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The Effect of Long-Term Body Awareness Training Succeeding a Multimodal Cognitive Behavior Program for Patients with Widespread Pain
Abstract
ABSTRACT
Objectives: Multimodal cognitive behavior programs are found to be appropriate treatment for patients with chronic widespread pain [CWP]. The aim of this study was to investigate whether follow-up body awareness group training could cause a greater long-lasting effect and promote more patients to return to work.
Methods: In a randomized controlled trial, 52 patients with CWP and more than 10 tender points were enrolled after having participated in a multimodal program. The intervention group attended a psychomotor physiotherapy group training 18 times during 1.5 years. The training started one month after the end of multimodal treatment. The control group received treatment as usual. Outcome measures were work status, Global Physiotherapeutic Examination, pain levels, and quality of life. All patients were tested within two weeks after the multimodal treatment, after 12 months, and after 18 months.
Results: Improvement in test scores was demonstrated in both groups over time. However, the intervention group demonstrated fewer tender points and a reduced distribution of pain. After one year, two-thirds of the intervention group and one-third of the control group was back at work, while after 1.5 years the difference between groups was less and not statistically significant.
Conclusions: Improvement over time was obtained for all patients who had participated in the multimodal program. Indication was provided that follow-up psychomotor physiotherapy based on body awareness training might cause additional improvement of symptoms and a higher rate of return to work. The research question should be further examined in randomized controlled trial studies providing similar baseline data between participating groups.
... The study showed that after 1 year, the 40 patients experienced reduced depression, anxiety, insomnia, fatigue, and improved quality of life, whereas the patients on a 6-month waiting list had not changed (Breitve et al., 2010). Furthermore, one randomized controlled trial (RCT) of NPMP has been performed, although given as group therapy only examined the effect of a multimodel treatment programme for patients with long-lasting musculoskeletal pain (Anderson, Strand, & Råheim, 2007). The study indicated that the participants receiving NPMP group treatment achieved fewer tender points, reduced distribution of pain, and a higher rate of return to work after 1 year, compared with the participants in the control (CT) group. ...
... The study indicated that the participants receiving NPMP group treatment achieved fewer tender points, reduced distribution of pain, and a higher rate of return to work after 1 year, compared with the participants in the control (CT) group. In this study, the dropout in the treatment group was large, making the results questionable (Anderson et al., 2007). Lastly, one-group prospective observational study of patients with low back pain receiving NPMP showed that nine of the 12 included patients improved significantly regarding pain, flexibility, and ability to relax (Alstad, Stiles, & Fladmark, 2011). ...
... Eighty-two per cent of the total sample of 62 participants were women, and the mean age was 44.3 years; 40% in the treatment group had higher education (>12 years); and half of them (50%) were on sickness leave or on disability pension all of which corresponds quite well with our results (Breitve et al., 2010). The positive effect of NPMP on pain in our study is also in line with the findings of the RCT by Anderson et al. (2007) where the group receiving NPMP as group treatment achieved fewer tender points and a reduced distribution of pain. Two other prospective studies, although with a weaker design, also indicate that NPMP can reduce long-standing pain (Aabakken et al., 1991;Alstad et al., 2011). ...
... Ten trials with 1023 participants 7,9,40,43,95,106,108,120,153,165 showed significant improvements in FIQ, pain, sleep, and depression with MDT compared with usual care ( Table 2; Supplementary Table 10, available at http://links.lww.com/PAIN/B513). There was no improvement in fatigue with MDT. ...
Fibromyalgia is a highly heterogeneous condition, but the most common symptoms are widespread pain, fatigue, poor sleep, and low mood. Non-pharmacological interventions are recommended as first-line treatment of fibromyalgia. However which interventions are effective for the different symptoms is not well understood. The objective of this study was to assess the efficacy of non-pharmacological interventions on symptoms and disease specific quality of life (QoL). Seven databases were searched from their inception until 1st June 2020. Randomised controlled trials (RCTs) comparing any non-pharmacological intervention to usual care, waiting list or placebo in people with fibromyalgia aged >16 years were included without language restriction. Fibromyalgia Impact Questionnaire (FIQ) was the primary outcome measure. Standardised mean difference (SMD) and 95% confidence interval (CI) were calculated using random effects model. The risk of bias (RoB) was evaluated using modified Cochrane tool. Of the 16,251 studies identified, 167 RCTs (n=11,012) assessing 22 non-pharmacological interventions were included. Exercise, psychological treatments, multi-disciplinary modality, balneotherapy and massage improved FIQ. Subgroup analysis of different exercise interventions found that all forms of exercise improved pain (ES -0.72 to -0.96) and depression (ES -0.35 to -1.22) except for flexibility-exercise. Mind-body and strengthening exercises improved fatigue (ES -0.77 to -1.00), whereas aerobic and strengthening exercises improved sleep (ES -0.74 to -1.33). Psychological treatments including cognitive behavioural therapy and mindfulness improved FIQ, pain, sleep, and depression (ES -0.35 to -0.55) but not fatigue. The findings of this study suggest that non-pharmacological interventions for fibromyalgia should be individualised according to the predominant symptom.
... Only one RCT of long-term NPMP in groups, with a comparing treatment has been performed (Anderson, Strand, & Råheim, 2007). ...
Background and purpose: Norwegian Psychomotor Physiotherapy (NPMP) has been an established treatment approach for more than 50 years, mostly in the Scandinavian countries, usually applied to patients with widespread and long-lasting musculoskeletal pain and/or psychosomatic disorders. Few studies have investigated the outcomes of NPMP, and no randomized clinical trials (RCT) with a comparing treatment group have systematically been tried out on individuals.
Methods: This is a pragmatic, single-blinded RCT where 128 participants with long-lasting widespread musculoskeletal pain and/or pain located to the neck and shoulders were block randomized to NPMP or Cognitive Patient Education combined with active individualized physiotherapy (COPE-PT). Intention-to-treat with linear mixed models were used to estimate the group differences in treatment effects. The outcomes at 3, 6, and 12 months follow-up were pain intensity, function, anxiety and depression, quality of life, sleep, fear of movement, and subjective health complaints. Risk profile (Örebro) was examined at 3 and 6 months. All participants underwent physical tests at baseline and 6 months.
Results: One-year data were available for 66.4% of the original participants. Calculated with intention-to-treat analysis, at 3 months statistically significant differences were found in favor of COPE-PT for pain, anxiety and depression, quality of life-physical dimension, risk profile and fear of movement. At 6 months, statistically significant differences in favor of COPE-PT were found for anxiety and depression, and sleep. At 12 months, the improvements were still statistically significant for anxiety, depression and sleep. Both groups improved, but no statistically significant differences were found between the groups on the physical tests at 6 months.
Conclusions: COPE-PT, which is targeted towards pain-coping and increasing activity, contribute to more improvements than NPMP.
... [8,10,13] Many physiotherapists in Scandinavia, particularly those working in pain clinics or those taking postgraduate specialization in NPPT, learn to use either present or former versions of the CBE or GPE, and the methods are used in the examination of many different patient groups. [4,[14][15][16][17][18][19][20] CBE has the main domains Posture, Respiration, Movement and Muscle, and a total of 14 subscales and 112 items (three to 14 items in each subdomain). [21] GPE has the same main domains as CBE, and in addition the main domain Skin, i.e. five main domains, 13 subdomains and a total of 52 items (four items in each subscale). ...
Background and aim:
There is evidence that clinicians' pain attitudes and beliefs are associated with the pain beliefs and illness perceptions of their patients and furthermore influence their recommendations for activity and work to patients with back pain. The Pain Attitudes and Beliefs Scale (PABS) is a questionnaire designed to differentiate between biomedical and biopsychosocial pain attitudes among health care providers regarding common low back pain. The original version had 36 items, and several shorter versions have been developed. Concern has been raised over the PABS' internal construct validity because of low internal consistency and low explained variance. The aim of this study was to examine and improve the scale's measurement properties and item performance.
