consistent evidence from meta - analyses and clinical practice guidelines strongly indicate 
 that exercise therapy should be a key component in the management of fibromyalgia syndrome 
 ( fms ) , a complex chronic pain condition1,2,3,4 .
however , the implementation of exercise 
 therapy as a management strategy for fms in practice is significantly hampered by poor 
 compliance5,6,7,8,9,10,11 .
a key predictor of poor 
 compliance often displayed among patients with fms has recently been identified as pain 
 catastrophization .
a cognitive strategy , pain catastrophization is broadly defined as  an 
 exaggerated negative orientation towards actual or anticipated pain experiences  that 
 significantly contributes to the maintenance of pain12,13,14,15,16 .
currently , the role of pain catastrophization is believed to be 
 more pronounced in fms than in other rheumatologic chronic pain condition and is recognized 
 as a barrier to the healthy reestablishment of psychological and physical functioning among 
 patients with fms13,14,15,16,17 .
of concern is that in 
 patients with fms , the presence of pain catastrophization leads to fear - avoidance behaviours 
 that often result in attrition from regular physical activity13 .
inactivity is particularly detrimental in fms and typically leads 
 to further complications such as deconditioning of the musculoskeletal system , increased 
 pain , increased fatigue and functional disability6 , 
 16 .
fundamentally , poor compliance with 
 exercise and physical activity among patients with fms is the primary factor contributing to 
 the chronicity and accelerated deterioration of the condition10 . to our knowledge
, there is a dearth of research into the actual management approaches aimed 
 at addressing poor compliance with prescribed exercise programs in fms .
strategies to 
 increase compliance to effective treatment strategies such as exercise therapy in fms are 
 therefore warranted .
the inference that pain catastrophization and subsequent fear - avoidance 
 behaviors may influence the compliance of patients with fms with exercise programs , and this 
 justifies finding treatment approaches to alter pain catastrophization in the management of 
 fms18 , 19 .
it is therefore postulated that by reducing pain catastrophization 
 in patients with fms , fear of movement would be decreased , compliance with exercise therapy 
 would be increased , and the real physiological and psychological benefits of exercise 
 therapy for patients with fms would be realized .
empirical evidence suggests that cognitive behavioural therapy ( cbt ) , specifically exposure 
 therapy , may be useful in the alteration of pain catastrophization observed in patients with 
 fms17 .
traditionally , exposure therapy 
 is conducted during real situations ( in vivo exposure therapy ) or during an imagined 
 situation ( imagined exposure therapy ) .
however , more recent innovations indicate that 
 exposure therapy may also be administered via virtual reality technology , namely virtual 
 reality exposure therapy ( vret ) or in virtuo exposure therapy20 , 21 .
vret is a type of 
 exposure therapy in which the user can be immersed into a computer - generated environment via 
 a head - mounted display and visually exposed to a simulation of a specific feared 
 situation20,21,22 .
contrary to other types 
 of exposure therapy , vret seems ideal for conditions in which the real situations are 
 inaccessible or costly ( in vivo exposure ) or individuals find it difficult to imagine 
 certain situations ( imagined exposure therapy)20 , 
 21 . to date , vret has successfully been 
 used for other forms of phobias , such as fear of spiders and flying20,21,22 , but has never been used in the treatment of fear of 
 movement / exercise , or for pain catastrophizing in chronic pain conditions .
investigation of a novel vret exercise program as a possible treatment option for pain 
 catastrophizing in fms is plausible because it has been shown that imagined exposure therapy 
 may effectively reduce pain catastrophizing in patients with fms17 .
however , since there is no available vret exercise 
 program for the treatment of pain catastrophizing in patients with fms ; preliminary steps 
 were required prior to further development and testing of such a program .
initially , it had 
 to be ascertained if visual exposure to catastrophized exercise activities cognitively 
 triggered functional brain areas associated with pain catastrophizing in patients with fms . 

