clinical diagnosis of fibromyalgia syndrome ( fms ) is based on many accompanying subjective 
 symptoms such as fatigue , sleep disorders , stiffness , irritable bowel syndrome , depression , 
 and anxiety , in addition to chronic widespread musculoskeletal pain1 . according to the american college of rheumatology ( acr ) 
 1990 classification criteria ,
fms is defined as > 3 months of continuous tenderness 
 determined by a finger pressure of around 4  kg at at least 11 out of 18 predefined sites and 
 widespread musculoskeletal pain2 . 

recently , new acr diagnostic criteria including fatigue , non - restorative sleep , abdominal 
 discomfort and cognitive symptoms have been proposed3 , 
 4 .
although it is reported that a multifactorial condition with various 
 biological and psychosocial factors may play a role in the initiation and maintenance of 
 pain , the etiopathogenesis of pain is not yet fully understood5 , 6 .
it is reported that the available 
 treatment modalities provide relief of symptoms in less than 50% of patients6 .
aerobic exercise programs 
 have been shown to improve the physical capacity of patients with fms1 . additionally , it has been suggested that aerobic exercise 
 has modest effects on some symptoms of fms and physical function6 , 7 .
researchers have 
 investigated the effectiveness of various exercises programs including bicycle ergometer , 
 side step in the pool , jogging , walking outdoors and walking on a treadmill6 , 8 . 

some studies have reported that aerobic exercise has positive effects on pain , disability 
 and mood8 , 9 . in a meta - analysis
, it was mentioned that the effectiveness of 
 aerobic and strengthening exercises on general well - being in fms is contradictory . in the 
 assessment of functional condition ,
the positive effects of exercise have been reported in 
 some studies using the fibromyalgia impact questionnaire ( fiq ) , but the absence of a 
 statistically significant difference has also been reported10 .
although there might be many reasons behind these differing 
 results , one possibility is the personality characteristics of the patients .
it has been 
 showed that the profiles of individuals with fms include difficulties regarding physical , 
 functional and psychological status .
additionally , it has been emphasized that odyophobia 
 lies at the bottom of psychological and behavior responses in the subgroups comprised of 
 individuals with fms and a self - management approach should be included in the treatment for 
 chronic pain11 . according to the 
 biopsychosocial model of health ,
it has been reported that when education programs developing self - managements 
 for individuals are supported by exercise programs , there are positive effects on physical 
 function and fms symptoms12 .
a previous 
 study also reported that some personality parameters assessed by the minnesota multiphasic 
 personality inventory ( mmpi ) differ with pain management13 . besides fms is a disease characterized by widespread pain and tender points , therefore it 
 is important to consider the psychological aspect of fms14 .
it has been reported that it is necessary to focus on dysfunction 
 in both physical and emotional aspects of treatment together9 .
evaluation of personality characteristics and the role of 
 personality characteristics in treatment planning are important in fms . in this study , we 
 aimed to evaluate the personality characteristics of patients with fms and to assess the 
 pain , quality of sleep , physical function , and depression parameters after a 6-week 
 home - based aerobic exercise program .
eighteen female patients admitted to the physical medicine and rehabilitation department of 
 bakirkoy dr .
sadi konuk training and research hospital and diagnosed with fms according to 
 1990 acr classification criteria were included in this study .
the exclusion criteria were as 
 follows : psychotic disorder ; suicidal ideation ; presence of neurological disease ; use of 
 neurological and psychiatric tricyclic antidepressant , antipsychotics , selective 
 serotonin - norepinephrine reuptake inhibitors , or medicines similar to anticonvulsants ; 
 presence of a systemic disease that would interfere with doing exercise ; pregnancy or 
 abnormality in routine tests .
sadi konuk training and research hospital and written informed consent was received from 
 each subject prior to their participation .
demographic characteristics , fms symptoms and the 
 number of tender points of the patients were identified .
pain and quality of sleep were 
 assessed using visual analog scale ( vas ) .
physical function was assessed with the fiq , 
 depression was assessed with the beck depression inventory ( bdi ) , and personality 
 characteristics were assessed with the mmpi . the structured clinical interview for dsm - iv 
 axis i disorders ( scid - i ) was used to determine whether the patients had dsm - iv axis i 
 disorders or not .
a home - based exercise program was performed three times a week for 6 
 weeks .
each exercise session lasted 60 minutes and consisted of a warming - up period of 10 
 minutes , moderate intensity aerobic exercises period of 40 minutes and a cooling down period 
 of 10 minutes .
the training program included exercises for strength , endurance , and 
 elasticity , and stretching of both the upper and lower extremities .
