Whole body vibration exercise training for fibromyalgia

Julia Bidonde; Angela J Busch; Ina van der Spuy; Susan Tupper; Soo Y Kim; Catherine Boden

doi:10.1002/14651858.CD011755.pub2

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Figure 1

Study flow diagram for vibration training interventions.

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Galileo Fitness Platform (Copyright © 2008‐2015 Novotec Medical GmbH; reproduced with permission)

Figure 2

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Copyright © 2012 Wellsports GmbH Krefeld ‐ PowerPlate International B.V., The Netherlands ‐ awaiting response.Sept15

Figure 3

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Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 5

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 WBV vs C, Outcome 1 HRQL, 1‐100 scale, lower means better HRQL.

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Analysis 1.2

Comparison 1 WBV vs C, Outcome 2 Balance, degrees of displacement, lower is best.

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Analysis 1.3

Comparison 1 WBV vs C, Outcome 3 Withdrawal.

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Analysis 2.1

Comparison 2 WBV + MX vs C, Outcome 1 WBV + MX vs C: HRQL, 0‐100 scale, lower is best.

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Analysis 2.2

Comparison 2 WBV + MX vs C, Outcome 2 WBV + MX vs C: pain, 0‐100 scale, lower is best.

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Analysis 2.3

Comparison 2 WBV + MX vs C, Outcome 3 WBV + MX vs C: fatigue, 0‐100 scale, lower is best.

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Analysis 2.4

Comparison 2 WBV + MX vs C, Outcome 4 WBV + MX vs C: stiffness, 0‐100 scale, lower is best.

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Analysis 2.5

Comparison 2 WBV + MX vs C, Outcome 5 WBV + MX vs C: balance, overall stability index ‐ eyes closed (degrees of displacement 0 to 20 scale, lower is best).

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Analysis 2.6

Comparison 2 WBV + MX vs C, Outcome 6 Withdrawal.

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Analysis 3.1

Comparison 3 WBV + MX vs Other, Outcome 1 WBV + MX vs Other: HRQL, 0‐100 scale, lower is best.

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Analysis 3.2

Comparison 3 WBV + MX vs Other, Outcome 2 WBV + MX vs Other: pain, 0‐100 scale, lower is best.

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Analysis 3.3

Comparison 3 WBV + MX vs Other, Outcome 3 WBV + MX vs Other: fatigue, 0‐100 scale, lower is best.

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Analysis 3.4

Comparison 3 WBV + MX vs Other, Outcome 4 WBV + MX vs Other: stiffness, 0‐100 scale, lower is best.

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Analysis 3.5

Comparison 3 WBV + MX vs Other, Outcome 5 WBV + MX vs Other: strength, measured in newtons and number of reps, higher values are best.

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Analysis 3.6

Comparison 3 WBV + MX vs Other, Outcome 6 WBV + MX vs Other: balance, overall stability index ‐ eyes closed (degrees of displacement 0 to 20 scale, lower is best).

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Analysis 3.7

Comparison 3 WBV + MX vs Other, Outcome 7 Withdrawal.

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Summary of findings for the main comparison. Whole body vibration versus control

Whole body vibration versus control
Patient or population: individuals with fibromyalgia Setting: community Intervention: whole body vibration (WBV) Comparison: control
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with control	Risk with WBV
Health‐related quality of life assessed by FIQ total scale, 0 to 100, 0 is best Follow‐up: 12 weeks	Mean health‐related quality of life was 59 points	Mean health‐related quality of life in intervention group was 3.73 points lower (10.81 lower to 3.35 higher) at post‐test than in control group	‐	41 (1 RCT)	♁◯◯◯ VERY LOW^a,b	Absolute improvement: 4% (95% CI 11% better to 3% worse) Relative change: 6.7% improvement (95% CI 19.6% improvement to 6.1% worse) NNTB: n/a^c
Pain intensity	Not measured	Not measured	‐	Not measured	Not measured	Not measured
Fatigue	Not measured	Not measured	‐	Not measured	Not measured	Not measured
Stiffness	Not measured	Not measured	‐	Not measured	Not measured	Not measured
Physical function	Not measured	Not measured	‐	Not measured	Not measured	Not measured
Adverse events (narrative)	Gusi 2010: "The program was reasonably safe: only 5% of the participants (n = 1) dropped out of the program because of acute pain in the legs. The program was completed by 85% of the participants, without secondary adverse effects" (page 1076; 1 study)
All‐cause withdrawal assessed by number of people who dropped out	Study population		RR 1.43 (0.27 to 7.67)	41 (1 RCT)	♁◯◯◯ VERY LOW^a,b	Absolute risk difference: 4% more events (95% CI 16% fewer to 24% more) Relative change: 43% more (73% fewer to 667% more) NNTH: n/a^c
	10 per 100 (2 of 20)	14 per 100 (3 of 21)
*Risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI) CI: confidence interval; NNTB: number needed to treat for an additional beneficial outcome; NNTH: number needed to treat for an additional harmful outcome; OR: odds ratio; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aImpresicion: number of participants lower than 400 rule of thumb; wide confidence interval (downgraded twice) ^bHigh risk of biases including detection, performance, and reporting biases ^cNumber needed to treat for an additional beneficial outcome (NNTB) or number needed to treat for an additional harmful outcome (NNTH) not applicable (n/a) when result is not statistically significant. NNT for dichotomous outcomes calculated with Cates NNT calculator (http://www.nntonline.net/visualrx/). NNT for continuous outcomes calculated with Wells calculator (CMSG Editorial Office)

Summary of findings for the main comparison. Whole body vibration versus control

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Summary of findings 2. Whole body vibration plus mixed exercise versus control

Whole body vibration plus mixed exercise versus control
Patient or population: individuals with fibromyalgia Setting: unspecified Intervention: WBV + MX Comparison: control
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with control	Risk with WBV + MX	Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
Health‐related quality of life assessed by FIQ total scale, 0‐100, 0 is best	Mean health‐related quality of life was 59.64 points at the end of the study	Mean health‐related quality of life in the intervention group was 16.02 points lower (31.57 lower to 0.47 lower) at post‐test than in the control group	‐	21 (1 RCT)	♁◯◯◯ VERY LOW^a,b	Absolute difference: 16% improvement (95% CI 32% to 0.5% improvement). Relative change: 24% (47% to 0.7%)^c NNTB^d: 3 (2 to 237)
Pain Intensity assessed by FIQ scale, 0 to 100 mm, 0 is no pain	Mean pain intensity was 69.38 mm in the control group at the end of the study	Mean pain Intensity in the intervention group was 28.22 mm lower (43.26 lower to 13.18 lower) at post‐test than in the control group	‐	21 (1 RCT)	♁◯◯◯ VERY LOW^a,b	Absolute difference: 28% (95% CI 43% to 13%). Relative difference: 39% (95% CI 18% to 60%) NNTB^d: 2 (1 to 4)
Fatigue assessed by FIQ scale, 0 to 100 mm, 0 is best	Mean fatigue was 75.17 mm at the end of the study	Mean fatigue in the intervention group was 32.84 mm lower (49.2 lower to 16.48 lower) at post‐test than in the control group	‐	21 (1 RCT)	♁◯◯◯ VERY LOW^a,b	Absolute difference: 33% (95% CI 49% to 16%). Relative difference: 47% (95% CI 23% to 70%) NNTB^d: 2 (1 to 4)
Stiffness assessed by FIQ scale, 0 to 100 mm scale, 0 is best	Mean stiffness was 68.71 mm at the end of the study	Mean stiffness in the intervention group was 26.27 mm lower (42.96 lower to 9.58 lower) at post‐test than in the control group	‐	21 (1 RCT)	♁◯◯◯ VERY LOW^a,b	Absolute difference 26% (95% CI 43% to 10%). Relative difference: 36.5% (95% CI 60% to 23%) NNTB^d: 2 (1 to 6)
Physical function	Not measured	Not measured	‐	Not measured	Not measured	Not measured
Adverse events (narrative)	Alentorn‐Geli 2008: "This program neither exacerbated FM‐related symptoms nor resulted in musculoskeletal injuries; however, 1 patient exhibited a mild anxiety attack on the first session of WBV" (page 978) Sañudo 2013: "This study, however, demonstrated that WBV training is safe (no adverse events)..." (page 683)
All‐cause withdrawal assessed by number of people who dropped out	33 per 100 (7 of 21)	8 per 100 (2 of 25)	RR 0.25, 95% CI 0.06 to 1.12	46 (2 RCTs)	♁◯◯◯ VERY LOW^a,b	Absolute risk difference: 24% (95% CI 3 to 51) NNTH^d: n/a
*Risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI) CI: confidence interval; NNTB: number needed to treat for an additional beneficial outcome; NNTH: number needed to treat for an additional harmful outcome; OR: odds ratio; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aImprecision: Number of participants lower than 400 rule of thumb; wide confidence interval. Need for more studies with more participants to reach optimal information size (downgraded twice) ^bHigh risk of biases including reporting and selection biases. Need for methodologically better designed and executed studies ^cBaseline control group mean (SD) = 67 (15.81), n = 10 ^dNumber needed to treat for an additional beneficial outcome (NNTB) or number needed to treat for an additional harmful outcome (NNTH) not applicable (n/a) when result is not statistically significant. NNT for dichotomous outcomes calculated with Cates NNT calculator (http://www.nntonline.net/visualrx/). NNT for continuous outcomes calculated with Wells calculator (CMSG Editorial Office)