the premise was that if visual stimuli of the catastrophized exercise activities cognitively 
 triggered pain catastrophizing in previously identified functional brain areas of patients 
 with fms23 , a vret program aimed at 
 exposing patients with fms to visuals of the feared or catastrophized exercises and 
 neutralizing feelings of catastrophization towards exercise activities could possibly 
 decrease pain catastrophizing and subsequently decrease fear of movement .
in turn , 
 compliance with prescribed exercise programs in clinical practice may be increased .
the following study was therefore primarily aimed at testing the novel concept that 
 exposing patients with fms ( who catastrophized pain related to exercise ) , to healthy 
 exercise activities presented via visuals elicits neurophysiological changes in functional 
 brain areas associated with pain catastrophization .
it was hypothesized that subjects with 
 fms , when compared with healthy matched controls , would display significant activation in 
 functional areas associated with pain catastrophization when exposed to visuals of exercise 
 activities .
ethical approval for this study was initially obtained from the health research ethics 
 committee of stellenbosch university , south africa , during july 2010 .
the study protocol was 
 also approved by the committee of postgraduate education of stellenbosch university , the 
 cape universities brain imaging centre ( cubic ) research committee , and the department of 
 health / provincial government of the western cape , south africa .
all eligible subjects were 
 required to read and sign an informed consent form in their preferred language prior to 
 participating in this study .
this study was conducted at cubic and the rheumatology clinic 
 and occupational therapy department of tygerberg hospital s ( tbh ) .
a sociodemographic data form was designed by the principal researcher to collect 
 sociodemographic information .
pain severity was assessed using a five - point pain severity 
 scale ( pss ) .
the south african pain catastrophizing scale ( sa - pcs ) was used to measure pain 
 catastrophizing . the south african tampa scale for kinesiophobia ( sa - tsk )
was used to 
 measure kinesiophobia ( fear of movement ) . the south african revised fibromyalgia impact 
 questionnaire ( sa - fiqr )
the sa - pcs , sa - tsk 
 and sa - fiqr had been previously cross - culturally adapted and validated among a group of 
 patients with fms living in and around the cape metropole area of the western cape , south 
 africa .
physical activity levels 
 were assessed using the general practice physical activity questionnaire ( gppaq ) . 

subjects were consecutively recruited from the available fms population currently 
 registered at the tbh rheumatology clinic , based on the following eligibility criteria : 
 female adults aged 18  years and older , clinically diagnosed with fms according to the 
 american college rheumatology ( acr ) criteria by a qualified rheumatologist , registered as a 
 patient at the tbh rheumatology clinic ; south african citizens residing in or around the 
 cape metropole area ; scored > 24 points on the sa - pcs and > 37 points on the sa - tsk , and 
 willing to undergo fmri scanning .
subjects were excluded if they were diagnosed with any 
 other conditions not related to fms , i.e. , cancer , hiv / aids , etc . ; had severe physical 
 disabilities ; suffered from other chronic rheumatoid conditions , i.e. , systemic lupus 
 erythematosus , rheumatoid arthritis , etc . ; suffered from psychological / psychiatric 
 disorders , i.e. , bipolar disorder , etc . ;
had previously been hospitalized for a major 
 psychiatric disorder ; had an uncontrolled endocrine / allergic disorder ; were using medication 
 other than the prescribed pharmacologic agents for fms symptoms ; were currently or had 
 previously abused any illicit substances or alcohol ; or were unable to discontinue intake of 
 antidepressants four weeks prior to commencement of the study .
controls were purposefully selected and matched based on age , race , gender , and 
 socioeconomic status and were recruited from areas surrounding the tbh area .
controls were 
 included if they were healthy and did not possess any chronic rheumatoid conditions , i.e. , 
 fms , systemic lupus erythematosus , rheumatoid arthritis , etc . ; any medical / psychological or 
 psychiatric conditions , i.e. , cancer , hiv / aids , bipolar disorder or clinical depression , 
 etc . ; or any physical disabilities .
