[ RESEARCH REPORT ]

KAREN HOLTGREFE, PT, DHS, OCS1 • CONSTANCE MCCLOY, PT, EdD, ATC2 • LISA ROME, PhD3

Changes Associated With a Quota-Based

Approach on a Walking Program for
Individuals With Fibromyalgia
ibromyalgia (FM), as defined by the American College of ening, or flexibility exercises, as defined

F
Downloaded from www.jospt.org at on November 15, 2022. For personal use only. No other uses without permission.

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
as the individual becomes weaker and
less able to do daily activities.
A search of the Cochrane Collabora-
tive7 yielded a comprehensive report on
T STUDY DESIGN: Single-subject, multiple-base-
line design across 3 subjects.
Journal of Orthopaedic & Sports Physical Therapy®
the of exercise in people with FM.
Criteria for selection in this review were
randomized controlled trials, with em-
phasis on training with aerobic, strength-
T RESULTS: Subjects 1 and 3 had a significant
decrease in the symptoms associated with FM
ity, and (2) strengthening exercises might
be beneficial in reducing symptoms. Un-
fortunately, flexibility exercises were so
poorly described that no recommenda-
tions could be made.
Another finding reported by the Co-
chrane reviewers and noted in other FM
studies7,15,16,31,32 was the poor description
of the exercise protocols. While some

T OBJECTIVE: To investigate the use of a quota-
based approach for prescribing a walking program
for individuals with fibromyalgia (FM).
T BACKGROUND: Exercise has been found to be
beneficial for individuals with FM. What has not
during the intervention phase (FIQ, P.05), but no
significant increase in (ASES). They
increased their walking distances used for exercise
by 640 and 480 m, respectively. Subject 2 had no
significant improvements in her symptoms of FM.
studies using aerobic exercise were per-
formed at levels recommended by the
ACSM,1,13,15,21,23,24,32 most research trials did
not indicate the intensity, duration, and
frequency of exercise that was prescribed.
been determined is the best way to implement
an exercise program that does not increase FM
symptoms.
T METHODS AND MEASURES: Three women
with FM were randomly assigned a baseline period
of 5, 6, or 7 weeks, which served as the control
phase, followed by an intervention period consist-
ing of an 8-week walking program. The walking
program progression was prescribed using a
quota-based approach. Weekly outcome measures
were the Fibromyalgia Impact Questionnaire (FIQ),
Arthritis Scale (ASES), and SF-36v2
(acute). A 6-minute walk test was recorded twice:
at the start of the baseline phase (after a trial
phase) and at the end of the intervention phase.
Despite a significant decrease in ASES (P.05), One study by Meyer and Lemley22 clearly
walking distance used for exercise by subject 2 in-
described the intensity and progression
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
Participants were randomly assigned to a
3, respectively.
low-intensity exercise group (starting at
T CONCLUSIONS: Prescribing a walking program
25% of heart rate reserve [HRR], then
using a quota-based exercise prescription resulted
increased weekly up to a maximum of
in increasing the distance walked for 3 subjects. It
60% HRR) or a high-intensity exercise
also decreased symptoms associated with FM in 2
of the 3 subjects, but did not increase group (starting at 40% HRR, then in-
creased weekly up to 85% HRR). Each
J Orthop Sports Phys Ther 2007;37(12):717-724.
group exercised 3 days per week. At the
doi:10.2519/jospt.2007.2607
end of the 24-week program, the low-in-
T KEY WORDS: exercise, Fibromyalgia Impact
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:
karen_holtgrefe@mail.msj.edu