Summary of findings 2. Whole body vibration plus mixed exercise versus control

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Table 1. Glossary of terms

Term	Definition
Allodynia	Pain resulting from a stimulus that would not normally provoke pain
Amplitude	Absolute value of maximum displacement from a zero value during 1 period of an oscillation
Damping	Energy dissipation properties of a material or system under cyclic stress
Endurance	Two forms of endurance that refer to health‐related physical fitness include cardiorespiratory endurance (also known as cardiovascular endurance, aerobic fitness, aerobic endurance, exercise tolerance), which "relates to the ability of the circulatory and respiratory systems to supply fuel during sustained physical activity and to eliminate waste products after supplying fuel," and muscle endurance, which "relates to the ability of muscle groups to exert external force for many repetitions" (Caspersen 1985)
Frequency	Number of cycles or completed alternations per unit time of a wave or oscillation
Hertz	One hertz is 1 cycle per second; therefore, when an individual is exposed to a vibration of 30 Hz, targeted muscles receive 30 cycles of vibration per second, which makes muscles contract and relax 30 times in the same period
Hyperalgesia	Increased pain from a stimulus that normally provokes pain
Natural frequency	Frequency at which a system oscillates when not subjected to continuous or repeated external forces
Paresthesia	Abnormal sensation that is spontaneous or is evoked by a stimulus (eg, numbness)
Phase angle	Particular stage or point of advancement in a cycle; fractional part of the period through which time has advanced, measured from some arbitrary origin often expressed as an angle (phase angle); the entire period being taken is 360°

Table 1. Glossary of terms

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Table 2. List of Abbreviations

Abbreviation	Description
A	amplitude
ACR	American College of Rheumatology
ACSM	American College of Sports Medicine
AE	aerobic exercise
EMG	electromyography
f	frequency
FIQ	Fibromyalgia Impact Questionnaire
FX	flexibility
g	gravitational load (G‐force) = 1 cm/s²
HR	heart rate
HRQL	health‐related quality of life
hz	Hertz
ITT	intention‐to‐treat
kg	kilogram
m/s²	unit of acceleration: 1 Gal = 0.01 m/s²
MCID	minimal clinically important difference
MD	mean difference
MX	mixed intervention (includes more than 1 mode of physical activity)
n	number of studies
N	number of individuals
RD	risk difference
Relax	relaxation
RT	resistance training
s	seconds
SD	standard deviation
SE	standard error
SMD	standardized mean difference
sTNFR1 and sTNFR2	soluble tumor necrosis factor receptor 1 and 2
VAS	visual analogue scale
WBV	whole body vibration
wk	week(s)
WU	warm‐up

Table 2. List of Abbreviations

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Table 3. Mixed exercise FITT (frequency, intensity, time, and type) parameters