in addition , both the subjects and controls were excluded if they displayed any 
 contraindications that prohibited the use of fmri , i.e. , cardiac pacemakers , metal implants , 
 claustrophobia , pregnancy , cochlear implants , etc . ; or if they had a bust / chest size of more 
 than 1.5  m in circumference since , the mri scanner at cubic did not cater for larger 
 bust / chest sizes .
a simple block design was used for the fmri task , which allowed for simple modelling of the 
 blood - oxygenation - level - dependent ( bold ) response , resulting in more robust and reproducible 
 results25 .
the fmri visual task was 
 designed in the e - studio 2.0.8.90 ( e - prime 2.0 ) software available at the cubic facility 
 using the selected visuals . the fmri visual task consisted of the following two stimuli : i ) 
 active visuals ( clips of various visuals of exercise / physical activities , i.e. , cycling , 
 running , etc . ) and ii ) passive visuals ( clips of visuals of everyday sedentary / relaxing 
 activities , i.e. , reading a book / magazine , drinking tea , etc . ) .
the fmri task was set up to 
 include twelve 20  s  off/rest periods ( no stimulus ) and twelve 30  s  on  periods ( stimuli ) . 

the  off/rest period comprised a fixation visual ( a small grey block in the middle of a 
 black screen ) .
the 30  s  on  periods 
 consisted of either six active visuals ( active condition ) or six passive visuals ( passive 
 condition ) .
each visual was flashed for 5 s. the active visuals , passive visuals , and rest 
 period were alternated .
the design of the fmri task model was as follows : 
 rarbrarbrarbrarbrarbrarb , where a = active condition , 
 b = passive condition , and r = rest period . in total , 
 from preparation to completion , the scanning procedure for each subject lasted approximately 
 40 min ( 15 min for preparation , plus 9 min for a multi - echo mprage ( mempr structural ) scan , 
 plus 10 min for the fmri task and approximately 5 min extra time ) . on the day of the scheduled fmri scanning , subjects / controls were escorted to the fmri 
 chamber room and asked to lie down inside the fmri chamber .
subjects / controls were required to wear 
 mri - compatible earplugs ( to minimize scanner noise ) and earmuffs ( for communication with the 
 radiographer / principle researcher during the scanning process ) .
a pilot study was conducted 
 to test the logistics ( including the duration , applicability and acceptability ) of the fmri 
 visual task and procedure .
one subject clinically diagnosed with fms and meeting the subject 
 inclusion criteria participated in the pilot study .
standard mprage ( mempr structural brain scans ) and blood - oxygenation - level - dependant ( bold ) 
 sequences were acquired using a siemens magnetom allegra 3 tesla ( 3 t ) mri scanner ( siemens , 
 munich , germany ) .
t1-weighted structural images interleaved in a sagittal direction and a 
 isocenter position were acquired using a multi - echo memprage sequence26 with the following parameters : an echo time ( te ) of 
 1.53  ms , recovery time ( tr ) of 2.53  ms , flip angle of 7 , 256  256 pixel matrix , field of 
 vision ( fov ) of 256  mm , 1.3  1  1.3  mm voxels , and 128 partitions per slab .
this 
 structural scanning session was followed by two functional scan sessions using multi - slice , 
 echo - planar imaging fmri acquisition with the following parameters : a te of 23  ms , tr of 
 1.6  s , flip angle of 73 , 64  64 pixel matrix , fov of 255 m , 30 horizontal 3  mm slices . 

these parameters allowed coverage of the entire brain with 4 mm voxels within 5 
 s. during each fmri session , the first four scans were discarded to allow for saturation of 
 the tissue . starting on the fourth scan , 20  s rest periods (  off  condition ) were alternated 
 with 30  s stimuli (  on  condition / active or passive visuals ) .
analysis was performed on the 
 scans acquired under the  on  and  off  conditions .
bold contrasts were acquired during the 
 fmri scans for the subject under the following conditions : 1 ) active > rest 
 condition ( where brain activations during the rest period were subtracted from 
 those during the active visuals ) ; 2 ) passive > rest condition ( where brain 
 activations during the rest period visuals were subtracted from those during the passive 
 visuals ) ; 3 ) active > passive condition ( where brain activations during 
 passive condition were subtracted from those during the active visuals ) ; and 4 ) 
 passive > active condition ( where brain activations during active 
 visuals were subtracted from those during the passive visuals ) .
