Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 9 , Pages 1628-1634, September 2009

Cardiovascular Autonomic Modulation After Acute Resistance Exercise in Women With Fibromyalgia

  • J. Derek Kingsley, MS

      Affiliations

    • Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL
    • Corresponding Author InformationCorrespondence to J. Derek Kingsley, MS, Dept of Nutrition, Food and Exercise Sciences, 436 Sandels Bldg, Florida State University, Tallahassee, FL, 32306
    • ,
  • Lynn B. Panton, PhD

      Affiliations

    • Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL
    • ,
  • Victor McMillan, MD

      Affiliations

    • McIntosh Clinic, Thomasville, GA
    • ,
  • Arturo Figueroa, MD, PhD

      Affiliations

    • Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL

Article Outline

Abstract 

Kingsley JD, Panton LB, McMillan V, Figueroa A. Cardiovascular autonomic modulation after acute resistance exercise in women with fibromyalgia.

Objective

To test the hypothesis that autonomic modulation after resistance exercise (RE) would be reduced in women with fibromyalgia (FM) compared with controls.

Design

Before-after trial.

Setting

Testing occurred in a university setting.

Participants

Women with FM (n=9) and healthy controls (n=9) underwent testing before (pre) and 20 minutes after (post) RE.

Interventions

Not applicable.

Main Outcome Measures

Normalized low-frequency (LFnu) and normalized high-frequency (HFnu) oscillations and the LFnu/HFnu ratio were indicative of sympathetic modulation, parasympathetic modulation, and sympathovagal balance, respectively. Baroreceptor reflex sensitivity (BRS) was also measured.

Results

Variables were similar in both groups at rest. HFnu decreased in controls (pre, 55.0±4.2%; post, 35.0±4.7%; P<.05) and increased in women with FM (pre, 57.0±5.7%; post, 63.2±4.6%; P<.05). LFnu increased in controls (pre, 43.3±4.4%; post, 63.2±4.8%; P<.05) and decreased in women with FM (pre, 41.8±5.6%; post, 35.6±4.7%; P<.05). The LFnu/HFnu ratio increased in controls (pre, 0.89±0.17; post, 2.43±0.64; P<.05) with no change in women with FM (pre, 0.90±0.22; post, 0.64±0.13; P=.13). BRS decreased in controls (pre, 8.78±1.42ms/mmHg; post, 5.49±0.66ms/mmHg; P<.05), but not in women with FM (pre, 5.91±1.22ms/mmHg; post, 9.23±2.4ms/mmHg; P=.16).

Conclusions

After acute RE, women with FM responded differently from controls, demonstrated by lower sympathetic and higher vagal modulation without altering BRS. These postexercise responses may be attributed to the altered autonomic responsiveness to physiologic stress that characterizes FM.

Key Words: Autonomic nervous system, Baroreflex, Rehabilitation, Vagus nerve

List of Abbreviations: 1RM, 1-repetition maximum, BMI, body mass index, BRS, baroreceptor reflex sensitivity, ECG, electrocardiogram, FM, fibromyalgia, HF, high frequency, HFnu, normalized high frequency, HRV, heart rate variability, LF, low frequency, LFnu, normalized low frequency, Ln, natural log, nu, normalized units, RE, resistance exercise

 

PRIMARILY DIAGNOSED IN women, FM is characterized by chronic widespread pain and discomfort when pressure is applied at specific musculoskeletal sites on the body termed, tender points.1 The characteristics of FM are diverse and include reduced muscular strength and endurance,2 orthostatic intolerance,3 parasthesis,3 irritable bowel,3 and intolerance to cold.4 Reports have demonstrated that RE training may help improve quality of life in women with FM.5

Recent research has suggested that many of the symptoms of FM may be explained by autonomic nervous system dysfunction.3 Studies evaluating autonomic nervous system modulation, via HRV, in women with FM have found increased sympathetic activity as well as decreased parasympathetic (vagal) activity at rest3 and the inability to compensate correctly in response to physiologic stress such as standing3 and cold exposure.4 These autonomic abnormalities in FM have been attributed to attenuated spontaneous BRS.6

BRS is one of the prime determinants of acute changes in cardiac autonomic modulation.6 Located within the aortic arch and carotid bodies, the arterial baroreceptors control the acute fluctuations in heart rate via modulation of vagal and sympathetic activities. Cardiovagal BRS modulation is reduced during exercise, but it increases to resting levels 30 minutes after moderate-intensity endurance exercise.7, 8 Interestingly, a greater reduction in overall HRV and vagal tone has been found 20 minutes after acute RE compared with endurance exercise in healthy participants.9 A reduction in BRS and HRV after exercise significantly increases the relative risk of cardiovascular events because of a reduction in vagal modulation and sympathetic predominance.9, 10 Because women with FM already have reduced HRV and vagal tone at rest, a further reduction in vagal modulation after acute RE may increase their relative risk for cardiovascular events. Therefore, we tested the hypothesis that autonomic modulation at rest and after a bout of RE would be reduced in women with FM compared with healthy controls.

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Methods 

Participants 

Eighteen sedentary women age 21 to 59 years participated in this study. The participants were classified as clinically diagnosed with FM (n=9) or as healthy controls (n=9). Before any data collection occurred, a diagnosis of FM was confirmed by a board-certified rheumatologist (V.M.) according to the guidelines outlined by the American College of Rheumatology.1 Women with FM were recruited via fliers and newspaper advertisements, while the age-matched and weight-matched healthy controls were recruited from the university community. Eight women were premenopausal (4 FM and 4 healthy controls), and 10 women were postmenopausal (5 FM and 5 healthy controls). Women with FM were taking the following medications: lipid-lowering (1), anti-inflammatory (3), progesterone-estrogen replacement (3), birth control (2), antidepressants (3), diuretics (2), and gastric antacid (2). Three of the healthy controls were taking progesterone-estrogen replacement; otherwise, no other medication was being taken. All participants were nonsmokers who had not smoked for at least 1 year, with no known history of cardiovascular disease, diabetes mellitus, or pulmonary disease. Sixteen of the participants had not participated in a regular physical activity program for more than 30 minutes, 3 times a week, for at least 6 months. Two of the healthy controls were considered active, both of whom were currently undergoing a resistance training program. All participants gave written informed consent, which was approved by the Institutional Review Board Committee at Florida State University.

Data Collection 

Participants came to the laboratory on 6 different occasions (fig 1). During the first and second visits, participants came to the laboratory to undergo testing for the determination of their 1RM lifts on the chest press and leg extension. Over the next 3 visits, participants were familiarized with proper lifting techniques on 8 other REs, which included the overhead press, leg press, leg curl, biceps curl, abdominal crunch, seated dip, seated row, and lower back hyperextension. During this familiarization period, a resistance load was ascertained that caused the participants to fatigue by 12 repetitions maximum on the 8 REs as well as the chest press and leg extension. Forty-eight hours after the end of the third familiarization visit, participants returned for cardiovascular autonomic function testing (see fig 1).

On the day of the cardiovascular autonomic function test, all participants arrived at the laboratory in the morning between 6 am and 11 am to account for circadian rhythm. Participants came to the laboratory at least 3 hours after their last meal, having abstained from caffeinated beverages for 12 hours, strenuous physical activity for 24 hours, and all medication for at least 8 hours. After a 15-minute quiet rest period in the seated position, 5 minutes of cardiovascular variables were collected, which included heart rate, HRV, and BRS. Thereafter, participants performed a 30-minute session of REs, 1 set of 12 repetitions on 10 exercises, following the recommended prescription for adults by the American College of Sports Medicine.11 The resistance load for the chest press and leg extension was at approximately 60% of the predetermined 1RM. While on the remaining 8 REs, the resistance was sufficient enough to elicit fatigue by the twelfth repetition, as previously determined from the familiarization period. Within 1 minute of finishing the exercise bout, the participants returned to the seated position. Participants rested for 20 minutes, followed by collection of cardiovascular autonomic variables for 5 minutes. To ensure that all participants were breathing at the same frequency during data collection at rest and recovery, a metronome was set at 12 breaths per minute to control for breathing rate. Prior to pre-exercise and postexercise data collection, general levels of pain were assessed using a 10-point numerical scale. The numerical scale used the anchors 0 equal to “no pain at all” and 10 equal to “most pain imaginable.”

Strength testing and familiarization 

Muscle strength was assessed using MedXa machines. For the 1RM, participants warmed up before testing using light resistance loads. Workloads were progressively increased to reach the 1RM, defined as the maximal weight that was moved 1 time through the full range of motion. Two to 3 minutes of rest was given between each attempt. The 1RMs were verified after at least 72 hours of the first determination, and the highest value of the 2 days of testing was used in the analysis for the 1RM. After the 1RM testing, the 2-week familiarization period was used to determine the 12 repetitions maximum on the other 8 exercises. Forty-eight hours after the last familiarization session, the participants came to the laboratory for cardiovascular autonomic function testing, in which all 10 REs were used to evaluate the acute effects of a RE bout on cardiovascular autonomic modulation.

Anthropometry 

Body weight was measured on a Secab balance beam scale to the nearest 0.1lb, which was subsequently converted to kilograms for further analysis. Height was measured with a Medart stadiometerc to the nearest centimeter. BMI was calculated as weight (kg)/height (m2).

Autonomic and hemodynamic measurements 

Continuous recordings of heart rate were obtained using a modified CM5 electrocardiogram lead interfaced with a Biopacd data acquisition system. ECG recordings were sampled at a frequency of 1000Hz and then stored on a computer. Five-minute segments at rest and recovery from exercise were used for data analyses. The ECG was visually inspected for any ectopic beats or artifacts prior to data analyses. Any artifacts or ectopics were linearly interpolated. Power spectrums of the R-to-R interval, the time interval between 2 consecutive R waves on the ECG, were derived by Fast Fourier transformation using the WinCPRS software.e Studies suggest that LF (0.04–0.15Hz) power of HRV is mediated by both sympathetic and parasympathetic modulations.10, 12, 13 HF (0.15–0.4Hz) power of HRV is mainly under the control of the vagus and is rhythmic with ventilation.10 The power for each individual frequency is evaluated by examination of the total area under the curve for that component and may be expressed in absolute (ms2) or normalized units.10 Normalized units (nu) are assessed by dividing the power of a component (HF or LF) by the total power, and then multiplying by 100.10 The LFnu component, in conjunction with the LF/HF ratio, is an indicator of cardiac sympathetic modulation and sympathovagal balance.10, 14, 15 LF power and HF power were derived from power spectral analysis as previously described.10 In the present study, power spectral densities were calculated in absolute units as well as nu relative to total power for LF (LFnu) and HF (HFnu). Cardiac sympathovagal balance was evaluated by the LFnu/HFnu ratio. Spontaneous BRS was derived using the sequence method. The sequence method quantifies sequences of 3 or more consecutive beats, which are accompanied by concurrent increases or decreases in systolic pressure and the R-to-R interval and are indicative of baroreflex modulation in the time domain.16 Sequences with a correlation greater than 0.80 were used for analyses. The arterial beat-to-beat pressures were determined by finger plethysmographyf on the nondominant hand. Automatic calibration was turned off during data collection. All measurements were collected by standards described by the Task Force of the European Society of Cardiology and North American Society of Pacing and Electrophysiology.10

Data Analyses 

Total power and LF and HF data were not normally distributed, as noted by the Kolmogorov-Smirnov normality test, and were subsequently logarithmically transformed (Ln function). A 2 × 2 analysis of variance with repeated measures (group [FM vs HC] by time [rest vs postexercise]) was used to evaluate differences between women with FM and healthy controls on all dependent variables, which included heart rate, Ln total power, Ln LF, Ln HF, LFnu, HFnu, the LFnu/HFnu ratio, BRS, and pain. Tukey Honestly Significant Difference was used for post hoc testing if significant differences were detected. Because the predominating factor of FM is pain, it was important to assess the relationship between the numerical pain scale and workload. A Pearson moment correlation was used. Data are presented as mean ± SEM, with all significance set a priori at P less than .05. SPSS 13.0g was used to analyze all data.

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Results 

Characteristics 

Participant characteristics are shown in table 1. Both groups of participants were of comparable age, height, weight, and BMI. Maximal strength for the chest press and leg extension was significantly lower in women with FM than healthy controls. The total work performed, calculated as the total amount of weight moved (weight × repetitions), on the exercise equipment was also reduced in the FM group (P<.05). When corrected for body weight, the workload was still significantly reduced from the workload for healthy controls.

Table 1. Participant Characteristics (N=18)
VariablesFM (n=9)Healthy Control (n=9)
Age (y)48±448±2
Height (m)1.61±0.021.63±0.02
Weight (kg)72.8±4.267.3±3.5
BMI (kg/m2)28.0±1.425.2±1.2
Chest press (kg)77±6116±8⁎
Leg extension (kg)95±4133±7⁎
Absolute workload (kg)3460±2405371±294⁎

NOTE. Values are mean ± SEM.

⁎P<.05, significantly different from FM.

Heart Rate 

Resting and postexercise heart rate are presented in table 2. There was no difference in resting heart rate between groups. Although resting heart rate in healthy controls was 15% lower than in women with FM, it was not statistically significant. Postexercise heart rate was elevated above resting values in both groups (P<.05), but there was no group difference (P=.14). The healthy controls had a 10% higher heart rate during recovery than their resting condition, while the FM group had only a 3% increase over resting conditions.

Table 2. Spectral Analysis of Heart Rate Variability, Baroreflex Sensitivity, and Pain (at Rest and Recovery)
VariablesFM (n=9)Healthy Control (n=9)
RestRecoveryRestRecovery
Heart rate (bpm)76±578±5⁎66±273±2⁎
Ln total power (ms2)6.81±0.266.63±0.327.01±0.256.77±0.34
LF (nu, %)41.8±5.635.6±4.7⁎43.3±4.463.2±4.8⁎†
Ln LF (ms2)4.98±0.314.63±0.335.28±0.325.48±0.37
HF (nu, %)57.0±5.763.2±4.6⁎55.0±4.235.0±4.7⁎†
Ln HF (ms2)5.33±0.425.26±0.345.53±0.344.83±0.46
LFnu/HFnu (ratio)0.90±0.220.64±0.130.89±0.172.43±0.64⁎†
BRS (ms/mmHg)5.91±1.229.23±2.48.78±1.425.49±0.66⁎†
BRS sequences (n)13±115±35±1†13±3
Pain assessment (numerical scale)2.89±0.653.67±0.62⁎1.33±0.692.11±0.73⁎

NOTE. Values are mean ± SEM.

⁎P<.05, significantly different from rest.

†P<.05, significantly different from FM.

Heart Rate Variability 

Resting and postexercise HRV are presented in table 2. There was no difference in resting HRV between groups. There was also no effect of RE on the absolute values of HRV in either group. A significant group-by-time effect was demonstrated in LFnu, because women with FM displayed a 14.8% reduction (P<.05) while healthy controls had a 46% increase (P<.05) in response to the exercise bout (fig 2A). A significant group-by-time interaction was detected (P<.05) in HFnu, such that there was a significant reduction (36.4%) in healthy controls and an increase (10.9%) in women with FM (fig 2B). There was a time-by-group interaction (P<.05) for LFnu/HFnu ratio, such that healthy controls had a 173% increase during recovery, while the LFnu/HFnu ratio did not change in women with FM (fig 2C).

  • View full-size image.
  • Fig 2. 

    Differences in women with FM and healthy control women at rest and during postexercise recovery for (A) normalized LF power, (B) normalized HF power, (C) LFnu/HFnu, and (D) BRS.*P<.05, significantly different from rest; †P<.05, significantly different from FM.

Baroreceptor Reflex Sensitivity 

The resting and postexercise BRS are presented in table 2. There was no difference in resting BRS between groups. A significant group-by-time interaction (P<.05) was demonstrated for BRS (fig 2D) as a result of a 3.7% reduction (P<.05) in healthy controls and a 5.6% increase (P=.16) in BRS in women with FM in response to the RE bout.

Pain 

The numerical pain scores are also shown in table 2. There was no difference in the baseline levels of pain between groups. The postexercise level of pain was similarly elevated above resting levels in both groups (P<.05). When corrected for workload, the postexercise levels of pain were elevated but not different between groups. There was a significant negative correlation (r=–.732; P<.05) between absolute workload and pain assessment during recovery in the women with FM, but not in the healthy controls (r=–.358; P>.05).

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Discussion 

To our knowledge, this is the first study to document differences in cardiac autonomic control in women with FM and healthy controls during recovery of an acute bout of moderate-intensity RE. The most notable finding of this study is that despite having similar autonomic profiles as healthy controls at rest, women with FM demonstrated a greater parasympathetic and lower sympathetic modulation than healthy controls in response to an acute bout of RE without altering BRS. These data suggest that women with FM have an alteration in their ability to modify vagal and sympathetic responses to acute RE appropriately, perhaps because of an abnormal postexercise augmentation of BRS.

Autonomic Modulation of the Cardiovasculature at Rest 

Unlike participants in other reports,3 women with FM in the present study did not differ from healthy controls in any of the HRV parameters at rest. Both Cohen,14 Furlan,3 and colleagues reported greater levels of total power and LFnu concurrently with lower HFnu in women with FM than age-matched controls in the supine position. Previous data suggested a predominance of sympathetic modulation and a reduction in vagal modulation in the supine position.3, 14 Differences in body positions and breathing patterns may account for these discrepancies compared with the other studies. In the present study, all participants were in the seated position during data collection, while in previous studies, participants were in the supine position.3, 14 The postural stress imposed by the seated position may cause a decrease in stroke volume, which could result in a reflex increase in sympathetic modulation in healthy controls. Therefore, the similarity in autonomic function in women with and without FM in the seated position may be attributed to an increase in sympathetic modulation in healthy controls and the attenuated response in women with FM. In addition, it is well established that changes in respiration rate alter the high-frequency component of HRV.17 Therefore, controlling for breathing rate, as was done in the present study, allows for a more precise evaluation of vagal modulation.

Autonomic Responses to Resistance Exercise 

There have been several reports investigating autonomic responses to endurance exercise,18, 19 but only a few on RE.9, 20, 21 After submaximal endurance exercise, heart rate returns to pre-exercise levels after 20 minutes of recovery22 and is associated with vagal reactivation.23 Figueroa et al8 demonstrated that HF power remained lower than pre-exercise values at 20 minutes of recovery from a 20-minute session of brisk walking in middle-age obese women with and without type 2 diabetes and lean healthy women. Heffernan et al9 used the 10-repetition maximum on REs similar to those used in the present study and reported that the heart rate did not return to resting levels after 25 to 35 minutes of an acute session, which coincides with our results. Niemela et al21 reported that heart rate did not recover for at least 1 hour after completion of RE at either 30% 1RM or 80% 1RM. In the present study, although the increase in heart rate in women with and without FM was similar, the response of the autonomic nervous system was drastically different. In agreement with results of Heffernan,9 Rezk,20 Niemela,21 and colleagues in healthy participants, we found that vagal modulation was reduced after RE only in healthy controls and not in the women with FM. Rezk,20 demonstrated that vagal withdrawal persists for 90 minutes after low-intensity (40% 1RM) and high-intensity (80% 1RM) exercise. In the present study, a greater postexercise HFnu in women with FM was unexpected, because postexercise vagal tone has been found to be lower in individuals with autonomic dysfunction than healthy individuals.24 However, previous studies have shown attenuated autonomic responses to tests that increase sympathetic and decrease parasympathetic tone in women with FM.14, 25 Raj et al25 noted that women with FM had no reduction in the HF component from a supine position to standing, via head upright tilt, while healthy controls experienced vagal withdrawal. Therefore, it is possible that the higher postexercise HF power in women with FM is attributed to an attenuated vagal response to exercise that persists during the recovery. Despite the higher postexercise vagal tone, heart rate recovery was similar in both groups, suggesting reduced sensitivity of the sinus node to autonomic modulation in women with FM.26

Consistent with findings of Heffernan,9 Rezk20 and colleagues indices of sympathetic modulation (LFnu and LF/HF) were elevated after RE compared with pre-exercise only in healthy controls. Niemela, et al21 also noted a significant increase in the LF/HF ratio after 30 minutes of RE at 80% 1RM. Conversely, postexercise LFnu and LF/HF were lower than baseline only in healthy controls. The change in both markers was higher in healthy controls than women with FM in the present study, supporting the finding of attenuated sympathetic response to various physiologic stimuli in previous studies.3, 25 Furlan, et al3 noted that women with FM had a reduced sympathetic response to orthostatic challenge compared with healthy controls. This attenuated sympathetic response to physiologic stress has been also observed during cold exposure in women with FM.4

Exercise decreases spontaneous BRS in an intensity-dependent manner.9, 21, 23 Reduced BRS has been observed after 20 minutes of recovery of moderate-intensity endurance exercise19, 23 and RE.21, 27 Niemela,21 found a reduction in BRS 30 minutes after 30% 1RM and 80% 1RM. Consistent with these findings, we found a reduced postexercise BRS in healthy controls. Conversely, postexercise BRS was not different from rest in our women with FM. Although not statistically significant, the women with FM had an increase in BRS postexercise, while there was a decrease in healthy controls. Faster postexercise BRS restoration to resting levels in women with FM seems unlikely because of the known autonomic dysfunction in this population. Alternatively, the lack of postexercise BRS reduction may be explained by the attenuated autonomic responses to physiologic stimuli that characterize women with FM.6 Therefore, we suggest that the reduced sympathetic and increased parasympathetic activities during recovery of RE are the result of the abnormally elevated postexercise BRS in women with FM. These postexercise autonomic activities differ from those that predispose cardiac complications,28 suggesting a low cardiac risk after acute RE in women with FM.

Researchers investigating FM have reported significantly higher levels of fatigue and pain compared with healthy controls.29 Greater levels of fatigue, attributed to reduced muscular strength and endurance,30, 31 in women with FM may be explained by alterations in muscle metabolism,32 reduced blood flow to the musculature,29, 32 and/or increased pain perception.33 Although the levels of pain assessed by the numerical pain scale were similar in both groups at rest and after RE, there was a strong negative correlation with workload in women with FM that was not present in healthy controls. This may suggest that with an increase in workload, there is a decrease in acute pain perception in the women with FM. This result would be consistent with findings in healthy controls from Koltyn and Arbogast34 in which a single bout of RE lowered acute pain ratings. Those women with FM who had a lower workload may not have been able to reach a threshold necessary to reduce acute pain perception.

It has been shown that the ability to contract a muscle intensely is an important determinant of the magnitude of autonomic responses to exercise.35 In the present study, we observed lower muscle strength in women with FM than healthy controls, suggesting that a reduced ability to contract the musculature could be associated with detraining as well as greater levels of fatigue and pain. This may explain the attenuated autonomic changes during and after the bout of RE in women with FM.

Study Limitations 

In a previous article,36 our laboratory demonstrated that chronic (16-wk) resistance training improved resting vagal modulation and pain perception at rest in women with FM. Thus, it is possible that the altered postexercise cardiovagal BRS noted in this study may improve after short-term RE training in women with FM. Although the ages of our participants were not statistically different, there was greater variability in women with FM. Although BMI differences were modest, it is likely that these differences mask some additional body composition discrepancies between the women with FM and the healthy controls. Data have demonstrated that both age and BMI play a main role in HRV modulation.17 Regardless, autonomic function was comparable at rest, suggesting that differences in responses to RE are attributed to FM. The participants in the present study were a mixture of premenopausal and postmenopausal women, with some women on birth control and others taking hormone replacements. Currently, data are mixed regarding the effects of hormone replacement therapy on cardiovascular autonomic variables.37, 38, 39 There was also no accounting for the menstrual cycle in the premenopausal women during cardiovascular autonomic function testing. Data have suggested that there are no effects of the different hormonal phases of the menstrual cycle on cardiovascular variables such as HRV and BRS. Leicht et al40 reported no alteration of HRV during the different stages of the menstrual cycle. Similarly, Cooke et al41 reported no alteration of BRS during different time points in a regular menstrual cycle. Our participants were also on a variety of medications. However, only the antidepressants would have had any effect on autonomic function in 3 of the women with FM. No medication was allowed at least 8 hours before autonomic testing to reduce the possible influence on HRV or BRS. Because of technical difficulties in the exercise room, autonomic function was collected only before and after, not during RE, limiting the interpretation of the data. While this study does have a small sample size, other studies have been published using 9 or fewer women with FM.42, 43

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Conclusions 

These findings indicate that women with FM have altered modulation of the autonomic system in response to acute RE compared with healthy controls. Specifically, the greater postexercise cardiac parasympathetic and lower sympathetic activity may be attributed to the lack of reduction in BRS during the recovery of exercise in women with FM compared with healthy controls.

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  • a MedX machines; MedX, 1030 N Orange Ave, Ste 101, Orlando, FL 32801.
  • b Seca, 1352 Charwood Rd, Ste E, Hanover, MD 21076.
  • c Medart stadiometer; Fred Medart Manufacturing Co, Potomac St, St. Louis, MO 63119.
  • d Biopac data acquisition system; Biopac Systems Inc, 42 Aero Camino, Goleta, CA 93117.
  • e WinCPRS software; Absolute Aliens, Korjasmäenkatu 16, Turku, Finland, FIN-20369.
  • f Finometer; Finapress Medical Systems, Paasheuvelweg 34a, Amsterdam, Netherlands, NL-1105.
  • g SPSS 13.0; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

 Reprints are not available from the author.

PII: S0003-9993(09)00334-7

doi:10.1016/j.apmr.2009.02.023

Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 9 , Pages 1628-1634, September 2009

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