AbstractBackground

Exercise and physical activity are an evidence-based practice for chronic pain. Health professionals need instruments to assess self-efficacy for this practice taking into account the specific barriers of patients with these health problems.

Purpose

To develop and test the psychometric properties of a new self-efficacy scale for physical activity and walking exercise in patients with fibromyalgia.

Design

A cross-sectional and prospective study was conducted in a Spanish Fibromyalgia Unit. Two hundred and eleven new patients signed the informed consent and participated in the study. All of them were women, referred to by either Primary or Specialized Health Care. In addition to the new scale, they filled out several self-reported and validated instruments to collect the data present in this study.

Results

Exploratory factor analysis showed a three-factor model (GFI = .99; RMSR = .06) that explained 74.2% of the total variance. They assessed how confident patients felt about walking quickly in both 30- and 60-minute sessions, (Factor I: 10 items; α = .97), to perform daily physical activities (Factor II: 10 items; α = .93) and to undertake moderate physical activity (Factor III: 5 items; α = .95). The total score of the scale and the three-factor scores showed good criterion validity and adequate validity based on the relationships with other constructs.

Conclusions

The scale showed adequate psychometric properties and can be a useful tool to help health professionals monitor patients’ self-efficacy perception and customize both physical activity and walking exercise intervention goals and their implementation.