data acquired from the subjects were preprocessed by the principal researcher using 
 oxford s fmrib software library ( fsl ) , a collection of functional and structural brain image 
 analysis tools , written by members of the image analysis group at the oxford centre for 
 functional magnetic resonance imaging of the brain , oxford university27 .
fsl standard routines and templates were used for 
 preprocessing of functional mri data : realignment , normalization ( resulting voxel size 2  2 
  2  mm ) , and smoothing ( 8  mm isotropic gaussian kernel ; high - pass filter cutoff of 100  s ) . 

each session of image acquisition was defined as a separate session in the realignment 
 procedure .
head motion was determined by motion detection software and visual inspection of 
 raw and processed images .
head motion greater than half a voxel was deemed a 
 priori to be unacceptable , and images meeting this criterion were excluded .
none 
 of the scans acquired in this study had head motion exceeding this criterion , so all images 
 were included in the analyses .
after preprocessing the data , individual subject data analysis was performed by linear 
 regression of the fmri data in fsl .
the preprocessed data were assigned to the following two 
 conditions in the model specification : the active condition and passive condition .
for each 
 of the participants , four bold contrast differences ( t - contrasts ) were determined as a 
 function of bold signal changes compared with the baseline condition ( active > rest ; 
 passive > rest ; active > passive ; passive > active ) according to the routine procedures 
 implemented .
the brain volumes collected during the  on  conditions were compared with the 
 brain volumes collected during the  off  conditions using the student s t - test .
resultant z 
 statistical volumes and mean differences volumes were registered into standardized space 
 using the statistical parametric mapping ( fsl ) echo - planar imaging template and re - sliced to 
 2 mm voxels .
anatomic regions were identified ( i ) by inspection of individual 
 functional images superimposed on an individual s structural image , and ( ii ) by conversion 
 of the coordinates to the coordinate system of the montreal neurological institute ( mni ) 
 atlas and localization using this atlas and automated software .
the scans were registered as 
 high resolution mni structural scans so that the fsl atlas tools could be used to correctly 
 locate these regions of interest ( rois ) .
statistic images were thresholded using clusters 
 determined by z>2.3 and a ( corrected ) cluster significance level of p=0.05 .
mean activation 
 of functional was compared within and between groups of fms subjects and the healthy 
 controls .
anatomical localization of activated brain regions was determined by reference to 
 the atlas tool automatically implemented in fsl .
the paired t- test was used for comparison 
 of two dependent samples and contrasts .
statistic images were thresholded using clusters 
 determined by z>2.3 and a ( corrected ) cluster significance level of p=0.05 .
a total of 13 subjects with fms and nine matched healthy controls participated in this 
 study . in table
1table 1.baseline comparison of sociodemographic characteristics of fms subjects and 
 matched controlsvariablefms subjectsmatched controlsn=13n=9genderfemalefemaleage ( yrs ) meansd46.009.7248.2214.77number of children2.751.142.750.88marital statussingle21married65separated20divorced22widowed11years living with fms meansd3.812.27naethnicitycolored96black43white00languageenglish21afrikaans65xhosa43level of education < grade 754 > grade 1242matric32tertiary education11employment statusunemployed61permanently employed05self - employed20casually employed10pensioner11housewife22disability grant10physical activity hours / week meansd9.626.7939.4412.61*na : not applicable , sd : standard deviation , * significant ( p<0.05 ) , a comparison of the sociodemographic information for the fms subject group 
 and control group is depicted .
one fms subject withdrew from the study shortly before the 
 fmri scans took place .
baseline demographic data were , however , included for this subject 
 along with the rest of the subjects ( table 1 ) . 
 all subjects and controls lived in the surrounding areas of the cape metropole .
there were 
 no significant differences ( p>0.05 ) in age or number of children between the fms subject 
 group and the matched control group .
there was , however , a significant difference in the 
 number of physically active hours per week ( p<0.0000 ) between the two study groups ( table 1 ) .
na : not applicable , sd : standard deviation , * significant ( p<0.05 ) the mean difference in activation of the functional brain areas between the two groups , the 
 fms subject group and the matched control group , was analyzed .