Methods:
A convenience sample of 667 Norwegian physiotherapists provided data for Rasch analysis. The biomedical and biopsychosocial subscales of the PABS were examined for unidimensionality, local response independency, invariance, response category function and targeting of persons and items. Reliability was measured with the person separation index (PSI). Items originally excluded by the developers of the scale because of skewness were re-introduced in a second analysis.
Results:
Our analysis suggested that both subscales required removal of several psychometrically redundant and misfitting items to satisfy the requirements of the Rasch measurement model. Most biopsychosocial items needed revision of their scoring structure. Furthermore, we identified two items originally excluded because of skewness that improved the reliability of the subscales after re-introduction. The ultimate result was two strictly unidimensional subscales, each consisting of seven items, with invariant item ordering and free from any form of misfit. The unidimensionality implies that summation of items to valid total scores is justified. Transformation tables are provided to convert raw ordinal scores to unbiased interval-level scores. Both subscales were adequately targeted at the ability level of our physiotherapist population. Reliability of the biomedical subscale as measured with the PSI was 0.69. A low PSI of 0.64 for the biopsychosocial subscale indicated limitations with regard to its discriminative ability.
Conclusions:
Rasch analysis produced an improved Norwegian version of the PABS which represents true (fundamental) measurement of clinicians' biomedical and biopsychosocial treatment orientation. However, researchers should be aware of the low discriminative ability of the biopsychosocial subscale when analyzing differences and effect changes.
Implications:
The study presents a revised PABS that provides interval-level measurement of clinicians' pain beliefs. The revision allows for confident use of parametric statistical analysis. Further examination of discriminative validity is required.
... After 12 months the 40 patients experienced reduced depression, anxiety, insomnia, fatigue and improved quality of life, while the patients on a 6 months waiting list had not changed. Only one RCT of NPMP has been performed, although only for groups and not on individuals, following a multi-model treatment program for patients with long-lasting musculoskeletal pain [19]. The study indicated that the patients receiving NPMP group treatment achieved fewer tender points, reduced distribution of pain and a higher rate of return to work after 1 year, compared to a control group of patients receiving usual follow-up at an out-patient rehabilitation clinic. ...
Background
Norwegian Psychomotor Physiotherapy (NPMP) has been an established treatment approach for more than 50 years, although mostly in the Scandinavian countries, and is usually applied to patients with widespread and long-lasting musculoskeletal pain and/or psychosomatic disorders. Few studies have been investigating outcome of NPMP and no randomized clinical trials (RCT) have been systematically tried out on individuals. Methods/designThis is a study protocol for a pragmatic, single blinded RCT, which will take place in a city of Norway. The participants will be block randomized either to receive NPMP or Cognitive Patient Education in combination with active individualized physiotherapy (COPE-PT). The intervention will reflect usual care and will be conducted in physiotherapy clinics by five experienced physiotherapists in each of the two treatment approaches. DiscussionThe findings of the present study may give an important contribution to our knowledge of the outcome of NPMP, on patients with long-lasting widespread musculoskeletal pain and/or pain located to the neck and shoulder region. Trial registrationThe study has been registered with ClinicalTrials.gov (June 9 th 2015, NCT02482792).
Background:
An extended group program called Mind and Body (MB), based on body awareness exercises and cognitive behavioral therapy (CBT), was offered to a subgroup of patients who had completed their traditional outpatient multidisciplinary rehabilitation and were motivated for further treatment.
Purpose:
To explore how patients with multisite musculoskeletal pain experienced participation in the MB program with respect to usefulness, meaningfulness, behavioral changes, and transferability to daily life and work.
Method:
The study is rooted in the phenomenological tradition. Individual, semi-structured interviews were performed with eight patients aged 29-56 years. The data were analyzed using systematic text condensation.
Results:
Two main themes emerged: 1) New knowledge provided increased body awareness, new ways of thinking, and acceptance of one's own situation. This theme reflected how new knowledge and MB coping strategies were useful in the process of changing problematic thoughts, increasing body awareness, and facilitating acceptance; and 2) Implementing new habits and strategies in daily life revealed how demanding it was to alter behavior, a process that unfolded over time.
Conclusion:
A combination of body awareness exercises and cognitive coping strategies was described as helpful in further improving function and coping with pain and stress in daily life and work.
Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.
Purpose
Chronic physical conditions often negatively affect work participation. The objective of this systematic review is to investigate the effectiveness and characteristics of vocational rehabilitation interventions for people with a chronic physical condition.
Methods
Searches in five databases up to April 2020 identified 30 studies meeting our inclusion criteria. Two reviewers independently assessed and extracted data. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) framework was used to evaluate quality of evidence for three outcome measures related to work participation.
Results
All vocational rehabilitation interventions consisted of multiple components, but their characteristics varied widely. Analysis of 22 trials yielded a moderate positive effect with moderate certainty of interventions on work status; analysis of five trials with low risk of bias showed a large positive effect with moderate certainty (risk ratio 1.33 and 1.57, respectively). In addition, in eight studies we found a moderate to small positive effect with low certainty on work attitude (standardized mean difference = 0.59 or 0.38, respectively). We found no effect on work productivity in nine studies.
Conclusion
The systematic review of the literature showed positive effects of vocational rehabilitation interventions on work status and on work attitude; we found no effect on work productivity.
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Implications for rehabilitation
• In rehabilitation, addressing work participation of persons with a chronic physical condition using targeted interventions is beneficial to improve or sustain work participation, irrespective of the intervention characteristics and diagnosis.
• Interventions that include multiple components and offer individual support, whether or not combined with group sessions, are likely to be more effective in improving work participation in persons with a chronic physical condition.
• The overview of vocational interventions in this systematic review may assist healthcare professionals in making informed decisions as to which intervention to provide.
• Vocational rehabilitation, as well as studies on work participation in chronic disease, should include a long follow-up period to explore if work participation is sustainable and contributes to health and wellbeing.
Background
There have been growing recommendations to include education in multi-disciplinary interventions targeting chronic pain management. However, effects of this strategy on short- and long-term self-management of chronic pain, remain largely unexplored.
Objectives
1. To provide an updated overview of studies that report on the impact of patient education in multi-disciplinary interventions, on self-management of chronic pain; 2. To explore associations between education and chronic pain self-management techniques; and 3. To identify the format and duration of suitable chronic pain interventions targeted at patient self-management.
Methods
Design: Narrative systematic literature review of randomised or controlled study designs. Data Sources: PubMed, CINAHL, EMBASE, PsycINFO. Participants: Adult patients with chronic pain of any aetiology participating in multi-disciplinary programs that included education. Main outcome measures: Assessments of level of pain, function, quality of life, self-efficacy, self-management, and any other relevant assessments. Study Appraisal and Synthesis Methods: PRISMA guidelines, Cochrane Risk of Bias tool, and TIDieR model.
Results
Database searching identified 485 potential papers. After removal of duplicates, and irrelevant articles by title and abstract, 120 full-text articles were reviewed and 27 studies were included in this systematic review. Studies were predominantly from the United States (n = 8; 29.6%). Over one hundred outcome measures were identified across all studies, with significant variation also observed in terms of how chronic pain duration was defined, and how education was delivered to participants. Overall, positive benefits of education were reported.
Conclusions
Education, as part of multi-disciplinary programs, is likely to improve self-management and self-efficacy in people with chronic pain of any aetiology. Heterogeneity in terms of: chronic pain duration; educational resources; healthcare professionals; and outcome measures, were identified as limitations. Further research, in the form of Randomised Controlled Trials addressing these limitations, is recommended.
Objectives
To assess the effectiveness of community- and workplace-based interventions to reduce sickness absence and job loss in workers with musculoskeletal disorders (MSDs).
Methods
We identified relevant randomised controlled trials (RCTs) and cohort studies, published since 1990, by screening citations from 35 earlier systematic reviews and by searching Medline and Embase to April 2010. We estimated effects by type of intervention and other features, including study quality.
Results
Among 42 finally included studies, 27 assessed return to work (RTW), 21 duration of sickness absence, and five job loss. Interventions included prescribed exercises, behavioural change techniques, workplace modifications and provision of extra services. Studies tended to be small (median sample 107 (IQR 77 – 148) and of limited quality. Most interventions appeared beneficial: the median RR for RTW was 1.21 (IQR 1.00–1.60) and that for avoiding MSD-related job loss, 1.25 (IQR 1.06–1.71); the median reduction in sickness absence was 1.11 (IQR 0.32–3.20) days/month. Effects were smaller, however, in larger better quality studies, suggesting potential publication bias. No intervention type was clearly superior to others, although effort-intensive interventions were less effective than simple ones. No study established statistically significant net economic benefits.
Conclusions
Benefits are generally small and of uncertain cost-effectiveness. Expensive interventions should be implemented only with careful cost-benefit evaluation planned from the start. Future research should focus on the cost-effectiveness of simple low cost interventions, and impacts on job retention.
The aims of this study were to investigate reliability and aspects of validity of a previously developed method called the Global Physiotherapeutic Muscle Examination (GPM), which comprises items related to palpation of Muscle (18 items) and Skin (12 items). Inter-tester reliability was examined by three physiotherapists examining 19 persons. Construct and discriminative validity was studied by data from 247 patients with long-lasting musculoskeletal pain and 104 healthy subjects. For the patients, concurrent validity was examined by correlating psychological functioning, measured with the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2), as well as information about pain, with the domains of Muscle and Skin. Reliability was acceptable, with overall intra-class correlation coefficients ranging from 0.54 to 0.84, but with low measurement error. Construct evaluation was done by means of Structural Equation Modeling (SEM), resulting in a modified and improved model with fewer tests: 12 within Muscle and eight within Skin. Composite scores of palpation differed significantly between healthy subjects and patients, and between sub-groups of patients. A relationship was found between Muscle and Skin and psychological characteristics, but differently for females and males. Pain showed a low but significant correlation only to the Muscle domain. The items included in a modified model of palpation can be used in a reliable and valid way when screening patients with long-lasting pain.
Clinical examination of respiration may be an important aspect of musculoskeletal problems, but has scarcely been reported. The aims of this study were to evaluate the reliability and validity of the domain Respiration, containing 12 items oriented towards the inspection of respiratory movement and rhythm. Inter-tester reliability was examined by three physiotherapists examining 19 persons. Construct and discriminative validity of the Respiration method was studied by data from 247 patients with long-lasting muscu loskeletal pain and 104 healthy subjects. Concurrent validity to psychological variables and pain was also examined. Responsiveness was studied by comparing change in Respiration in patients who returned fully to work vs. those still on sick leave 6 months after rehabilitation. The results indicated fair but acceptable reliability. A modified Respiration scale consisting of eight items was obtained by means of Structural Equation Modeling (SEM). Respiration scores differed significantly between healthy subjects and patients. A relationship was found between Respiration and psychological characterisin tics, and between Respiration and pain, particularly in patients with widespread pain. Responsiveness of the Respiration method to clinically important change was demonstrated. Respiration can be reliably and validly assessed, and the method seems useful in the evaluation of patients with musculoskeletal problems and used as an outcome measure in rehabilitation.
The present paper is a review of the literature on fibromyalgia (FM) and a discussion of the consequences this knowledge may have for physiotherapists. FM is characterized by chronic widespread muscle pain, an excessive feeling of fatigue, and poor sleep. The etiology is unknown and the pathogenesis is unclear. Depression and reduced physical capacity have been found that may be the consequences of FM rather than the causes. Patients with FM also report difficulty in performing daily activities at home and work as well as during leisure time. Recent studies have found normal energy metabolism of the muscles and no sign of muscle injuries. Results from several studies suggest that there is a hypersensitivity within the central nervous system, as well as a hyporesponsiveness of the sympathetic nervous system and the hypothalamus-pituitary-adrenal axis. There are no known physiotherapeutic modalities that normalize such dysfunctions. However, it is some support that stimulation of endorphin mechanism by TENS may modify pain in patients with FM. It also appears that it is important to assist patients with FM in adjusting their activities in such a way that they can stay as physically active as possible.
Objective. To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia. Methods. Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training 2) exercise training 3) a combination treatment, or 4) an educational/attention control program. Results. All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period. Conclusion. This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.
Test-retest reliability of a pain drawing instrument was investigated. Pain drawings of chronic pain patients (n = 51) were scored for percentage of total body surface in pain and location of pain. A test-retest reliability coefficient of r = 0.85 was calculated for a time interval that averaged 71 days. In addition, a percentage of agreement based on distribution of pain over time was calculated at 88.2%. The effect on reliability of age, gender and time-interval differences was investigated. The utility of the pain drawing instrument as a measure of extent of pain and location of pain over time is discussed.
A chronology of populations of patients eligible for analysis in clinical trials is discussed. A practical definition of the intention–to–treat population is given and its role relative to the efficacy analyzable population discussed for both parallel groups and crossover trials. Sensitivity analyses are proposed to address dilemmas as to which population of patients is appropriate for the final analysis of the trial. Associated issues regarding multiple comparisons, exclusion analyses, and post hoc analyses are discussed in the context of the intention–to–treat approach to statistical analysis. Examples for analgesia, intermittent claudication, anxiety or depression, and duodenal ulcers are given to illustrate the points discussed.
Objectives: This paper reviews multidisciplinary treatment programs designed for people with fibromyalgia [FMS], identifies factors that may be associated with treatment efficacy, and makes recommendations for future FMS interventions. Findings: Most efficacious interventions included physical activity and cognitive-behavioral therapy. Recommendations for future research studies include: 1. the use of aerobic exercise and cognitive-behavioral therapy training in coping skills and relaxation; 2. individualized exercise training; 3. power analysis conducted a priori to determine appropriate sample size; 4. uniformity in outcome measurement and follow-up assessment; and 5. the use of randomized, controlled trials that can lead to stronger conclusions regarding treatment efficacy. Conclusions: Multidisciplinary treatment programs for FMS patients are generally effective. Researchers should continue to develop multi-disciplinary treatment interventions incorporating the above recommendations.
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in ⩾ 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
Objective. To determine the prevalence and characteristics of fibromyalgia in the general population.
Methods. A random sample of 3,006 persons in Wichita, KS, were characterized according to the presence of no pain, non-widespread pain, and widespread pain. A subsample of 391 persons, including 193 with widespread pain, were examined and interviewed in detail.
Results. The prevalence of fibromyalgia was 2.0% (95% confidence interval [95% CI] 1.4, 2.7) for both sexes, 3.4% (95% CI 2.3, 4.6) for women, and 0.5% (95% CI 0.0, 1.0) for men. The prevalence of the syndrome increased with age, with highest values attained between 60 and 79 years (>7.0% in women). Demographic, psychological, dolorimetry, and symptom factors were associated with fibromyalgia.
Conclusion. Fibromyalgia is common in the population, and occurs often in older persons. Characteristic features of fibromyalgia–pain threshold and symptoms–are similar in community and clinic populations, but overall severity, pain, and functional disability are more severe in the clinic population.