Abdominal Massage in Functional Chronic Constipation: A Randomized Placebo-Controlled Trial.

OBJECTIVE: The aim of this study was to investigate the effects of abdominal massage on the severity of constipation, bowel function, and quality of life (QoL) in patients with functional chronic constipation in a randomized placebo-controlled design. METHODS: Seventy-four patients diagnosed with functional constipation according to the Rome IV diagnostic criteria were included. Patients were randomly assigned to the intervention group (abdominal massage plus lifestyle advice) or the control group (placebo therapeutic ultrasound plus lifestyle advice). Abdominal massage or placebo ultrasound was applied for 4 weeks. The primary outcome measure was the Constipation Severity Instrument score. Bowel diary data and the Patient Assessment of Constipation Quality of Life Questionnaire score were used as secondary outcome measures. Differences in outcome measures within and between groups were analyzed by repeated-measures analysis of variance. RESULTS: Although constipation severity, bowel function indicators (defecation frequency and duration and stool consistency), and QoL were found to improve significantly over time in both groups, improvements in both primary and secondary outcomes were much more significant in the abdominal massage group. In addition, group × time interaction effects were found to be significant for constipation severity, bowel function findings, and QoL. There were approximately 70% and 28% reductions in constipation severity, 56% and 38% improvement rates in QoL, and 70% and 43% increases in defecation frequency in the intervention and placebo groups, respectively. CONCLUSION: Abdominal massage should be one of the first-line conservative approaches in the management of functional chronic constipation. Further randomized placebo-controlled studies with long-term follow-up are needed. IMPACT: For functional constipation, which is a common gastrointestinal problem, abdominal massage should be considered as an option in first-line therapy because of its effect beyond the placebo effect. LAY SUMMARY: If you have functional constipation, your physical therapist may be able to provide abdominal massage to help reduce your symptoms.

Complex Decongestive Therapy in the Physical Therapist Management of Rosacea-Related Edema (Morbus Morbihan Syndrome): A Case Report With a New Approach.

OBJECTIVE: The aim of this case report was to describe the use of complete decongestive therapy (CDT) with a new approach in the management of a male with facial edema related to Morbus Morbihan Syndrome (MMS). METHODS: An 18-year-old male with MMS after acne treatment was the subject of this case report. Volume assessment was performed with distance measurements of the facial area using standard reference points, the overflow method, and the measurement of the percentage of subdermal fluid. Participant-reported symptoms of lymphedema (feeling of swelling and tightness) and body image perception were evaluated with the visual analogue scale, and the severity of anxiety was evaluated with the State and Trait Anxiety Inventory. In addition, the participant's perception of improvement was determined using a Likert-type scale. Evaluations were performed at baseline, week 4 (during the treatment), and week 8 (immediately after treatment). CDT was applied to the participant in a total of 24 sessions, 3 d/wk for 8 weeks. RESULTS: Compared with the baseline measurement, the facial distances (tragus-mental cavity, tragus-mouth corner, mandibula-nasal canal, mandibula-internal orbita, mandibula-external orbita, mental cavity-internal orbita, mental cavity-mandibula, right-left tragus, and hairline in the forehead-mental cavity), the volume, and the percentage of subdermal fluid of facial area were decreased at the week 4 and 8 measurements. The anxiety score, participant reports of feelings of swelling and tightness, and body image perception improved after the 8 weeks of treatment compared with baseline. CONCLUSION: This case report described the use of CDT in treating edema and participant symptoms in an individual with facial lymphedema related to MMS. Body image and level of anxiety improved.

Comparison of the Effect of Kinesio Taping and Manual Lymphatic Drainage on Breast Engorgement in Postpartum Women: A Randomized-Controlled Trial.

Objectives: To investigate the effect of kinesio taping (KT) and manual lymphatic drainage (MLD) on pain severity, breast engorgement, and milk volume in postpartum women. Materials and Methods: In this prospective randomized-controlled trial, we recruited 67 postpartum women who had breast engorgement and randomly assigned them to the KT, MLD, and control group. In the KT group, taping plus breast care was performed, MLD plus breast care was performed in the MLD group, and in the control group, only routine breast care was given for 10 days. Pain, breast engorgement, body temperature, and milk volume were measured. Examinations were repeated on days 1, 4, and 10. Results: The MLD group had significant reductions in pain and breast engorgement at all postintervention days compared with the control and KT group (p < 0.05). Milk volume increased among three groups, but the change in the MLD group was higher than in the KT and control groups (p < 0.05). There was no significant difference in the milk volume among the KT and control groups at all postintervention days (p > 0.05). Conclusions: MLD relieved breast pain and firmness more and increased milk volume in postpartum women compared with the KT and control groups. MLD can be recommended to postnatal mothers to better manage breast engorgement.

Is the Effect of Complex Decongestive Therapy the Same for Primary and Secondary Lower Lymphedema?

Background: The aim was to compare edema and quality of life (QOL) after complex decongestive therapy (CDT) in two types of lymphedema: primary lower limb lymphedema (PLL) and secondary lower limb lymphedema (SLL). Methods and Results: Participants with PLL (n = 20) and SLL (n = 20) were recruited in this prospective single-blinded study. Patients in both groups were treated with CDT for 4 weeks 5 days a week. The amount of edema in their lower extremities was assessed by circumference measurement. The QOL for the patients was evaluated by a Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL) before and immediately following the therapy. There was no significant difference in the volume reductions between the two groups (p > 0.05). Overall initial QOL was significantly lower in patients with PLL than in patients with SLL scores. Post-CDT differed significantly between PLL and SLL groups, QOL was significantly lower for patients with PLL than for patients with SLL scores (p < 0.05). When the changes in both groups were examined, it was found that their QOL increased after the treatment (p < 0.05). Conclusions: While there was no difference in the amount of edema in both groups, the results of patients with SLL were more positive than patients with PLL in terms of QOL. Lymphedema therapists should approach patients with different therapeutic considerations specific to each type of lymphedema before using CDT in clinical practice.

Comparison of Connective Tissue Manipulation and Abdominal Massage Combined With Usual Care vs Usual Care Alone for Chronic Constipation: A Randomized Controlled Trial.

OBJECTIVE: The aim of the present study was to determine and compare the effects of connective tissue manipulation (CTM) and abdominal massage when combined with usual care on the symptoms of constipation and quality of life (QoL) immediately following a 4-week treatment in patients suffering from chronic constipation. METHODS: A total of 60 patients with chronic constipation were randomly assigned to CTM, abdominal massage, or control groups. Connective tissue manipulation and abdominal massage were conducted at 5 sessions a week for 4 weeks. Each session was approximately 15 to 20 minutes. The severity of constipation by the Constipation Severity Instrument, symptoms of constipation by a bowel diary and Bristol Stool Scale, and QoL by patient assessment of QoL questionnaire were evaluated at baseline and at the end of 4 weeks. RESULTS: There were significant differences in the changes in constipation severity (P < .001), symptoms of constipation (P ≤ .001), and QoL (P < .001) among the 3 groups. However, based on pair-wise analysis, there were no significant differences in the changes of the severity and symptoms of constipation and QoL between the CTM and abdominal massage groups (P > .05). CONCLUSION: The findings of the present study revealed that compared to usual care alone, the combination of usual care and CTM or abdominal massage may be more beneficial for chronic constipation. However, the superiority of CTM or abdominal massage was not observed. Further high-quality studies with long-term follow-up are needed to investigate the optimal massage therapy program in patients with chronic constipation.

The effect of kinesio taping and lifestyle changes on pain, body awareness and quality of life in primary dysmenorrhea.

The aim of this study was to investigate the effects of kinesio taping and lifestyle changes on pain, body awareness, and quality of life in individuals with primary dysmenorrhea (PD). Subjects in the first group underwent kinesio taping and lifestyle changes and subjects in the second group were instructed only lifestyle changes. The pain levels were evaluated using a visual analogue scale, menstrual symptoms using the Menstrual Symptom Questionnaire, health-related life quality using the Short Form-36, and changes in body awareness using the Body Awareness Questionnaire form. Pain intensity decreased, and body awareness and quality of life increased in both groups (p < 0.05). However, in the first group, pain severity decreased more, and body awareness and quality of life increased more (p < 0.05). As a result, it is thought that both kinesio taping and lifestyle changes can be used to improve quality of life and body awareness and to decrease pain level.

Short-term effects of connective tissue manipulation in women with primary dysmenorrhea: A randomized controlled trial.

AIM: To evaluate the short-term effectiveness of connective tissue manipulation (CTM) for relieving menstrual pain and symptoms in primary dysmenorrhea (PD). METHODS: Forty-four women with PD were randomly assigned to treatment (n = 21) or control group (n = 23). While the control group was given only advising, the treatment group additionally received CTM. The primary outcome was the menstrual pain intensity by Visual Analogue Scale. Secondary outcomes included the number of pain medications, menstrual pain catastrophizing by Pain Catastrophizing Scale (PCS), menstrual symptoms by Menstrual Symptom Questionnaire (MSQ) and menstrual attitude by Menstrual Attitude Questionnaire (MAQ). RESULTS: Compared with the control group, CTM group showed statistically significant improvement in pain, medication use, PCS, MSQ (p = 0.001) and in the perception of menstruation as a natural event (p = 0.029). However, no significant differences were detected between groups for some aspects of MAQ (p > 0.05). CONCLUSIONS: CTM seems to be an effective approach in the short-term in PD.

The effects of connective tissue manipulation and Kinesio Taping on chronic constipation in children with cerebral palsy: a randomized controlled trial.

PURPOSE: The aim of this study was to investigate the effects of connective tissue manipulation (CTM) and Kinesio Taping® (KT) on constipation and quality of life in children with cerebral palsy (CP). METHOD: This study was designed as a randomized controlled trial. Forty children diagnosed with chronic constipation based on Rome III criteria were randomly assigned to CTM group [6 females, 7 males; 8 y 6 mo (SD = 3y 4 mo)], KT group [7 female, 7 male; 8y 7 mo (SD =3y 5 mo)] or control group [6 female, 7 male; 8y 3 mo (SD = 3y 6 mo)]. All patients were assessed with 7-day bowel diaries, Bristol Stool Form Scale (BSFS), Visual Analog Scale (VAS), and Pediatric Quality of Life Inventory (PEDsQL). Kruskal-Wallis, Wilcoxon's signed-rank, and Mann-Whitney U tests were used to determine intra-group and inter-group differences. The level of significance was p < 0.05. RESULTS: Among the CTM, KT, and control groups, there were statistically significant differences regarding the changes in defecation frequency (2.46, 3.00, 0.30, ES 1.16, p < 0.001), duration of defecation (5.07, 5.35, 0.15, ES 2.37, p = 0.003), BSFS (1.84, 2.14, 0.07, ES 0.91, p < 0.001), VAS (4.83, 3.87, 0.23, ES 1.98, p < 0.001), and PEDsQL total scores (7, 14, 8.36, -0.85, ES 4.08, p < 0.001). CONCLUSIONS: This study revealed that CTM and KT seem equally effective physiotherapy approaches for the treatment of pediatric constipation and these approaches may be added to bowel rehabilitation program. Implications for rehabilitation CTM and KT have similar effectiveness in alleviating the constipation-related symptoms and improving quality of life in children with CP. CTM and KT can be integrated into bowel rehabilitation programs. Considering the characteristics of patients, these treatment options can be used as an alternative of each other by physiotherapists.

Effects of active/passive interventions on pain, anxiety, and quality of life in women with fibromyalgia: Randomized controlled pilot trial.

The authors of this study compared the effects of pilates exercises and connective tissue massage (CTM) on pain intensity; pain-pressure threshold; and tolerance, anxiety, progress, and health-related quality of life in females with fibromyalgia. It was a pilot, assessor masked, randomized controlled trial conducted between January and August of 2013. Twenty-one women with fibromyalgia were randomly assigned to the pilates exercise program (six of whom did not complete the program), and 22 were randomly assigned to CTM (one of whom did not complete this program). Each group received the assigned intervention three times per week during a 4-week period. The Visual Analogue Scale, algometry, State-Trait Anxiety Inventory, Fibromyalgia Impact Questionnaire, and Nottingham Health Profile were used at baseline and at the end of treatments. Significant improvements were found in both groups for all parameters. However, the scores for pain-pressure threshold were significantly elevated and the symptoms of anxiety were significantly diminished in the exercise group compared to the massage group. Thus, exercise and massage might be used to provide improvements in women with fibromyalgia. The exercise group showed more advantages than the massage group and thus might be preferred for patients with fibromyalgia. However, an adequately powered trial is required to determine this with certainty.

A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial.

