Patient’s Perception and Real Execution of Walking as Physical Exercise: Looking at Self-Efficacy as a Key Variable in Adherence in Patients with Fibromyalgia

Round 1

Reviewer 1 Report

Reviewer comments:

Line 24-25-Please clarify what is considered as vigorous (is there a certain threshold that could be put in (  )

Line 36-37 Are you trying to say that 80% of the 3% of the Spanish population suffering from chronic pain deal with fibromyalgia or are women? It is unclear, as it can’t be 80% suffer from fibromyalgia while only 3% of the population has chronic pain. Please clarify this opening sentence.

One glaring omission in this manuscript is the recognition that women without fibromyalgia (no fear of movement) don’t walk or exercise sufficiently. So this lack of physical activity can’t be attributed to  a fear of experiencing pain upon activity. We live in a sedentary society and this needs to be acknowledged in the introduction or discussion.

A major weakness of this study is the lack of a control group (subjects without fibromyalgia) as this allows assumptions to be made that may not be correct. For example, if healthy women had a significant tendency to overestimate the amount and intensity of their activity, how would that impact the interpretation of the data in the current study with only fibromyalgia?

Line 88 Please define moderate and intense activity, what are you considering as intense? This should appear early in the manuscript.

Line 177-178 It would be beneficial and interesting to include the amount of time (or episodes) with intensity below 20 continuous minutes. I suspect since a large percentage of subjects were taking sleep aids, pain medication, antidepressants, muscle relaxers (all of which will increase sleep time and sedentary time throughout one’s day.

Figure 1 move up 222 to avoid arrow cutting through text. Figure 2 the “boxes” are blocking some of the text.

The author’s need to acknowledge in the Discussion the role or potential role sleep aids, pain medication, antidepressants, muscle relaxers play in their study and the likelihood that these medications will enhance sedentary activity thus it might not be fear of movement, responsible for less vigorous activity or decrease in activity levels. This should be investigated in future studies.

It would be beneficial to include the actual questions on the various instruments as supplemental material to provide better context to self-report of moderate or vigorous activity or walking behavior.

Line336  define 2 types of intensities

Line 361 Catastrophic beliefs about pain are not solely responsible, as mentioned above sleep aids, pain meds, antidepressants, muscle relaxers all are playing a role in lower physical activity in fibromyalgia patients. Also as mentioned, women (and men) without fibromyalgia have very low physical activity levels (easily supported in the literature). Many people just don’t like to exercise, plain and simple, they have an aversion to intense or even moderate physical activity. This needs to be acknowledged in some fashion in this manuscript.

Acknowledge lack of a control group as a study limitation

Author Response

We would like to thank you for your interest in our manuscript entitled “Patient’s perception and real execution of walking as physical exercise. Looking at self-efficacy as a key variable in adherence in patients with fibromyalgia” (applsci-2138459). We appreciate the time that you and the other reviewers have dedicated to reading the manuscript and providing suggestions. Your suggestions have enriched the manuscript considerably. Likewise, we have incorporated all the comments suggested. Following your directions, we have proceeded to revise our manuscript, highlighting the changes by using the track changes mode in MS Word.

At the end of this letter, you will find an explanation of the changes made to the manuscript in accordance with your comments.

Once again, we wish to express our appreciation for the clear improvement of the article made possible by the reviewer and editor’s contributions. We hope the new changes meet their expectations, and we hope that they consider the work apt for publication in Applied Sciences.

Please do not hesitate to suggest any further changes. We are at your disposal for anything else you may require.

Best regards,

 

Reviewer 1

Line 24-25-Please clarify what is considered as vigorous (is there a certain threshold that could be put in (  ).

Response: We appreciate your comment regarding the clarification of the perception of vigorous activity and its association to the objective activity recorded by the accelerometer. In objective terms, any physical activity is measured in metabolic equivalents (METs) which consist of physiological units representing the metabolic cost of a daily activity. Specifically, vigorous activity is considered to exceed 6 METs. We have included this data in parentheses to objectively define vigorous physical activity.

Line 36-37 Are you trying to say that 80% of the 3% of the Spanish population suffering from chronic pain deal with fibromyalgia or are women? It is unclear, as it can’t be 80% suffer from fibromyalgia while only 3% of the population has chronic pain. Please clarify this opening sentence.

Response: Thank you for your suggestion. We have modified the wording of this sentence.

One glaring omission in this manuscript is the recognition that women without fibromyalgia (no fear of movement) don’t walk or exercise sufficiently. So this lack of physical activity can’t be attributed to a fear of experiencing pain upon activity. We live in a sedentary society and this needs to be acknowledged in the introduction or discussion.

 

Response: We agree with the view offered by the reviewer regarding the effect of a sedentary lifestyle. We have included an introductory sentence, based on a previous study, which indicates a sedentary lifestyle as a risk factor for the development of chronic diseases. Following this suggestion, we have discussed our results based on the existing literature on the severity of sedentary behavior.

A major weakness of this study is the lack of a control group (subjects without fibromyalgia) as this allows assumptions to be made that may not be correct. For example, if healthy women had a significant tendency to overestimate the amount and intensity of their activity, how would that impact the interpretation of the data in the current study with only fibromyalgia?

Response: We appreciate the reviewer's reflection. Since this study does not include a control group, we have proceeded to incorporate this limitation in the corresponding section.

Line 88 Please define moderate and intense activity, what are you considering as intense? This should appear early in the manuscript.

Response: We have proceeded to introduce a definition of light, moderate and intense activity based on the objective units of measurement of physical exercise.

Line 177-178. It would be beneficial and interesting to include the amount of time (or episodes) with intensity below 20 continuous minutes. I suspect since a large percentage of subjects were taking sleep aids, pain medication, antidepressants, muscle relaxers (all of which will increase sleep time and sedentary time throughout one’s day.

Response: We appreciate your comment. Indeed, given the consumption of drugs in this population, the statistical analyses have been repeated once more, incorporating as covariates the consumption of analgesics, sleeping pills, and antidepressants (pills per day) as they are the most frequent drugs in this population. Of these, only the role of analgesics is statistically significant. The results show that, controlling for these variables, the established model continues to be significant, drawing the same conclusions as those established in the previous version of the manuscript. However, as numerical data change, the new results have been incorporated into this revised version of the manuscript.

Figure 1 move up 222 to avoid arrow cutting through text. Figure 2 the “boxes” are blocking some of the text.

Response: Thank you for your comment. We have modified the appearance of the figures mentioned above.

The author’s need to acknowledge in the Discussion the role or potential role sleep aids, pain medication, antidepressants, muscle relaxers play in their study and the likelihood that these medications will enhance sedentary activity thus it might not be fear of movement, responsible for less vigorous activity or decrease in activity levels. This should be investigated in future studies.

 

Response: Thanks to the comment that the reviewer has previously made to us on issues related to the one mentioned here, we have proceeded to incorporate the most frequent medication in this population and in particular in our sample (analgesics, sleeping pills, and antidepressants) as covariates in the new analyses carried out. However, we agree with the reviewer on the need to study the effect of these drugs in greater depth and to dedicate more space to reflect on their effects on the variables studied in this manuscript. It is because of that, we have reviewed previous literature on the relationship between psychotropic drugs and sedentary behavior in the discussion section. 

It would be beneficial to include the actual questions on the various instruments as supplemental material to provide better context to self-report of moderate or vigorous activity or walking behavior.

 

Response: Thank you for your comment. Indeed, indicating some items of the self-report instruments used helps the reader to contextualize the results of our research. Following your suggestion, some items of each of the instruments have been incorporated into the corresponding section. If the reader is interested in obtaining more information about the instrument in question, the bibliographical reference is included to access it. However, if the reviewer considers that it would be additionally interesting to incorporate the complete instruments as supplementary material, this could be done.

Line336  define 2 types of intensities

Response: The subjective and objective measurement of walking behavior does not refer to 2 types of intensities, but to 2 different types of measures of walking behavior. We have specified this issue in parentheses.

Line 361 Catastrophic beliefs about pain are not solely responsible, as mentioned above sleep aids, pain meds, antidepressants, muscle relaxers all are playing a role in lower physical activity in fibromyalgia patients. Also as mentioned, women (and men) without fibromyalgia have very low physical activity levels (easily supported in the literature). Many people just don’t like to exercise, plain and simple, they have an aversion to intense or even moderate physical activity. This needs to be acknowledged in some fashion in this manuscript.

Response: We agree with your suggestion and, therefore, we have searched for previous literature that emphasizes the predictive role of environmental factors in the practice of exercise in healthy individuals. We consider it appropriate that this factor could be studied in future studies focused on patients with chronic pain.

Acknowledge lack of a control group as a study limitation

Response: We have included this limitation. Thanks.

 

 

Author Response File: Author Response.doc

Reviewer 2 Report

The study focuses on an interesting and clinical relevant topic, since exercise in patients with fibromyalgia has a low adherence, due to multiple disturbing symptoms and an overestimation of perceived fatigue.

Only minor revisions are required:

- Abstract: Please, use the bold for the titles of the paragraphs.

 

 - Methods:

Please, describe the setting where the recruitment and the assessment had been placed.

Exclusion criteria are not specified. Were all the adult women diagnosed with fibromyalgia without impediments to any activity included? Were comorbidities or other criteria not considered?

- Results:

 

Please, specify the total number of participants at the beginning of the paragraph, together with the number women of completing the study.

 

Table 2: Please, add the unit of measure for the means of each parameter, when applicable.

 

 

Author Response

We would like to thank you for your interest in our manuscript entitled “Patient’s perception and real execution of walking as physical exercise. Looking at self-efficacy as a key variable in adherence in patients with fibromyalgia” (applsci-2138459). We appreciate the time that you and the other reviewers have dedicated to reading the manuscript and providing suggestions. Your suggestions have enriched the manuscript considerably. Likewise, we have incorporated all the comments suggested. Following your directions, we have proceeded to revise our manuscript, highlighting the changes by using the track changes mode in MS Word.

At the end of this letter, you will find an explanation of the changes made to the manuscript in accordance with your comments.

Once again, we wish to express our appreciation for the clear improvement of the article made possible by the reviewer and editor’s contributions. We hope the new changes meet their expectations, and we hope that they consider the work apt for publication in Applied Sciences.

Please do not hesitate to suggest any further changes. We are at your disposal for anything else you may require.

Best regards,

 

Reviewer 2:

The study focuses on an interesting and clinical relevant topic, since exercise in patients with fibromyalgia has a low adherence, due to multiple disturbing symptoms and an overestimation of perceived fatigue.

Response: Thank you for the positive assessment of our manuscript.

Only minor revisions are required:

- Abstract: Please, use the bold for the titles of the paragraphs.

Response: Thank you for your comment. Indeed, the titles of the paragraphs in the abstract will necessarily be in bold. However, thanks to another reviewer's comment, reviewing the journal's rules, the abstract must go without headings (“The abstract should be a single paragraph and should follow the style of structured abstracts, but without headings”), so we have proceeded to modify it in accordance with these rules.

- Methods:

Please, describe the setting where the recruitment and the assessment had been placed.
Response: Thank you for your comment. We have described the physical location where the participants' data were collected.

Exclusion criteria are not specified. Were all the adult women diagnosed with fibromyalgia without impediments to any activity included? Were comorbidities or other criteria not considered?

Response: Thank you for your suggestion to improve the quality of the manuscript. We have drafted the exclusion criteria proposed for the study.

- Results:

 Please, specify the total number of participants at the beginning of the paragraph, together with the number women of completing the study.

 Response: We thank you for your comments as we consider them to be important. We have included the initial number of participants who started the evaluations and the final number of participants who completed the two phases of the study.

Table 2: Please, add the unit of measure for the means of each parameter, when applicable.

Response: we have included the specific objective unit in the corresponding measures. In the measures provided by the self-report, we have specified that these are arbitrary units.

 

Author Response File: Author Response.doc

Reviewer 3 Report

Dear Authors,

 

The aims of this systematic review were to identify non-invasive objective markers of Human Assumed Central Sensitization and the instruments to assess these markers in patients with fibromyalgia.

 

The study was in line with the aims of the journal. 

However, there are some issues that should be addressed.

Firstly, I suggest introducing the term “rehabilitation” in the title and implementing the rehabilitative part both in Introduction and Discussion Sections.

Moreover, please modify the paper according to the following minor revisions:

 

Abstract

·      Please follow the journal guideline (https://www.mdpi.com/journal/applsci/instructions).The abstract should be a total of about 200 words maximum. The abstract should be a single paragraph and should follow the style of structured abstracts, but without headings: 1) Background: Place the question addressed in a broad context and highlight the purpose of the study; 2) Methods: Describe briefly the main methods or treatments applied. Include any relevant preregistration numbers, and species and strains of any animals used. 3) Results: Summarize the article's main findings; and 4) Conclusion: Indicate the main conclusions or interpretations. The abstract should be an objective representation of the article: it must not contain results, which are not presented and substantiated in the main text and should not exaggerate the main conclusions.

·      Line 18. Please, do not start the sentence with a number.

·      “Approximately 3% of the Spanish population suffer from chronic pain problems, with fibromyalgia (FM) being particularly relevant in 80% of women.” Please, better clarify this sentence.

·      An English native should revise the paper.

·      The Introduction section was well written.

·      I suggest improving the Introduction section reporting also the telerehabilitative approaches for FM (you could cite and discuss “Telerehabilitation proposal of mind-body technique for physical and psychological outcomes in patients with fibromyalgia. Front Physiol. 2022 Aug 26;13:917956. doi: 10.3389/fphys.2022.917956.” and “. Mental health and well-being during the COVID-19 pandemic: stress vulnerability, resilience and mood disturbances in fibromyalgia and rheumatoid arthritis. Clin Exp Rheumatol. 2021 May-Jun;39 Suppl 130(3):153-160. doi: 10.55563/clinexprheumatol/4nb0ku.).

·      Discussion section was well reported.

Author Response

We would like to thank you for your interest in our manuscript entitled “Patient’s perception and real execution of walking as physical exercise. Looking at self-efficacy as a key variable in adherence in patients with fibromyalgia” (applsci-2138459). We appreciate the time that you and the other reviewers have dedicated to reading the manuscript and providing suggestions. Your suggestions have enriched the manuscript considerably. Likewise, we have incorporated all the comments suggested. Following your directions, we have proceeded to revise our manuscript, highlighting the changes by using the track changes mode in MS Word.

At the end of this letter, you will find an explanation of the changes made to the manuscript in accordance with your comments.

Once again, we wish to express our appreciation for the clear improvement of the article made possible by the reviewer and editor’s contributions. We hope the new changes meet their expectations, and we hope that they consider the work apt for publication in Applied Sciences.

Please do not hesitate to suggest any further changes. We are at your disposal for anything else you may require.

Best regards,

 

Reviewer 3:

Abstract

• Please follow the journal guideline (https://www.mdpi.com/journal/applsci/instructions).The abstract should be a total of about 200 words maximum. The abstract should be a single paragraph and should follow the style of structured abstracts, but without headings: 1) Background: Place the question addressed in a broad context and highlight the purpose of the study; 2) Methods: Describe briefly the main methods or treatments applied. Include any relevant preregistration numbers, and species and strains of any animals used. 3) Results: Summarize the article's main findings; and 4) Conclusion: Indicate the main conclusions or interpretations. The abstract should be an objective representation of the article: it must not contain results, which are not presented and substantiated in the main text and should not exaggerate the main conclusions.

Response: Thank you for your comment. Following your comment and the rules of the journal, we have adjusted the abstract and reduced the number of words.

• Line 18. Please, do not start the sentence with a number.

Response: We have modified the expression in line 18.

• “Approximately 3% of the Spanish population suffer from chronic pain problems, with fibromyalgia (FM) being particularly relevant in 80% of women.” Please, better clarify this sentence.

Response: Thank you for your suggestion. We have modified the wording of this sentence.

• An English native should revise the paper.

Response: Thank you for your suggestion. We have assessed the suitability of the language review with an expert native speaker.

• The Introduction section was well written.

Response: Thank you for your comment.

• I suggest improving the Introduction section reporting also the telerehabilitative approaches for FM (you could cite and discuss “Telerehabilitation proposal of mind-body technique for physical and psychological outcomes in patients with fibromyalgia. Front Physiol. 2022 Aug 26;13:917956. doi: 10.3389/fphys.2022.917956.” and “. Mental health and well-being during the COVID-19 pandemic: stress vulnerability, resilience and mood disturbances in fibromyalgia and rheumatoid arthritis. Clin Exp Rheumatol. 2021 May-Jun;39 Suppl 130(3):153-160. doi: 10.55563/clinexprheumatol/4nb0ku.).