1.between-group comparison of significant activation ( p<0.05 ) of functional areas in 
 the active > passive condition illustrates significant differences ( p<0.05 ) in functional brain area activation 
 for the active > passive condition between the fms subject group and the matched control 
 group . between - group comparison of significant activation ( p<0.05 ) of functional areas in 
 the active > passive condition in table 2table 2.significant differences in functional area activation for fms subjects >
matched 
 controls contrast during the active > passive conditionfunctional areaco - ordinates mni ( fsl)xyzright inferior temporal gyrus , right cerebellum 
 posterior lobe476122*right inferior and middle frontal gyrus421023*left inferior frontal gyrus442414*left superior parietal lobe , l supramarginal 
 gyrus295453*left thalamus23299*mni : montreal neurological institute , fsl : oxford s fmrib software library , 
 * significant ( p<0.05 ) , the z co - ordinates ( x , y and z ) , z - scores as well as p - values for all the 
 areas significantly activated ( p<0.05 ) during the active > passive condition for fms 
 subject group > matched control group , where brain activations acquired for the matched 
 control group were subtracted from the brain activations acquired for the fms subject group 
 during the active > passive condition .
mni : montreal neurological institute , fsl : oxford s fmrib software library , 
 * significant ( p<0.05 )
the current paper reports on the first investigation ( to our knowledge ) into proving the 
 novel concept that exposing patients with fms to healthy exercise activities via visuals 
 elicits neurophysiological changes in functional brain areas associated with pain 
 catastrophization .
preliminary support was provided for the further development and testing 
 of a vret exercise program aimed at reducing pain catastrophization related to exercise 
 therapy in patients with fms .
the study findings indicated that the fms subject group showed significant activation in 
 the right and left inferior frontal gyri ( p<0.0000 ) in the active > passive condition 
 when compared with the healthy controls .
these results concur with a study conducted by 
 gracely et al . , who found that activity in the inferior frontal gyrus was associated with 
 pain catastrophization in high catastrophizing patients with fms23 .
more recently , however , studies have examined the role of 
 the inferior frontal cortex in belief - bias reasoning and deductive reasoning tasks using 
 repetitive transcranial magnetic stimulation ( rtms)28 , 29 .
the studies found that 
 the inferior frontal gyrus may play a significant role in belief - bias reasoning and 
 deductive reasoning tasks28 , 29 .
belief bias is currently defined as the tendency of an 
 individual to be  erroneously biased when logical conclusions are incongruent with belief 
 about the world28 .
although the 
 definition of belief - bias reasoning is different from that of pain catastrophizing , the 
 significant activation of the right and left inferior frontal gyri in the fms subjects , but 
 not the controls , in the active > passive condition in this study implies that there may 
 have been a tendency for the fms subjects to have a belief - bias reasoning reaction in 
 response to the exercise activities similar to the catastrophization reaction of the 
 subjects in response to exercise activities . although the study conducted by gracely et al . 
 differed considerably from the current study in terms of the stimuli used during the fmri 
 task , the fact that the right and left inferior frontal gyri were exclusively activated in 
 the fms subject group may provide further support for the involvement of the inferior 
 frontal gyri in pain catastrophization and belief - bias reasoning related to non - painful 
 stimuli . however
, further research is required to ascertain the exact involvement of the 
 inferior frontal gyri in pain catastrophization and belief - bias reasoning in patients with 
 fms .
right posterior cerebellum activation was also significant ( p<0.000 ) for the fms subject 
 group in the active > passive condition when compared with the healthy controls .
the 
 cerebellum plays an important role in motor control but may also be involved in some 
 cognitive functions such as attention and language , and affective regulation , such as 
 regulating of fear and pleasure responses30 , 31 .
previously it was also reported that 
 viewing emotional images from the international affective picture scale ( iaps ) activates the 
 posterior lobe of the cerebellum when compared with viewing neutral images32 .
activation of the cerebellum was also 
 seen in neuroimaging studies investigating panic , as well as sadness and grief31 .
the posterior cerebellum has also been 
 found to be activated during painful stimulation but to be more specifically activated 
 during the anticipation of pain33 . 

furthermore , studies have also found that the posterior cerebellar regions are involved when 
 processing one s own painful experiences31 and may also be associated with pain catastrophization in high 
 catastrophizing fms patients23 .
the 
 functions currently reported for the posterior cerebellum can possibly explain the 
 significant activation of the posterior cerebellum when the subjects were exposed to visuals 
 of exercise activities in the active > passive condition .
although we can not be certain if 
 the activation of the posterior cerebellum was exclusively associated with pain 
 catastrophization related to the exercise activities depicted in the active visuals , we 
 can not definitively discard this finding .
regardless , the posterior cerebellum is also 
 reportedly involved in a variety of emotional processes , such as fear30 , 31 , and these 
 processes may explain the activation of this functional brain area in the active > passive 
 condition in the fms subject group , and lack of activation in the control group .
the fms 
 subject group may have experienced feelings of fear , if not catastrophization , in response 
 to the visuals depicting the exercise activities .
the involvement of the posterior 
 cerebellum in the processing of pain catastrophization and fear in response to exercise 
 activities in patients with fms needs to however be confirmed .
significant activation ( p<0.0000 ) in the right middle frontal gyrus was also found in 
 the fms subject group in the active > passive condition .
the middle frontal gyrus is 
 involved in high - level executive functions and decision - related processes such as cognitive 
 control , working memory , semantic processing , target detection , memory retrieval , 
 recognition , prospective memory , and processing of emotional stimuli34 .
in addition , it has also been reported that the middle 
 frontal gyrus may be associated with pain catastrophization in high catastrophizing fms 
 patients23 .
these functions reported 
 for the middle frontal gyrus may explain activation of this area in the fms subject group in 
 the active condition .
the fms group would have most probably seen the active visuals , 
 recognized what the visuals were depicting ( recognition ) , retrieved a memory related to that 
 particular activity depicted in the visuals ( memory retrieval ) , and then either processed an 
 emotion in response to that particular activity depicted in the visuals ( processing of 
 emotional stimuli ) or thought of what they would feel if they performed the activity 
 ( prospective memory ) ; they may even have catastrophized in response to the exercise 
 activities .
although this reaction to the active visuals can not be stated for certain , it 
 does provide a logical explanation for the activation of the middle frontal gyrus in the fms 
 subject group during the active > passive condition in this study .
the role of the middle 
 frontal gyrus in processing emotions and constructs such as pain catastrophization in 
 response to exercise activities in patients with fms , however , should be further 
 investigated . according to russ et al .
, the supramarginal gyrus , in addition to the middle and superior 
 gyrus and the postcentral gyrus , may be involved in the enactment effect of memory35 .
the enactment effect of memory is 
 basically  learning by doing  or  encoding by performing  , and it refers to the fact that 
 performing a task verbally provided improves subsequent memory performance35 . despite the involvement of the other 
 mentioned areas , the supramarginal gyrus , however , was believed to play a central role in 
 this function35 .
there are , however , 
 various steps in enactment of memory procedures35 , and since the fms subjects did not enact the activity they were 
 exposed to during the fmri scan to memorize it , they may have elicited activation of the 
 left supramarginal gyrus in preparation for enacting what was being shown .
however , this is 
 pure speculation , and further research is warranted to ascertain the role of the 
 supramarginal gyrus when an individual is exposed to visuals of various activities . since the inferior frontal gyrus , posterior cerebellum , and middle frontal gyrus have been 
 previously associated with pain catastrophization in patients with fms23
, the findings of this study may indicate that subjects 
 with fms catastrophized the exercise activity visuals and not the passive visuals .
however , 
 it can not be stated for certain whether the activation of these areas was solely associated 
 with pain catastrophization in the patients with fms due to one of their other reported 
 functions of these areas .
nonetheless , the findings of this study provide preliminary 
 support for the testing of a novel vret exercise program as a treatment for pain 
 catastrophization in patients with fms .
it is however recommended that further research be 
 conducted to investigate the roles of the inferior frontal gyrus , posterior cerebellum , and 
 middle frontal gyrus , as well as the amygdala , in processing pain catastrophization in 
 response to exercise activities .
although every effort was made to ensure that the visuals included in the final fmri task 
 were the most appropriate to elicit the construct of interest , i.e. , pain catastrophization , 
 the development of an fmri task may require much more than was possible in this study .
time 
 and financial constraints , however , prohibited us from extending the validation of the fmri 
 task indefinitely .
there is , therefore , the possibility that subjects may have become bored 
 or may have ceased to pay attention to the task for the entire duration of the scan , which 
 could have influenced the activations in the brain and led to incorrect results .
we would 
 recommend that the fmri tasks used in this study be further validated in larger samples to 
 ensure that the tasks are indeed optimal to achieve accurate results . in conclusion , although it may be many years before an adequate management strategy for 
 treating pain catastrophization in response to exercise therapy in fms is successfully 
 implemented in clinical practices across the globe , the findings of this research 
 significantly add to the current body of knowledge regarding the possibility of objectively 
 identifying cognitive behavioural strategies like pain catastrophization often observed 
 among chronic pain patients within the physiotherapy practice scope .
the results of this 
 study also provide a rather promising suggestion that a program like vret aimed at reducing 
 pain catastrophization related to exercise activities among patients with fms may be worth 
 further investigation .
the development of such a program may finally provide 
 physiotherapists with a tool to address issues such as poor patient compliance in clinical 
 practice , which often hinders the successful management of fms and other chronic conditions . 

physiotherapists would not only be involved in prescribing exercise therapy in the 
 management of fms but could also become more involved in changing existing negative thoughts 
 ( i.e. , catastrophizing thoughts ) that a patient may have towards exercises .
this research 
 significantly contributes to a new era of research relating to finding evidence for the 
 further development of effective strategies that may aid in the successful implementation 
 and maintenance of exercise programs and other treatment modalities among patients with 
 fms .
 [ purpose ] pain catastrophizing is a key predictor of poor compliance to exercises among 
 patients with fibromyalgia syndrome . 
 alteration of pain catastrophizing in this group is 
 thus warranted . 
 this study aimed to provide proof - of - concept of a novel virtual reality 
 exposure therapy program as treatment for exercise - related pain catastrophizing in 
 patients with fibromyalgia syndrome . 
 [ subjects and methods ] an exploratory , 
 case - controlled study was conducted ( fibromyalgia syndrome group and matched control 
 group ) . 
 functional magnetic resonance imaging was used to acquire neural correlates . the 
 functional magnetic resonance imaging task consisted of two stimuli : active ( exercise 
 activity visuals ) and passive ( relaxing visuals ) . 
 structural images and 
 blood - oxygenation - level - dependent contrasts were acquired for the conditions and compared 
 within subjects / groups and between groups . 
 statistic images were thresholded using 
 corrected clusters ( determined by z>2.3 ; level of significance : 0.05 ) . 
 [ results ] 
 thirteen fibromyalgia syndrome subjects and nine healthy matched controls were included . 
 
 the right inferior frontal gyrus , right middle frontal gyrus , right posterior cerebellum , 
 left thalamus , and left supramarginal gyrus were activated in the fibromyalgia syndrome 
 subjects . 
 [ conclusion ] the study results provide preliminary proof indicating that 
 exposing patients with fibromyalgia syndrome to visuals of exercises elicits 
 neurophysiological changes in functional brain areas associated with pain 
 catastrophization and add to the current body of knowledge regarding the possibility of 
 objectively identifying cognitive behavioral strategies like pain catastrophization . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION