Jospt 2007 2607
Jospt 2007 2607
KAREN HOLTGREFE, PT, DHS, OCS1 • CONSTANCE MCCLOY, PT, EdD, ATC2 • LISA ROME, PhD3
F
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Rheumatologists (ACR), is a chronic condition characterized by by the American College of Sports Medi-
cine (ACSM).1 Based on the results of
widespread pain that covers half the body and has lasted for
16 qualified studies, reviewers made the
more than 3 months, 11 of 18 ACR-identified tender points at following conclusions: (1) aerobic exer-
specific sites throughout the body, nonrestorative sleep, and morning cise appeared beneficial in reducing FM
2,34
Common problems include fatigue and decreased ability to symptoms and improving exercise capac-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
exercise due to pain. These symptoms may lead to further debilitation ity, and (2) strengthening exercises might
be beneficial in reducing symptoms. Un-
as the individual becomes weaker and the of exercise in people with FM. fortunately, flexibility exercises were so
less able to do daily activities. Criteria for selection in this review were poorly described that no recommenda-
A search of the Cochrane Collabora- randomized controlled trials, with em- tions could be made.
tive7 yielded a comprehensive report on phasis on training with aerobic, strength- Another finding reported by the Co-
chrane reviewers and noted in other FM
T STUDY DESIGN: Single-subject, multiple-base- T RESULTS: Subjects 1 and 3 had a significant studies7,15,16,31,32 was the poor description
line design across 3 subjects. decrease in the symptoms associated with FM of the exercise protocols. While some
Journal of Orthopaedic & Sports Physical Therapy®
T OBJECTIVE: To investigate the use of a quota- during the intervention phase (FIQ, P.05), but no studies using aerobic exercise were per-
based approach for prescribing a walking program significant increase in (ASES). They formed at levels recommended by the
for individuals with fibromyalgia (FM). increased their walking distances used for exercise ACSM,1,13,15,21,23,24,32 most research trials did
by 640 and 480 m, respectively. Subject 2 had no not indicate the intensity, duration, and
T BACKGROUND: Exercise has been found to be
beneficial for individuals with FM. What has not significant improvements in her symptoms of FM. frequency of exercise that was prescribed.
been determined is the best way to implement Despite a significant decrease in ASES (P.05), One study by Meyer and Lemley22 clearly
an exercise program that does not increase FM walking distance used for exercise by subject 2 in-
described the intensity and progression
symptoms. creased by 2080 m. Six-minute walk test distances
of exercise utilized for subjects with FM.
increased 76, 32, and 106 m for subjects 1, 2, and
T METHODS AND MEASURES: Three women Participants were randomly assigned to a
3, respectively.
with FM were randomly assigned a baseline period low-intensity exercise group (starting at
of 5, 6, or 7 weeks, which served as the control T CONCLUSIONS: Prescribing a walking program
25% of heart rate reserve [HRR], then
phase, followed by an intervention period consist- using a quota-based exercise prescription resulted
ing of an 8-week walking program. The walking increased weekly up to a maximum of
in increasing the distance walked for 3 subjects. It
program progression was prescribed using a 60% HRR) or a high-intensity exercise
also decreased symptoms associated with FM in 2
quota-based approach. Weekly outcome measures of the 3 subjects, but did not increase group (starting at 40% HRR, then in-
were the Fibromyalgia Impact Questionnaire (FIQ), creased weekly up to 85% HRR). Each
J Orthop Sports Phys Ther 2007;37(12):717-724.
Arthritis Scale (ASES), and SF-36v2 group exercised 3 days per week. At the
doi:10.2519/jospt.2007.2607
(acute). A 6-minute walk test was recorded twice:
end of the 24-week program, the low-in-
at the start of the baseline phase (after a trial T KEY WORDS: exercise, Fibromyalgia Impact
phase) and at the end of the intervention phase. Questionnaire, tensity group had a significant decrease
in the Fibromyalgia Impact Question-
1
Assistant Professor of Physical Therapy, College of Mount St Joseph, Cincinnati, OH. 2 Associate Professor of Physical Therapy, University of Indianapolis, Indianapolis, IN.