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.
The high-intensity group had an 8% in-
crease in the FIQ score. The authors sug-
gested that the increased symptoms and
decreased function in this group were due
to the high intensity of the exercise pro-
gram. Similar results related to the effect
of high-intensity exercise were reported
by Nichols and Glenn.24
In addition to the lack of detail relat-
ed to exercise prescription parameters,
many investigations had high dropout
rates. Mannerkori and Iverson20 reviewed
Downloaded from www.jospt.org at on November 15, 2022. For personal use only. No other uses without permission.
27 randomized controlled trials of exer-
cise in individuals with FM, and reported
dropout rates as high as 25%, particularly
for subjects enrolled in exercise groups.
One plausible explanation for high
dropout rates may have been the types
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of exercise and that their parameters (ie,
intensity, duration, and frequency) in-
creased FM symptoms. Mengshoel et al22
studied the pain and fatigue that could
be triggered with exercise in individuals
with FM compared to sedentary healthy
subjects. For all types of exercise, the FM
group reported significantly higher pain
scores and rate of perceived exertion
Journal of Orthopaedic & Sports Physical Therapy®
(RPE) than the non-FM group.
Because intensity of exercise appears
to have an impact on both exercise adher-
ence and exercise outcome for individuals
with FM, addressing intensity of exercise
prescription is important. This same is-
sue has been addressed with individuals
with chronic pain. Researchers studying
patients with chronic pain have utilized
a method of controlling and progressing
exercise intensity, called “exercise quo-
tas.”8,9,12 Fordyce et al12 described exercise
quotas as a specific target or goal for a par-
ticular exercise. In their study the quota
was established after a baseline period of
2 to 3 exercise sessions. During this base-
line period each subject completed a self-
selected number of repetitions of a given
exercise (ie, strengthening or aerobic
exercises). The self-selected amounts of
exercise for each session were averaged.
This average was then set 10% lower and
became the “initial exercise quota” used
718 | december 2007 | volume 37 | number 12 | journal of orthopaedic & sports physical therapy
TABLE 1 Patient Demographics
Subject Sex Age (y)
1 F 71
2 F 51
3 F 35
Abbreviations: BMI, body mass index; F, female; FM, fibromyalgia.
to initiate the exercise program. During
the exercise sessions each participant
was verbally encouraged to complete
the set quota. The quota for each exer-
cise was then gradually increased. The
authors reported a significant increase
in the amount of exercise (walking and
sit-ups) performed during the 4 weeks
of treatment when they prescribed and
progressed the exercise in this manner.
Doleys et al9 reported similar results.
While the benefits of exercise for indi-
viduals with FM has been established, very
little research has been published that ad-
dresses the problems related to prescribing
and progressing exercise for individuals
with FM without increasing their symp-
toms. Therefore, additional investigation is
needed to address this area of concern. The
purpose of this study was to investigate the
effects of a quota-based approach for pre-
scribing aerobic exercise (walking). The
hypothesis was that use of a quota-based
approach would increase the quantity of
exercise tolerated, reduce the symptoms
associated with FM as measured by the
FIQ, increase self-efficacy related to FM
as measured by the Arthritis Self-Efficacy
Scale (ASES), and increase functional
health and well-being as measured by the
Medical Outcomes Trust, Short Form-36,
Version 2.0 (SF-36v2 [acute]).
METHODS
Subjects
S
ubject demographics are pro-
vided in TABLE 1. Subjects were re-
cruited by posting informational
flyers about the study via e-mail to all
faculty, staff, and students at the College
of Mount St Joseph in Cincinnati, OH.
]
Baseline
FM Duration (y) BMI (kg/m2) Assignment (Week)
5 35.9 5
4 25.0 6
4 22.8 7
The inclusion criteria were that subjects
(1) were adults between 18 and 75 years
of age who had physician-diagnosed FM,
as described by the American College of
Rheumatologists,34 (2) had made previ-
ous attempts at exercise that resulted in
increased FM symptoms, and (3) were
presently not participating in a walking
program. Volunteers were excluded if
they had cardiopulmonary conditions or
lower extremity muscular or joint condi-
tions that would limit their ability to par-
ticipate in a walking program.
Prior to participating, volunteers
were provided with information about
the study. Each subject signed an in-
formed consent form approved by the
Institutional Review Boards at the Col-
lege of Mount St Joseph, OH and at the
University of Indianapolis, IN. The first 3
volunteers (TABLE 1) to meet the inclusion
criteria were selected.
Design
A single-subject research design requires
repeated measurements of desired out-
comes during a baseline phase and after
implementation of the treatment (in-
tervention phase). The baseline phase
acts as a control. By adding multiple
baselines of varying lengths (nonconcur-
rent multiple baselines), the ability to
distinguish observed effects of the treat-
ment from the effects due to chance are
increased.3,4,25,27,29 Each subject was ran-
domly assigned a baseline period of 5,
6, or 7 weeks. The length of the baseline
phase was predetermined.
Measurements
Three primary outcome measures were
used in this study: the FIQ, ASES, and
 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:
11 items on physical functioning, 2 items
related to missed work/housework and
days feeling well, and 7 items related to
other symptoms of FM (work, pain, fa-
tigue, sleep, stiffness, anxiousness, and
depression). Possible scores range from
0 to 100, with higher scores indicating
greater impairment. The scale has been
reported to be reliable and valid.6,10
The ASES assessed participants’ be-
liefs that they could control their physi-
Downloaded from www.jospt.org at on November 15, 2022. For personal use only. No other uses without permission.
cal functioning and symptoms associated
with FM. The current scale contains 8
items with a higher score (total 10 points),
indicating greater self-efficacy. The ASES
has established reliability and validity for
individuals with FM.19
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
The SF-36v2 (acute) was used to assess
the impact of the symptoms related to FM
on functional health and well-being. The