Vibration + Mixed vs Mixed + Placebo vs Control
Author, year	Intervention	Frequency (times per week \| length in weeks)		Total duration	Supervised or home program	Aerobic component	Resistance component	Flexibility Component	Other
Author, year	Intervention	Frequency (times per week \| length in weeks)		Total duration	Supervised or home program	I (intensity): ACSM classification and physiological measure; M (mode): mode of exercise; T (time): duration of aerobic component in minutes	M (muscle groups, joints or areas of body); I (intensity resistance, repetitions, sets); T (type), T (time)	M (muscle groups, joints or areas of body); T (type of stretch, repetition, set), T (time)	Other
Alentorn‐Geli 2008	AE + FX + Relax	2 times/wk	6 weeks	90’	Not specified	I: moderate to vigorous (65%‐85% HR max), T: primarily level ground walking with games and dance, T: 30'	Not applicable	M: 5 whole body stretches involving lower and upper limbs, neck, back; T: dynamic, 5 reps held for 30 s with 30 s rests, T: 25'	Relaxation
Vibration + Mixed vs Mixed
Sañudo 2010	AE + RT + FX	2 times/wk	6 weeks	60’	Supervised	I: light to moderate (50%‐69% HR max), M: not specified, T: 4‐6 intervals of 2‐3’, 1‐2’ rest between intervals	M: major muscle groups, I: 8 exercises, 1 × 8‐10 reps with 1‐3 kg, T: not specified	M: not specified, I: 1x 3 reps holding for 30s, T: not specified
Sañudo 2013	AE + RT + FX	2 times/wk	8 weeks	45‐60’	Supervised	I: moderate (65%‐70% HR max), M: not specified, T: 10‐15’	M: deltoids, biceps, neck, hips, back, and chest, I: 1 set of 8‐10 reps for 8 different muscle groups against 1‐3 kg, T: 15‐20’	M: deltoids, biceps, neck, hips, back, and chest I: 1 set of 3 reps for 8‐9 different ex, maintained for 30 s, T: 10’

Table 3. Mixed exercise FITT (frequency, intensity, time, and type) parameters

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Table 4. Vibration specifications

Study name/year	Name of device	Vibration frequency and amplitude	Position of participant	Stabilizing support	Footwear	Static/Dynamic; unilateral/bilateral
Alentorn‐Geli 2008	PowerPlate (PowerPlate International B.V., Badhoevendorp, The Netherlands)	30 Hz; 2 mm vertical amplitude	The following 6 exercises were performed for 30 s each during whole body vibration (WBV) and were repeated 6 times with recovery of 3 minutes between repetitions (a) static squat at 100° of knee flexion (b) dynamic squat between 90° and 130° of knee flexion (c) maintained ankle plantar‐flexion with legs in extension (d) flexion‐extension of right leg between 100° and 130° of knee flexion (e) flexion‐extension of left leg between 100° and 130° of knee flexion (f) squat at 100° of knee flexion shifting body weight from 1 leg to the other For adaptation purposes, only tasks (a), (b), and (c) (repeated 3 times) were performed during first 2 sessions	Yes ‐ for all tasks, individuals held onto the supporting bar	Does not state	Static bilateral
Gusi 2010	Galileo Fitness Platform (Novotec Medical, Pforzheim, Germany)	12.5 Hz; 3 mm vertical amplitude	Participants alternated between 2 stances for each repetition Stance A: feet perpendicular to midline axis of the platform with right foot placed slightly ahead of left foot. Toes of right foot and heel of left foot lifted 4 mm above surface of the platform. Knees bent to 45° angle. Back and head kept straight Stance B: as per Stance A, except with left foot placed slightly ahead of right foot	Not reported and not pictured in Figure 2	Balance testing was performed barefoot. Does not specify that exercise was done barefoot, but Figure 2 indicates this	Static and dynamic both unilateral and bilateral
Sañudo 2010	Galileo Fitness Platform (Novotec Medical, Pforzheim, Germany)	20 Hz; variable amplitude of 2‐3 mm	Three sets of 45 s of bilateral static squat with 120 s recovery between sets (amplitude = 3 mm) followed by 4 sets of 15 s of unilateral static squat on each leg (amplitude = 2 mm). During WBV, participants stood with both knees in 120° isometric knee flexion (half‐squatting position) as measured by a goniometer	Does not state	Does not state	Static unilateral and bilateral
Sañudo 2013	PowerPlate, North America Inc., Northbrook, IL, United States	30 Hz; vertical displacement of 4 mm (71.1 m/s‐2 ≈ 7.2 g)	Standing on the platform, with knees in 120º isometric knee flexion (measured by a goniometer) and trunk upright Bilateral static squat: 6 sets of 30 s, with 45‐s recovery between sets Unilateral static squat: 4 sets of 30 s each leg	Does not state	All participants wore sport shoes for vibration exercises	Static unilateral and bilateral