3
Assistant Professor of Math, College of Mount St. Joseph, Cincinnati, OH. No funding or grants were received for this investigation. This study was approved by The Internal
Review Board of the College of Mount St Joseph and the University of Indianapolis. Address correspondence to Karen Holtgrefe, 5701 Delhi Road, Cincinnati, OH 45233. E-mail:
[email protected]
journal of orthopaedic & sports physical therapy | volume 37 | number 12 | december 2007 | 717
[ RESEARCH REPORT ]
naire (FIQ) scores of 35%, indicating an
improvement in symptoms and function. TABLE 1 Patient Demographics
The high-intensity group had an 8% in-
crease in the FIQ score. The authors sug- Baseline
gested that the increased symptoms and Subject Sex Age (y) FM Duration (y) BMI (kg/m2) Assignment (Week)
decreased function in this group were due 1 F 71 5 35.9 5
to the high intensity of the exercise pro- 2 F 51 4 25.0 6
gram. Similar results related to the effect 3 F 35 4 22.8 7
of high-intensity exercise were reported Abbreviations: BMI, body mass index; F, female; FM, fibromyalgia.
by Nichols and Glenn.24
In addition to the lack of detail relat- to initiate the exercise program. During The inclusion criteria were that subjects
ed to exercise prescription parameters, the exercise sessions each participant (1) were adults between 18 and 75 years
many investigations had high dropout was verbally encouraged to complete of age who had physician-diagnosed FM,
rates. Mannerkori and Iverson20 reviewed the set quota. The quota for each exer- as described by the American College of
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27 randomized controlled trials of exer- cise was then gradually increased. The Rheumatologists,34 (2) had made previ-
cise in individuals with FM, and reported authors reported a significant increase ous attempts at exercise that resulted in
dropout rates as high as 25%, particularly in the amount of exercise (walking and increased FM symptoms, and (3) were
for subjects enrolled in exercise groups. sit-ups) performed during the 4 weeks presently not participating in a walking
One plausible explanation for high of treatment when they prescribed and program. Volunteers were excluded if
dropout rates may have been the types progressed the exercise in this manner. they had cardiopulmonary conditions or
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of exercise and that their parameters (ie, Doleys et al9 reported similar results. lower extremity muscular or joint condi-
intensity, duration, and frequency) in- While the benefits of exercise for indi- tions that would limit their ability to par-
creased FM symptoms. Mengshoel et al22 viduals with FM has been established, very ticipate in a walking program.
studied the pain and fatigue that could little research has been published that ad- Prior to participating, volunteers
be triggered with exercise in individuals dresses the problems related to prescribing were provided with information about
with FM compared to sedentary healthy and progressing exercise for individuals the study. Each subject signed an in-
subjects. For all types of exercise, the FM with FM without increasing their symp- formed consent form approved by the
group reported significantly higher pain toms. Therefore, additional investigation is Institutional Review Boards at the Col-
scores and rate of perceived exertion needed to address this area of concern. The lege of Mount St Joseph, OH and at the
Journal of Orthopaedic & Sports Physical Therapy®
(RPE) than the non-FM group. purpose of this study was to investigate the University of Indianapolis, IN. The first 3
Because intensity of exercise appears effects of a quota-based approach for pre- volunteers (TABLE 1) to meet the inclusion
to have an impact on both exercise adher- scribing aerobic exercise (walking). The criteria were selected.
ence and exercise outcome for individuals hypothesis was that use of a quota-based
with FM, addressing intensity of exercise approach would increase the quantity of Design
prescription is important. This same is- exercise tolerated, reduce the symptoms A single-subject research design requires
sue has been addressed with individuals associated with FM as measured by the repeated measurements of desired out-
with chronic pain. Researchers studying FIQ, increase self-efficacy related to FM comes during a baseline phase and after
patients with chronic pain have utilized as measured by the Arthritis Self-Efficacy implementation of the treatment (in-
a method of controlling and progressing Scale (ASES), and increase functional tervention phase). The baseline phase
exercise intensity, called “exercise quo- health and well-being as measured by the acts as a control. By adding multiple
tas.”8,9,12 Fordyce et al12 described exercise Medical Outcomes Trust, Short Form-36, baselines of varying lengths (nonconcur-
quotas as a specific target or goal for a par- Version 2.0 (SF-36v2 [acute]). rent multiple baselines), the ability to
ticular exercise. In their study the quota distinguish observed effects of the treat-
was established after a baseline period of METHODS ment from the effects due to chance are
2 to 3 exercise sessions. During this base- increased.3,4,25,27,29 Each subject was ran-
line period each subject completed a self- Subjects domly assigned a baseline period of 5,
selected number of repetitions of a given 6, or 7 weeks. The length of the baseline
S
ubject demographics are pro-
exercise (ie, strengthening or aerobic vided in TABLE 1. Subjects were re- phase was predetermined.
exercises). The self-selected amounts of cruited by posting informational
exercise for each session were averaged. flyers about the study via e-mail to all Measurements
This average was then set 10% lower and faculty, staff, and students at the College Three primary outcome measures were
became the “initial exercise quota” used of Mount St Joseph in Cincinnati, OH. used in this study: the FIQ, ASES, and
718 | december 2007 | volume 37 | number 12 | journal of orthopaedic & sports physical therapy
the SF-36v2 (acute), a general health sta- improvement (global patient rating of each subject completed the FIQ, ASES,
tus questionnaire. All 3 are self-adminis- change) using the Spearman rank order and SF-36 weekly, and was instructed
tered tools. The FIQ consists of 20 items: correlation (R = 0.51, P.001). Further to abstain from any form of exercise. No
11 items on physical functioning, 2 items statistical analysis indicated a large effect other activity took place during this time
related to missed work/housework and size (ES) (–1.38), standardized response except for completion of the 6MW twice
days feeling well, and 7 items related to mean (SRM) (–1.04), and Guyatt respon- on an indoor track during the first week.
other symptoms of FM (work, pain, fa- siveness statistic (RG) (–1.44), indicating The first 6MW was a practice trial; par-
tigue, sleep, stiffness, anxiousness, and that the FIQ provided strong estimates ticipants completed the baseline 6MW 2
depression). Possible scores range from of the magnitude of change (in this case, days later.
0 to 100, with higher scores indicating improvement in symptoms).
greater impairment. The scale has been In addition to the primary outcomes, Intervention
reported to be reliable and valid.6,10 the 6-minute walk test (6MW) was utilized Subject 1 started the intervention phase
The ASES assessed participants’ be- to determine functional exercise capacity. on week 6, subject 2 started on week 7,
liefs that they could control their physi- Research has demonstrated that the 6MW and subject 3 on week 8. The intervention
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cal functioning and symptoms associated is a reliable and valid tool for individuals phase consisted of a walking program
with FM. The current scale contains 8 with FM, but the baseline measure should performed 3 days per week. Following
items with a higher score (total 10 points), be taken after a practice trial.17,28 the quota-based approach described by
indicating greater self-efficacy. The ASES Finally, RPE and vital signs consisting Fordyce et al,12 the “initial exercise quo-
has established reliability and validity for of blood pressure and heart rate were as- ta” was established as follows: during the
individuals with FM.19 sessed during each walking session and first 2 sessions the participants walked at
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
The SF-36v2 (acute) was used to assess the 6MW to determine any contraindi- a self-selected pace until weakness, pain,
the impact of the symptoms related to FM cations to performing the exercise, and or fatigue caused them to stop. The time
on functional health and well-being. The to assess any abnormal response as de- and distance were recorded. The results
acute version is designed to detect weekly scribed by the ACSM.1 If the response had of these 2 sessions were averaged togeth-
changes. Two summary measures (physi- been abnormal, the exercise would have er and the threshold or starting point was
cal health and mental health) are further been stopped and the subject referred to set 1 lap (160 m) lower, thus establishing
subdivided into 4 categories: physical a physician. RPE has been reported to the “initial exercise quota.” This exercise
health (physical functioning, role-physi- have a high correlation (0.80-0.90) with quota was then increased at regular inter-
cal, bodily pain, general health), mental heart rate, and is a good indicator of how vals (such as 1 lap per session or 1 lap per
Journal of Orthopaedic & Sports Physical Therapy®
health (vitality, social functioning, role- difficult the exercise is for the subject.4 A week), as determined by the individual,
emotional, mental health). The SF-36 15-grade RPE scale (6-20) was used (7, with input from the principal investiga-
has established reliability and validity very, very light; 13, somewhat hard; 19, tor. The principal investigator gave each
for the general population. The scores very, very hard). subject positive feedback when the sub-
range from 0 to 100 when norm based, ject met the established exercise quota,
with a score below 50 indicating a below Measurement Procedures but did not comment if the quota was not
average health status.33 While the SF-36 A trained faculty member in the physi- met. Blood pressure, heart rate, and RPE
has been used in studies of individuals cal therapy department administered were recorded during all walking ses-
with FM,7,21,31 no reports of its reliability the FIQ, ASES, and SF-36v2 (acute) to sions. Finally, the principal investigator
and validity in this population has been subjects on a weekly basis in the Depart- supervised a cool-down phase of gentle
established. ment of Health Sciences at the College of stretches of the quadriceps, hamstrings,
Responsiveness or sensitivity to Mount St Joseph throughout the study. and gastrocnemius/soleus after each
changes in subject status is an impor- The principal investigator administered walking session.
tant characteristic of effective outcome the 6MW, established the walking pro-
measurement tools. While no published gram, and monitored each session docu- Data Analysis
reports were found to assess the sensitiv- menting distance completed during the Data analysis was completed using the
ity of the ASES and SF-36 in individu- intervention phase of the study (13-15 SINGWIN software (Allyn and Bacon
als with FM, Dunkl et al10 did assess the weeks total). The principal investigator Software, Boston, MA). Data in each
responsiveness of the FIQ compared to was blinded to the results of the 3 pri- phase were assessed for autocorrela-
patient pain ratings, number of tender mary outcomes throughout the study. tion or serial dependency using the lag-1
points, and total tender point pain inten- method. Serial dependency is indicative
sity score. They reported that the FIQ was Baseline of the extent that scores at 1 point in a
the most responsive to perceived clinical In the baseline phase, lasting 5 to 7 weeks, series are predictive of scores in anoth-
journal of orthopaedic & sports physical therapy | volume 37 | number 12 | december 2007 | 719
[ RESEARCH REPORT ]
er point in the same set of data. If data phase fell outside the band, the result was index, which used a pooled SD from the
were found to be autocorrelated they considered significant at P.05.3,25,27 baseline and intervention phases rather
were transformed using a moving-aver- The ES, while not a statistical test, al- than from the baseline phase only.6
age transformation prior to further data lows an assessment of how large a change The SF-36 was scored online and
analysis. The moving-average transfor- occurred between the baseline and in- norm referenced by QualityMetric.30 Four
mation is recommended for data with tervention phases. It was calculated by subcategories were assessed: physical
fluctuations.3,4,25,27 subtracting the mean of the intervention functioning, role-physical, bodily pain,
Based on the small number of baseline phase from the mean of the baseline phase and mental health. Each participant’s
points (5-7), 2 analyses were chosen for and dividing result by the SD of the base- score was averaged for each phase and
the FIQ and ASES: the 2-SD band meth- line phase. In general, the larger the ES, compared to normative data for healthy
od and effect size (ES). The 2-SD band the greater the effect the intervention has women in their age group. A comparison
was calculated from the baseline data and on the outcomes. An ES of 0.2 was con- was also made between the baseline and
graphed from the baseline phase through sidered small, 0.5 medium, and 0.8 large. intervention phases.
the intervention phase. If 2 or more suc- Due to the small number of baseline data The 6MW results were analyzed in 2
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cessive data points in the intervention points, the ES was analyzed using the d ways. First, the change in distance from the
baseline to intervention phase was deter-
mined. Then the result of each phase was
100 compared to a predicted distance calculat-
90 ed from a reference equation for healthy
80
Subject 1 Scores
T
90 he data for the intervention
Journal of Orthopaedic & Sports Physical Therapy®
70
60 related and thus were transformed
50 prior to completion of additional data
40
30 analysis. The 2-SD band method showed
20 that subjects 1 and 3 each had a signifi-
10
0 cant improvement (P.05) in their FIQ
1 2 3 4 5 6 7 8 9 10 11 12 13 scores between baseline and intervention
Week phases, while subject 2 demonstrated no
100 significant change (FIGURE 1).
90 The ES for subjects 1 and 3 was large
80 (–1.56 and –1.66, respectively), with a
Subject 3 Scores
70
decrease or improvement in symptoms
60
50
associated with FM (44% and 45%, re-
40 spectively). Subject 2 had a moderate ES
30 (–0.54), with a 20% improvement.
20
10 Arthritis Self-Efficacy Scale
0
Because the data for the intervention
1 2 3 4 5 6 7 8 9 10 11 12 13 14
phase of subject 1 were autocorrelated,
Week
they were transformed prior to comple-
tion of data analysis. While subject 1’s data
FIGURE 1. Fibromyalgia Impact Questionnaire (FIQ) 2-SD band graph for baseline and intervention phases. on the ASES included 3 points in the in-
Scores on the FIQ range from 0 to 100, larger scores indicating greater impairment.
tervention phase outside the 2-SD band,
720 | december 2007 | volume 37 | number 12 | journal of orthopaedic & sports physical therapy
from the initial 6MW to the final test 13
SF-36 Average Score at Baseline and to 15 weeks later, and had higher values of
TABLE 2
Intervention Compared to Normative Values their predicted distance for age calculat-
ed from a reference equation for healthy
Baseline Intervention Baseline Intervention adults (TABLE 3).11
Mean Mean Norms* Percentile Rank† Percentile Rank
Subject 1 Walking Program
PF 33 33 42 25th 25th Subject 1’s initial exercise quota was 800
RP 35 39 44 25th 25th m. She tried to increase her distance by 1
BP 32 38 46 25th 25th lap (160 m) per week, but found that she
MH 57 58 51 75th 75th could not tolerate this increase. Subse-
Subject 2 quently, she changed her quota distance
PF 40 49 48 25th 50th to an increase of 1 lap every 2 weeks. She
RP 40 45 49 25th 25th improved her total walking distance by
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Comparison to a Predicted Distance for Age11 was unable to meet her established quo-
tas during week 4 (1760-2080 m). She
Predicted Percent reported experiencing these problems
Initial (m) Final (m) Change (m) Distance (m)* Difference every time she started exercising. When
Subject 1 409 484 76 240 50% higher she stopped the exercise, all of her symp-
Subject 2 604 635 32 425 33% higher toms subsided. Because this may have
Subject 3 524 639 106 532 17% higher been her normal response to exercise
*Predicted distance is lower limit of normal; percentage difference is compared to final walk test. and there was no observed change in her
gait pattern, no further assessment was
the points were not successive; therefore, SF-36v2 (Acute) made to determine a specific cause of
the results were not significant (FIGURE 2). The mean baseline and intervention the hip pain. The principal investigator
However, the ES was large (1.51), with an scores for all 3 subjects for physical func- recommended a reduction in her exercise
increase in scores between baseline and tioning, role physical, and bodily pain quota. The subject decided to decrease
intervention phases of 43%. were below the mean national norms for her exercise quota during week 5 to 1600
The ASES results for subject 2 indi- their age group both at baseline and at m and to remain at this level for the final
cated a significant decrease (P.05) in the end of the study. The mental health 4 weeks of the study. Her FM symptoms
self-efficacy from baseline levels (FIGURE subscale was at or above the mean na- and right hip pain decreased during this
2). The ES was large (–1.26), with a de- tional norms for subjects 1 and 2, but be- time and she completed a final walk of
crease in scores of 40%. low these norms for subject 3 (TABLE 2).33 1600 m in 13 minutes 33 seconds, with
The ASES results for subject 3 indi- an RPE of 16.
cated no significant difference (FIGURE 2) Six-Minute Walk Test
and only a small ES (0.29), with an 11% Each of the 3 subjects demonstrated Missing Data
improvement in self-efficacy. marked increases in walking distance Subject 2 had 1 week of FIQ data missing
journal of orthopaedic & sports physical therapy | volume 37 | number 12 | december 2007 | 721
[ RESEARCH REPORT ]
from the intervention phase, and subject tas were established after 2 walking ses- her FIQ scores decreased significantly
3 had 1 week of FIQ data missing from sions, with each subject choosing her own (FIGURE 1).
the baseline phase due to not completing method of progression, from a gradual in- Authors of previous studies have
the second page of the form. The missing crease to an increase of 1 lap per session. demonstrated that some types of aero-
data were not believed to affect the final When subject 3 experienced increased bic exercise can reduce the symptoms of
results. Subject 2 had enough data points pain, she reduced her exercise quota and FM.7,14,13,21,23,24,32 Our results are in agree-
in the intervention phase and none were successfully completed this quota for the ment with this finding. In the current
outside the 2-SD band. Subject 3 had the remainder of the study. During that time, study, subjects 1 and 3 had a significant
longest baseline phase and, consequently,
a sufficient number of baseline points for
data comparison (6 points). 10
9
DISCUSSION 8
7
Subject 1 Scores
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T
he purpose of this study was to
determine if using a quota-based 5
approach for prescribing a walking 4
program for individuals with FM would 3
increase walking distance, decrease 2
symptoms associated with FM (FIQ), in- 1
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
722 | december 2007 | volume 37 | number 12 | journal of orthopaedic & sports physical therapy
decrease in FIQ scores, with a large change results. Despite the significant improve- scored significantly lower, but not signifi-
in scores from baseline to intervention ment in FIQ in subjects 1 and 3, and the cantly lower on mental health. Subjects in
(ES, –1.56 and –1.66), similar to those re- success that all experienced in the walking the current study had similar results when
ported by Rooks et al32 (ES, –1.39). program, none of our subjects demonstrat- compared to the normative population
Researchers have expressed concerns ed an improvement in self-efficacy as mea- (lower overall scores for physical function-
regarding the intensity of exercise for in- sured by the ASES. While our results did ing, role physical, and bodily pain). The
dividuals with FM. Meyer and Lemley23 not support previous findings, there might results of the SF-36 gave us an indication
and Nichols and Glenn24 suggested that be several possible explanations. First, sub- of how the symptoms of FM affected each
the intensity and frequency of exercise ject 1 did have 3 data points outside the 2 subject’s functional health and well-being.
recommended by the ACSM1 may be too SD band for ASES, but they were not suc- In addition, the change in scores follow-
strenuous for individuals with FM. Meng- cessive. While this was not a statistically ing the intervention allowed us to assess
shoel et al22 also reported higher RPEs significant finding, it did suggest that there the impact of the intervention on overall
(16-18) in individuals with FM who exer- was a trend toward increased self-efficacy health.33 The results in TABLE 2 showed that
cised. However, our results contradicted over the course of the study. Plus she re- all 3 subjects had increased SF-36 scores
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these findings. Each of our subjects was ported improvements in her daily activi- after the intervention, with subject 2 hav-
able to attain ACSM guidelines1 for sub- ties, such as climbing stairs without the use ing the largest improvement.