Response: Thank you for your contribution. We find it interesting to include information on telerehabilitation programs as one of the fundamental pillars in the multidisciplinary approach to patients with chronic pain and which have reported their benefits since the pandemic period. We have provided this information on the Introduction section.

• Discussion section was well reported.

Response: Thank you for your comment.

 

Author Response File: Author Response.doc

Reviewer 4 Report

In the manuscript, the authors reported on the relationship between the perception of walking intensity and the actual behavioral indicator among patients with fibromyalgia and found a mediating role of self-efficacy in the relationship. The study was carefully designed, and the results were well presented. The findings in the manuscript have implications in psychosomatic medicine. While it reaches the threshold for publication, there are some minor issues that can be solved in order to improve the manuscript.

1. A few more sentences may be added in the first paragraph to mention the importance of studying fibromyalgia as a public health issue around the world, which would attract attention from a broad range of readers.

2. Self-efficacy should be explained a bit more in the introduction. As the main psychological construct examined in the study, it needs to be explicitly defined and its measurements should be discussed.

3. Given the considerable portion of older individuals in the sample, cognitive decline may be a confounding factor. A self-report measure of cognitive problem may not be sufficient to assess age-related cognitive decline.

4. In Figure 2, the p value of Depression is missing, and it looks like there are some numbers in the same figure were masked.

Author Response

We would like to thank you for your interest in our manuscript entitled “Patient’s perception and real execution of walking as physical exercise. Looking at self-efficacy as a key variable in adherence in patients with fibromyalgia” (applsci-2138459). We appreciate the time that you and the other reviewers have dedicated to reading the manuscript and providing suggestions. Your suggestions have enriched the manuscript considerably. Likewise, we have incorporated all the comments suggested. Following your directions, we have proceeded to revise our manuscript, highlighting the changes by using the track changes mode in MS Word.

At the end of this letter, you will find an explanation of the changes made to the manuscript in accordance with your comments.

Once again, we wish to express our appreciation for the clear improvement of the article made possible by the reviewer and editor’s contributions. We hope the new changes meet their expectations, and we hope that they consider the work apt for publication in Applied Sciences.

Please do not hesitate to suggest any further changes. We are at your disposal for anything else you may require.

Best regards,

 

Reviewer 4:

In the manuscript, the authors reported on the relationship between the perception of walking intensity and the actual behavioral indicator among patients with fibromyalgia and found a mediating role of self-efficacy in the relationship. The study was carefully designed, and the results were well presented. The findings in the manuscript have implications in psychosomatic medicine. While it reaches the threshold for publication, there are some minor issues that can be solved in order to improve the manuscript.

Response: Thank you for the positive assessment of our manuscript.

1. A few more sentences may be added in the first paragraph to mention the importance of studying fibromyalgia as a public health issue around the world, which would attract attention from a broad range of readers.

Response: Thank you for your suggestion. We have provided national and international data on the prevalence of fibromyalgia to emphasize the importance of this public health problem.

2. Self-efficacy should be explained a bit more in the introduction. As the main psychological construct examined in the study, it needs to be explicitly defined and its measurements should be discussed.

Response: Following the reviewer's recommendation, we have defined the construct of self-efficacy (Introduction section). Additionally, we have discussed its measurement together with catastrophizing beliefs and their influence on physical activity in the Discussion section.

3. Given the considerable portion of older individuals in the sample, cognitive decline may be a confounding factor. A self-report measure of cognitive problem may not be sufficient to assess age-related cognitive decline.

Response: Thanks for your suggestion. We have provided this indication as a limitation of the present study.

4. In Figure 2, the p value of Depression is missing, and it looks like there are some numbers in the same figure were masked.

Response: We are sorry for the error in the illustration. We have modified the image so that the significant data of our proposed model can be visualized.

 

Author Response File: Author Response.doc

Round 2

Reviewer 1 Report

Authors have responded appropriately to reviewer comments and the manuscript has been improved.