acute version is designed to detect weekly
changes. Two summary measures (physi-
cal health and mental health) are further
subdivided into 4 categories: physical
health (physical functioning, role-physi-
cal, bodily pain, general health), mental
Journal of Orthopaedic & Sports Physical Therapy®
health (vitality, social functioning, role-
emotional, mental health). The SF-36
has established reliability and validity
for the general population. The scores
range from 0 to 100 when norm based,
with a score below 50 indicating a below
average health status.33 While the SF-36
has been used in studies of individuals
with FM,7,21,31 no reports of its reliability
and validity in this population has been
established.
Responsiveness or sensitivity to
changes in subject status is an impor-
tant characteristic of effective outcome
measurement tools. While no published
reports were found to assess the sensitiv-
ity of the ASES and SF-36 in individu-
als with FM, Dunkl et al10 did assess the
responsiveness of the FIQ compared to
patient pain ratings, number of tender
points, and total tender point pain inten-
sity score. They reported that the FIQ was
the most responsive to perceived clinical
journal of orthopaedic & sports physical therapy | volume 37 | number 12 | december 2007 |
correlation (R = 0.51, P.001). Further
statistical analysis indicated a large effect
size (ES) (–1.38), standardized response
mean (SRM) (–1.04), and Guyatt respon-
siveness statistic (RG) (–1.44), indicating
that the FIQ provided strong estimates
of the magnitude of change (in this case,
improvement in symptoms).
In addition to the primary outcomes,
the 6-minute walk test (6MW) was utilized
to determine functional exercise capacity.
Research has demonstrated that the 6MW
is a reliable and valid tool for individuals
with FM, but the baseline measure should
be taken after a practice trial.17,28
Finally, RPE and vital signs consisting
of blood pressure and heart rate were as-
sessed during each walking session and
the 6MW to determine any contraindi-
cations to performing the exercise, and
to assess any abnormal response as de-
scribed by the ACSM.1 If the response had
been abnormal, the exercise would have
been stopped and the subject referred to
a physician. RPE has been reported to
have a high correlation (0.80-0.90) with
heart rate, and is a good indicator of how
difficult the exercise is for the subject.4 A
15-grade RPE scale (6-20) was used (7,
very, very light; 13, somewhat hard; 19,
very, very hard).
Measurement Procedures
A trained faculty member in the physi-
cal therapy department administered
the FIQ, ASES, and SF-36v2 (acute) to
subjects on a weekly basis in the Depart-
ment of Health Sciences at the College of
Mount St Joseph throughout the study.
The principal investigator administered
the 6MW, established the walking pro-
gram, and monitored each session docu-
menting distance completed during the
intervention phase of the study (13-15
weeks total). The principal investigator
was blinded to the results of the 3 pri-
mary outcomes throughout the study.
Baseline
In the baseline phase, lasting 5 to 7 weeks,
to abstain from any form of exercise. No
other activity took place during this time
except for completion of the 6MW twice
on an indoor track during the first week.
The first 6MW was a practice trial; par-
ticipants completed the baseline 6MW 2
days later.
Intervention
Subject 1 started the intervention phase
on week 6, subject 2 started on week 7,
and subject 3 on week 8. The intervention
phase consisted of a walking program
performed 3 days per week. Following
the quota-based approach described by
Fordyce et al,12 the “initial exercise quo-
ta” was established as follows: during the
first 2 sessions the participants walked at
a self-selected pace until weakness, pain,
or fatigue caused them to stop. The time
and distance were recorded. The results
of these 2 sessions were averaged togeth-
er and the threshold or starting point was
set 1 lap (160 m) lower, thus establishing
the “initial exercise quota.” This exercise
quota was then increased at regular inter-
vals (such as 1 lap per session or 1 lap per
week), as determined by the individual,
with input from the principal investiga-
tor. The principal investigator gave each
subject positive feedback when the sub-
ject met the established exercise quota,
but did not comment if the quota was not
met. Blood pressure, heart rate, and RPE
were recorded during all walking ses-
sions. Finally, the principal investigator
supervised a cool-down phase of gentle
stretches of the quadriceps, hamstrings,
and gastrocnemius/soleus after each
walking session.
Data Analysis
Data analysis was completed using the
SINGWIN software (Allyn and Bacon
Software, Boston, MA). Data in each
phase were assessed for autocorrela-
tion or serial dependency using the lag-1
method. Serial dependency is indicative
of the extent that scores at 1 point in a
series are predictive of scores in anoth-
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
were transformed using a moving-aver-
age transformation prior to further data
analysis. The moving-average transfor-
mation is recommended for data with
fluctuations.3,4,25,27
Based on the small number of baseline
points (5-7), 2 analyses were chosen for
the FIQ and ASES: the 2-SD band meth-
od and effect size (ES). The 2-SD band
was calculated from the baseline data and
graphed from the baseline phase through
the intervention phase. If 2 or more suc-
Downloaded from www.jospt.org at on November 15, 2022. For personal use only. No other uses without permission.
considered significant at P.05.3,25,27
The ES, while not a statistical test, al-
lows an assessment of how large a change
occurred between the baseline and in-
tervention phases. It was calculated by
subtracting the mean of the intervention
phase from the mean of the baseline phase
and dividing result by the SD of the base-
line phase. In general, the larger the ES,
the greater the effect the intervention has
on the outcomes. An ES of 0.2 was con-
sidered small, 0.5 medium, and 0.8 large.
Due to the small number of baseline data
baseline and intervention phases rather
than from the baseline phase only.6
The SF-36 was scored online and
norm referenced by QualityMetric.30 Four
subcategories were assessed: physical
functioning, role-physical, bodily pain,
and mental health. Each participant’s
score was averaged for each phase and
compared to normative data for healthy
women in their age group. A comparison
was also made between the baseline and
intervention phases.
The 6MW results were analyzed in 2

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

70 adults. The reference equation for women

Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

60 that determined the lower limit of normal

50
40
for the predicted distance in meters, us-
30 ing body mass index (BMI), was11 1017 m
20 – (6.24 s BMI) – (5.78 s age) – 139 m.
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 RESULTS
Week
Fibromyalgia Impact Questionnaire
100

T
90 he data for the intervention
Journal of Orthopaedic & Sports Physical Therapy®

80 phase of subject 2 were autocor-

Subject 2 Scores

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
Downloaded from www.jospt.org at on November 15, 2022. For personal use only. No other uses without permission.

BP 39 45 48 25th 50th 80%, finishing with 1440 m in 21 minutes

MH 50 52 49 50th 50th 29 seconds, with an RPE of 13.
Subject 3‡ Subject 2’s initial exercise quota was
PF 35 43 52 25th 25th 1920 m. She chose to increase her quota
RP 36 40 51 25th 25th by 1 lap every session, up to 25 laps (4000
BP 31 38 50 25th 25th m). Her total walking distance improved
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

MH 14 19 48 25th 25th 108% over 8 weeks, and she finished by

Abbreviations: BP, bodily pain subscale; MH, mental health subscale; PF, physical functioning sub- walking 4000 m in 44 minutes 4 seconds,
scale; RP, role-physical subscale.
with an RPE of 13.
* Norms: national norms for females by age group.
†
Percentile rank: based on national norms for females by age group. Subject 3 started with a baseline ex-
‡
Subject 3’s percentile rank is much lower than the 25th percentile for each category (baseline, 14-30 ercise quota of 1120 m, increasing 1 lap
less; intervention, 7-25 less).
per session until the third week, when
she reached 1600 m. At that time she ex-
perienced an increase in FM symptoms,
Six-Minute Walk Test Results With developed right lateral hip pain, and
TABLE 3
Journal of Orthopaedic & Sports Physical Therapy®

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
self-efficacy from baseline levels (FIGURE
2). The ES was large (–1.26), with a de-
crease in scores of 40%.
The ASES results for subject 3 indi-
cated no significant difference (FIGURE 2)
and only a small ES (0.29), with an 11%
improvement in self-efficacy.
the end of the study. The mental health
subscale was at or above the mean na-
tional norms for subjects 1 and 2, but be-
low these norms for subject 3 (TABLE 2).33
Six-Minute Walk Test
Each of the 3 subjects demonstrated
marked increases in walking distance
4 weeks of the study. Her FM symptoms
and right hip pain decreased during this
time and she completed a final walk of
1600 m in 13 minutes 33 seconds, with
an RPE of 16.
Missing Data
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
3 had 1 week of FIQ data missing from
the baseline phase due to not completing
the second page of the form. The missing
data were not believed to affect the final
results. Subject 2 had enough data points
in the intervention phase and none were
outside the 2-SD band. Subject 3 had the
longest baseline phase and, consequently,
a sufficient number of baseline points for
data comparison (6 points).
DISCUSSION
Downloaded from www.jospt.org at on November 15, 2022. For personal use only. No other uses without permission.
]
tas were established after 2 walking ses- her FIQ scores decreased significantly
sions, with each subject choosing her own (FIGURE 1).
method of progression, from a gradual in- Authors of previous studies have
crease to an increase of 1 lap per session. demonstrated that some types of aero-
When subject 3 experienced increased bic exercise can reduce the symptoms of
pain, she reduced her exercise quota and FM.7,14,13,21,23,24,32 Our results are in agree-
successfully completed this quota for the ment with this finding. In the current
remainder of the study. During that time, study, subjects 1 and 3 had a significant
10
9
8
7
Subject 1 Scores

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.

crease self-efficacy (ASES), and increase 0

functional health and well-being (SF- 1 2 3 4 5 6 7 8 9 10 11 12 13
36). Results indicated that all 3 subjects Week
increased their walking distances from 10
43% to 108% from baseline. Subjects 1 9
and 3 had a significant decrease in the 8
FIQ, but no subjects demonstrated an 7
Subject 2 Scores

increase in self-efficacy. In addition, all 3 6

subjects had increased scores on the SF- 5
Journal of Orthopaedic & Sports Physical Therapy®

36 for physical functioning, role physical, 4

bodily pain, and mental health following 3
the intervention phase. 2
The use of a quota-based exercise ap- 1

proach as described by Fordyce et al12 for 0

use with patients with chronic pain rep- 1 2 3 4 5 6 7 8 9 10 11 12 13

resented a form of operant conditioning. Week

Their hypothesis was that pain behaviors
10
and limitations related to exercise could 9
be diminished by changing how these fac- 8
tors were addressed. First, exercise quotas 7
Subject 3 Scores

were set 10% below the threshold reported 6

by the subject during the first few sessions 5
of exercise. This below-threshold exercise 4
quota was expected to lead to successful 3
completion of that quota. When the quota 2
was met, positive reinforcement was giv- 1
en. If the quota was not met, there was no 0
response. Finally, the exercise quota was 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
increased gradually. Prescribing exercise Week
in this way has led to significant increases
in exercise intensity.8,9,12 FIGURE 2. Arthritis Self-Efficacy Scale (ASES) 2-SD band graph for baseline and intervention phases. Scores on
the ASES range from 0 to 10, larger scores indicating greater self-efficacy.
In the current study the exercise quo-

722 | december 2007 | volume 37 | number 12 | journal of orthopaedic & sports physical therapy
 decrease in FIQ scores, with a large change
in scores from baseline to intervention
(ES, –1.56 and –1.66), similar to those re-
ported by Rooks et al32 (ES, –1.39).
Researchers have expressed concerns
regarding the intensity of exercise for in-
dividuals with FM. Meyer and Lemley23
and Nichols and Glenn24 suggested that
the intensity and frequency of exercise
recommended by the ACSM1 may be too
strenuous for individuals with FM. Meng-
shoel et al22 also reported higher RPEs
(16-18) in individuals with FM who exer-
cised. However, our results contradicted
Downloaded from www.jospt.org at on November 15, 2022. For personal use only. No other uses without permission.
these findings. Each of our subjects was
able to attain ACSM guidelines1 for sub-
maximal exercise, as evidenced by RPE
(range, 7-17) and heart rate data (range,
88-164 beats per minute). A possible rea-
son for this discrepancy was that in our
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
study each subject was allowed to deter-
mine her walking distance and method of
progression within her walking program
and walked at a self-selected pace.
The relationship between self-efficacy
and participation in exercise has also been
studied in individuals with FM. Gowans
et al14 investigated the effect of exercise on
mood and physical function. The subjects
Journal of Orthopaedic & Sports Physical Therapy®
who exercised experienced a significant
increase in their scores on the ASES scale
as compared to the control group, indi-
cating that the exercisers reported greater
feelings of control over their FM symp-
toms. In addition, Oliver and Cronan26
investigated predictors of exercise success
in 444 patients with FM and found that
high exercise self-efficacy was a strong
predictor for success in exercising.
In addition, Dolce et al8 prescribed
exercises following the quota system and
investigated the effect of this approach
on self-efficacy expectancies related to
exercise and worry/concern regarding ex-
ercise. Results indicated that all subjects
increased their exercise intensity by an
average of 42% (range, 20%-90%), and
that exercisers using the quota system
had a significant increase in self-efficacy
expectancies and a significant decrease in
worry/concern about exercise.
Our findings did not agree with these
journal of orthopaedic & sports physical therapy | volume 37 | number 12 | december 2007 |
results. Despite the significant improve-
ment in FIQ in subjects 1 and 3, and the
success that all experienced in the walking
program, none of our subjects demonstrat-
ed an improvement in self-efficacy as mea-
sured by the ASES. While our results did
not support previous findings, there might
be several possible explanations. First, sub-
ject 1 did have 3 data points outside the 2
SD band for ASES, but they were not suc-
cessive. While this was not a statistically
significant finding, it did suggest that there
was a trend toward increased self-efficacy
over the course of the study. Plus she re-
ported improvements in her daily activi-
ties, such as climbing stairs without the use
of handrails, and planned on walking after
the study was completed.
Subject 2 experienced a significant
decrease in ASES, indicating that her be-
lief that she could control her symptoms
had worsened by the end of the study.
While subject 2 was the most successful
with her walking program, she did not
experience a significant decrease in her
FIQ scores. Thus it is possible that lack
of improvement in her FM symptoms
may have contributed to her decreased
feelings of self-efficacy. In addition, she
did not think she would continue walking
because no one would be monitoring her
and counting the laps.
Subject 3 also did not experience im-
provement in self-efficacy. However, her
score on the mental health subscale of
the SF-36 was the lowest score of all the
subjects and the lowest for her age group
comparison. These low scores might have
indicated more serious mental health
concerns, such as depression or anxiety,
which may have affected her beliefs re-
lated to self-efficacy, as well as her tem-
porary increase in FM symptoms. She
was hoping to continue exercising but
did not know if she would be able to once
she started graduate school.
Kosinski et al18 compared the SF-36
scores of individuals who had osteoar-
thritis and rheumatoid arthritis to those
of a normative population, and reported
that individuals with arthritis for physical
functioning, role physical, and bodily pain
scored significantly lower, but not signifi-
cantly lower on mental health. Subjects in
the current study had similar results when
compared to the normative population
(lower overall scores for physical function-
ing, role physical, and bodily pain). The
results of the SF-36 gave us an indication
of how the symptoms of FM affected each
subject’s functional health and well-being.
In addition, the change in scores follow-
ing the intervention allowed us to assess
the impact of the intervention on overall
health.33 The results in TABLE 2 showed that
all 3 subjects had increased SF-36 scores
after the intervention, with subject 2 hav-
ing the largest improvement.
Contrary to several studies of exercise
and individuals with FM,13,15,20,21,23,24,31 no
subjects dropped out of the current study.
Subjects 1 and 2 did not experience in-
creased FM symptoms. While subject 3
reported an increase in FM symptoms,
her FIQ scores did not increase during
this time (FIGURE 1). She stated that she
would normally discontinue exercising;
however, the principal investigator was
able to show her that by making adjust-
ments to her exercise quota, she could
reduce her symptoms and continue to ex-
ercise. In fact, during the final 3 weeks of
the intervention phase, she had a signifi-
cant decrease in FIQ scores, indicating
a decrease in symptoms. This suggested
that the use of established exercise quotas
and self-selected walking pace might have
improved compliance in this individual.
The current investigation had several
limitations. First, it was a small study
with only 3 subjects. Although this would
appear to limit the ability of establishing
causality from the intervention, this prob-
lem was reduced by the study design. The
use of 3 subjects with 3 different baseline
time frames increased our ability to dis-
tinguish observed effects of the treatment
from the effects due to chance. In addi-
tion, the baseline period served as a con-
trol phase, and the different baseline time
frames increased the internal validity of
the study by controlling the effect of his-
tory and maturation.4,29
The second limitation was that the
723
 [ RESEARCH REPORT
baseline phase had a small number of
data points. However, the baseline phase
was designed to be limited in this way to
decrease the amount of time subjects had
to wait to begin the intervention phase,
and to decrease the possibility of sub-
ject dropout. While a detailed analysis
of baseline variability and trend could
not be performed with less than 8 data
points, this was not a limitation for the
2-SD band method and ES analysis.6,27
A final limitation was that the sub-
jects might have become overly familiar
with the process of completing the out-
Downloaded from www.jospt.org at on November 15, 2022. For personal use only. No other uses without permission.
come tools after 13 to 15 weeks. While
the instruments chosen were designed
to detect weekly changes, subjects may
have recalled their previous ratings. It is
possible that the subjects either did not
want to make changes in their outcome
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
scores or they wanted to alter the results
to please the principal investigator. Even
though the principal investigator was
blinded to the outcomes, she was present
for each walking session. Subsequently,
the scores might not have accurately
reflected the actual state of the subjects
during the previous week.
Journal of Orthopaedic & Sports Physical Therapy®
CONCLUSION
T
he results of this study dem-
onstrated that the use of a quota-
based exercise program for prescrib-
ing and progressing walking exercise for
individuals with FM may be beneficial.
More stringent research studies with
larger number of participants need to be
conducted to further assess this method
of exercise prescription.T
REFERENCES
1. American College of Rheumatology. Fibromyal-
gia fact sheet. Atlanta, GA: American College of
Rheumatology; 2003.
2. American College of Sports Medicine. American
College of Sports Medicine’s Guidelines for Exer-
cise Testing and Prescription. Philadelphia, PA:
Lippincott Williams & Wilkins; 2000.
3. Backman CL, Harris SR, Chisholm JA, Monette
AD. Single-subject research in rehabilitation: a
review of studies using AB, withdrawal, multiple
724 | december 2007 | volume 37 | number 12 | journal of orthopaedic & sports physical therapy
]
baseline, and alternating treatments designs.
Arch Phys Med Rehabil. 1997;78:1145-1153.
4. Bloom M, Fischer J, Orme J. Evaluating Practice:
Guidelines for the Accountable Professional. 4th
ed. Boston, MA: Allyn & Bacon; 2003.
5. Borg G, Hassmen P, Lagerstrom M. Perceived
exertion related to heart rate and blood lactate
during arm and leg exercise. Eur J Appl Physiol
Occup Physiol. 1987;56:679-685.
6. Burckhardt CS, Clark SR, Bennett RM. The fibro-
myalgia impact questionnaire: development and
validation. J Rheumatol. 1991;18:728-733.
7. Busch A, Schachter CL, Peloso PM, Bombardier
C. Exercise for treating fibromyalgia syndrome.
Cochrane Database Syst Rev. 2002:CD003786.
8. Dolce JJ, Crocker MF, Moletteire C, Doleys DM.
Exercise quotas, anticipatory concern and self-
efficacy expectancies in chronic pain: a prelimi-
nary report. Pain. 1986;24:365-372.
9. Doleys DM, Crocker M, Patton D. Response of
patients with chronic pain to exercise quotas.
Phys Ther. 1982;62:1111-1114.
10. Dunkl PR, Taylor AG, McConnell GG, Alfano AP,
Conaway MR. Responsiveness of fibromyalgia
clinical trial outcome measures. J Rheumatol.
2000;27:2683-2691.
11. Enright PL, Sherrill DL. Reference equations
for the six-minute walk in healthy adults. Am J
Respir Crit Care Med. 1998;158:1384-1387.
12. Fordyce WE, Fowler RS, Jr., Lehmann JF, De-
lateur BJ, Sand PL, Trieschmann RB. Operant
conditioning in the treatment of chronic pain.
Arch Phys Med Rehabil. 1973;54:399-408.
13. Gowans SE, deHueck A, Voss S, Richardson M. A
randomized, controlled trial of exercise and edu-
cation for individuals with fibromyalgia. Arthritis
Care Res. 1999;12:120-128.
14. Gowans SE, deHueck A, Voss S, Silaj A, Abbey
SE, Reynolds WJ. Effect of a randomized, con-
trolled trial of exercise on mood and physical
function in individuals with fibromyalgia. Arthri-
tis Rheum. 2001;45:519-529.
15. Hammond A, Freeman K. Community patient
education and exercise for people with fibromy-
algia: a parallel group randomized controlled
trial. Clin Rehabil. 2006;20:835-846.
16. Karper WB, Jannes CR, Hampton JL. Fibromyal-
gia syndrome: the beneficial effects of exercise.
Rehabil Nurs. 2006;31:193-198.
17. King S, Wessel J, Bhambhani Y, Maikala R, Sholt-
er D, Maksymowych W. Validity and reliability of
the 6 minute walk in persons with fibromyalgia.
J Rheumatol. 1999;26:2233-2237.
18. Kosinski M, Keller SD, Hatoum HT, Kong SX,
Ware JE, Jr. The SF-36 Health Survey as a gener-
ic outcome measure in clinical trials of patients
with osteoarthritis and rheumatoid arthritis:
tests of data quality, scaling assumptions and
score reliability. Med Care. 1999;37:MS10-22.
19. Lorig K, Chastain RL, Ung E, Shoor S, Holman
HR. Development and evaluation of a scale to
measure perceived self-efficacy in people with
arthritis. Arthritis Rheum. 1989;32:37-44.
20. Mannerkorpi K, Iversen MD. Physical exercise in
fibromyalgia and related syndromes. Best Pract
Res Clin Rheumatol. 2003;17:629-647.
21. Martin L, Nutting A, MacIntosh B, Edworthy S,
Butterwick D, Cook J. An exercise program in
the treatment of fibromyalgia. J Rheumatology.
1996;23(6):1050-1053.
22. Mengshoel AM, Vollestad NK, Forre O. Pain and
fatigue induced by exercise in fibromyalgia pa-
tients and sedentary healthy subjects. Clin Exp
Rheumatol. 1995;13:477-482.
23. Meyer BB, Lemley KJ. Utilizing exercise to affect
the symptomology of fibromyalgia: a pilot study.
Med Sci Sports Exerc. 2000;32:1691-1697.
24. Nichols DS, Glenn TM. Effects of aerobic ex-
ercise on pain perception, affect, and level of
disability in individuals with fibromyalgia. Phys
Ther. 1994;74:327-332.
25. Nourbakhsh MR, Ottenbacher KJ. The statistical
analysis of single-subject data: a comparative
examination. Phys Ther. 1994;74:768-776.
26. Oliver K, Cronan T. Predictors of exercise be-
haviors among fibromyalgia patients. Prev Med.
2002;35:383-389.
27. Ottenbacher K. Evaluating Clinical Change:
Strategies for Occupational and Physical Thera-
pists. Baltimore, MD: Williams & Wilkins; 1986.
28. Pankoff B, Overend T, Lucy D, White K. Validity
and responsiveness of the 6 minute walk test
for people with fibromyalgia. J Rheumatol.
2000;27:2666-2670.
29. Portney L, Watkins M. Foundations of Clinical
Research: Applications for Practice. Upper
Saddle River, NJ: Prentice Hall Health; 2000.
30. QualityMetric, Inc. Online Scoring. Available at:
http://www.qualitymetric.com. Accessed Janu-
ary 1, 2006.
31. Redondo JR, Justo CM, Moraleda FV, et al.
Long-term efficacy of therapy in patients with
fibromyalgia: a physical exercise-based program
and a cognitive-behavioral approach. Arthritis
Rheum. 2004;51:184-192.
32. Rooks DS, Silverman CB, Kantrowitz FG. The
effects of progressive strength training and
aerobic exercise on muscle strength and cardio-
vascular fitness in women with fibromyalgia: a
pilot study. Arthritis Rheum. 2002;47:22-28.
33. Ware JE, Jr., Kosinski M, Dewey J. How to Score
Version 2 of the SF-36 Health Survey. Lincoln, RI:
QualityMetric, Inc; 2000.
34. Wolfe F, Smythe HA, Yunus MB, et al. The Ameri-
can College of Rheumatology 1990 Criteria for
the Classification of Fibromyalgia. Report of
the Multicenter Criteria Committee. Arthritis
Rheum. 1990;33:160-172.
@
MORE INFORMATION
WWW.JOSPT.ORG