Fibromyalgia is a chronic widespread musculoskeletal pain condition that is often presented with other symptoms such as fatigue, sleep disturbance, emotional problems, cognitive, and somatic complaints (; Wolfe et al., 2016Wolfe F. Clauw D.J. Fitzcharles M.A. Goldenberg D.L. Häuser W. Katz R.L. Mease Ph.L. Russell A.S. Russell I.J. Walitt B. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria.). Fibromyalgia is a complex health condition associated with high perceived health impact and socio-economic burden (Knight et al., 2013Knight T. Schaefer C. Chandran A. Zlateva G. Winkelmann A. Perrot S. Health-resource use and costs associated with fibromyalgia in France, Germany, and the United States.) and is more prevalent in women. From a biopsychosocial point of view, the most effective intervention for fibromyalgia combines pharmacologic strategies, physical exercise, and cognitive-behavioral therapy (). In particular, a lifestyle with physical activity and regular exercise have shown benefits in fibromyalgia health outcomes (Andrade et al., 2020Andrade A. Dominski F.H. Sieczkowska S.M. What we already know about the effects of exercise in patients with fibromyalgia: An umbrella review.; Bidonde et al., 2017Bidonde J. Busch A.J. Schachter C.L. Overend T.J. Kim S.Y. Góes S.M. Foulds H.J.A. Aerobic exercise training for adults with fibromyalgia.). Walking is an easy and accessible form of exercise with low musculoskeletal impact which is suggested due to its positive effects in chronic pain and fibromyalgia health conditions (Gusi et al., 2009Gusi N. Parraca J. Adsuar J Ejercicio físico y Fibromialgia [Physical Exercise and Fibromyalgia].; O'Connor et al., 2015O'Connor S.R. Tully M.A. Ryan B. Bleakley C.M. Baxter G.D. Bradley J.M. McDonough S.M. Walking exercise for chronic musculoskeletal pain: Systematic review and meta-analysis.). Despite the benefits associated with health, women with fibromyalgia have reported low physical activity and low frequency of walking exercise (López-Roig et al., 2016López-Roig S. Pastor-Mira M.A. Peñacoba C. Lledó A. Sanz Y. Velasco L. Prevalence and predictors of unsupervised walking and physical activity in a community population of women with fibromyalgia.; McLoughlin et al., 2011McLoughlin M.J. Colbert L.H. Stegner A.J. Cook D.B. Are women with fibromyalgia less physically active than healthy women?.). In previous studies, women with fibromyalgia who reported high control perception increased their likelihood of adhering to a walking program around threefold, in comparison with women with low control perception (Pastor-Mira et al., 2020Pastor-Mira M.A. López-Roig S. Peñacoba C. Sanz-Baños Y. Lledó A. Velasco L. Predicting walking as exercise in women with fibromyalgia from the perspective of the theory of planned behavior.). These findings support the evidence in other populations in regard to the role of control perception in physical activity (McEachan et al., 2011McEachan R.R.C. Conner M. Taylor N.J. Lawton R.J. Prospective prediction of health-related behaviours with the theory of planned behaviour: A meta-analysis.).Self-efficacy is conceptualized as a control belief referring to the confidence in one's abilities to carry out the behaviors needed to reach a desired outcome (). Self-efficacy, a powerful driving force and a causal agent of human behavior, it determines the personal effort and persistence facing the obstacles that may arise while progressing towards one's own goals. Bandura´s formulation of self-efficacy underlined its behavioral specificity and the need to take into account the different difficulties that people can find. In general, undertaking and maintaining regular exercise is a difficult task, mainly in chronic pain disorders such as fibromyalgia, where patients report many difficulties due to their own illness (Pastor-Mira et al., 2015Pastor-Mira M.A. López-Roig S. Sanz Y. Peñacoba C. Cigarán M. Lledó A. Écija C. Andar como forma de ejercicio físico en la Fibromialgia: un estudio de identificación de creencias desde la teoría de la acción planeada.). Self-efficacy has demonstrated promoting proper lifestyle and exercise behaviors in healthy adults (Williams and French, 2011Williams S.L. French D.P. What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behaviour — and are they the same?.) and people with fibromyalgia ( Beal et al., 2009Beal C.C. Stuifbergen A.K. Brown A. Predictors of a health promoting lifestyle in women with fibromyalgia syndrome.; , ). It has also been the psychological process involved in increasing physical activity and exercise (Jones et al., 2004Jones Kim Dupree Burckhardt C.S. Bennett J.A Motivational interviewing may encourage exercise in persons with fibromyalgia by enhancing self-efficacy.). Moreover, in this context there is evidence regarding the positive effects of self-efficacy on health outcomes (Dobkin et al., 2010Dobkin P.L. Liu A. Abrahamowicz M. Ionescu-Ittu R. Bernatsky S. Goldberger A. Baron M. Predictors of disability and pain six months after the end of treatment for fibromyalgia.; Jackson et al., 2014Jackson T. Wang Y. Wang Y. Fan H. Self-efficacy and chronic pain outcomes: A Meta-analytic review.; Miles et al., 2011Miles C.L. Pincus T. Carnes D. Taylor S.J.C. Underwood M. Measuring pain self-efficacy.) and its role in the effectiveness of self-management interventions, which usually include physical training ().The self-efficacy theory has been proposed to develop nursing interventions to increase physical activity and exercise in special populations (Lee et al., 2008Lee L.L. Arthur A. Avis M. Using self-efficacy theory to develop interventions that help