The Dosing of Aerobic Exercise Therapy on Experimentally-induced Pain in Healthy Female Participants.
Phase: NA
Conditions: Pain
Sponsor: Duquesne University

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Title Page: 
Study Protocol 
Managing Pain: Testing the dosing and social aspects of exercise therapy using a multi-
school collaborative approach with human participants. 
NCT number not available 
6/2/16 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Protocol Summary Form 
Managing Pain: Testing the dosing and social aspects of exercise therapy using a multi-
school collaborative approach with human participants. 
 
1. 
Statement of the research question 
What is the effect of exercise dose and social interactions on the ability of exercise to reduce 
acute pain in healthy human participants? 
2. 
Purpose and significance of the study 
Chronic pain is a serious problem in the US that affects 116 million adults1. Chronic pain 
(e.g. fibromyalgia, chronic lower back pain) can be linked both epidemiologically and biologically 
with major depressive disorder (MDD) and various anxiety disorders.  Rates of MDD, 
depressive, or anxiety symptoms in patients with chronic pain are very high (13-82%)2,3.  As 
such, the treatment options for patients with pain AND behavioral abnormalities have focused 
on agents that target this comorbidity. One type of non-pharmacologic therapy that has shown 
promise in chronic pain is exercise. Regular physical activity and exercise improves many 
aspects of a person’s general health, including cardiorespiratory function, mental health, and 
pain. Despite the purported benefits of exercise, 1 in 3 Americans are sedentary and do not 
meet the activity guidelines developed by the Surgeon General4 (moderate intensity exercise, 
30 minutes per day, 5 days per week). Sedentary behaviors are more prevalent in persons with 
chronic pain. Exercise therapy is an attractive therapy for chronic pain because of its low cost 
and ability to reduce sedentary behavior, depression, and pain5,6,7. One of the challenges at 
both the research and clinical level in implementing exercise as a therapy are the numerous 
variables inherent in prescribing exercise to patients with pain which include the best dose of 
exercise and social anxiety surrounding exercise. Walking has been emphasized because it is 
an easy exercise that most people can accomplish without special equipment or training.  The 
2008 Physical Activity Guidelines4 suggest that even light physical activity is better than none for 
improving health.  Especially for those persons with chronic pain, it may be most beneficial to 
begin a physical activity exercise protocol at a lower intensity and/or dose and increase physical 
activity as tolerated. Before a recommendation of low-dose or low-intensity exercise can be 
made, it is necessary to determine if physical activity at these lower levels will also provide the 
benefit of exercise-induced analgesia.  
In this study we will examine the effect of dose related to exercise therapy for pain in 
healthy adult humans. We will be using an acute pain model to study the effect of exercise dose 
on pain. Acute pain models are currently used to study pain (both acute and chronic) in human 
samples as there is currently no chronic pain model.  
We hypothesize that therapy done at a low dose will produce the best cost-to-risk ratio 
for patients.  
 
3. 
Research design and procedures 
This study is designed as a randomized controlled trial with repeated measures.  
Aim – the effect of exercise dose on pain: subjects will be randomly assigned to one of 
four exercise groups: 1.) no exercise (control); 2.) low dose exercise (3x/week); 3.) moderate 
dose exercise (5x/week); 4.) high dose exercise (10x/week). 
The co-primary investigators (co-PI’s) will be involved in the procedures listed below. 
Graduate research students will assist with recruitment, data collection, and data processing. A 
PhD student in the Biology department (Anna Polaski) will assume primary responsibility for 
data collection. The graduate students will be trained on all procedures involved in this study by 
the co-PI’s. Prior to data collection, the prospective subjects will complete a full screening, using 
a checklist of the inclusion/exclusion criteria and the PAR-Q and AHA health questionnaires 
(see Instruments) to determine eligibility. The purpose of the study, the methods of data 
collection and all potential risks will be verbally communicated to prospective subjects at the 

initiation of the first data collection session (Day 0) (Figure 1). Prospective subjects will be given 
an approved informed consent form to read and sign. Subjects will then complete the 
International Physical Activity Questionnaire long form (IPAQ-long) to assess baseline level of 
daily physical activity and the Social Interaction Anxiety Scale (SIAS) for a measure of 
participant’s anxiety. The researcher will explain the questionnaires to subjects and will be 
available to answer any questions while the subjects complete these forms. Basic health 
information obtained from the subject will assess whether the subject has been diagnosed with 
any cardiac, respiratory, neurological or musculoskeletal disorder, chronic pain or currently has 
acute pain.  Subjects who report any of the above medical diagnoses or pain during screening 
will be excused from participation in the study, but will receive compensation for attending the 
screening session. Any identifying information used to determine eligibility, including the 
checklist of inclusion/exclusion criteria and the health questionnaires, will be destroyed.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Subjects will then be set-up for training on the exercise protocol, physical pain measures 
and pedometer use. Subjects will become familiarized with the exercise protocol, including the 
physiological measures to be assessed [heart rate (HR)], the Borg Rate of Perceived Exertion 
(RPE) Scale, and the treadmill speed at which they will be walking (3.5mph). Typical walking 
speed to engage in moderate intensity physical activity (3-5.99 METs) is a brisk pace of 3-4 
mph and anticipated activity heart rate will be 60% of age-adjusted maximal heart rate8. The 
subject will walk on the treadmill for 5 minutes to become comfortable with the exercise 
procedure. Subjects will be instructed to step up onto the treadmill and stand on the sides not 
the belt or belt deck. The researcher will slowly raise the speed to 2 mph. The subject will be 
instructed to step on the treadmill at this time. After 30 seconds, the speed will be ramped up to 
2.5 mph and after another 30 seconds, the speed will be ramped up to their prescribed session 
speed. They will also be instructed to walk with a natural gait pattern, allowing bilateral arm 
swing. To allow a natural arm swing, subjects are unable to hold onto the treadmill arm rails.  
Subjects will be introduced to the Borg RPE scale and asked to provide subjective feedback on 
their level of exertion at the initiation of and during the final minute of this 5-minute training 
period. Subjects will be given a standard pedometer and instructed to wear it on their wrist 
during all hours (except showering/bathing) for the 6 consecutive days during the week in which 
they participate in data collection. The digital screen will be covered as awareness of daily step 
counts may influence participant’s normal daily physical activity. Subjects will be given an 
instruction sheet for testing sessions and pedometer use.   
During the enrollment period subjects will also be given a full description of all sensory 
and pain measures that will be taken.  With initial consent, all subjects will be allowed to 
experience all sensory/pain measures before full enrollment. All sensory and pain assays are 
Figure 1: Study Design. 
Subjects will be randomly 
assigned to the control, 
low- dose exercise, or 
high-dose exercise group. 
Intervention will occur on 
Days 1-5 depending on 
group assignment. 
Assessment of physical 
and pain measures occurs 
on Days 1, 3, 5, and 6. 
  Intake (Day 0)  
Baseline pain testing 
  Intervention  
(Days 1-5) 
  
Assessment 
(Days 1, 3, 5, & 6) 
  Exercise 
Groups 
  Healthy human 
subjects  
  High  
dose
  Pain 
measures 
  Pain 
measures 
  Pain 
measures 
  Pain 
measures 
  Low 
dose
  
Moderate 
dose 
  No 
exercise 
  Control  

based on well-established assays used in both healthy human participants and patients with 
chronic pain9.  All assays involve either innocuous (non-painful stimuli) or acute noxious stimuli 
(painful stimuli) that do not damage tissue. Time between different tests will be >5 min to allow 
the subject to rest. Timing of testing on experimental days will be 5 minutes and 30 minutes 
following the completion of exercise or 30 minutes of rest (for control subjects and for all 
subjects on day 6).  For all testing days order will proceed in the following manner. Training and 
description of each measure is as follows: 
 
Cutaneous mechanical sensitivity assay10: Enrolled participants will be asked to sit in a chair 
(chair provided with arm-rests). Assay involves determining the sensitivity threshold for 
innocuous cutaneous stimulation.  Stimulation is provided with standard sensory evaluator 
filaments (see equipment section below for image of filament). These are small nylon filaments 
each apply a single force (ranging from 0.008gram to 1.0gram). Before the start of the first 
experimental trial, subjects will be allowed to feel and manipulate the filaments. Starting with the 
smallest filament (0.008g; below the sensory threshold for human detection), 5 trials will be 
directed at the subject’s forearm. During testing, subject is asked to look away from their 
forearm/calf.  Experimenter will ask “Can you feel this” while the experimenter applies the 
filament to the subject’s forearm or calf.  With each filament, the experimenter will apply the 
filament 3 times in the “positive” trials. For the other 2 trials, the experimenter will not apply the 
filament but ask the subject, “Can you feel this?” These 2 “negative” trials will be randomly 
inserted with the 3 “positive” trials and are designed to test for false responses.  If a subject 
detects >2 of the positive trials and 0 negative trials for a filament, that force will be the subject’s 
“mechanical sensory threshold.” For a single filament, if the subject detects <2 of the real trials 
and/or >0 of the false trials, the experiment will start another round of 5 trials with the next 
biggest filament until the sensory threshold is reached. Typical testing time for each body part 
(forearm and calf) is about 5 minutes. 
 
Radiant heat sensitivity assay11:  Assay involves determining the sensitivity threshold for 
painful thermal stimulation. Stimulation is provided with a radiant heat device11. This device 
uses a focused light beam to slowly heat a subject’s skin. Before the start of the training/ 
experimental trials, subjects will be shown device and allowed to feel the stimulus with their 
hand.  Subject will be asked to rest their forearm or calf on a room temperature glass plate.  
Using a mirror, the light source will be positioned under a marked area on the subject’s forearm 
or calf. Subjects are told to raise their leg or arm when they feel the stimulus transition from 
“innocuous warmth or heat” to “painful heat.” When the leg or arm is raised from the surface of 
the glass, the thermal stimulus automatically stops and the time since the beginning of the trial 
is recorded as “latency to respond.” Each trial lasts for a maximum of 20 seconds. The device is 
set so that typical withdrawal thresholds occur at approximately 10 seconds into the trial.  The 
temperature on the glass at this point is ~47oC (121oF).  The maximum temperature of the trial 
at the 20 second cutoff time point is 50oC which is well below the temperature that causes tissue 
damage in humans. For each limb, two trials will be completed in two distinct marked areas to 
avoid re-testing at a single site. Total testing time (2 trials on forearm and 2 trials on calf) is <5 
minutes. 
A second assay will be used to evaluate the quality and unpleasantness of thermal pain.  
Each subject will receive a constant 45oC stimulus. 45oC is a standard temperature that is the 
typical minimal stimulus necessary to feel thermal pain. Stimulus (3cm x5cm heating block) will 
be applied for 3 seconds. Immediately following stimulus, the subject will be asked to evaluate 
the intensity and unpleasantness of the pain. This is done with a standard 0-10 visual analog 
scale (VAS). On the “intensity scale”, “0” is represented as “no pain” and “10” is represented as 
“the worst pain imaginable.” On the “unpleasantness scale”, “0” is represented as “not 
unpleasant” and “10” is represented as “the most unpleasant sensation imaginable.”  

Example instructions for intensity VAS – “Please use the scale below to tell us how 
intense your pain is.  Place an “X” on the scale that best describes the intensity of your pain.”  
Example instructions for unpleasantness VAS – “Now that you have told us about the 
physical quality of the pain, we want you to tell us overall how unpleasant your pain is to you.  
Words used to describe very unpleasant pain include “miserable” and “intolerable.”  Remember, 
pain can have a low intensity, but still feel extremely unpleasant, and some kinds of pain can 
have a high intensity but be very tolerable.  With this scale, please tell us how unpleasant your 
pain feels.” 
 
Mechanical pressure sensitivity assays10,12:  Assay involves determining the sensitivity 
threshold for painful pressure stimulation and then determining the quality and unpleasantness 
of that same pressure in a separate trial. Stimulation is provided with a standard clinical 
pressure algometer (see below instrument section). This device consists of a 0.5-2cm probe 
connected to a pressure meter. The probe is placed on the subject’s forearm or calf and 
pressure is gradually applied. Before the first training/experimental trial subjects will be allowed 
to apply the stimulus to themselves. During a trial, pressure will gradually be applied until the 
stimulus transitions from “innocuous pressure” to “painful pressure.” At this point, subject will 
say “stop” and the stimulus will be removed from the subject’s forearm/calf. When algometer is 
removed from the subject, the greatest pressure applied is automatically recorded in the device.  
This is the “pressure pain threshold” for the trial. 2 trials will be applied each to the forearm and 
calf in two distinct sites (on each limb) to avoid damage to a single area. After the pressure 
threshold has been determined for a subject, 1 additional trial on each limb will be applied (in a 
third testing site).  In this trial, the subject will be asked to evaluate the intensity and 
unpleasantness of a pressure stimulus given for 3 seconds. This is done with a standard 0-10 
visual analog scale (VAS). On the “intensity scale”, “0” is represented as “no pain” and “10” is 
represented as “the worst pain imaginable.” On the “unpleasantness scale”, “0” is represented 
as “not unpleasant” and “10” is represented as “the most unpleasant sensation imaginable.”  
During this trial, the experimenter will tell the subject that they are going to apply a painful 
stimulus to the subject and then ask the subject to evaluate that pain (on the two VASs).  The 
exact stimulus will be matched to the subject’s pain threshold determined during the baseline 
trials (e.g. if baseline trials for forearm indicated a pressure threshold of 50 N then subject will 
be asked to evaluate the pain of that stimulus). During subsequent testing days (days 1, 3, 5, 6), 
the pressure pain threshold will be re-measured to determine if there is a change from baseline.  
For the intensity/unpleasantness testing, subjects will be tested on experimental days 1, 3, 5, 6 
at their original baseline pressure threshold (from day 0) AND the threshold determined on each 
individual day. This will allow an analysis of change from baseline and pain at threshold for each 
experimental day. 
Procedures: Following the screening and training session, subjects will be randomized to one of 
four conditions (Control, Low Frequency of Exercise, Moderate Frequency of Exercise, and High 
Frequency of Exercise) and scheduled for their exercise and data collection sessions (Figure 1). 
Subjects in the control group will be scheduled for three experimental sessions within a five-day 
period: Days 1, 3, and 5. Control subjects will complete all of the physical and sensory/pain 
tests following a 30-minute period of rest (no physical activity) on each of these days. These 
subjects will be set up in a private room with various reading materials during this time period. 
Subjects in the low frequency of exercise group will be scheduled for three exercise sessions 
within a five-day period: Days 1, 3, and 5. Subjects in the moderate frequency exercise group 
will be scheduled for five exercise sessions within a five-day period: Days 1-5. Subjects in the 
high frequency exercise group will be scheduled for ten exercise sessions within a five-day 
period: Days 1-5. For all subjects, physical and sensory/pain measures will be taken on exercise 
days 1, 3, and 5, 5 and 30 minutes after exercise, and also on Day 6 (no exercise).  
 

Exercise Session  
Subjects will arrive at the Health Science Exercise Physiology Lab on their scheduled 
exercise days. Sessions will be scheduled at the same approximate time each day to control for 
factors that may influence exercise performance. At the initiation of each exercise session, HR 
measures will be taken. At the initiation of the session on days 1, 3, and 5, pain measurement 
will be made using the 3 assays described in detail above. For each assay, pain will be 
individually defined on a 0-10 visual analog scale (VAS), a common scale used in human pain 
testing13. Each assay is safe and produces only mild escapable acute (<1 min) pain. Pain 
measurements will be completed on both the calf and volar non-dominant forearm for each 
subject. On days 2 and 4 for subjects in the moderate frequency and high frequency of exercise 
group, sensory and pain measures are not collected. 
The heart rate monitor will be strapped to the subjects’ chest to monitor HR throughout 
the exercise session. The purpose of monitoring HR is two-fold: 1.) to ensure the subject is 
working at a moderate level of intensity, and 2.) to ensure the subject is safely participating in 
physical activity with no abnormal or adverse changes in HR. Subjects will provide a rating of 
their perceived exertion on the Borg RPE scale before beginning the exercise task. Subjects will 
then be set-up to begin walking on the treadmill. Subjects will be reminded of the instructions for 
how to step onto the treadmill and the process for ramping up the speed as described in the 
training session. Once walking on the treadmill at the prescribed speed, subjects will be 
instructed to walk until the researcher returns (30 minutes). Subjects will be told that they can 
stop walking if they become excessively fatigued (≥17 on the Borg RPE scale) or experience 
symptoms of overexertion, such as lightheadedness and excessive sweating. The Borg RPE 
scale will be positioned in front of them for a visual reminder of the fatigue scale and the 
treadmill safety key will be secured to the subject’s shorts. After 30 minutes, the researcher will 
return to the room. At this time, perceived exertion on the Borg RPE scale will be assessed 
again. The researcher will then slow the treadmill speed down to approximately 2 mph for a 2-
minute cool-down. Pain measures will be completed as described above following completion of 
the treadmill walking at 5 minutes and 30 minutes.  
Subjects will perform their exercise session alone, with no close supervision by study 
staff. To ensure safety during exercise, the subject will be monitored with 2 wireless video 
cameras. Camera 1 will be focused on the subject to visually observe the subject’s performance 
and ensure there are no visual signs that the subject is over-exerted. Camera 2 will be focused 
on the treadmill interface to monitor real-time HR and ensure the subject does not adjust the 
speed. Video recordings from the cameras will not be saved and is only used to monitor the 
subject’s physical response to exercise. Subjects will be unaware that they are being monitored 
via camera. All subjects will return on Day 6 to complete a final round of pain/sensory testing.  
 
4. 
Instruments 
Screening Questionnaires 
PARQ and You will be used to determine if a participant is not healthy enough to participate in 
the study due to a presence of a heart conditions, chest pain, dizziness, joint problems, and 
drug use.  
AHA/ACSM Health Fitness Facility Preparticipation Screening Questionnaire collects past 
medical history, current health issues, and cardiovascular risk factors that would indicate 
exclusion from participation.  
 
Physical performance  
For all conditions, we will evaluate daily normal physical activity and intensity with a 
pedometer.  
The International Physical Activity Questionnaire long version14 (IPAQ-long) will be used 
to obtain estimates of weekly physical activity. Based on subjects’ responses, the total energy 

expenditure for participation in different physical activities can be calculated. The total energy 
expenditure is used to categorize subjects based on the amount of vigorous, moderate, or low 
intensity activity they engage in.     
The Borg RPE scale15 is used to collect a subjective measure of fatigue. The Borg RPE 
scale ranges from 6 (no exertion at all) to 20 (maximal exertion). This scale is based on 
expected heart rate during minimal, moderate, and vigorous intensity exercise. A subject who 
rates their exertion level as a 12 on this scale is working at a moderate intensity and should 
have a heart rate of 120 beats per minute (12 x 10). 
All exercise sessions will be monitored using two wireless cameras (Dropcam Wireless 
Video Camera) to avoid influence of social observation while continuing to monitor subject’s 
performance and physiological measures (HR) of exercise. Video will be transmitted via a 
secure Wi-Fi signal to a university-owned laptop computer. Either a PI or graduate student will 
view the real-time video to ensure subject’s safety and continued optimal performance. Video 
will be transmitted via secure wireless signal to ensure confidentiality. 
 
Pain measures –As described above, the three tests are for tactile sensitivity, thermal pain, and 
pressure pain.   
 
Cutaneous Stimulators –  
For cutaneous mechanical sensation, we will use standard von Frey 
filaments (Touch Test Sensory Evaluators; North Coast Medical).  These filaments 
(ranging from 0.008g to 1.0g) are used to measure threshold for sensation to 
innocuous stimulation. See above for full description of assay.   
 
Radiant Heat –  
For radiant thermal heat measurements, we will use a standard “Hargreaves” 
apparatus (IITC Thermal Stimulus Apparatus) (see image to right).   
 
 
Pressure Algometer –  
For pressure pain testing, we will use a standard mechanical 
pressure algometer (Wagner Instruments). 
 
 
Anxiety measures   
All groups will be assessed for anxiety with questionnaire methods using the Social 
Interaction Anxiety Scale (SIAS)16. The SIAS measures anxiety with respect to social 
interactions. It is one of the more often-used self-report measures of social anxiety, with 
numerous evidence-based studies demonstrating its reliability and construct validity17. The SIAS 
contains 20 items which are rated from 0 (not at all characteristic or true of participant) to 4 
(extremely characteristic or true of participant). Items are self-statements describing one's 
typical cognitive, affective, or behavioral reaction to a variety of situations requiring social 
interaction in dyads or groups (e.g., going to a party, talking to an attractive member of the 
opposite gender, expressing one's feelings).  
 
5. 
Sample selection and size 
Healthy adults will be recruited for participation in this study. The PAR-Q and You form and the 
AHA screening questionnaire will be administered during the screening process to determine 
whether potential subjects meet the inclusion/exclusion criteria. 
 
Inclusion criteria include:  

• 
Between age 18-40  
• 
Normal BMI (18.5-25)   
• 
HR 60 to 100 
• 
BP less than or equal to 140/90 
*HR and BP will be taken as part of the screening process to determine eligibility and 
also taken at the beginning of each exercise session. 
Exclusion criteria include as indicated by the PAR-Q and You and AHA screening forms: 
• 
Age less than 18 or greater than 40 years 
• 
Cardiac, respiratory, neurological or musculoskeletal disease  
• 
Acute pain  
• 
Chronic pain condition  
• 
Diabetes 
• 
BMI ≥ 25.1 or ≤ 18.4  
• 
Regular participation in high intensity athletic/sporting activities 
• 
Sedentary 
• 
Anxiety or depression disorders.   
• 
Tape allergy 
• 
Currently pregnant 
 
A power analysis of pain outcome indicates that a minimum of 10 people/condition will be 
sufficient to detect statistical differences in our primary dependent variable (pain sensitivity), but 
to account for variability, our recruitment goal is 15 people/condition.  When 10 participants per 
group have completed the study, a preliminary analysis will be conducted for statistical power, if 
we reach 0.80, recruitment will stop. 
 
6. 
Recruitment of subjects 
Participants will be recruited using flyers and announcements in class. Students, staff, 
and faculty from Duquesne University will be invited to participate in this study.  All recruitment 
efforts are expected to take place on the campus of Duquesne University. Student recruitment 
will include announcements made at the beginning of class time. After securing approval of a 
course’s instructor, a general announcement describing the study will be made to students in 
the class. The purpose, procedures, and inclusion/exclusion criteria will be briefly described. A 
hand-out further detailing the study with the PI’s contact information will be given. Students will 
be asked to contact the PI for a more detailed explanation if interested in participating in this 
study. A flyer detailing the study and with the PI’s contact information will be displayed within the 
Health Sciences Building and other campus buildings in student areas and faculty/staff areas. 
These recruitment methods will maintain confidentiality of potential subject information and limit 
coercion. 
When prospective subjects contact the PI, the PI will conduct a brief eligibility screening 
then invite eligible subjects to enroll. Prior to participation, the subject’s BP and HR will be taken 
as well. Should a potential participant be disqualified, screening forms, the checklist, and any 
identifying information will be destroyed. Recruitment and enrollment will be conducted without 
regard for gender, race or ethnic background. Participation in this study will not affect a 
student’s standing in any course, their department or school, and staff or faculty’s relationships 
within their school or university. 
 
7. 
Informed consent procedures 
At the initiation of the data collection session, the PI will explain the purpose of the study, 
the methods of data collection and all potential risks associated with participation to prospective 
subjects. Prospective subjects will then be given an approved informed consent form to read. If 

they agree to participate, they will be asked to sign two copies of the form; one copy to be 
retained by the PI and the second copy for the subject’s records. Subjects will be made aware 
during the consent process that they may withdraw from participation at any time during their 
enrollment with no repercussions. 
 
8. 
Collection of data and method of data analysis 
The collection of data has been described in detail under “Procedures”. The primary 
outcome is a change in Quantitative Sensory Testing. This includes a series (8) of Quantitative 
Sensory Tests measured at baseline and at the completion of the 1-week intervention period.  
These tests are measured at two sites (calf and forearm).  Significant differences between 
groups for 7 of the tests (per body site) will be identified using a one-way ANOVA comparing 
percent change from baseline (post-test (i.e. day 6)/baseline test (i.e. day 0)). Given the number 
of statistical tests that will be required for the primary outcome measurements, p<0.01 will be 
utilized for each body site. An additional test for mechanical sensitivity will be measured at each 
site using a rank sum test at p<0.05.  
The secondary outcomes for this study include (1) HR during exercise, (2) Borg RPE 
before and after exercise and (3) testing “acute” effects of exercise on QST testing. HR during 
exercise and Borg RPE are measured to make sure that exercise causes a change in HR 
and/or perceived exertion. HR and Borg RPE data will be analyzed using percent change from 
start of exercise (post-exercise/pre-exercise) with two-way ANOVA for 3 treatment groups (3-
day, 5-day, 10 day) across time (day 1, 3, 5) with an adjusted p value of p<0.03. Control group 
will not be included in that analysis as HR was not measured on the control days and perceived 
exertion is at “0” on all days. For acute effects of exercise, participants were given 8 QST tests 
(on each forearm and calf) 5 min and 30 min after each exercise (or control session) on days 1, 
3, and 5. Significant differences between groups for these tests (per body site) will be identified 
using a two-way MANOVA comparing percent change from baseline (post-exercise/baseline 
test (i.e. day 0)) across the three days (day 1, day 3, day 5) and at the 5 min and 30 min time 
QST measuring point. Given the number of statistical tests (n=8) that will be required for the 
QST secondary outcome measurements, p<0.01 will be utilized for each body site.  
The following demographic variables will be collected and compared between groups to 
further check against potential bias; age, handedness, body mass index (BMI), baseline heart 
rate (HR), baseline blood pressure (BP), baseline IPAQ-short, and STAI (state-trait anxiety).  A 
significant difference in the proportion handedness will be tested using the Chi-Square test 
where a p<0.05 will be considered significant.  All other continuous variables will be tested using 
the one-way ANOVA to test for significance differences between the four study groups (p<0.05). 
 
9. 
Dissemination of Results 
 
Results of this study will be submitted to a peer-reviewed journal for publication and will 
be available to the public.  
 
10. 
Emphasize issues relating to interactions with subjects and subjects' rights 
Subjects will be notified of their rights, all risks and benefits of participation in this study 
during the informed consent procedure. Subjects will be informed that they may withdraw from 
participation at any time. Data collection sessions will be scheduled at times that are mutually 
convenient for the subject and the researchers and all efforts will be made to work with the 
subject’s schedule.  All personal and health information will be kept confidential as data will be 
coded. Identifiers will be stored in a locked filing cabinet and all coded data will be stored in 
either a separate locked filing cabinet or a password protected computer. Only researchers and 
staff directly involved on this study will have access to this information. Health information 
obtained for this study will come directly from the participant and not their healthcare providers 

or medical records. This information will be obtained during screening occurring in the Rangos 
School of Health Sciences exercise physiology lab and therefore is not under HIPAA.  
Subjects will be instructed that they are able to stop the exercise and pain 
measurements at any time due if they experience excessive discomfort/pain. Treadmill exercise 
will be monitored visually by a researcher in the adjacent room using a wireless camera system. 
Physiological measures, including heart rate, will also be monitored in real-time to ensure no 
issues during exercise. Subjects will be encouraged to stop exercise if they experience any 
discomfort or symptoms of over-exertion (≥ 17 on the Borg RPE scale). These symptoms will be 
explained during the informed consent process. There is a risk of falling off the treadmill. 
Subjects will be instructed to hold onto the rails if they feel like they are losing their balance or 
are going to fall. The safety key will be on the waist of their pants to turn off the treadmill if they 
move too far back on the belt. Also, in case they do fall off the machine, padded mats will 
surround the treadmill to minimize risk of injury. Because individuals recruited for this study will 
be young and healthy, the risk of falling is minimal. 
Risk of injury related to cutaneous mechanical testing is extremely rare and unlikely.  
Mechanical testing is widely used and safe.  Risks to the individual are minimal, because 1) this 
is not a painful/noxious stimulus; 2) subjects are instructed that they may stop any procedure at 
any time with no adverse consequences; and 3) the level of sensation experienced by subjects 
is well below their tolerance level and threshold for pain.  
Risk of injury related to thermal pain testing is minimal.  Thermal testing is widely used 
and safe.  While thermal testing does produce pain, risks to the individual are minimal, because 
1) the pain is transient in nature and generally subsides immediately after the procedure; 2) 
subjects are instructed that they may stop any procedure at any time with no adverse 
consequences; and 3) the level of pain experienced by subjects is below their tolerance level.  
With thermal stimulation there is a very slight risk of a burn, but this is minimized by the 
following: 1) positive lockout of stimulus parameters above 50°C; 2) the stimulator has built in a 
shut-down system to prevent the delivery of prolonged or high intensity stimuli (20 sec); 3) and 
before each use, temperature at glass surface will be verified with an electronic thermometer.  
Trials will proceed only if temperature detected at 20 sec cutoff is < 50oC. Moreover, risk is 
further mitigated by limiting enrollment to healthy young individuals.  Colleagues who have used 
this pain paradigm inform us that they have completed thermal testing with this stimulator on 
over 1000 subjects without producing a single burn. However, skin will be monitored for 
changes consistent with burns, such as redness that persists greater than one day and 
blistering. If a burn occurs, standard medical treatment will be recommended. 
Risk of injury related to pressure pain testing is minimal.  Pressure testing is widely used 
and safe.  While pressure testing does produce pain, risks to the individual are minimal, 
because 1) the pain is transient in nature and generally subsides immediately after the 
procedure; 2) subjects are instructed that they may stop any procedure at any time with no 
adverse consequences; 3) the level of pain experienced by subjects is below their tolerance 
level; and 4) the pain applied is never more than that subjects pain threshold, which is well 
below any pressure that could cause damage.  Moreover, risk is further mitigated by limiting 
enrollment to healthy individuals.    
 
 

References: 
1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and 
Research. (Institute of Medicine of the National Academies, Washington D.C., 2011). 
 
2. Wierwille, L. Fibromyalgia: diagnosing and managing a complex syndrome. Journal of the 
American Academy of Nurse Practitioners 24, 184-192, doi:10.1111/j.1745-7599.2011.00671.x 
(2012). 
 
3. Cornwall, A. & Donderi, D. C. The effect of experimentally induced anxiety on the experience 
of pressure pain. Pain 35, 105-113 (1988). 
 
4. Ed Department of Health and Human Services (2008). 
 
5.  Jordan, K. D. & Okifuji, A. Anxiety disorders: differential diagnosis and their relationship to 
chronic pain. Journal of pain & palliative care pharmacotherapy 25, 231-245, 
doi:10.3109/15360288.2011.596922 (2011) 
 
6. Milad, M. R. & Rauch, S. L. The role of the orbitofrontal cortex in anxiety disorders. Annals of 
the New York Academy of Sciences 1121, 546-561, doi:10.1196/annals.1401.006 (2007). 
 
7. Carek, P. J., Laibstain, S. E. & Carek, S. M. Exercise for the treatment of depression and 
anxiety. International journal of psychiatry in medicine 41, 15-28 (2011). 
 
8. National Center for health Statistics 
 
9. Drury, D. G., Stuempfle, K. J., Shannon, R. & Miller, J. An investigation of exercise-induced 
hypoalgesia after isometric and cardiovascular exercise. Journal of Exercise Physiology 7 
(2004). 
 
10. Rolke, R. et al. Quantitative sensory testing: a comprehensive protocol for clinical trials. Eur 
J Pain 10, 77-88, doi:10.1016/j.ejpain.2005.02.003 (2006). 
 
11. Sternberg, W. F., Bokat, C., Kass, L., Alboyadjian, A. & Gracely, R. H. Sex-dependent 
components of the analgesia produced by athletic competition. J Pain 2, 65-74, 
doi:10.1054/jpai.2001.18236 (2001). 
 
12. Kinser, A. M., Sands, W. A. & Stone, M. H. Reliability and validity of a pressure algometer. 
Journal of strength and conditioning research / National Strength & Conditioning Association 23, 
312-314 (2009). 
 
13. Dixon, J.S., & Bird, H.A. Reproducibility along a 10 cm vertical visual analogue scale. Ann 
Rheum Dis 40(1), 87-9 (1981). 
 
14. Kim, Y., Park, I., & Kang, M. Convergent validity of the International Physical Activity 
Questionnaire (IPAQ): meta-analysis. Public Health Nutrition 16(3), 440-452. 
 
15. Borg RPE Scale, “Physical Activity for Everyone,” n.d 
 
16. Heimberg, R. G., Mueller, G. P., Holt, C. S. & Hope, D. A. Assessment of anxiety in social 
interaction and being observed by others: The social interaction anxiety scale and the Social 
Phobia Scale. Behavior Therapy 23, 53-73 (1992). 

17. Heimberg, R. G., & Turk, C. L. (2002). Assessment of social phobia. Cognitive-behavioral 
group therapy for social phobia: Basic mechanisms and clinical strategies, 107-126.