maximal exercise, as evidenced by RPE of handrails, and planned on walking after Contrary to several studies of exercise
(range, 7-17) and heart rate data (range, the study was completed. and individuals with FM,13,15,20,21,23,24,31 no
88-164 beats per minute). A possible rea- Subject 2 experienced a significant subjects dropped out of the current study.
son for this discrepancy was that in our decrease in ASES, indicating that her be- Subjects 1 and 2 did not experience in-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
study each subject was allowed to deter- lief that she could control her symptoms creased FM symptoms. While subject 3
mine her walking distance and method of had worsened by the end of the study. reported an increase in FM symptoms,
progression within her walking program While subject 2 was the most successful her FIQ scores did not increase during
and walked at a self-selected pace. with her walking program, she did not this time (FIGURE 1). She stated that she
The relationship between self-efficacy experience a significant decrease in her would normally discontinue exercising;
and participation in exercise has also been FIQ scores. Thus it is possible that lack however, the principal investigator was
studied in individuals with FM. Gowans of improvement in her FM symptoms able to show her that by making adjust-
et al14 investigated the effect of exercise on may have contributed to her decreased ments to her exercise quota, she could
mood and physical function. The subjects feelings of self-efficacy. In addition, she reduce her symptoms and continue to ex-
Journal of Orthopaedic & Sports Physical Therapy®
who exercised experienced a significant did not think she would continue walking ercise. In fact, during the final 3 weeks of
increase in their scores on the ASES scale because no one would be monitoring her the intervention phase, she had a signifi-
as compared to the control group, indi- and counting the laps. cant decrease in FIQ scores, indicating
cating that the exercisers reported greater Subject 3 also did not experience im- a decrease in symptoms. This suggested
feelings of control over their FM symp- provement in self-efficacy. However, her that the use of established exercise quotas
toms. In addition, Oliver and Cronan26 score on the mental health subscale of and self-selected walking pace might have
investigated predictors of exercise success the SF-36 was the lowest score of all the improved compliance in this individual.
in 444 patients with FM and found that subjects and the lowest for her age group The current investigation had several
high exercise self-efficacy was a strong comparison. These low scores might have limitations. First, it was a small study
predictor for success in exercising. indicated more serious mental health with only 3 subjects. Although this would
In addition, Dolce et al8 prescribed concerns, such as depression or anxiety, appear to limit the ability of establishing
exercises following the quota system and which may have affected her beliefs re- causality from the intervention, this prob-
investigated the effect of this approach lated to self-efficacy, as well as her tem- lem was reduced by the study design. The
on self-efficacy expectancies related to porary increase in FM symptoms. She use of 3 subjects with 3 different baseline
exercise and worry/concern regarding ex- was hoping to continue exercising but time frames increased our ability to dis-
ercise. Results indicated that all subjects did not know if she would be able to once tinguish observed effects of the treatment
increased their exercise intensity by an she started graduate school. from the effects due to chance. In addi-
average of 42% (range, 20%-90%), and Kosinski et al18 compared the SF-36 tion, the baseline period served as a con-
that exercisers using the quota system scores of individuals who had osteoar- trol phase, and the different baseline time
had a significant increase in self-efficacy thritis and rheumatoid arthritis to those frames increased the internal validity of
expectancies and a significant decrease in of a normative population, and reported the study by controlling the effect of his-
worry/concern about exercise. that individuals with arthritis for physical tory and maturation.4,29
Our findings did not agree with these functioning, role physical, and bodily pain The second limitation was that the
journal of orthopaedic & sports physical therapy | volume 37 | number 12 | december 2007 | 723
[ RESEARCH REPORT ]
baseline phase had a small number of baseline, and alternating treatments designs. Res Clin Rheumatol. 2003;17:629-647.
Arch Phys Med Rehabil. 1997;78:1145-1153. 21. Martin L, Nutting A, MacIntosh B, Edworthy S,
data points. However, the baseline phase
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and to decrease the possibility of sub- fatigue induced by exercise in fibromyalgia pa-
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724 | december 2007 | volume 37 | number 12 | journal of orthopaedic & sports physical therapy