The Critical Role of Physical Activity and Weight Management in Knee and Hip Osteoarthritis: A Narrative Review.

Physical activity (PA) and weight management are critical components of an effective knee and hip osteoarthritis (OA) management plan, yet most people with OA remain insufficiently active and/or overweight. Clinicians and their care teams play an important role in educating patients with OA about PA and weight management, eliciting patient motivation to engage in these strategies, and referring patients to appropriate self-management interventions. The purpose of this review is to educate clinicians about the current public health and clinical OA guidelines for PA and weight management and highlight a variety of evidence-based self-management interventions available in community and clinical settings and online.

Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement.

After an anterior cruciate ligament (ACL) injury, people need secondary prevention strategies to identify osteoarthritis at its earliest stages so that interventions can be implemented to halt or slow the progression toward its long-term burden. The Osteoarthritis Action Alliance formed an interdisciplinary Secondary Prevention Task Group to develop a consensus on recommendations to provide clinicians with secondary prevention strategies that are intended to reduce the risk of osteoarthritis after a person has an ACL injury. The group achieved consensus on 15 out of 16 recommendations that address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models. We hope this statement raises awareness among clinicians and researchers on the importance of taking steps to mitigate the risk of osteoarthritis after an ACL injury.

Evidence Review for Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement.

CONTEXT: The Osteoarthritis Action Alliance formed a secondary prevention task group to develop a consensus on secondary prevention recommendations to reduce the risk of osteoarthritis after a knee injury. OBJECTIVE: Our goal was to provide clinicians with secondary prevention recommendations that are intended to reduce the risk of osteoarthritis after a person has sustained an anterior cruciate ligament injury. Specifically, this manuscript describes our methods, literature reviews, and dissenting opinions to elaborate on the rationale for our recommendations and to identify critical gaps. DESIGN: Consensus process. SETTING: Virtual video conference calls and online voting. PATIENTS OR OTHER PARTICIPANTS: The Secondary Prevention Task Group consisted of 29 members from various clinical backgrounds. MAIN OUTCOME MEASURE(S): The group initially convened online in August 2020 to discuss the target population, goals, and key topics. After a second call, the task group divided into 9 subgroups to draft the recommendations and supportive text for crucial content areas. Twenty-one members completed 2 rounds of voting and revising the recommendations and supportive text between February and April 2021. A virtual meeting was held to review the wording of the recommendations and obtain final votes. We defined consensus as >80% of voting members supporting a proposed recommendation. RESULTS: The group achieved consensus on 15 of 16 recommendations. The recommendations address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models. CONCLUSIONS: This consensus statement reflects information synthesized from an interdisciplinary group of experts based on the best available evidence from the literature or personal experience. We hope this document raises awareness among clinicians and researchers to take steps to mitigate the risk of osteoarthritis after an anterior cruciate ligament injury.

Barriers and facilitators to the adoption and implementation of evidence-based injury prevention training programmes: a narrative review.

While there is a multitude of evidence supporting the efficacy of injury prevention training programmes, the literature investigating the implementation of these programmes is, in contrast, rather limited. This narrative review sought to describe the commonly reported barriers and facilitators of the implementation of injury prevention training programmes among athletes in organised sport. We also aimed to identify necessary steps to promote the uptake and sustainable use of these programmes in non-elite athletic communities. We identified 24 publications that discussed implementing evidence-based injury prevention training programmes. Frequently reported barriers to implementation include the perceived time and financial cost of the programme, coaches lacking confidence in their ability to implement it, and the programme including exercises that were difficult or confusing to follow. Frequently reported facilitators to implementation include the coach being aware of programme efficacy, shared motivation to complete the programme from both coaches and athletes, and the ability to easily integrate the programme into practice schedules. The current literature is focused on high-income, high-resource settings. We recommend that future studies focus on understanding the best practices of programme dissemination in culturally and economically diverse regions. Programmes ought to be of no financial burden to the user, be simply adaptable to different sports and individual athletes and be available for use in easily accessible forms, such as in a mobile smartphone application.

Exercise prescription for weight management in obese adults at risk for osteoarthritis: synthesis from a systematic review.

BACKGROUND: The aim of this systematic review was to identify principles of exercise interventions associated with improved physical function, weight management or musculoskeletal pain relief among young and middle-aged adults with obesity and propose an evidence-based exercise prescription that could assist in secondary prevention of osteoarthritis. METHODS: A structured electronic review was conducted using MEDLINE, PubMed, and SPORTDiscus. The search string included 1) "obes*" AND "exercise" AND "interven*" AND "musculoskeletal pain OR knee pain OR hip pain". Studies 1) were randomized controlled trials of humans, with a non-exercise control, 2) included participants aged 18-50 years, and 3) had outcomes that included physical function, musculoskeletal pain, and/or body composition. Studies were excluded if participants had peri-menopausal status, cancer, or obesity-related co-morbidities. A recommended exercise prescription was developed based on common principles used in the included exercise interventions with greatest change in function or pain. RESULTS: Seven studies were included. Similarities in exercise intensity (40-80% VO2max), frequency (three times per week), duration (30-60 min), and exercise mode (treadmill, cross-trainer, stationary bike, aquatic exercise) were observed in exercise interventions that resulted in improved physical function and/or pain, compared to non-exercise control groups. CONCLUSION: Common principles in exercise prescription for improvements in weight management, physical function and pain relief among otherwise healthy people with obesity. Exercise prescription including moderate intensity exercise for 30-60 min, three times per week can be considered an effective treatment for weight management and obesity-related musculoskeletal symptoms. Exercise should be recommended to at-risk individuals as part of secondary prevention of osteoarthritis.

Public Health Interventions for Osteoarthritis - updates on the Osteoarthritis Action Alliance's efforts to address the 2010 OA Public Health Agenda Recommendations.

Osteoarthritis (OA) is a painful joint disease affecting more than 32.5 million adults in the US and over 350 million adults worldwide. The prevalence is expected to rise continually over the next several decades with significant impacts to societal health and economic costs as well as individuals' daily activities and quality of life. In 2008, the Centers for Disease Control and Prevention (CDC) and the Arthritis Foundation (AF) led a collaborative effort to address approaches to reduce the burden of OA via public health interventions, policies (systems and environmental), and communication strategies. This collaboration resulted in the National Public Health Agenda for OA (OA Agenda), which was vetted by more than 75 stakeholder organisations and released in 2010. The OA Agenda listed ten recommendations focused on public health interventions for OA including weight management, physical activity, self-management education, and injury prevention, and policies, systems, communication, research and evaluation. In 2011, the CDC and AF mobilised the OA Action Alliance (OAAA), a national coalition of organisations concerned with mitigating the public health impact of OA, to operationalise the recommendations set forth in the OA Agenda. Since then, the OAAA has grown to include more than 110 organisations that work collectively to increase awareness about the prevention and management of OA, provide educational resources, and expand access to evidence-based programmes for target audiences including individuals with OA, community-based organisations, healthcare systems and providers, and policymakers. This review highlights the OAAA's progress to date in addressing the OA Agenda recommendations; successes and challenges in delivery of effective communication, programmes, and resources; and future implications.

Physical Activity as a Vital Sign: A Systematic Review.

INTRODUCTION: Physical activity (PA) is strongly endorsed for managing chronic conditions, and a vital sign tool (indicator of general physical condition) could alert providers of inadequate PA to prompt counseling or referral. This systematic review examined the use, definitions, psychometric properties, and outcomes of brief PA instruments as vital sign measures, with attention primarily to studies focused on arthritis. METHODS: Electronic databases were searched for English-language literature from 1985 through 2016 using the terms PA, exercise, vital sign, exercise referral scheme, and exercise counseling. Of the 838 articles identified for title and abstract review, 9 articles qualified for full text review and data extraction. RESULTS: Five brief PA measures were identified: Exercise Vital Sign (EVS), Physical Activity Vital Sign (PAVS), Speedy Nutrition and Physical Activity Assessment (SNAP), General Practice Physical Activity Questionnaire (GPPAQ), and Stanford Brief Activity Survey (SBAS). Studies focusing on arthritis were not found. Over 1.5 years of using EVS in a large hospital system, improvements occurred in relative weight loss among overweight patients and reduction in glycosylated hemoglobin among diabetic patients. On PAVS, moderate physical activity of 5 or more days per week versus fewer than 5 days per week was associated with a lower body mass index (-2.90 kg/m2). Compared with accelerometer-defined physical activity, EVS was weakly correlated (r = 0.27), had low sensitivity (27%-59%), and high specificity (74%-89%); SNAP showed weak agreement (κ = 0.12); GPPAQ had moderate sensitivity (46%) and specificity (50%), and SBAS was weakly correlated (r = 0.10-0.28), had poor to moderate sensitivity (18%-67%), and had moderate specificity (58%-79%). CONCLUSION: Few studies have examined a brief physical activity tool as a vital sign measure. Initial investigations suggest the promise of these simple and quick assessment tools, and research is needed to test the effects of their use on chronic disease outcomes.

"Where Does it Hurt?" Implications of Obesity on Musculoskeletal Health.

Obesity and musculoskeletal health are inextricably linked across risk factors, prevalence rates, and societal burden. They are also linked across management strategies. It is necessary to consider the mutual impact of musculoskeletal health and obesity in order to inform effective and safe weight management and physical activity solutions.

Physical exercise as non-pharmacological treatment of chronic pain: Why and when.

Chronic pain broadly encompasses both objectively defined conditions and idiopathic conditions that lack physical findings. Despite variance in origin or pathogenesis, these conditions are similarly characterized by chronic pain, poor physical function, mobility limitations, depression, anxiety, and sleep disturbance, and they are treated alone or in combination by pharmacologic and non-pharmacologic approaches, such as physical activity (aerobic conditioning, muscle strengthening, flexibility training, and movement therapies). Physical activity improves general health, disease risk, and progression of chronic illnesses such as cardiovascular disease, type 2 diabetes, and obesity. When applied to chronic pain conditions within appropriate parameters (frequency, duration, and intensity), physical activity significantly improves pain and related symptoms. For chronic pain, strict guidelines for physical activity are lacking, but frequent movement is preferable to sedentary behavior. This gives considerable freedom in prescribing physical activity treatments, which are most successful when tailored individually, progressed slowly, and account for physical limitations, psychosocial needs, and available resources.

Effects of sleep restriction and exercise deprivation on somatic symptoms and mood in healthy adults.

OBJECTIVES: Exposure to acute 'stressors' (e.g. infections, pain, trauma) often results in altered sleep habits and reductions in routine activity. In some individuals, these behavioural responses to acute stressors may contribute to the development of chronic somatic symptoms such as widespread pain, fatigue, memory difficulties and mood disturbances, much like those associated with 'functional somatic syndromes' (FSS) such as fibromyalgia or chronic fatigue syndrome. METHODS: Eighty-seven healthy young adults who reported sleeping between 7 and 9 hours nightly and exercising regularly were randomised to one of four groups: exercise cessation, sleep restriction (6 hours nightly), both, or neither. Symptoms of pain, fatigue, cognitive dysfunction and negative mood were measured before and after the 10-day restriction period. RESULTS: Sleep restriction was a potent contributor to the development of somatic symptoms. Exercise cessation was less influential leading only to fatigue. There were no significant interactions between exercise cessation and sleep restriction, except that males were much more likely to develop somatic symptoms when deprived of both sleep and exercise than one or the other. Women were generally much more likely to develop somatic symptoms than men. CONCLUSIONS: This study supports previous research suggesting that both sleep and exercise are critical in 'preventing' somatic symptoms among some individuals. Furthermore, to our knowledge, this is the first time there is data to suggest that women are much more sensitive to decrements in routine sleep and exercise than are men.

Large candidate gene association study reveals genetic risk factors and therapeutic targets for fibromyalgia.

OBJECTIVE: Fibromyalgia (FM) represents a complex disorder that is characterized by widespread pain and tenderness and is frequently accompanied by additional somatic and cognitive/affective symptoms. Genetic risk factors are known to contribute to the etiology of the syndrome. The aim of this study was to examine >350 genes for association with FM, using a large-scale candidate gene approach. METHODS: The study group comprised 496 patients with FM (cases) and 348 individuals with no chronic pain (controls). Genotyping was performed using a dedicated gene array chip, the Pain Research Panel, which assays variants characterizing >350 genes known to be involved in the biologic pathways relevant to nociception, inflammation, and mood. Association testing was performed using logistic regression. RESULTS: Significant differences in allele frequencies between cases and controls were observed for 3 genes: GABRB3 (rs4906902; P = 3.65 × 10(-6)), TAAR1 (rs8192619; P = 1.11 × 10(-5)), and GBP1 (rs7911; P = 1.06 × 10(-4)). These 3 genes and 7 other genes with suggestive evidence for association were examined in a second, independent cohort of patients with FM and control subjects who were genotyped using the Perlegen 600K platform. Evidence of association in the replication cohort was observed for TAAR1, RGS4, CNR1, and GRIA4. CONCLUSION: Variation in these 4 replicated genes may serve as a basis for development of new diagnostic approaches, and the products of these genes may contribute to the pathophysiology of FM and represent potential targets for therapeutic action.

Neuroimaging of fibromyalgia.

The primary symptom of fibromyalgia is widespread pain. This symptom is accompanied by secondary symptoms, such as cognitive difficulties and sensitivity to painful stimulation, and by numerous co-morbidities. The first neuroimaging studies addressed the primary symptom by examining differences between patients and controls using single-photon-emission-computed tomography (SPECT). Subsequent studies focussed on the secondary symptom of increased sensitivity to painful stimulation. Functional MRI (fMRI) studies using the blood-oxygen-level-dependent (BOLD) method to assess brain activation demonstrated augmented sensitivity to painful pressure and the association of this augmentation with variables such as depression and catastrophising. These studies have also assessed brain processes associated with cognitive dysfunction. Neuroimaging studies of fibromyalgia have now come full circle, using new techniques to provide information about differences that may relate to underlying mechanisms and the primary symptom of widespread pain. Using a wide array of techniques, these studies have found differences in opioid receptor binding, concentration of metabolites associated with neural processing in pain-related regions and differences in functional brain networks and in regional brain volume and in white-matter tracks. This array of neuroimaging techniques continues to provide increasing information about supraspinal mechanisms associated with fibromyalgia that will aid in diagnosis, including identification of diagnostic subgroups, the development of new efficacious treatments that address both causes and symptoms and the matching of patients to treatments.

Assessor status influences pain recall.

UNLABELLED: Anecdotal clinical reports suggest that patients report differing levels of pain, depending on the status within the medical hierarchy of the individual gathering the pain rating. This observation has clinical relevance, given the practice of delegating the assessment of pain to lower status clinic staff members. In this study, both pain and mood were assessed in 70 patients diagnosed with low back pain at pretreatment, immediately after epidural lumbar injection, and again 2 weeks later by phone. At the 2-week follow-up, patients were also asked to recall the postprocedural rating that they had given immediately after the injection. This rating was obtained by either the treating physician or by a research assistant who was present at the time of injection, on a randomly determined basis. Current ratings of pain and mood did not differ for either group before the epidural injection, after the epidural injection, or at the 2-week follow-up. Two-week recall of postprocedural pain did, however, differ depending on assessor status. Those called by the physician provided recalled pain ratings that closely matched the ratings provided immediately after the procedure. Those called by the research assistant provided ratings that were 86% higher (that is, worse) than their original ratings. This status-driven bias in recalled postprocedural pain reporting is discussed in the context of social demands inherent in the physician-patient relationship, with implications for assessing treatment effectiveness in clinical practice and research. PERSPECTIVE: Accurate assessment of patients' pain is critical to effective pain management and treatment planning. This study found evidence of a status-based bias in which physicians elicited lower ratings of previously experienced pain associated with treatment procedures than did staff members of lower status.

Momentary relationship between cortisol secretion and symptoms in patients with fibromyalgia.

OBJECTIVE: To compare the momentary association between salivary cortisol levels and pain, fatigue, and stress symptoms in patients with fibromyalgia (FM), and to compare diurnal cycles of cortisol secretion in patients with FM and healthy control subjects in a naturalistic environment. METHODS: Twenty-eight patients with FM and 27 healthy control subjects completed assessments on salivary cortisol levels and pain, fatigue, and stress symptoms, 5 times a day for 2 consecutive days, while engaging in usual daily activities. Only those participants who adhered to the protocol (assessed via activity monitor) were included in the final analyses. RESULTS: Twenty FM patients and 16 healthy control subjects adhered to the protocol. There were no significant differences in cortisol levels or diurnal cortisol variation between FM patients and healthy controls. Among women with FM, a strong relationship between cortisol level and current pain symptoms was observed at the waking time point (t = 3.35, P = 0.008) and 1 hour after waking (t = 2.97, P = 0.011), but not at the later 3 time points. This association was not due to differences in age, number of symptoms of depression, or self-reported history of physical or sexual abuse. Cortisol levels alone explained 38% and 14% of the variation in pain at the waking and 1 hour time points, respectively. No relationship was observed between cortisol level and fatigue or stress symptoms at any of the 5 time points. CONCLUSION: Among women with FM, pain symptoms early in the day are associated with variations in function of the hypothalamic-pituitary-adrenal axis.

Ambulatory monitoring of physical activity and symptoms in fibromyalgia and chronic fatigue syndrome.

OBJECTIVE: Fibromyalgia (FM) and chronic fatigue syndrome (CFS) are associated with substantial physical disability. Determinants of self-reported physical disability are poorly understood. This investigation uses objective ambulatory activity monitoring to compare patients with FM and/or CFS with controls, and examines associations of ambulatory activity levels with both physical function and symptoms during activities of daily life. METHODS: Patients with FM and/or CFS (n = 38, mean +/- SD age 41.5 +/- 8.2 years, 74% women) completed a 5-day program of ambulatory monitoring of physical activity and symptoms (pain, fatigue, and distress) and results were compared with those in age-matched controls (n = 27, mean +/- SD age 38.0 +/- 8.6 years, 44% women). Activity levels were assessed continuously, ambulatory symptoms were determined using electronically time-stamped recordings at 5 time points during each day, and physical function was measured with the 36-item Short Form health survey at the end of the 5-day monitoring period. RESULTS: Patients had significantly lower peak activity levels than controls (mean +/- SEM 8,654 +/- 527 versus 12,913 +/- 1,462 units; P = 0.003) and spent less time in high-level activities when compared with controls (P = 0.001). In contrast, patients had similar average activity levels as those of controls (mean +/- SEM 1,525 +/- 63 versus 1,602 +/- 89; P = 0.47). Among patients, low activity levels were associated with worse self-reported physical function over the preceding month. Activity levels were inversely related to concurrent ambulatory pain (P = 0.031) and fatigue (P < 0.001). Pain and fatigue were associated with reduced subsequent ambulatory activity levels, whereas activity levels were not predictive of subsequent symptoms. CONCLUSION: Patients with FM and/or CFS engaged in less high-intensity physical activities than that recorded for sedentary control subjects. This reduced peak activity was correlated with measures of poor physical function. The observed associations may be relevant to the design of behavioral activation programs, because activity levels appear to be contingent on, rather than predictive of, symptoms.

The effect of brief exercise cessation on pain, fatigue, and mood symptom development in healthy, fit individuals.

OBJECTIVE: Abnormalities of the biological stress response (hypothalamic-pituitary-adrenal axis and the autonomic nervous system) have been identified in both fibromyalgia (FM) and chronic fatigue syndrome (CFS). Although these changes have been considered to be partly responsible for symptom expression, we examine an alternative hypothesis that these HPA and autonomic changes can be found in subsets of healthy individuals in the general population who may be at risk of developing these conditions. Exposure to "stressors" (e.g., infections, trauma, etc.) may lead to symptom expression (pain, fatigue, and other somatic symptoms) in part by precipitating lifestyle changes. In particular, we focus on the effect of deprivation of routine aerobic exercise on the development of somatic symptoms. METHODS: Eighteen regularly exercising (>/=4 h/week) asymptomatic, healthy adults refrained from physical activity for 1 week. We predicted that a subset of these individuals would develop symptoms of FM/CFS with exercise deprivation, and this manuscript focuses on the baseline HPA axis, immune, and autonomic function measures that may predict the development of symptoms. RESULTS: Eight of the subjects reported a 10% increase in one or more symptoms (pain, fatigue, mood) after 1 week of exercise deprivation. These symptomatic subjects had lower HPA axis (baseline cortisol prior to VO2max testing), immune (NK cell responsiveness to venipuncture), and autonomic function (measured by heart rate variability) at baseline (prior to cessation of exercise) when compared to the subjects who did not develop symptoms. CONCLUSIONS: A subset of subjects developed symptoms of pain, fatigue, or mood changes after exercise deprivation. This cohort was different from the individuals who did not develop symptoms in baseline measures of HPA axis, immune, and autonomic function. We speculate that a subset of healthy individuals who have hypoactive function of the biological stress response systems unknowingly exercise regularly to augment the function of these systems and thus suppress symptoms. These individuals may be at risk for developing chronic multisymptom illnesses (CMIs) (e.g., FM or CFS among others) when a "stressor" leads to lifestyle changes that disrupt regular exercise.

Sex effects on heart rate variability in fibromyalgia and Gulf War illness.

OBJECTIVE: To investigate autonomic abnormalities in male and female fibromyalgia (FM) and Gulf War illness (GWI) patients by comparing heart rate variability (HRV) with that of age- and sex-matched healthy controls. METHODS: Subjects included 26 (19 women, 7 men) with FM, 11 (6 men, 5 women) with GWI, and 36 (18 men,18 women) healthy controls. HRV was determined from Holter recordings obtained in the Clinical Research Center. Analysis of variance compared 24-hour, daytime, and nighttime HRV by sex within groups and by group within sex. RESULTS: In women with FM or GWI, HRV was significantly lower than in men with FM or GWI. HRV was similar in male and female controls. When HRV was compared by group within sex, HRV was significantly decreased in women with FM or GWI and no significant differences were seen for men with these conditions. CONCLUSION: Decreased HRV in FM and GWI appears to be sex dependent. Results suggest that different mechanisms may be operative in symptom expression in men and women with this spectrum of illness.

Knee pain and radiographic osteoarthritis interact in the prediction of levels of self-reported disability.

OBJECTIVE: To determine predictors of disability depending on whether joint deformity and pain reporting exist independently or concurrently. METHODS: Subjects were 154 volunteers for an osteoarthritis screening examination. Eligible subjects completed questionnaires for physical function, pain, and depressive symptoms; underwent evoked pain testing for tenderness assessment; and had anteroposterior and lateral radiographs taken of both knees. Two blinded rheumatologists scored the images using Kellgren-Lawrence criteria to determine presence of deformity. RESULTS: Subjects were divided into 3 subgroups based on radiographic evidence of deformity and self-reported pain. Disability was greatest when pain and deformity occurred together (F[2,151] = 18.8, P < 0.0001). Self-reported disability in the absence of deformity was predicted by body mass index, pain threshold, and anxiety symptoms; disability was predicted by the number of osteophytes and depressive symptoms when pain and deformity occurred together. CONCLUSION: Self-reported disability in osteoarthritis of the knee is greatest with concurrent pain and joint deformity. When pain and deformity do not cooccur, disability appears to be related to separate factors, including anxiety and pain threshold (e.g., tenderness).

Increased pain sensitivity in fibromyalgia: effects of stimulus type and mode of presentation.

Fibromyalgia (FM) is defined in part by sensitivity to blunt pressure. Pressure pain sensitivity in FM is evaluated typically by the use of 'ascending' testing methods such as tender point counts or dolorimetry, which can be influenced by response bias of both the subject and examiner. Methods that present stimuli in a random, unpredictable fashion might minimize the influence of these factors. In this study, we compared the results of ascending and random assessments of both pressure and thermal pain sensitivities in 43 FM patients and 28 age- and gender-matched controls. Even though FM is defined on the basis of pressure sensitivity, this group was also more sensitive to heat stimuli, presented in either ascending or random paradigms. In both the patient and control groups, the pain ratings to painful sensations evoked by both thermal and pressure stimuli were significantly greater in the random, compared with the ascending method. The number of subjects classified as 'expectant' because they rated pain higher in ascending than random paradigms was similar for FM and control groups. Both patients and controls exhibited a similar degree of sensitization to pressure and thermal stimuli. The increased sensitivity to both pressure and thermal stimuli for threshold and suprathreshold stimuli in FM patients is consistent with central augmentation of pain processing.