Comparison of the International Physical Activity Questionnaire (IPAQ) with a multi-sensor armband accelerometer in women with fibromyalgia: the ...
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Comparison of the International Physical Activity Questionnaire
(IPAQ) with a multi-sensor armband accelerometer in women
with fibromyalgia: the al-Ándalus project
V. Segura-Jiménez1, D. Munguía-Izquierdo2, D. Camiletti-Moirón1,3,
I.C. Álvarez-Gallardo1, F.B. Ortega1, J.R. Ruiz1, M. Delgado-Fernández1
1
Department of Physical Education ABSTRACT Introduction
and Sports, Faculty of Sport Sciences, Objective. To compare levels of physi- Fibromyalgia is a chronic musculo-
University of Granada, Granada, Spain; cal activity (PA) assessed by the Inter- skeletal condition (1) found primarily
2
Department of Sport and Informatics,
Section of Physical Education and Sports, national Physical Activity Question- in women and characterised by pain
University Pablo de Olavide, Seville, Spain; naire (IPAQ) with PA measured with disorder and multiple tender points in
3
Department of Physiology and Institute the SenseWear Pro Armband (SWA) in all body quadrants (2, 3). It is also usu-
of Nutrition and Food Technology, Faculty women with fibromyalgia, and to assess ally accompanied by other wide variety
of Pharmacy, University of Granada, the test-retest reliability of the IPAQ. of symptoms (2, 4, 5) and it commonly
Granada, Spain.
Methods. The study comprised a total accompanies other chronic conditions
Víctor Segura-Jiménez, BSc of 183 women with fibromyalgia aged (6). Different treatments are currently
Diego Munguía-Izquierdo, PhD
Daniel Camiletti-Moirón, BSc 51.1±8.2 years. Participants wore the used to improve the symptomatol-
Inmaculada C. Álvarez-Gallardo, BSc SWA for 9 consecutive days and filled ogy of the disease (7-9). Several stud-
Francisco B. Ortega, PhD in the IPAQ twice (separated by a ies have shown the benefits of regular
Jonatan R. Ruiz, PhD 9-day interval). Total PA, time spent physical activity (PA) on pain, as well
Manuel Delgado-Fernández, PhD on moderate and vigorous intensity PA, as on body composition, physical fit-
Please address correspondence to: and sitting time assessed by the IPAQ ness (10, 11), flexibility (12), psycho-
Víctor Segura Jiménez, and the SWA (n=123) were compared. logical outcomes (13) and global well-
Department of Physical Education
and Sports, Faculty of Sport Sciences,
Results. Time spent on PA at different being (14) in fibromyalgia patients.
University of Granada, intensities (total, moderate and vigor- Accelerometers are now extensively
Carretera de Alfacar, s/n, ous) was higher and sedentary time used in research focused on measur-
18011 Granada, Spain. was lower when assessed by the IPAQ ing PA. A wearable body-monitoring
E-mail: vsegura@ugr.es compared with the SWA (all pObjectively and subjectively measured physical activity in FM women / V. Segura-Jiménez et al.
problems (attention, working memory, ics Committee of the Hospital Virgen tion/concentration, delayed recall and
long-term verbal memory and spatial de las Nieves (Granada, Spain). language.
memory) (28, 29) and bipolar disor- International Physical Activity Ques-
ders (30) associated to fibromyalgia Procedures tionnaire is used internationally to
can distort or alter the fibromyalgia pa- The participants visited the laboratory obtain comparable estimates of PA
tients’ perception about their PA levels. twice. At the first visit, the tender points at population level (21). The original
Even the nature of fibromyalgia symp- count and the weight and height were questionnaire was developed for adults
toms itself (widespread pain, physical measured. The MMSE, demographic aged 18–65 years (21). The long form
function impairments, reduced PA, data and the IPAQ were also completed of the IPAQ includes 27 items that
tiredness, fatigue, depression, etc.) (5, and the completion time was record- identify the frequency (times per week)
31) might also alter the own percep- ed. Participants were asked to wear a and duration (minutes or hours per day)
tion of PA levels. Taken together, this SWA for 9 consecutive days, starting of PA performed in different domains
may negatively affect the accuracy of the same day they received the moni- of PA in the last seven days: occupa-
self-reported PA. Therefore, whether tor. They were instructed to wear the tion, transportation, housework, house
self-report measures such as IPAQ are SWA on their arm attached by an elastic maintenance and family care, recrea-
adequate to assess PA in fibromyalgia belt during full day as well as sleeping tion, sport and leisure, and time spent
people is uncertain. The aims of the hours. For security reasons, participants sitting in a weekday and in a weekend
present study were: i) to compare PA were asked to take them off while bath- day. To adapt the questionnaire to our
assessed by the IPAQ with PA meas- ing. Participants had the second visit study population, two items were add-
ured by the SWA (objective measure) with 9 days interval for completing the ed about time spent lying as an indica-
in Spanish women with fibromyalgia; IPAQ (retest) and they also returned the tor of sedentary behaviour. Sitting and
ii) to study the test-retest reliability of SWAs to the researchers. lying were summed and combined as
the IPAQ in Spanish women with fibro- total sitting time. For all PA domains,
myalgia. Measures participation in vigorous and moder-
Tender points count. We assessed 18 ate intensity PA was obtained. Seden-
Materials and methods tender points according to the ACR cri- tary time was set as sitting plus vehicle
Participants teria for classification of fibromyalgia transport time. There are no cultural as-
An invitation to participate in this study (2) using a standard pressure algometer pects to be acknowledged when using
was sent to all people from two local (FPK 20; Effegi, Alfonsine, Italy). The the Spanish version of the IPAQ.
Associations of fibromyalgia patients total count of positive tender points One Metabolic Equivalent (MET) is
from Granada and Seville (Southern was recorded for each participant. the amount of oxygen consumed while
Spain). A total of 243 potentially eligi- Fibromyalgia Impact Questionnaire sitting at rest and is equal to 3.5 ml
ble patients were willing to participate (FIQ) comprises 10 subscales of dis- O2·kg-1·min-1 and 1 kcal·kg–1·hr–1 as
in the study and gave their written in- abilities and symptoms (physical func- the caloric equivalent for adults (34).
formed consent after receiving detailed tion, work missed day, job ability, feel PA intensities were set according to the
information about the aims and study good, pain, fatigue, sleep, stiffness, IPAQ guidelines: moderate intensity as
procedures. Participants were excluded anxiety and depression) and has previ- 4 METs, vigorous intensity as 8 METs,
from the analysis if they did not meet ously used and validated for Spanish and walking as 3.3 METs. Total day PA
the American College of Rheumatol- fibromyalgia patients (33). The total (MET-min/day) was computed by mul-
ogy (ACR) criteria: widespread pain score ranges from 0 to 100. A higher tiplying METs by minutes of partici-
for more than 3 months, and pain ≤4 score indicates a greater impact on the pation in the specific category of PA,
kg/cm2 of pressure reported for 11 or person’s life. and divided by 7 days. Sitting was ex-
more of 18 tender points (2); had acute Body Mass Index (BMI). We measured pressed as min/day. The methods used
or terminal illness; had severe demen- weight (kg) with an eight-polar tactile- to score the long-IPAQ can be found on
tia (Mini-Mental State Examination electrode impedanciometer (InBody the IPAQ website (www.ipaq.ki.se).
(MMSE)Objectively and subjectively measured physical activity in FM women / V. Segura-Jiménez et al.
Table I. Clinical and sociodemographic at the midpoint between the acromion subjective (IPAQ) measures of PA fol-
characteristics of fibromyalgia women, and olecranon processes. Nine days lowing the Bland-Altman method (38).
n=183. of consecutive data were collected. The association between the mean dif-
Variable n % Energy expenditure was computed at ference and the magnitude of the meas-
1-minute intervals. Data obtained us- urement (i.e. heteroscedasticity) was
Tender points count, mean (SD) 17.3 (1.6) ing the SWA were downloaded using examined by conducting regression
FIQ, mean (SD)* 64.6 (18.6)
software developed by the manufactur- analysis after inverting negative data.
Body mass index* 28.2 (5.3)
MMSE, mean (SD) 28.2 (1.9) er (SenseWear Professional software We calculated the mean difference,
Age (years) version 6.1a). 95% confidence intervals (CIs) of the
≤50 72 39.3 The first and last days of recording difference, and the 95% limits of agree-
>50 111 60.7 were not included in the analysis to ment (mean difference ± 1.96 standard
Years since clinical diagnosis* minimise reactivity. We excluded from deviation (SD) of the differences).
≤5 years 82 45.3
the analyses data with less than 7 days We studied the test-retest reliability of
>5 years 99 54.7
of collection and a threshold of 95% the IPAQ with a paired t-test. We also
Marital status
Married 149 80.9 “on-body” time was used to include an calculated the SD of the mean differ-
Unmarried 18 9.8 individual in the data analysis. Sleep- ences, the 95% CIs for the mean dif-
Separated / Divorced / Widowed 17 9.3 ing time was removed from analysis. ference, the 2-way mixed average
Educational status* We set the PA levels as follows: measures intraclass correlation coeffi-
Unfinished studies 12 6.6 a) total PA, expressed as a measure cient (ICC) (39), 95% of CIs for ICC,
Primary school 88 48.4
Secondary school 47 25.8 of overall PA; and time engaged in b) the standard error of the measurement
University degree 35 19.2 sedentary, c) moderate, and d) vigorous (SEM) (40), and the intra-individual
Occupational status* intensity PA based upon the IPAQ cut- SD (41). The agreement between test
Working 62 39.5 off of 6 METs per minute, and retest was also studied following
Unemployed 64 40.8
respectively. the Bland-Altman method (38) as de-
Retired 31 19.7
scribed above. All analyses were per-
Values are n and % unless otherwise indicated. Statistical analysis formed using the Statistical Package
SD, standard deviation. *Missing data. The difference between the objective for Social Sciences IBM-SPSS, ver-
and subjective measures of PA was sion 20.0 for Windows, and the level of
temperature, near-body temperature) calculated by means of paired t-test. significance was set at pObjectively and subjectively measured physical activity in FM women / V. Segura-Jiménez et al.
Table III. Concordance correlation coefficient (rc) and Pearson correlation coefficient (rp) Figure 1 shows the Bland-Altman plot
for total physical activity (PA) and time spent on PA intensities from the International Phys- for inter-method agreement between
ical Activity Questionnaire (IPAQ) and the SenseWear armband (SWA), n=123. the IPAQ and the SWA. The mean dif-
IPAQ (min/day) SWA (min/day) rc rp PPearson ference (SD) for total PA, vigorous
intensity PA, walking time and moder-
Sitting Sedentary -0.01 -0.12 0.18 ate plus walking time from the IPAQ
Sitting + Transport Sedentary -0.02 -0.11 0.22 and SWA was -211 (265), -23 (68), 33
Moderate Moderate 0.03 0.06 0.54 (108) and -188 (237) min/day, respec-
Moderate + Walking Moderate 0.04 0.13 0.16 tively (all pObjectively and subjectively measured physical activity in FM women / V. Segura-Jiménez et al. Table IV. Test-retest agreement and measurement errors for the International Physical Activity Questionnaire (IPAQ), n=183. Mean test Mean retest Mean 95% CI Mean Intra- SEM ICC 95% CI Coefficient (SD) (SD) difference (SD) difference individual ICC of (SD) Repeatability IPAQ, total score (MET/day) 924 (874) 1172 (1198) -249 (90)*** -380; -117 2378 639 0.77 0.70; 0.83 1299 Sitting (min/day) 318 (174) 314 (167) 4 (167) -21; 28 35 118 0.68 0.58; 0.76 232 Vehicle (min/day) 45 (64) 43 (67) 2 (75) -9; 13 19 53 0.52 0.35; 0.64 104 Walking (MET/day) 280 (364) 326 (422) -46 (374) -101; 8 441 265 0.71 0.61; 0.78 523 Moderate (MET/day) 500 (439) 634 (621) -134 (608)** -222; -45 1277 430 0.53 0.37; 0.65 863 Vigorous (MET/day) 144 (395) 198 (581) -54 (366)* -107; 0 513 259 0.84 0.79; 0.88 513 Working (MET/day) 202 (554) 352 (936) -149 (656)** -245; -54 1430 464 0.78 0.70; 0.83 932 Active Transport (MET/day) 142 (221) 152 (237) -11 (256) -48; 27 103 181 0.55 0.39; 0.66 355 Domestic (MET/day) 415 (353) 483 (484) -68 (443)* -132; -3 648 313 0.62 0.50; 0.72 621 Leisure (MET/day) 158 (231) 185 (229) -27 (256) -64; 10 257 181 0.55 0.40; 0.67 357 Differences between the test and retest from the IPAQ tested for physical activity using a t-test. *p
Objectively and subjectively measured physical activity in FM women / V. Segura-Jiménez et al.
Fig. 2. Bland-Altman plot for test-retest agreement for the International Physical Activity Questionnaire (IPAQ).
morbid fibromyalgia. This perception greater variability in their manner of SWA in the present study suggests that
might manifest in an overestimation self-report than healthy controls (42). the IPAQ fail to adequately capture PA
of the PA performed (51). Moreover, Therefore, the absence of a significant behaviours in fibromyalgia patients.
fibromyalgia patients may also have a relationship between the IPAQ and the The present study did not show over-
S-99Objectively and subjectively measured physical activity in FM women / V. Segura-Jiménez et al.
all satisfactory test-retest reliability Otherwise, our sample population was 4. MUNGUIA-IZQUIERDO D, LEGAZ-ARRESE
A: Exercise in warm water decreases pain
for the IPAQ domains. The mean dif- between 23 to 64 years old, which is
and improves cognitive function in middle-
ference was low for sitting, vehicle, the same as for whom the IPAQ was aged women with fibromyalgia. Clin Exp
walking, active transport and leisure designed and which strengthens de va- Rheumatol 2007; 25: 823-30.
activities from the IPAQ. Despite we lidity of our results. The SWA is a valid 5. SILVERMAN SL, HARNETT J, ZLATEVA G,
MARDEKIAN J: Identifying fibromyalgia-
obtained ICC values from 0.52 to 0.84 device to measure PA in people with fi- associated symptoms and conditions from a
in all domains and PA intensities, total, bromyalgia (20). General criticisms of clinical perspective: a step toward evaluating
moderate and vigorous PA, and work- belt-mounted PA monitors include the healthcare resource utilization in fibromyal-
ing and domestic domains showed sig- inability to detect arm movements and gia. Pain Pract 2010; 10: 520-9.
6. IANNUCCELLI C, SPINELLI FR, GUZZO MP
nificant test-retest mean differences, so load work performed by pushing, lift- et al.: Fatigue and widespread pain in sys-
that we did not accept the good reliabil- ing, or carrying objects. The SWA may temic lupus erythematosus and Sjögren’s
ity of the instrument in these specific solve these issues through heat produc- syndrome: symptoms of the inflammatory
PA intensities and domains. Kaleth et tion measurements and placement on disease or associated fibromyalgia? Clin Exp
Rheumatol 2012; 30 (Suppl. 74): S117-21.
al. (43) showed low reliability of the the upper arm. The quality of the SWA 7. IANNUCCELLI C, MANNOCCI F, GUZZO MP
IPAQ short-form in a smaller sample data (7 consecutive valid days) was an et al.: Complementary treatment in fibromy-
(n=28) of patients with fibromyalgia important strength of our study. The algia: combination of somatic and abdominal
than ours (n=183). Furthermore, they absence of a men sample did not let us acupuncture. Clin Exp Rheumatol 2012; 30
(Suppl. 74): S112-16.
only provided the ICC as a reliability know whether these findings apply to 8. SEGURA-JIMENEZ V, CARBONELL-BAEZA
measure, whereas we provided a great- men, so future studies should analyse A, APARICIO VA et al.: A Warm Water Pool-
er number of reliability measures. Spe- the validity and reliability of the IPAQ Based Exercise Program Decreases Immedi-
ate Pain in Female Fibromyalgia Patients:
cifically the use of the SEM (together in men with fibromyalgia.
Uncontrolled Clinical Trial. Int J Sports Med
with the ICC) has been highly recom- In conclusion, the present study showed 2013; 34: 600-5.
mended (40). This measure provides an that the IPAQ is not comparable with a 9. CARBONELL-BAEZA A, RUIZ JR, APARICIO
absolute index of reliability, unlike the multi-sensor armband accelerometer VA et al.: Land- and water-based exercise
intervention in women with fibromyalgia:
ICC which is a relative measure of reli- (SenseWear Pro3 Armband) and is not the al-andalus physical activity randomised
ability (40). Other researches with dif- a reliable tool to assess PA in women controlled trial. BMC Musculoskelet Disord
ferent study populations showed that with fibromyalgia. The results suggest 2012; 13: 18.
the IPAQ short-form seems not to be that the IPAQ overestimates PA. The 10. CARBONELL-BAEZA A, APARICIO VA, ORTE-
GA FB et al.: Does a 3-month multidiscipli-
a good indicator of PA behaviour (52- instrument reported acceptable test-re- nary intervention improve pain, body com-
54). Previous studies examining the test reliability in sitting, vehicle, walk- position and physical fitness in women with
reliability of IPAQ showed reliability ing, active transport and leisure activi- fibromyalgia? Br J Sports Med 2011; 45:
coefficients greater than 0.70 (21, 23, ties; but not in the total PA score, mod- 1189-95.
11. CARBONELL-BAEZA A, APARICIO VA, MAR-
55-58), whereas other studies showed erate and vigorous intensity, as well as TINS-PEREIRA CM et al.: Efficacy of Biodan-
low reliability coefficients (25, 59, 60). working and domestic domains. za for treating women with fibromyalgia. J
The heteroscedasticity observed in the Altern Complement Med 2010; 16: 1191-200.
Bland-Altman plots of the IPAQ test- Acknowledgments 12. CARBONELL-BAEZA A, ROMERO A, APA-
RICIO VA et al.: Preliminary findings of a
retest suggested that the reproducibil- We would like to thank the researchers 4-month Tai Chi intervention on tenderness,
ity of the data decreased as the amount for the CTS-545 research group and we functional capacity, symptomatology, and
of reported time in a specific domain also acknowledge the AGRAFIM (as- quality of life in men with fibromyalgia. Am
J Mens Health 2011; 5: 421-9.
(vehicle, walking, active transport and sociation of fibromyalgia from Grana-
13. ROMERO-ZURITA A, CARBONELL-BAEZA A,
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