the intensity of 
 exercise was performed at a heart rate ( hr ) of between 60% and 80% of the maximal heart 
 rate , which was calculated by karvonen formula ( target hr= ( ( 220-age)-resting hr )  0.60 + 
 resting hr5 ) .
the training program 
 was checked by a physical therapy and rehabilitation specialist every 2 weeks . in this study , we assessed whether there were significant differences in the pain , quality 
 of sleep , physical function and depression parameters of the patients with fms before and 
 after the exercise program . additionally , features of the psychiatric diagnosis and 
 personality profiles of the patients were evaluated .
ncss ( number cruncher statistical system ) 2007 statistical software ( utah , usa ) program was 
 used for the statistical analysis performed in this study .
the paired t - test was used for 
 comparisons of descriptive statistics ( mean , standard deviation ) as well as for comparisons 
 of data before and after treatment .
mcnemar s test was used for the comparison of 
 qualitative data , and pearson s correlation test was used for the comparison of the 
 correlations among the variables .
four of 18 patients included in our study dropped out of the study because they did not 
 want to maintain the exercise program .
therefore , the data of only 14 patients with fms used 
 in the analysis . the mean age of the patients with fms was 435.33  years ( minimum : 25 , 
 maximum : 43 ) , and their mean body mass index ( bmi ) was 24.213.3 ( minimum : 17.99 , maximum : 
 30.11 ) 
the other demographic characteristics are shown in table 1table 1.demographic characteristics of the patients with fibromyalgia syndromevariablemean  sdminimummaximumage ( year)35.43  5.332543bmi ( kg / m)24.21  3.317.9930.11number of children1.5  1.1603variable n%educationprimary school214.3secondary school321.4high school535.7university428.6marrial statussingle214.3married1178.6divorced17.1occupationhousewives857.14employees321.43public official17.14private sector214.9smokingyes321.4no1178.6bmi : body mass index , sd : standard deviation .
bmi : body mass index , sd : standard deviation after exercise , the symptoms accompanying fms ( fatigue , morning stiffness , disturbance of 
 sleep , morning fatigue , paresthesia , headache , irritable bowel syndrome and soft tissue 
 edema ) were determined to be significantly lower than before exercise ( p<0.05 ) ( table 2table 2.comparison of accompanying fibromyalgia syndrome before and after 
 exercisebefore exerciseafter exercisevariablen%n%fatigue*1392.9642.9morning stiffness*1392.9535.7sleep disorder*1285.7428.6morning tiredness*1392.9857.1paresthesia*1178.6321.4headache*1392.977raynaud s phenomenon00.000irritable bowel syndrome*750.017.1sicca symptoms321.417.1female urethral syndrome535.717.1soft tissue edema*1178.617.1dysmenorrhea857.1221.4*p<0.05 ) .
the number of tender points , vas values for pain , and quality of sleep after exercise were 
 found to be significantly lower than their respective values before exercise ( p<0.05 ) 
 ( table 3table 3.comparison of clinical parameters before and after exercisevariablebefore exerciseafter exercisemean  sdmean  sdnumber of tender points by palpation*14.79  1.378.36  3,05vas pain*7.71  2.164.29  2.43vas sleep*6.14  2.983.64  2.68fiq physical function*5.21  1.544.34
2.47fiq job loss0  00  0fiq working5.4  3.443.8  0.84fiq pain*7.79  2.044.64  2.31fiq fatigue*8.21  1.536.71  2.81fsesf resting*9  1.246.71  2.81fiq stiffness*7.29  2.555.14  3.37fiq anxiety*7.93  2.165.5  2.9fiq depression*7.29  1.984.57  2.9total fiq*70.58  14.6450.57  20.53bdi*17.57  7.8210.64  7.52*p<0.05 , vas : visual analog scale , fiq : fibromyalgia impact questionnaire , bdi : 
 beck depression inventory , sd : standard deviation ) .
* p<0.05 , vas : visual analog scale , fiq : fibromyalgia impact questionnaire , bdi : 
 beck depression inventory , sd : standard deviation in the patients with fms , mean values of physical function , feeling good , pain , fatigue , 
 resting , stiffness , anxiety , depression parameters and total fiq scores after the exercise 
 program , except the working parameter , ( p>0.05 ) were determined to be significantly 
 improved compared to before the exercise program ( p<0.05 ) ( table 3 ) .
mean bdi after exercise was found to be significantly lower than mean bdi before exercise 
 ( p<0.05 ) ( table 3 ) .
when scid - i was investigated , major depression , dysthymia or depressive disorder not 
 otherwise specified were determined in 5 patients ( 35.7% ) .
social phobia , generalized 
 anxiety disorder , or obsessive compulsive disorder were determined in 6 patients ( 42.9% ) , 
 and specific phobia in 3 patients ( 21.4% ) .
anxiety disorder not otherwise specified was 
 determined in 9 patients ( 64.3% ) , and somatoform disorders in 8 patients ( 57.1% ) .
diagnosis 
 of panic disorder , post trauma stress disorder , adjustment disorder or other dsm iv 
 disorders were not seen in any patient .
major depression , dysthymia or depressive disorder 
 not otherwise specified according to scid - i lifetime values were determined in 13 patients 
 ( 92.9% ) .
obsessive compulsive disorder was determined in 6 patients ( 42.9% ) and anxiety 
 disorder not otherwise specified in 9 patients ( 64.3% ) .
adjustment disorder was determined 
 in 4 patients ( 28.6% ) , social phobia or generalized anxiety disorder in 12 patients ( 85.7% ) 
 and specific phobia in 7 patients ( 50% ) .
somatoform disorders were determined in 8 patients 
 ( 57.1% ) but post - traumatic stress disorder , panic disorder or other dsm iv disorders were 
 not found in any patient . according to the mmpi personality inventory , only the hysteria subscale score ( 71.218.84 ) 
 was determined to be above the significance level ( table 4table 4.assessment of the personality characteristics of the patients with fibromyalgia 
 syndrome by the minnesota multiphasic personality inventorymmpimean  sdminimummaximumlie55.43 
11.374181frequency50.64  7.473865correction52  10.363772hypochondriasis63.86  6.625071depression58.57  10.974278hysteria71.21  8.845286psychotic deviation53.86  9.73573male - female48.21  10.283466paranoia51  9.663162psychasthenia56.93  9.474273schizophrenia52.86  7.613863hypomania48.43  7.63764social introversion58.64  8.714574mmpi : the minnesota multiphasic personality inventory , sd : standard deviation ) .
non - pharmacological approaches to treatment of fms have gradually gained in importance in 
 recent years .
a physical exercise program is an important treatment option either alone or 
 combined with the other treatment components in the treatment of fms due to its relatively 
 ease of applicability , low risk and low cost10 , 15,16,17 .
it has been reported that a home exercise 
 program is effective at easing the level of pain and improving functional status18 .
in addition researchers have suggested 
 that active individual exercise programs improve muscle function19 . in the literature ,
the positive effects of aerobic exercise on pain , physical function and 
 quality of life have been reported9 , 10 , 15 .
a meta - analysis reported a significant improvement in the number of 
 tender points by palpation after aerobic exercise alone or in combination with strengthening 
 exercises , and its authors emphasized that improvement in the number of tender points 
 through exercise supports the reduction of widespread pain and tenderness in female patients 
 with fms20 .
jones et al.21 reported positive effects of submaximal 
 aerobic exercise on pain , fatigue and the quality of life .
huser et al.16 reported positive effects of aerobic and 
 mixed exercise on physical function .
in contrast , king et al.22 concluded that aerobic exercise was ineffective in the treatment of 
 physical function as assessed by fiq in the patients with fms . on the other hand , in the 
 systematic review performed by busch et al.23 the positive effects of aerobic exercise on fms symptoms
again emphasized the positive 
 effects of aerobic exercise on pain , the number of tender points , physical function and fms 
 symptoms , albeit with the caveat that more comprehensive studies of exercise prescription 
 and compliance of patients with the exercise program were necessary24 . according to the results of our study ,
a significant improvement was seen in the symptoms 
 accompanying fms , the number of tender points by palpation , vas score of pain and quality of 
 sleep in the patients with fms after the home - based aerobic exercise program . according to 
 the assessment of physical function by the fiq
the symptoms of the patients with fms , and the type and levels 
 of physical exercise affect the response to fms treatment9 .
most authors have recommended gradually increasing the intensity of 
 exercise and the  start low and go slow  approach and moderate intensity exercise programs 
 are especially recommended .
a reduction in post - exercise pain and fatigue complaints with 
 these approaches suggest that this type of approach is most suitable9 , 25 .
the authors of a 
 previous study tried to develop a formula to calculate target heart rate for aerobic 
 exercise program using a mathematical model . according to this model ,
the recommended 
 exercise intensity for patients with fms is within the range of 5260% of heart rate reserve 
 or 7585% of hr at the anaerobic threshold26 . in our present study ,
in addition to fms symptoms , and characteristics of physical exercise , the importance of 
 psychological characteristics has also been mentioned in relation to fms treatment9 .
the correlation between chronic pain and 
 emotional , physical and social function was shown in two studies10 , 27 . in a 
 meta - analysis , it was reported that aerobic exercise interventions had positive effects on 
 depression16 .
mannerkorpi et al.12 used the hospital depression scale to 
 assess the psychological status before and after exercise and reported that there was a mild 
 improvement in the scale . in our study ,
post - exercise mean bdi was significantly lower than 
 the pre - exercise mean bdi .
some studies have reported poor patient compliance with exercise regimes and high dropout 
 rates28 , 29 .
in our study , 4 patients dropped out because they did not want to 
 continue the exercise program .
although it was reported that the personality characteristics 
 of patients with fms were heterogeneous in a review , studies performed on this subject have 
 been very few .
assessment tools and the characteristics of the patients included in studies 
 might have contributed to these differences30 . in our study
, we evaluated the personality characteristics of the 
 patients with fms using the mmpi . according to the mmpi personality inventory
the hysteria scale of the mmpi is a subset of 
 individuals with higher scores who mainly use denial , who are childishly egoistic , and have 
 anxiety - related somatic complaints .
it is known that personality plays a major role in the 
 etiology of psychosomatic disorders31 . 

taking account of this , multidisciplinary approaches should be planned to increase the 
 participation of patients in an exercise program by evaluation of personality 
 characteristics and psychological status of the patients before the exercise program .
some studies have reported the effectiveness of 
 home - based programs including exercise program .
for example , in a controlled study , it was 
 reported that targeted individual training increases the effectiveness of exercise in the 
 treatment of fms34 .
another study 
 mentioned that frequent visits during a training program had significant effects on the 
 psychosocial status of patients with fms35 . in our study , the 6-week home - based aerobic exercise programs of 
 the patients with fms were checked by a physical therapy and rehabilitation specialist every 
 two weeks . in a meta - analysis performed by huser et al.36 , results were assessed over a period of 115 months .
moreover , the 
 assessment was performed according to whether the total exercise period was shorter or 
 longer than 30 hours .
huser et al . emphasized that short - term and long - term aerobic 
 exercise program had positive effects on physical function and depression but that 
 multicomponent treatment programs are necessary to increase compliance with an exercise 
 program during long - term home care . with
the development of individually focused 
 psychological strategies for patients with fms , it is generally accepted that maintaining 
 compliance with an aerobic exercise program increases the success of the treatment .
fms is a 
 highly complicated syndrome and its etiopathogenesis is not yet well understood .
however , 
 many studies indicate that it is a neurobiological disease and emphasize its association 
 with central sensitization , endocrine factors , sleep disorders , psychosocial , physical 
 stress and physical trauma37 .
it has also 
 been reported that physical function , anxiety , pain , stiffness , general fatigue and morning 
 tiredness of fms patients are significantly improved by psychosocial training33 .
psychosocial training programs for personality profiles and the psychological status of the 
 patients with fms can be included in aerobic exercise programs . in this study
, we 
 investigated the personality characteristics of the patients with fms while assessing the 
 effectiveness of aerobic exercise .
we wanted to confirm that aerobic exercise is effective 
 in the treatment of fms , and that emotional status and personality characteristics should be 
 considered during the planning process of the treatment for fms .
we think that many more 
 studies with a larger number of patients are required on this subject .
 [ purpose ] the aim of this study was to assess the effectiveness of a 6-week aerobic 
 exercise program on pain , physical function , and psychological status , and to evaluate the 
 personality characteristics of fibromyalgia syndrome ( fms ) patients . [ subjects and 
 methods ] fourteen women with fms were enrolled . 
 they were trained for a 6-week home - based 
 aerobic exercise program . 
 the fibromyalgia impact questionnaire , the beck depression 
 inventory , the visual analog scale of pain and sleep quality were measured at baseline and 
 at the end of week 6 . 
 the personality profiles were evaluated using the minnesota 
 multiphasic personality inventory ( mmpi ) . 
 [ results ] after the exercise program , 
 significant improvements were determined in pain , sleep quality , physical function , 
 depression and fms symptoms compared to baseline . 
 in addition , the hysteria item 
 ( 71.218.84 ) of the mmpi was significantly higher in fms . 
 [ conclusion ] our findings 
 indicate that home - based aerobic exercise may be a useful treatment in the management of 
 fms . 
 personality characteristics should be considered during the planning process of the 
 treatment of fms . 
 personality is a filter between life events and psychological responses . 
 
 it is defined to be the integration of effective and behavioral patterns . 
 long - term 
 studies involving larger clinical samples are needed to define the role of personality 
 characteristics in fms . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION