in the physical domain of FM patients,

physiotherapy,aprofessionalmodalityconsistingofan

arse-naloftechniquesresponsibleforbreakingtheviciouscycle

of symptoms characteristic of chronic patients, deserves

to be highlighted.4–6 _{Scientific evidence shows that}

cine-siotherapeuticexercisesminimizepain,fatigueandmuscle

tension,improvinglevelsofstress,anxietyanddepressionin

fibromyalgiapatients,whenperformedonaregularbasisand

undermonitorization.7,8

Thestretchingexercises,inturn,allowfunctionalmuscle

lengthrecovery,providingstressrelief,posturalrealignment

andimprovementinamplitude,aswellasfreedomand

aware-nessofmovement.9,10_{However,althoughextensivelyusedin}

physicaltherapyclinicalroutinebybeingeasytoperformand

tolerate,theredoesnotseemtoexist??aconsensusonthe

moresuitablestretchingtype,frequencyandintensityforthe

treatmentofpatientswithFM.4,7

Thus,theaimofthisarticleistosystematizethe

scien-tificevidenceontheuseofmusclestretchingexercisesinthe

treatmentofFM.

Material

and

methods

A systematic literature review was performed from a

ret-rospectiveconsultationwithnochronologicalandlinguistic

limits, to Literature Analysisand RetrievalMedical System

Online (MEDLINE), Latin American and Caribbean

Litera-tureonHealthSciences(LILACS),ScientificElectronicLibrary

Online(SciELO)andPhysiotherapyEvidenceDatabase(PEDro)

databases, aswell the search engine PubMed. Thepapers’

collection washeld inOctober2012, withthesearch

strat-egyformulatedbycrossingofdescriptors(DeCSandMmeSHs)

andtermsrelevanttothesubject(freeterms–FT),inEnglish,

PortugueseandSpanishidioms.

OnMedline,LILACS,SciELOandPEDro,thefollowing

cross-ings:“Fibromyalgia”(DeCS)AND“Stretching”(FT)OR“Muscle

stretching exercises” (DeCS)OR “Flexibility” (FT)OR

“phys-iotherapy “(DeCS) OR” Physical Therapy Modalities” (DeCS)

OR“Exercise”(TL)OR“Rehabilitation”(DeCS)were used.On

PubMed,thearticleswereobtainedfromthecrossingbetween

“Fibromyalgia” (MeSH) AND “Stretching” (FT) OR “Muscle

stretchingexercises”(MeSH)OR“Flexibility”(FT)OR“Range

rev bras reumatol.2015;55(2):167–173

169

“Physical Therapy Specialty” (MeSH) OR “Physical Therapy

Modalities”(MeSH)OR“Exercise[major]”(MeSH)OR

“Reha-bilitation”(MeSH).

RCTscomposedonlybypatientswithclinicaldiagnosisof

FMandpresentingmusclestretchingexercisesasa

therapeu-ticmeasureinatleastoneoftheinterventiongroupswere

included.Thesearchandselectionofarticles,aswellasthe

analysisofresults,werejudiciouslyperformedbytwo

inde-pendentreviewers. Initially, articleswere excluded bytitle,

followedbysummaryand,finally,byfullreadingofthestudy.

Thestudieswhichmettheinclusioncriteriawereassessed

formethodological qualityusingPEDroscale11,12 _consisting

of10 questions about thestudy, withatotal scoreof 0-10

points.Surveyswith<3pointswereexcluded,forshowinglow

methodologicalqualityandwithfewpossibilitiesof

extrapo-latingtheirresultstoclinicalpractice.Thereferencesatthe

endofselectedarticleswere analyzedinordertohighlight

additionalsources.

Duetothesmallnumberofclinicaltrialsonthesubject

andthelargevariabilityamongtheproposedinterventions,

acriticalreviewanalysisofthecontents,withnopossibility

ofastatisticalanalysisbymeta-analysis,wasperformed.The

relevantinformationwaspresentedinthe formof

descrip-tivetables,consideringthefollowingvariables:year,country,

sample,evaluatedoutcomes/assessmenttools,

methodologi-caldesign,interventionandeffectsfound.

Results

Thesearch indatabasestotaled anaverage of6,794items,

withthelargestnumberofstudiesfoundthroughMEDLINE

viaBIREME(n=3,068)andPubMed(n=3,181).Accordingto

eli-gibilitycriteria,onlyfivearticleswereselected, andthatby

Bressanetal.(2008)13_{wasexcludedbecauseofitslow}

method-ologicalquality(PEDroscale=2).Asafinalresult,fourarticles,

presentedinchronologicalorderinTable1and

methodologi-callyevaluatedaccordingtoTable2,wereanalyzed.

Discussion

Analyzing the results obtained by the search strategy, we

observedahigherconcentrationofstudiesinthe2000s;10,15,16

there is only one publication in the year 1986.14 _{It is}

worthnotingthatallinvestigationswereconductedinNorth

American14,15 _{and South American countries,}10,16 _{and the}

pioneer14_{researchwaspublishedinCanada,thehostcountry}

ofthe1stInternationalConferenceonHealthPromotion,also

heldintheyear198617_{fromthismeeting,discussionsabout}

improvingqualityoflifeworldwidewereinitiated,duetothe

broadeningoftheconceptofhealthandtheidentificationof

anevergrowingagingpopulation.17,18

Giventhechanging epidemiologicalprofileofthe

popu-lation, anincreaseinthe prevalenceofchronicdiseases is

observed,resultinginaneedforresearchconsidering

ther-apeuticapproachesconsistentwiththenewreality.18_In1990,

theAmericanCollegeofRheumatologypublisheddiagnostic

criteria forFM19 _{and strengthened researcheson the}

syn-dromeintheAmericas,withtheconsolidationofgroupsof

researchersonthesubject,ascouldbeseeninthisreview,with

theselectionoftwoitemsdevelopedbythesameauthorsin

SãoPaulo,Brazil.10,16

OnlythestudiesofJonesetal.(2002)15_{andofBerssaneti&}

Marques(2010)16_{describethecalculationofminimumsample}

size,establishedwithbasisonthevariables“isokineticmuscle

strength”and“qualityoflife”,respectively.Therulesofwriting

andpublicationofRCTs,constituentsofCONSORT,highlight

theimportanceofdeterminingthesamplesizefor

extrapola-tionofresultsfound.20_{Therefore,inouranalysistherewasno}

homogeneitywithrespecttothenumberofparticipants.

Incontrast,althoughthe authors havedefineddifferent

agegroupsintheinclusioncriteriaofvolunteers,themean

age ofthe samplesfrom analyzedstudiescorresponded to

the middle-aged population, which is consistent with the

literature.21–23 _{These samestudies pointtoahigh}

percent-ageofwomenwithFM,21–23 _{afactalsonotedinthisreview,}

inwhichmenwereincludedonlyinthestudyconductedby

McCain(1986),14_{probablyduetothelowmethodologicalrigor}

requiredininterventionalresearchesdevelopedinthe1980s.

The variable “pain” was the onlyselected unanimously

fortheresearchers’hypothesistesting;however,inthestudy

publishedin198614_{thedolorimetrytesttoassesspain}

thresh-old wasperformedinadifferentway,beingappliedinfive

specific points, because the diagnosis criteria for FMwere

establishedonlylater,inthe1990s.19 _{Therewasconsensus}

ontheapplicationofFIQandSF-36questionnairesfor

assess-mentofsymptomsandqualityoflifeinfibromyalgiapatients;

both are validatedfor theBrazilian populationand exhibit

goodsensitivityandspecificity,beingreliableandreproducible

tools.24,25

Themanuscriptsrevealavarietyofphysicaltestsapplied,

withtheexceptionofMatsutanietal.(2007);16_{theseauthors,}

faithful to their purposes, considered adequate to analyze

onlyvariablesofasubjectivecharacter.Amongtheflexibility

testschosen,Jonesetal.(2002)15_{werelimitedtothe}

evalua-tionofupperlimbsthroughactivefunctionaltestsofinternal

andexternalshoulderrotators;Berssaneti&Marques(2010)16

electedthethirdfinger-floortest,26_{widelyusedinthe}

evalu-ationofflexibilityoftheposteriormusclesofthetrunkand

lowerlimbs,butthatrequiresexperienceoftheevaluatorto

avoid compensationduring its execution, such asopening

thetibiotarsalangleordecreasinghipflexion.Constraintson

thechoiceofthetestemployedcanbeexplainedbylackof

physicalexaminationsspecificallyvalidatedforpatientswith

fibromyalgia.

Heterogeneityininterventiontimesandinthefrequencyof

sessions,aswellasintheintensityofexercise,wereobserved,

corroboratingpreviousfindings4,7_{whichreportedlackof}

con-sensusregardingtheapplicationofthetherapeuticstretching

approachinpatients withFM.However,we emphasizethe

educationalcontributionsincorporatedinthemethodologies

ofthestudiesbyJonesetal.(2002),15_{Matsutanietal.(2007)}16

andBerssaneti&Marques(2010),10_{highlightingtheneedfor}

anawarenessofpatients,withtheaimtoincreasetheir

adher-encetothetreatment,andalsotoobtainsomeguarantee,to

theextentpossible,ofcontinuityoftherapy.

Asfortheresultsfound,astatisticallysignificant

improve-ment in almost all parameters evaluated by the analyzed

studies in this systematic review was observed. When

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Table1–Descriptionofrandomizedclinicaltrialsthatusemusclestretchingexercisesasphysicaltherapyinterventioninthetreatmentoffibromyalgia.

Study Sample Outcomesevaluated Methodologicalstudy Intervention Effectsfound

(McCain,1986)14

Canada

Meanage:42years Groups:

EG:Cardiovasculartraining (n=12♀and6♂)

PG:Stretching(n=16♀)

Pain:

-DolorimetryofChattillonto assesspainthresholdonfive specificpoints(TP+); -VisualAnalogueScale(VAS); -Diagramofpain.

Fitnesstest: -PWC-170CycleTest.

Randomizedclinical trial;reviews

pre/post-interventionof 20weeks.

EGandPG:60sessionswith three-weeklyfrequency (durationnotdescribed). EG:Exerciseinacycle ergometermaintaininga minimalof150bpm.PG: Generalflexibilityexercises.

Improvementinalltheaspects evaluatedinbothgroups,with highergainsobtainedinthe cardiovasculartraininggroup.

(Jonesetal., 2002)15

USA

Meanage:48years Groups:

EG:Strengthening(n=28♀) CG:Stretching(n=28♀)

Pain:

-DolorimetryofFishertoassess thenumberofpositivetender points(TP+)andpainthreshold (PT);

-TotalscoreofPT;

-VisualAnalogueScale(VAS). Qualityoflife:

-FibromyalgiaImpact Questionnaire(FIQ); -Qualityoflifescale(QOLS). Depression:

-BeckDepressionQuestionnaire. Anxiety:

-BeckAnxietyQuestionnaire. Self-efficacy:

-ArthritisSelf-efficacyScale. Muscleforce:

-Maximalvoluntarycontraction (MVC)ofkneeflexorsand extensorsandinternaland externalshoulderrotatorswithan isokineticdynamometer. Flexibility:

-Functionaltestingofinternaland externalshoulderrotators. Bodycomposition: -Fat(caliper); -Weight(kg).

Randomizedclinical trial;Reviews2weeks beforeand2weeksafter 12-weekintervention.

EGandCG:Educational meeting,followedby24 sessionsofgeneralexercises, lasting60minutesand biweeklyfrequency,inwhich: GE:initial5minutesforheating (walking+stretching),followed by45minutesofstrengthening exerciseswithevolutionof loadandnumberofrepetitions (4-5upto12)and10minutesof deceleration+stretching. GC:initial10minutesof walking,followedby 40minutesofstretching (mediumintensityof discomfort)and10minutesof relaxation.

GE:Thestrengtheninggroup showedimprovementin12 evaluatedmeasures(totalscoreof PT,VAS,MVCofknee

flexion/extensionandshoulder rotations,functionalflexibility tests,FIQ,BeckScale,QOLSand self-efficacyscale).

GC:Thestretchinggroupshowed improvementinsixofthenine measurements(MVCofknee extensionandshoulderrotations, functionaltests

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–Table1(Continued₎

Study Sample Outcomesevaluated Methodologicalstudy Intervention Effectsfound

(Matsutanietal., 2007)16

Brazil

Meanage:45years

Groups:

EG:Stretching/Laser(n=10 ♀)

CG:Stretching(n=10♀)

Pain:

-DolorimetryofFishertoassess thenumberofpositivetender pointspositive(TP+); -VisualAnalogueScale(VAS). Qualityoflife:

-FibromyalgiaImpact Questionnaire(FIQ);-SF-36.

Randomizedclinical trial;reviews pre/post-5-week intervention.

EGandCG: initialeducational guidelinesandin10treatment sessionslasting1hourand withbiweeklyfrequency. EG:Applicationoflaserin tenderpoints(3J/cm2_,830nm, 30mW)andgeneralstretching exercises.

CG:generalstretching exercises.

Improvementinallaspects evaluated,withnodifference betweentheinterventiongroups.

(Berssaneti& Marques, 2010)10

Brazil

Meanage:46years Groups:

EG1:Stretching(n=14♀) EG2:Strengthening(n=16 ♀)

CG:Notreatment(n=14♀)

Pain:

-DolorimetryofFishertoassess painthresholdontenderpoints (PT)andnumberofpositivetender points(TP+);

-VisualAnalogueScale(VAS). Symptoms:

-FibromyalgiaImpact Questionnaire(FIQ). Qualityoflife: -SF-36. Flexibility:

-3rdfinger-floorTest(3FF). Muscleforce:

-Maximumvoluntaryisometric contraction(MVC)oftheknee flexorsandextensorswithload cell(EMGSystemofBrazil).

Randomizedclinical trial;reviews pre/post-12-week intervention.

GE:educationalguidelinesin 24generalexercisesessions, lasting40minutesand biweeklyfrequency,inwhich: EG1:initially3setsof

30seconds,increasingmonthly until5series;medium intensityofdiscomfort. EG2:1setof8repsinitially unloaded,withadditionof 0.5kgweekly,sincethepatient presentsBorgScale=13. CG:Patientrevisedafter12 weeks,withoutintervention.

SG1:Improvementinvariables:PT, 3FF,fatigue,sleep,stiffness,FIQ totalscore,functionalcapacity, vitality,mentalhealth,painand physicalandemotionaltotalsof SF-36.

EG2:Improvementinvariables:PT, TP+,3FF,MVCofkneeflexion, fatigue,sleep,stiffness,anxiety, depression,FIQtotalscore, functionalcapacity,vitality, mentalhealthandemotionaltotal ofSF-36.

GC:Noimprovement.

Comparisonbetweengroups:stretching andstrengtheningexercises

significantlyimprovepain,FM symptomsandqualityoflifeand canbeconsideredcomplementary, becausetheyactondifferent aspects.

172

Table2–MethodologicalclassificationofstudiesselectedbythePEDroScale.

McCain(1986)14 _{Jonesetal.(2002)}15 _{Matsutanietal.(2007)}16 _{Berssaneti&Marques}

(2010)10

1Inclusioncriteriaspecified Yes Yes Yes Yes

2Randomallocation Yes Yes Yes Yes

3Secrecyinallocation No No No No

4Basiscomparison Yes Yes Yes Yes

Subjects“blinded” Yes No No No

Therapists“blinded” No No No No

7Raters“blinded” Yes Yes No Yes

8.Adequatefollow-up No Yes No No

9Analysisbyintentiontotreat No No No No

10Statisticalcomparisonbetweengroups Yes Yes Yes Yes

11Pointestimatesandvariability Yes Yes Yes Yes

PEDroTOTALSCORE 6 6 4 5

OBS.:Specificationoftheinclusioncriteria(item1)doesnotreceivePEDroscores.

exercisesinthestudiesbyJonesetal.(2002)15_{andBerssaneti&}

Marques(2010),10_{orwiththeuseoflaserinaphototherapeutic}

studybyMatsutanietal.(2007),16_{therewasnosuperiorityof}

benefitsamongthetechniques,confirmingthatpatientswith

FMneednotonlyaninterdisciplinarytreatment,butalsoan

approachthatencompassesdifferentresourcesduringtheir

therapy.6,7,27

Conclusion

Giventheabove,itisevidenttheimportanceofconducting

therapeuticexercisesforphysicalandmentalimprovement

inpatientswithFM.However,wemustemphasizetheneed

forclinical trialswithgreater methodologicalrigorinorder

that,infact,therealbenefitsofphysiotherapyresourcesused,

especially those with muscle stretching exercises, become

known.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1. SmithHS,HarrisR,ClauwD.Fibromyalgia:anafferent processingdisorderleadingtoacomplexpaingeneralized syndrome.PainPhysician.2011;14:E217–45.

2. CardosoFS,CurtoloM,NatourJ,LombardiJúniorI.Avaliac¸ão daqualidadedevida,forc¸amuscularecapacidadefuncional emmulherescomfibromialgia.RevBrasReumatol.

2011;51:338–50.

3. WolfeF,ClauwDJ,FitzcharlesMA,GoldenbergD,KatzRS, MeaseP,etal.TheAmericanCollegeofRheumatology PreliminaryDiagnosticCriteriaforFibromyalgiaand MeasurementofSymptomSeverity.ArthritisCare& Research.2010;62:600–10.

4. GürA.Physicaltherapymodalitiesinmanagementof fibromyalgia.CurrPharmDes.2006;12:29–35.

5. WinkelmannA,HäuserW,FriedelE,Moog-EganM,SeegerD, SettanM,etal.Physiotherapyandphysicalagenttherapies forfibromyalgiasyndrome.Systematicreview,meta-analysis andguidelines.DerSchmerz.2012;26:276–86.

6.MendesEV.Ocuidadodascondic¸õescrônicasnaatenc¸ão primáriaàsaúde:Oimperativodaconsolidac¸ãodaestratégia dasaúdedafamília.Brasília:Organizac¸ãoPan-Americanada Saúde;2012.

7.BuschAJ,BarberKA,OverendTJ,PelosoPM,SchachterCL. Exercisefortreatingfibromyalgiasyndrome.Cochrane DatabaseSystRev.2007;17:CD003786.

8.JonesKD,LiptanGL.ExercisesinterventioninFibromyalgia: clinicalapplicationsfromtheevidence.RheumDisClinNorth Am.2009;35:374–91.

9.AndersC,SprottH,ScholleHC,SurfaceEMG.ofthelumbar partoftheerectortruncimuscleinpatientswith

fibromyalgia.ClinExpRheumatol.2001;19:453–5.

10.BerssanetiAA.Exercíciosdealongamentoefortalecimento muscularnotratamentodepacientescomfibromialgia:um ensaioclínicorandomizado[tesededoutorado].SãoPaulo: UniversidadedeSãoPaulo,FaculdadedeMedicina;2010.

