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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345120/

Prevalence of the Fibromyalgia Phenotype in Spine Pain Patients Presenting to a Tertiary Care Pain Clinic and the Potential Treatment Implications

Chad M. Brummett, M.D., Assistant Professor,1 Jenna Goesling, Ph.D., Post-doctoral fellow,1 Alex Tsodikov, PhD,Professor,2 Taha S. Meraj, B.S., Medical Student,3 Ronald A. Wasserman, M.D., Clinical Assistant Professor,1 Daniel J. Clauw, MD, Professor,1 and Afton L. Hassett, Psy.D., Associate Research Scientist1
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Abstract
Objective
Injections for spinal pain have high failure rates, emphasizing the importance of patient selection. It is possible that detecting the presence of a fibromyalgia-like phenotype could aid in prediction, because in these individuals a peripheral injection would not address pain due to alterations in central neurotransmission. We hypothesized that spine pain patients meeting survey criteria for fibromyalgia would be phenotypically distinct from those who do not meet criteria.

Methods
548 patients with a primary spine pain diagnosis were studied. All patients completed validated self-report questionnaires, including the Brief Pain Inventory, PainDETECT, Hospital Anxiety and Depression Scale, measures of physical function, and the American College of Rheumatology survey criteria for fibromyalgia.

Results
42% met survey criteria for fibromyalgia (FM+). When compared with criteria negative patients, FM+ patients were more likely to be younger, unemployed, receiving compensation, have greater pain intensity, pain interference and neuropathic pain descriptors, as well as higher levels of depression and anxiety, and lower level of physical function (p < 0.0001 for each comparison). Gender, neuropathic pain, pain interference, physical function, and anxiety were independently predictive of fibromyalgia status in a multivariate analysis (p < 0.01, all variables). ROC analysis showed the strength of association of 0.81 as measured by the cross-validated C-statistic.

Conclusion
Using the survey criteria for fibromyalgia, we demonstrated profound phenotypic differences in a spine pain population. Although centralized pain cannot be confirmed with a survey alone, the pathophysiology of fibromyalgia may help explain a portion of the variability of responses to spine interventions.
 
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These would be your discogram patients.
 

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So they took information from intake sheets and declared a high prevalence of FMS, which now doesn't even have diagnostic criteria more than "I hurt all over." I didn't see a basic examination mentioned in the methods.

It would not occur to me to develop a study this ridiculous let alone have some editor somewhere find enough value in it to publish it.
 
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pmrmd

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^ I know this. But centralized pain needs some kind of input to produce the changes. Also, how many people have generalized pain on their intake forms and you find something specific after the H&P? Tons. This study addresses none of this. It's ridiculous.
 
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Aside from a pain diagram, how do you screen for centralized pain? Is it on your intake
questionnaire or do you ask explicit questions? I use a PHQ-4, PCS, PC-PTSD and a ROS
that intentionally includes things like: difficultly sleeping, restless legs, Elhers Danlos,
IBS, interstitial cystitis, chronic fatigue, mental clouding, etc. If you don't go to that extreme
you will miss it.
 

drpainfree

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The point of conducting of detailed FACE-TO-FACE detailed history and physical exam is NOT to diagnose FM. After all, FM is really a diagnosis of EXCLUSION. So you really have to work hard to EXCLUDE other possible diagnosis.
 

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Paul isn't interested in helping folks, he is interested in proving that he is smarter than the rest of us. Of course, folks with somatiform disorders can still sustain injuries, and suffer from both nociceptive as well as neupropathic pain from peripheral generators. Same way recovering addicts are still able to sustain injuries that warrant the use of opioids, albeit with a very tight leash.

Apparently, if you present to Dr. Coehlo's clinic and have previously been diagnosed with FMS, or have Medicaid for insurance, you are just too nuts to also have legitimate pain.
 
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ampaphb

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Aside from a pain diagram, how do you screen for centralized pain? Is it on your intake
questionnaire or do you ask explicit questions? I use a PHQ-4, PCS, PC-PTSD and a ROS
that intentionally includes things like: difficultly sleeping, restless legs, Elhers Danlos,
IBS, interstitial cystitis, chronic fatigue, mental clouding, etc. If you don't go to that extreme
you will miss it.
CONCLUSION:
Using the FM criteria and severity scales, we demonstrated profound phenotypic differences in a population of patients with spine pain. Although centralized pain cannot be confirmed with a self-report instrument alone, the pathophysiology of FM may help explain a portion of the variability of responses to spine interventions. (Hoisted by his own petard)
 
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emd123

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Paul isn't interested in helping folks, he is interested in proving that he is smarter than the rest of us. Of course, folks with somatiform disorders can still sustain injuries, and suffer from both nociceptive as well as neupropathic pain from peripheral generators. Same way recovering addicts are still able to sustain injuries that warrant the use of opioids, albeit with a very tight leash.

Apparently, if you present to Dr. Coehlo's clinic and have previously been diagnnosed with FMS, or have Medicaid for insurance, you are just too nuts to also have legitimate pain.
The "central pain patients" he describes are obvious. When their PMH shows FMS "difficultly sleeping, restless legs, Elhers Danlos, IBS, interstitial cystitis, chronic fatigue, mental clouding" and "my whole body hurts," nothing works, injections don't work" and "my pain is 10, opiates don't do anything but I NEED MORE of them" they are OBVIOUS. No one should need a battery of psychological screening tools to see the obvious, only basic history skills.

Everyone knows these patients. Everyone knows the drama. Everyone knows the region above their neck plays a HUGE HUGE role in their pain and many patients with chronic pain. Everybody knows they need psych, they need to rework their entire life, brain, past history and future.

Everybody knows that many have been referred to psych 10 tens times and either didn't go, or their insurance didn't cover it, or they "tried it and it didn't work" or just plain aren't interested in doing the hard work. We're all delighted when the psych treatments make a dramatic difference but we know this is the minority, and no more of a "cure" than any other treatment for this chronic, relenting, condition.

Yet, we're supposed to be convinced that somebody coming along, and telling us that what is above a patient's C1 plays an important role in pain, that it's somehow earth shattering?

We're supposed to believe that all we need to do is flip a switch and magically by realizing psychology plays a huge role in Pain (which everyone knows anyways) that somehow we've cured chronic pain with an SNRI and a psych referral and abandoning all other modalities?

Sure, psych plays a huge role in Pain, and I know I can't fix something psychological with a needle or an opiate. But psychology isn't the only aspect of pain, and I'm not about to abandon all other pain treatment modalities, and their appropriate use in appropriate situations because someone has a personal agenda, such as what you've described.
 
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maybe his point is different. you state you know you cant fix something psychological with a needle or an opiate, so why are you (euphemistically speaking, not directed at you) still doing injections or writing opioids?

many pain docs are, either in pursuit of the almighty dollar, or some misguided attempt to placate the patient into doing "something".

additionally, you know we don't cure anything. but look all around you, not just pain management physicians, but all comers with regards to pain. "guaranteed to cure back/leg/migraine pain or your money back!!!" "I was better in 1 treatment!!" "Laser guided state of the art!!" "So-and-so had it done and now he is back in the Octagon!!"


he is being nihilistic, but I take his point to be that we do not deceive these CS patients any longer, and do not offer options that have high risk, minimal reward (to the patient)...
 

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maybe his point is different. you state you know you cant fix something psychological with a needle or an opiate, so why are you (euphemistically speaking, not directed at you) still doing injections or writing opioids?

many pain docs are, either in pursuit of the almighty dollar, or some misguided attempt to placate the patient into doing "something".

additionally, you know we don't cure anything. but look all around you, not just pain management physicians, but all comers with regards to pain. "guaranteed to cure back/leg/migraine pain or your money back!!!" "I was better in 1 treatment!!" "Laser guided state of the art!!" "So-and-so had it done and now he is back in the Octagon!!"


he is being nihilistic, but I take his point to be that we do not deceive these CS patients any longer, and do not offer options that have high risk, minimal reward (to the patient)...
If you have bought into Paul's particular line of bull$hit, then he is sadly converting intelligent docs to his nihilistic worldview.

Crazy patients can still have legitimate pain. Patients with pre-existing central sensitization can still have legitimate pain. Somatoform patients can still have legitimate pain. Maybe not in Corvallis, but then again, maybe the doc there is a bit too narcissistic to reconsider PROP dogma.
 
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"he is being nihilistic"

I think I am trying to be honest, when this specialty left that path years ago. And I am not being nihilistic, I am following Clauw's recommendations - and Tauben/Loeser - to
offer treatment, but not treatment that either fattens my wallet or enables continued cure seeking/catastrophizing.

I'm coming to the conclusion that screening for CS needs to be mandatory on intake - pain clinic - or occur in primary care, before the referral ever gets made to IPM. I don't think I'm alone in that perspective either.
 

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345120/

Prevalence of the Fibromyalgia Phenotype in Spine Pain Patients Presenting to a Tertiary Care Pain Clinic and the Potential Treatment Implications

Chad M. Brummett, M.D., Assistant Professor,1 Jenna Goesling, Ph.D., Post-doctoral fellow,1 Alex Tsodikov, PhD,Professor,2 Taha S. Meraj, B.S., Medical Student,3 Ronald A. Wasserman, M.D., Clinical Assistant Professor,1 Daniel J. Clauw, MD, Professor,1 and Afton L. Hassett, Psy.D., Associate Research Scientist1
Author information ► Copyright and License information ►

See other articles in PMC that cite the published article.

Go to:
Abstract
Objective
Injections for spinal pain have high failure rates, emphasizing the importance of patient selection. It is possible that detecting the presence of a fibromyalgia-like phenotype could aid in prediction, because in these individuals a peripheral injection would not address pain due to alterations in central neurotransmission. We hypothesized that spine pain patients meeting survey criteria for fibromyalgia would be phenotypically distinct from those who do not meet criteria.

Methods
548 patients with a primary spine pain diagnosis were studied. All patients completed validated self-report questionnaires, including the Brief Pain Inventory, PainDETECT, Hospital Anxiety and Depression Scale, measures of physical function, and the American College of Rheumatology survey criteria for fibromyalgia.

Results
42% met survey criteria for fibromyalgia (FM+). When compared with criteria negative patients, FM+ patients were more likely to be younger, unemployed, receiving compensation, have greater pain intensity, pain interference and neuropathic pain descriptors, as well as higher levels of depression and anxiety, and lower level of physical function (p < 0.0001 for each comparison). Gender, neuropathic pain, pain interference, physical function, and anxiety were independently predictive of fibromyalgia status in a multivariate analysis (p < 0.01, all variables). ROC analysis showed the strength of association of 0.81 as measured by the cross-validated C-statistic.

Conclusion
Using the survey criteria for fibromyalgia, we demonstrated profound phenotypic differences in a spine pain population. Although centralized pain cannot be confirmed with a survey alone, the pathophysiology of fibromyalgia may help explain a portion of the variability of responses to spine interventions.

I don't understand why everyone is disparaging this article. Our field desperately needs fully validated mechanisms for stratifying patients from a therapeutic standpoint, and this article is a step in this direction. We need a fully validated mechanism for identifying patients who are at markedly increased risk for treatment failure via conventional approaches, especially interventional approaches and systemic opioids. A questionnaire that would enable interventional pain physicians to identify (with a high degree of accuracy) patients with centralized pain phenotypes and do so EARLY in the treatment course would be a valuable tool.
 
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drusso

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I don't understand why everyone is disparaging this article. Our field desperately needs fully validated mechanisms for stratifying patients from a therapeutic standpoint, and this article is a step in this direction. We need a fully validated mechanism for identifying patients who are at markedly increased risk for treatment failure via conventional approaches, especially interventional approaches and systemic opioids. A questionnaire that would enable interventional pain physicians to identify (with a high degree of accuracy) patients with centralized pain phenotypes and do so EARLY in the treatment course would be a valuable tool.
I don't think anyone disagrees. Instead of unreliable paper-and-pencil measures, I hope for more crisply validated neurophysiological markers for central sensitization. There are interesting PET studies. And, heart-rate variability, startle reflex, and EEG are robustly validated markers in many other forensic and clinical domains. I'd like to see this kind of work develop further and be validated for use in the clinical setting.

Psychosom Med. 2015 Sep;77(7):721-32. doi: 10.1097/PSY.0000000000000217.

Affective Modulation of Brain and Autonomic Responses in Patients With Fibromyalgia.

Rosselló F1, Muñoz MA, Duschek S, Montoya P.

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  • 1From the Research Institute on Health Sciences (IUNICS) and Department of Psychology (Rosselló, Montoya), University of Balearic Islands, Palma de Mallorca, Spain; Department of Personality (Muñoz), University of Granada, Granada, Spain; and Institute of Applied Psychology (Duschek), University for Health Sciences Medical Informatics and Technology (UMIT), Hall in Tyrol, Austria.
Abstract

OBJECTIVES:

Emotional dysregulation and abnormal processing of affective information are thought to play a significant role for the maintenance of pain in fibromyalgia. The motivational priming hypothesis states that negative emotions could increase pain via activation of the aversive system, thus leading to an affective modulation of defensive reflexes. Nevertheless, little is known about peripheral and central correlates of affective reflex modulation in fibromyalgia.

METHODS:

Thirty patients with fibromyalgia and 30 healthy individuals were asked to view three video clips from a self-perspective to induce specific mood states. Video clips consisted of the same virtual walk through different locations of a park under three affective environments (unpleasant, pleasant, and neutral). Startle eyeblink reflex and heart rate response elicited by abrupt startle noises, as well as heart rate variability and electroencephalography (EEG) oscillations were recorded when participants were passively viewing the virtual environments.

RESULTS:

Patients with fibromyalgia rated all environments as more negative and arousing than did healthy controls (p values < .05). Nevertheless, startle eyeblink reflex and heart rate response were lower in patients with fibromyalgia than in healthy controls when viewing all three environments (p values < .05). Patients with fibromyalgia also displayed lower heart rate variability, as well as higher EEG power (2-22 Hz) during all environments than did healthy controls (p values < .05).

CONCLUSIONS:

Patients with fibromyalgia were characterized by relevant deficits in affective modulation of startle and cardiac responses, heart rate variability, and EEG power spectra in response to sustained induction of affective states. These findings suggest an alteration of emotional and attentional aspects of information processing at subjective, autonomic, and central nervous system levels.
 

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The distinction being drawn is that the OP uses this article to justify doing nothing other than providing psychological care for such patients.

The study does not support this conclusion however. What it does identify is that comorbidities exist within this population, and thus patients would benefit from a multidisciplinary approach.

The OP comes to this discussion with a very specific agenda. Opioids bad. Injections bad. Psychological care good.

He believes he is smarter than all the rest of us, and feels the need to denigrate others, claiming we are all in it for the money. In fact, most of us pursue the multimodal approach this paper implicitly advocates.
 
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drusso

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The distinction being drawn is that the OP uses this article to justify doing nothing other than providing psychological care for such patients.
Wouldn't it be cool if there was a "mind-body" connection that mediated treatment response to any modality we use in medicine?

PM R. 2015 Mar 21. pii: S1934-1482(15)00164-1. doi: 10.1016/j.pmrj.2015.03.014. [Epub ahead of print]

Modulation of Cervical Facet Joint Nociception and Pain Attenuates Physical and Psychological Features of Chronic Whiplash: A Prospective Study.
Smith AD1, Jull G2, Schneider GM3, Frizzell B3, Hooper RA3, Sterling M4.
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Abstract
OBJECTIVE:
To investigate changes in clinical (physical and psychological) features of individuals with chronic whiplash-associated disorder who had previously undergone cervical radiofrequency neurotomy at the time point when the effects of radiofrequency neurotomy had dissipated and pain returned.

DESIGN:
Prospective cohort observational trial of consecutive patients.

SETTING:
Tertiary spinal intervention centre in Calgary, Alberta, Canada.

PATIENTS:
A total of 53 consecutive individuals with chronic whiplash-associated disorder.

METHODS:
Individuals underwent radiofrequency neurotomy and were assessed before radiofrequency neurotomy; at 1 and 3 months postprocedure, and then after the return of pain (approximately 10 months postprocedure).

MAIN OUTCOME MEASUREMENTS:
Quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test), nociceptive flexion reflex, and motor function (cervical range of movement; craniocervical flexion test) were measured. Self-reported disability, psychological distress, pain catastrophization, and posttraumatic stress disorder symptoms also were measured.

RESULTS:
Upon the return of pain after radiofrequency neurotomy, levels of disability increased (P < .0001), and were no different to those before radiofrequency neurotomy (P = .99). There also was a significant deterioration in quantitative sensory testing measures and reduced cervical range of motion after the return of pain (all P < .05); all approaching values were recorded before radiofrequency neurotomy (P > .22). There were no significant changes in pressure hyperalgesia (P > .054) or craniocervical flexion test performance (P > .07), after the return of pain. Psychological distress and pain catastrophizing increased significantly after the return of pain (P < .01), and again were no different than measures taken prior to radiofrequency neurotomy (P > .13). However, there was no difference in number or severity of posttraumatic stress symptoms after the return of pain (P > .30).

CONCLUSIONS:
Physical and psychological features of chronic whiplash-associated disorder are modulated dynamically with cervical radiofrequency neurotomy. These findings indicate that peripheral nociception is involved in the manifestations of chronic whiplash-associated disorder in this cohort of individuals.

Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
 

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The distinction being drawn is that the OP uses this article to justify doing nothing other than providing psychological care for such patients.

The study does not support this conclusion however. What it does identify is that comorbidities exist within this population, and thus patients would benefit from a multidisciplinary approach.

The OP comes to this discussion with a very specific agenda. Opioids bad. Injections bad. Psychological care good.

He believes he is smarter than all the rest of us, and feels the need to denigrate others, claiming we are all in it for the money. In fact, most of us pursue the multimodal approach this paper implicitly advocates.
I have to respectfully disagree with you on this one. I actually know the senior authors of this paper quite well. They're all interventional pain physicians at Michigan. They're not anti-procedure or vehemently opposed to the use of systemic opioids, but they are definitely strong proponents for multidisciplinary care of chronic pain patients.

We need great research in our specialty, and Dr. Brummett is one of the few docs out there consistently churning out high quality data. Just because this study implicitly discourages the use of interventional approaches for patients with fibromyalgia (a view that I happen to agree with), please don't assume that the authors are "anti-procedures" or "anti-opioids." If you talk to them in person, I think you would find that they are strong advocates for interventional pain, but they simply view interventions and systemic opioids as tools in an pain physician's arsenal--sometimes they're appropriate, sometimes they're not. The challenge is knowing which category patients fall into, and that's why we need more research like this. Plain and simple.
 
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ampaphb

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My reference was to the OP, NOT the authors of the paper
 

ampaphb

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"he is being nihilistic"

I think I am trying to be honest, when this specialty left that path years ago. And I am not being nihilistic, I am following Clauw's recommendations - and Tauben/Loeser - to
offer treatment, but not treatment that either fattens my wallet or enables continued cure seeking/catastrophizing.

I'm coming to the conclusion that screening for CS needs to be mandatory on intake - pain clinic - or occur in primary care, before the referral ever gets made to IPM. I don't think I'm alone in that perspective either.
Given that the very paper you posted concludes, in part "Although centralized pain cannot be confirmed with a survey alone ..." How do you propose we "screen"
 

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this study implicitly discourages the use of interventional approaches for patients with fibromyalgia (a view that I happen to agree with), .
Who ever recommended treating fibromyalgia pain with injections?
 

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Who ever recommended treating fibromyalgia pain with injections?
Nope, they say if patient has FMS, then they re excluded from having pain treated from comorbid conditions with interventions/meds. So if you have FMS and get a lung met to L3: no opiates, no kypho. Bullets are cheap.
 

emd123

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Nope, they say if patient has FMS, then they re excluded from having pain treated from comorbid conditions with interventions/meds. So if you have FMS and get a lung met to L3: no opiates, no kypho. Bullets are cheap.
But if they have an acute disc herniation with radic symptoms they can't have ESI

Lol

But send them to surgery! That's okay. Lol
 
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http://www.journalagent.com/agri/pdfs/AGRI_27_3_123_131.pdf
Agri. 2015 Jul;27(3):123-31. doi: 10.5505/agri.2015.67044.
Are fibromyalgia and failed back surgery syndromes actually "functional somatic syndromes" in terms of their symptomatological, familial and psychological characteristics? A comparative study with chronicmedical illness and healthy controls.
Duruk B1, Sertel Berk HÖ2, Ketenci A3.
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Abstract
OBJECTIVES:
The aim of this study was to investigate whether Fibromyalgia and Failed Back Surgery Syndromes (FMS-FBSS) may be evaluated under the single heading of Functional Somatic Syndromes (FSS) with respect to their symptomatological characteristics such as intensity, frequency, age of onset, duration, painful areas, fear of pain, and pain coping styles; familial characteristics such as family history ofchronic medical illness, psychopathology and pain; and psychological characteristics such as manner of dealing with pain, fear of pain, alexithymia, symptom interpretation, somatosensory amplification and depression.

METHODS:
The study comprised 150 individuals, separated into 3 groups; The FSS Group comprised 47 patients who were referred to the Physical Medicine and Rehabilitation Clinic at Istanbul University's Faculty of Medicine with FMS (n=35) and FBSS (n=12), the healthy control group (HC Group) comprised 47 individuals, and the chronic medical illness control group (CMIC Group) was made up of 56 individuals. Turkish versions of the Toronto Alexithymia Scale, Symptom Attribution Inventory, Somatosensory Amplification Scale and Beck Depression Inventory, along with a semi-structured form questioning general health, pain and demographics were administered to all participants.

RESULTS:
FMS and FBSS participants (FSS Group) did not differ as a function of the major familial, symptomatological and clinical features considered in this study. Additionally, this group significantly differed from the HC and CMIC Groups with respect to almost all these features.

CONCLUSION:
This study is Important Insofar as it simultaneously evaluated FMS and FBSS groups in the presence of a control group. The results suggest that FMS and FBSS, currently treated as two different diagnostic categories in general medical practice, may be evaluated under the single heading of FSS.
 

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Conclusion was written before the study was done.
 

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http://www.journalagent.com/agri/pdfs/AGRI_27_3_123_131.pdf
Agri. 2015 Jul;27(3):123-31. doi: 10.5505/agri.2015.67044.
Are fibromyalgia and failed back surgery syndromes actually "functional somatic syndromes" in terms of their symptomatological, familial and psychological characteristics? A comparative study with chronicmedical illness and healthy controls.
Duruk B1, Sertel Berk HÖ2, Ketenci A3.
Author information

Abstract
OBJECTIVES:
The aim of this study was to investigate whether Fibromyalgia and Failed Back Surgery Syndromes (FMS-FBSS) may be evaluated under the single heading of Functional Somatic Syndromes (FSS) with respect to their symptomatological characteristics such as intensity, frequency, age of onset, duration, painful areas, fear of pain, and pain coping styles; familial characteristics such as family history ofchronic medical illness, psychopathology and pain; and psychological characteristics such as manner of dealing with pain, fear of pain, alexithymia, symptom interpretation, somatosensory amplification and depression.

METHODS:
The study comprised 150 individuals, separated into 3 groups; The FSS Group comprised 47 patients who were referred to the Physical Medicine and Rehabilitation Clinic at Istanbul University's Faculty of Medicine with FMS (n=35) and FBSS (n=12), the healthy control group (HC Group) comprised 47 individuals, and the chronic medical illness control group (CMIC Group) was made up of 56 individuals. Turkish versions of the Toronto Alexithymia Scale, Symptom Attribution Inventory, Somatosensory Amplification Scale and Beck Depression Inventory, along with a semi-structured form questioning general health, pain and demographics were administered to all participants.

RESULTS:
FMS and FBSS participants (FSS Group) did not differ as a function of the major familial, symptomatological and clinical features considered in this study. Additionally, this group significantly differed from the HC and CMIC Groups with respect to almost all these features.

CONCLUSION:
This study is Important Insofar as it simultaneously evaluated FMS and FBSS groups in the presence of a control group. The results suggest that FMS and FBSS, currently treated as two different diagnostic categories in general medical practice, may be evaluated under the single heading of FSS.
The authors attempt a version of trying to prove the null hypothesis: Because one doesn't find a difference, it does not mean no difference exists.
 

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Who does this quatatiative sensory testing?? My understanding is that its not very reliable test, I have never sent a patient to have this done. The measures for this study seem all subjective feedback, with exception of ROM and motor function. GIGO

MAIN OUTCOME MEASUREMENTS:

Quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test), nociceptive flexion reflex, and motor function (cervical range of movement; craniocervical flexion test) were measured. Self-reported disability, psychological distress, pain catastrophization, and posttraumatic stress disorder symptoms also were measured