Table 4. Vibration specifications

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Table 5. Quality of evidence. GRADE assessment for WBV + MX vs Other

Quality assessment							No. of participants		Quality	Importance
No. of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Aerobic exercise (AE) intervention	AE control
Health‐related quality of life (HRQL), 0‐100, lower is best
2	Randomized trial	Very serious¹	Not serious	Not serious	Serious²		23	26	⊕⊝⊝⊝ very low	CRITICAL
Pain intensity, 0‐100, lower is best
1	Randomized trial	Serious³	Not serious	Not serious	Serious²	One very small study	11	12	⊕⊝⊝⊝ very low	CRITICAL
Fatigue, 0‐100, lower is best
1	Randomized trial	Serious¹	Not serious	Not serious	Serious²	One very small study	11	12	⊕⊝⊝⊝ very low	IMPORTANT
Stiffness, 0‐100, lower is best
1	Randomized trial	Serious¹	Not serious	Not serious	Serious²	One very small study	11	12	⊕⊝⊝⊝ very low	IMPORTANT
Physical function, not reported
Withdrawals
3	Randomized trial	Very serious⁴	Not serious	Not serious	Serious²		3/39 (7.69%)	4/38 (10.52%)	⊕⊝⊝⊝ very low	IMPORTANT
Adverse events:Alentorn‐Geli 2008: "This program neither exacerbated FM‐related symptoms nor resulted in musculoskeletal injuries; however, one patient exhibited a mild anxiety attack on the first session of WBV" (page 978); Sañudo 2010: Trial authors clarified that one person in the comparison group ("other exercise group") dropped out owing to an injury that was not an injury related to the program (participant fell down on the street); Sañudo 2013: "This study, however, demonstrated that WBV training is a safe (no adverse effects), suitable (no dropouts due to the intervention), and effective (increased lower limb muscle strength) way to exercise the musculoskeletal system, and potentially a feasible intervention for those patients who cannot participate in conventional strength training" (page 683)

Table 5. Quality of evidence. GRADE assessment for WBV + MX vs Other

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Comparison 1. WBV vs C

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 HRQL, 1‐100 scale, lower means better HRQL Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Balance, degrees of displacement, lower is best Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Withdrawal Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 1. WBV vs C

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Comparison 2. WBV + MX vs C

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 WBV + MX vs C: HRQL, 0‐100 scale, lower is best Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2 WBV + MX vs C: pain, 0‐100 scale, lower is best Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 WBV + MX vs C: fatigue, 0‐100 scale, lower is best Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

4 WBV + MX vs C: stiffness, 0‐100 scale, lower is best Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

5 WBV + MX vs C: balance, overall stability index ‐ eyes closed (degrees of displacement 0 to 20 scale, lower is best) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6 Withdrawal Show forest plot	2	46	Risk Ratio (M‐H, Random, 95% CI)	0.25 [0.06, 1.12]

Comparison 2. WBV + MX vs C

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Comparison 3. WBV + MX vs Other

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 WBV + MX vs Other: HRQL, 0‐100 scale, lower is best Show forest plot	2	49	Mean Difference (IV, Random, 95% CI)	‐6.67 [‐14.65, 1.31]

2 WBV + MX vs Other: pain, 0‐100 scale, lower is best Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

3 WBV + MX vs Other: fatigue, 0‐100 scale, lower is best Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

4 WBV + MX vs Other: stiffness, 0‐100 scale, lower is best Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 WBV + MX vs Other: strength, measured in newtons and number of reps, higher values are best Show forest plot	2	54	Std. Mean Difference (IV, Random, 95% CI)	0.77 [0.20, 1.35]

6 WBV + MX vs Other: balance, overall stability index ‐ eyes closed (degrees of displacement 0 to 20 scale, lower is best) Show forest plot	2	54	Mean Difference (IV, Random, 95% CI)	‐0.22 [‐1.56, 1.11]

7 Withdrawal Show forest plot	3	77	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.17, 3.11]

Comparison 3. WBV + MX vs Other

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