11.MaherCG,SherringtonC,HerbertRD,MoseleyAM,ElkinsM. ReliabilityofthePEDroScaleforRatingQualityof

RandomizedControlledTrials.PhysicalTherapy. 2003;83:713–21.

12.MortonNA.ThePEDroScaleisavalidmeasureofthe methodologicalqualityofclinicaltrials:ademographicstudy. AustralianJournalofPhysiotherapy.2009;55:129–33.

13.BressanLR,MatsutaniLA,Assumpc¸ãoA,MarquesAP,Cabral CM.Efeitosdoalongamentomuscularecondicionamento físiconotratamentofisioterápicodepacientescom Fibromialgia.RevBrasFisioter.2008;12:88–93.

14.McCainGA.RoleofPhysicalFitnessTraininginthe Fibrositis/FibromyalgiaSyndrome.JAMA.1986;81 Suppl3A:73–7.

15.JonesKD,BurckhardtCS,ClarkSR,BennettRM,PotempaKM. Arandomizedcontrolledtrialofmusclestrengtheningversus flexibilitytraininginfibromyalgia.JRheumatol.2002;29, 1041:8.

16.MatsutaniLA,MarquesAP,FerreiraEAG,Assumpc¸ãoA,Lage LV,CasarottoRA,etal.Effectivenessofmusclestretching exerciseswithandwithoutlasertherapyattenderpointsfor patientswithfibromyalgia.ClinExpRheumatol.

2007;25:410–5.

17.MinistériodaSaúde(Brasil),SecretariadePolíticasdeSaúde. ProjetoPromoc¸ãodaSaúde.AsCartasdaPromoc¸ãodaSaúde. Brasília:MinistériodaSaúde;2002.p.56.

18.WorldHealthOrganization.Envelhecimentoativo:uma políticadesaúde.Brasília:Organizac¸ãoPan-Americanada Saúde;2005.p.60.

rev bras reumatol.2015;55(2):167–173

173

1990CriteriafortheClassificationofFibromyalgia.Reportof theMulticenterCriteriaCommittee.ArthritisRheum. 1990;33:160–72.

20.SchulzKF,AltmanDG,MoherD,ConsortGroup.CONSORT 2010Statement:updatedguidelinesforreportingparallel grouprandomisedtrials.BMCMedicine.2010;8:18.

21.WolfeF,RossK,AndersonJ,RussellJ,HerbertL.The prevalenceandcharacteristicsofFibromyalgiainthegeneral population.ArthritisRheum.1995;38:19–28.

22.WhiteKP,SpeenchleyM,HarthM,OstbyeT.Comparing self-reportedfunctionandworkdisabilityin100community casesoffibromyalgiasyndromeversuscontrolsinLondon. OntarioArthritisRheum.1999;42:76–83.

23.Assumpc¸ãoA,CavalcanteAB,CapelaCE,SauerJF,ChalotSD, PereiraCA,etal.Prevalenceoffibromyalgiainalow

socioeconomicstatuspopulation.BMCMusculoskeletDisord. 2009;10:64.

24.MarquesAP,SantosAMB,Assumpc¸ãoA,MatsutaniLA,Lage LV,PereiraCA.Validac¸ãodaversãobrasileiradoFibromyalgia ImpactQuestionnaire(FIQ).RevBrasReumatol.2006;46: 24–31.

25.CiconelliRM,FerrazMB,SantosW,MeinãoL,QuaresmaMR. Traduc¸ãoparaalínguaportuguesaevalidac¸ãodo

questionáriogenéricodeavaliac¸ãodequalidadedevida SF-36(BrasilSF-36).RevBrasReumatol.1999;39:143–50.

26.PerretC,PoiraudeauS,FermanianJ,ColauMM,Benhamou MA,RevelM.Validity,reliability,andresponsivenessofthe fingertip-to-floortest.ArchPhysMedRehabil.

2001;82:1566–70.