older people overcome psychological barriers to physical activity: A discussion paper.). In this regard, improving the sense of self-efficacy is one of the goals to create routine exercise in both fibromyalgia and chronic patients (; Lorig et al., 2001Lorig KR Sobel DS Ritter PL Laurent D Hobbs M. Effect of a self-management program on patients with chronic disease.). The effort of health professionals from this perspective is essential since adherence in walking programs has been higher when, mainly nurses, supervised the exercise process (Sanz-Baños et al., 2018Sanz-Baños Y. Pastor-Mira M.A. Lledó A. López-Roig S. Peñacoba C. Sánchez-Meca J. Do women with fibromyalgia adhere to walking for exercise programs to improve their health? Systematic review and meta-analysis.). It is commonly known that advice and information about activity and exercise are not enough to motivate the patient. They need to rely on their capabilities to carry out the required behavior (Jones et al., 2004Jones Kim Dupree Burckhardt C.S. Bennett J.A Motivational interviewing may encourage exercise in persons with fibromyalgia by enhancing self-efficacy.; Lee et al., 2008Lee L.L. Arthur A. Avis M. Using self-efficacy theory to develop interventions that help older people overcome psychological barriers to physical activity: A discussion paper.). Nurses are key professionals in helping patients with fibromyalgia. From a biopsychosocial point of view, nurses have applied different interventions to improve the patients’ health status, from those that are single-component, such as music therapy (Onieva-Zafra et al., 2013Onieva-Zafra M.D. Castro-Sánchez A.M. Matarán-Peñarrocha G.A. Moreno-Lorenzo C. Effect of music as nursing intervention for people diagnosed with fibromyalgia.) or guided imagery relaxation therapy (Onieva-Zafra et al., 2015Onieva-Zafra M.D. Hernandez García L. Gonzalez Del Valle M. Effectiveness of guided imagery relaxation on levels of pain and depression in patients diagnosed with fibromyalgia.) to those that are multi-component, from a multidisciplinary perspective, mainly focused on providing education and self-management strategies (Vincent et al., 2011Vincent A. Whipple M.O Oh T.H. Guderian J.A. Barton D.L. Luedtke C.A. Early experience with a brief, multimodal, multidisciplinary, treatment program for fibromyalgia.). They have also carried out evidence-based interventions built on information technology for fibromyalgia educative purposes, such as the FibroGuide specific tool (Sparks et al., 2016Sparks T. Kawi J. Menzel N.N. Hartell K. Implementation of health information technology in routine care for fibromyalgia: Pilot study.), which includes one module about being active. All of these interventions have shown positive effects in specific fibromyalgia health outcomes, showing the usefulness of self-management strategies for daily coping with this chronic pain problem. It is worth underlining the importance of improving self-efficacy to implement self-management of healthy habits in fibromyalgia ().Thus, there is evidence about the main role of self-efficacy beliefs to understand and promote health and exercise. However, most of the instruments available in the context of chronic pain do not specifically address exercise and physical activity or the usual obstacles that prevent people from undertaking these behaviors. They usually comprise several domains like self-efficacy for managing pain and other symptoms, for physical function (mainly related to daily activities) or for communication with health professionals (Miles et al., 2011Miles C.L. Pincus T. Carnes D. Taylor S.J.C. Underwood M. Measuring pain self-efficacy.). To the best of our knowledge, there is a need to develop self-efficacy instruments for physical activity and exercise that take into account the common barriers in the chronic pain and fibromyalgia population. Physical activity and exercise are evidence-based recommendations for fibromyalgia both for its implementation as part of a new lifestyle due to the illness and as treatment from a rehabilitative point of view. Therefore, our aim is to develop a self-efficacy scale for physical activity and walking exercise for women with fibromyalgia and test its psychometric properties preliminarily.Method ParticipantsTwo hundred and eleven women attending the Fibromyalgia Unit (FU) of the Valencian Community, diagnosed with the American College of Rheumatology criteria (Wolfe et al., 1990Wolfe F. Smythe H.A. Yunus M.B. Bennett R.M. Bombardier C. Goldenberg D.L. Tugwell P. Campbell S.M. Abeles M. Clark P. Fam A.G. Farber S.J. Fiechtner J.J. Franklin C.M. Gatter R.A. Hamaty D. Lessard J. Lichtbroun A.S. Masi A.T. McCain G.A. Reynolds W.J. Romano Th.J. Russell J. Sheon R.P. The American college of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee., Wolfe et al., 2010Wolfe F. Clauw D.J. Fitzcharles M.A. Goldenberg D.L. Katz R.S. Mease P. Russell A.S. Russell I.J. Winfield J.B. Yunus M.B. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.), participated in this study. Most were married (67.3%; n = 142), with primary (47.6%; n = 100), secondary (33.3%; n = 70), and university studies (10.5%; n = 22); 25.6% of participants were working out of home (n = 54), 19% were housewives (n = 40), 20.4% unemployed (n = 43), 7.1% were retired due to pain (n = 15), 6.2% were retired (n =13), and 21.8% were on sick leave (n = 46). The mean age was 52.6 (SD 7.9). The mean time from the appearance of symptoms was 13.9 years (SD 9.7) and 7.0 years (SD 7.3) from the diagnosis. On a scale of 10, mean pain intensity perception was 7.00 (SD 1.6). Variables and Instruments

Socio-demographic and clinical variables were measured with an “ad hoc” questionnaire.

 Self-efficacy for physical activity scale (SEPAS)We adapted the Spanish self-efficacy scale for physical activity scale (SEPAS) ( ) designed for primary health care settings. With 39 items answered on an 11-point scale (0 = not at all confident, 10 = completely confident) this questionnaire assessed the confidence people felt in their ability to do regular physical activity despite several barriers. It comprises three behavioral domains: practicing regular physical exercise at least three times a week, doing physical activity related to daily tasks, and walking. In our adaptation, to ensure content validity, these domains were changed considering: (1) the sedentary condition of women with fibromyalgia (López-Roig et al., 2016López-Roig S. Pastor-Mira M.A. Peñacoba C. Lledó A. Sanz Y. Velasco L. Prevalence and predictors of unsupervised walking and physical activity in a community population of women with fibromyalgia.), (2) the three intensity levels of physical activity (light, moderate and vigorous) assessed in physical activity questionnaires (Munguía-Izquierdo et al., 2011Munguía-Izquierdo D. Legaz-Arrese A. Mannerkorpi K. Transcultural adaptation and psychometric properties of a Spanish-language version of physical activity instruments for patients with fibromyalgia.), and (3) the walking recommendations for women with fibromyalgia aimed in our research. (Pastor-Mira et al., 2014Pastor-Mira M.A. López-Roig S. Lledó A. Peñacoba C. Velasco L. Schweiger-Gallo I. Sanz Y. Combining motivational and volitional strategies to promote unsupervised walking in patients with fibromyalgia: Study protocol for a randomized controlled trial.). In addition, we used the five most frequent exercise barriers associated with fibromyalgia, which include pain, fatigue, bad weather, feeling stressed, sad and worried, and having a bad day due to fibromyalgia (Pastor-Mira et al., 2015Pastor-Mira M.A. López-Roig S. Sanz Y. Peñacoba C. Cigarán M. Lledó A. Écija C. Andar como forma de ejercicio físico en la Fibromialgia: un estudio de identificación de creencias desde la teoría de la acción planeada.). Therefore, the SEPAS was composed of 35 items clustered in seven situations (walking while taking advantage of doing other activities; light, moderate, and vigorous physical activity; brisk walking at least 30, 60, or 90 minutes) with the aforementioned five barriers included in each situation.

With five items we asked for the perceived self-efficacy of walking when doing regular physical activity related to daily activities, despite the previously mentioned barriers (How confident are you that you can walk at least 30 minutes while taking advantage of going to work, shopping or taking the dog out, despite …?). Another fifteen items asked for the perceived self-efficacy of doing 30 minutes of light and moderate physical activity and 20 minutes of vigorous physical activity, despite the same five barriers (How confident are you that you can do light physical activity, such as going upstairs or swimming, for at least 30 minutes, despite…?); we repeated the question changing the level and examples of the physical activity. The remaining fifteen items were related to self-efficacy in regard to walking as physical exercise, despite the same barriers (How confident are you that you can walk quickly at least 30 minutes twice a week doing physical exercise, despite …?); we repeated the question, changing the time for 60 and 90 minutes. Responses were recorded with Fernandez's 11-point scale (0 = not at all, 10 = completely). Higher scores indicate higher physical activity and walking self-efficacy.

 Chronic pain self-efficacy beliefsThey were assessed by the Spanish adaptation of the Chronic Pain Self-efficacy Scale (Martín-Aragón et al., 1999Martín-Aragón M. Pastor-Mira M.A. Rodríguez-Marín J. March M.J. Lledó A. López-Roig S. Terol M.C. Percepción de autoeficacia en dolor crónico. Adaptación y validación de la 'Chronic Pain Self-efficacy Scale'.). The items are distributed among three self-efficacy factors: for coping with symptoms, for physical function, and for pain management. Responses were recorded on an 11-point scale (0 = not at all confident, 10 = completely confident). Higher scores indicate higher self-efficacy. We used the subscales and the total scores measured. The internal consistencies in our sample was α = .89, α = .83, α = .84, respectively, and α = .92 for the total scale. With this scale we tested the SEPAS criterion validity. Despite not specifically including an exercise subscale, the instrument has two related items in the physical function subscale. We expected positive and significant relationships between the subscales and total scores.

In order to test the validity based on the relationships with other constructs, we assessed:

 Physical activityWe obtained scores of the Metabolic Equivalence (MET) minutes-week spent walking, moderate and vigorous intensity activities, as well as overall physical activity level, using the Spanish version of the International Physical Activity Questionnaire–Short Form (IPAQ-S; www.ipaq.ki.se). The IPAQ-S asks for the amount of time the person has spent in the last seven days on different activities.

In addition, with five ‘ad hoc’ questions following the wording of the SEPAS, patients were asked how many times in the last seven days they did at least 30 minutes of daily walking, 30 minutes of light, moderate and walking exercise, and 20 minutes of vigorous activity (ie: In the last seven days, how many times did you walk at least 30 minutes while taking advantage of going to work, shopping or taking the dog out?). We used the mean score to obtain the frequency of the physical activity variable.

These variables were measured 10 days after the first measures (see design and procedure section). We hypothesized significant and positive relationships between SEPAS scores and physical activity measures.

 Pain intensity perception

Measured with the mean score of the maximum, minimum, and usual pain intensity during the last week and pain intensity at time of the assessment. These four items were answered with an 11-point numerical rating scale (0 = “no pain at all” and 10 = “the worst pain you can imagine”) (α = .80). Higher scores indicate high pain intensity perception.

 Perceived impact of fibromyalgia and disabilityWe used the total score of the Spanish adaptation of the Revised Fibromyalgia Impact Questionnaire (FIQ-R; Salgueiro et al., 2013Salgueiro M García-Leiva JM Ballesteros J Hidalgo J Molina R Pita-Calandre E Validation of a Spanish version of the Revised Fibromyalgia Impact Questionnaire (FIQR).) and the score of its physical function subscale (which assesses the perceived difficulty in doing nine daily activities). The internal consistency for this sample was α =.89 and α =.83, respectively. Higher scores represent higher fibromyalgia impact perception and disability.

We expected significant and negative relationships between SEPAS, pain perception, fibromyalgia impact, and disability.

Finally, taking into account that self-efficacy perception influences the personal persistence of behavioral efforts and the thoughts and emotional reactions (), we expected a) significant and positive relationships with the commitment of an active lifestyle and exercise goals, and b) significant and negative relationships with catastrophizing and fear of movement. Therefore, we measured: Commitment to being physically active and doing exercise

With two items, answered on a 10-point scale, we asked to what extent did the patients feel committed to being active and to doing physical exercise (1 = very little, 10 = a lot).

 CatastrophizingWe used the total score of the Spanish adaptation of the Pain Catastrophizing Scale (García Campayo et al., 2008García Campayo J. Rodero B. Alda M. Sobradiel N. Montero J. Moreno S. Validación de la versión española de la escala de la catastrofización ante el dolor (Pain Catastrophizing Scale) en la fibromialgia.), with 13 items answered on a 5-point scale (0 = not at all, 4 = all the time). Higher scores indicate higher catastrophizing (α = .95). Fear of movementWith the total score of the Spanish adaptation of the Tampa Scale for Kinesiophobia (Gómez-Pérez et al., 2011Gómez-Pérez L. López-Martínez A.E. Ruiz-Párraga G.T. Psychometric properties of the spanish version of the Tampa Scale for Kinesiophobia (TSK).). The scale contains 11 items answered on a four-point scale (1= completely agree, 4= completely disagree). Higher scores indicate higher fear of movement (α = .80). Design and Procedure

This work is part of a broader research approved by the Ethic Committees of the Alicante General Hospital and the Miguel Hernandez University which aims to identify a physical activity and exercise self-regulation model in women with fibromyalgia in rehabilitation settings. For 18 months, all new patients attending the FU, who met the inclusion criteria, were invited to participate in the study (n = 248). Inclusion criteria consisted of women, aged 18–70 years, with a fibromyalgia diagnosis confirmed by the FU and the ability to properly fill out the questionnaires. Two hundred and eleven accepted and signed the informed consent. We conducted a cross-sectional, prospective design with two measurement times where only physical activity variables were recorded 10 days after the first assessment.

 Data analysisWe used the SPSS-v25 and Factor 10.10.1 () for the exploratory factor analysis (EFA). We used the unweighted least squares method (ULS) extraction method with Promin rotation and Optimal Implementation of Parallel Analysis () to decide the number of factors. The goodness of fit of the data was evaluated with the goodness-of-fit index (GFI ≥ .95) (Miles and Shevlin, 1998Effects of sample size, model specification and factor loadings on the GFI in confirmatory factor analysis.), root mean aquare residual (RMSR ≤ .08) (Hu and Bentler, 1999Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives.), and the percentage of total variance explained by the factors. We obtained the Kaiser-Meyer-Olkin and the Bartlett sphericity tests to explore sampling and data adequacy. Items were retained with loading values greater than .40. Pearson correlation was used to calculate the item-corrected scale correlation and to assess the relationships between SEPAS and other constructs. The internal consistency was calculated with Cronbach's alpha.Results Preliminary Item Analysis

Six participants were eliminated from the analysis because they showed atypical patterns of response. The score of all or most of the items related to one situation were a) the maximum (9 or 10) or b) the extremes (0 or 10). Therefore, the sample for analysis was 205 participants. The EFA included 201 participants because some items were not answered by all subjects.

The mean of the items ranged from 1.16 (item 20) to 5.83 (item 1). The items with the highest mean were those assessing self-efficacy for daily activity walking and light physical activity; the items with the lowest mean were those related to vigorous physical activity and walking exercise in either 60 or 90 minutes. The item skewness indices were between [–.31, 2.07] and the kurtosis indices between [–1.25, 4.46]. The 10 self-efficacy items about undertaking vigorous physical activities and about walking fast for 90 minutes were removed from the analysis due to their no normality distribution and the high skewness and kurtosis indexes (Table 1).

Table 1Descriptive statistics and discrimination index of the removed items

Sk= Skewness; K= Kurtosis; r I-T=item-total correlation

Items number 27 and 30 had high skewness and kurtosis indexes (Table 2) but they were not excluded because they were qualitatively informative and belong to the same exercise situation. Hence, the final SEPAS had 25 items which addresses both light and moderate physical activity and walking exercise lasting 30 or 60 minutes at least twice a week. The mean of these items ranged from 1.4 (number 30) to 5.8 (number 1). The central category (5) obtained the highest percentage of response in the items referring to daily activities, walking, light intensity physical activity with pain, fatigue, bad weather or feeling sad, stressed, or worried. In most items the category with the lowest response rate was 9.

Table 2Exploratory Factor Analysis. Descriptive statistics and discrimination index

Sk= Skewness; K= Kurtosis; r I-T=item-total correlation

 Construct ValidityThe sample and the correlation matrix were suitable in performing the EFA (KMO = .86; Bartlett = 7310.7, df = 300, pTable 2 shows the pattern coefficients from the rotated matrix. The items loading on Factor I, ‘Self-efficacy for walking exercise,” assessed how confident patients felt in their ability to walk fast for both 30 and 60 minutes (10 items; α = 0.97). The items loading on Factor II, “Self-efficacy for daily physical activities,” assessed patient confidence in carrying out walking and light intensity physical activity (10 items; α = 0.93). The items loading on Factor III, “Self-efficacy for moderate physical activity,” assessed the patients’ confidence in undertaking this level of activity (5 items; α = .95). The internal consistency of the total scale was α = 0.96.

The correlations of Factor I with Factor II and Factor III were r = 0.43 and r = 0.56, respectively. Factor II and Factor III showed the highest relationship (r = 0.64). This last value suggested a second-order model which would group the items of Factor II and III. We also tested this two-factor model (fit indices: GFI = 0.97, RMSR = 0.09; explained variance = 66.81%).

 Criterion ValidityAll relationships between SEPAS scores and the other self-efficacy measures were significant and ranged from r = 0.32 (Factor I and ‘self-efficacy for symptoms management’ scores) to r = 0.59 (total scores of the two scales). Table 3 shows these data.

Table 3Correlation coefficients and descriptive statistics of SEPAS and CPSESa

SEPAS= Self-efficacy for physical activity scale; CPSES= Chronic pain self-efficacy scale;

a = All correlations at p ≤ .01

 Validity Based on the Relationships with Other ConstructsSignificant correlations between SEPAS and physical activity measures ranged from r = .14 (Factor I and frequency of physical activity scores, p ≤ .05) to r = 0.28 (Factor II and frequency of physical activity, p ≤ .01) (Table 4).

Table 4Correlations of the SEPAS with physical activity variables and other constructs

SEPAS= Self-efficacy for physical activity scale; IPAQ-S= International Physical Activity

Questionnaire-Short Form; a= In table only IPAQ variables with significant correlations with SEPAS

(no significant correlations with IPAQ vigorous activity); b= in the last week; * p ≤ .05; ⁎⁎ p ≤ .01

SEPAS measures, except Factor I, showed significant relationships with disability and the total FIQ-R score. They ranged from r = –0.18 to r = –0.26 (both p ≤ .01) for Factor II and Factor III with the total FIQ-R score respectively (Table 4). All SEPAS scores were significantly related to commitment with physical activity and exercise goals (positive sign) and to fear of movement and cat