STUDY DESIGN: Randomized clinical trial. BACKGROUND: Little is known about the efficacy of providing manual therapy in addition to cervical and scapulothoracic stabilization exercises in people with mechanical neck pain (MNP). Objectives To compare the effects of stabilization exercises plus manual therapy to those of stabilization exercises alone on disability, pain, range of motion (ROM), and quality of life in patients with MNP. METHODS: One hundred two patients with MNP (18-65 years of age) were recruited and randomly allocated into 2 groups: stabilization exercise without (n = 51) and with (n = 51) manual therapy. The program was carried out 3 days per week for 4 weeks. The Neck Disability Index, visual analog pain scale, digital algometry of pressure pain threshold, goniometric measurements, and Medical Outcomes Study 36-Item Short-Form Health Survey were used to assess participants at baseline and after 4 weeks. RESULTS: Improvements in Neck Disability Index score, night pain, rotation ROM, and the Medical Outcomes Study 36-Item Short-Form Health Survey score were greater in the group that received stabilization exercise with manual therapy compared to the group that only received stabilization exercise. Between-group differences (95% confidence interval) were 2.2 (0.1, 4.3) points for the Neck Disability Index, 1.1 (0.0, 2.3) cm for pain at night measured on the visual analog scale, -4.3° (-8.1°, -0.5°) and -5.0° (-8.2°, -1.7°) for right and left rotation ROM, respectively, and -2.9 (-5.4, -0.4) points and -3.1 (-6.2, 0.0) points for the Medical Outcomes Study 36-Item Short-Form Health Survey physical and mental components, respectively. Changes in resting and activity pain, pressure pain threshold, and cervical extension or lateral flexion ROM did not differ significantly between the groups. Pressure pain threshold increased only in those who received stabilization exercise with manual therapy (P<.05). CONCLUSION: The results of this study suggest that stabilization exercises with manual therapy may be superior to stabilization exercises alone for improving disability, pain intensity at night, cervical rotation motion, and quality of life in patients with MNP. LEVEL OF EVIDENCE: Therapy, level 1b.

Cervical and scapulothoracic stabilization exercises with and without connective tissue massage for chronic mechanical neck pain: A prospective, randomised controlled trial.

This study was planned to assess and compare the effectiveness of cervical and scapulothoracic stabilization exercise treatment with and without connective tissue massage (CTM) on pain, anxiety, and the quality of life in patients with chronic mechanical neck pain (MNP). Sixty patients with chronic MNP (18-65 years) were recruited and randomly allocated into stabilization exercise with (Group 1, n = 30) and without the CTM (Group 2, n = 30). The program was carried out for 12 sessions, 3 days/week in 4 weeks. Pain intensity with Visual Analog Scale, pressure pain threshold with digital algometer (JTech Medical Industries, ZEVEX Company), level of anxiety with Spielberger State Trait Anxiety Inventory, and quality of life with Short Form-36 were evaluated before and after the treatment. After the program, pain intensity and the level of anxiety decrease, physical health increase in Group 1 and 2 were found (p < 0.05). Pressure pain threshold and mental health increase were detected in only Group 1 (p < 0.05). The intergroup comparison showed that significant difference in pain intensity at night, pressure pain threshold, state anxiety and mental health were seen in favor of Group 1 (p < 0.05). The study suggested that stabilization exercises with and without the CTM might be a useful treatment for patients with chronic MNP. However, stabilization exercises with CTM might be superior in improving pain intensity at night, pressure pain threshold, state anxiety and mental health compared to stabilization exercise alone.

Effect of Connective Tissue Manipulation on Symptoms and Quality of Life in Patients With Chronic Constipation: A Randomized Controlled Trial.

OBJECTIVE: The purpose of this study was to examine the effects of connective tissue manipulation (CTM) on the severity of constipation and health-related quality of life in individuals diagnosed with chronic constipation. METHODS: Fifty patients with a diagnosis of chronic constipation according to Rome III criteria were recruited and randomized to an intervention (n = 25) or control group (n = 25). The intervention group received CTM in addition to the lifestyle advice, whereas the control group was given only lifestyle advice for constipation. All assessments were performed at baseline and at the end of 4 weeks. The primary outcome measure was the Constipation Severity Instrument. Secondary outcomes included Patient Assessment of Constipation Quality of Life Questionnaire, Bristol Stool Scale, and 7-day bowel diary. Differences between groups were analyzed with t tests, Mann-Whitney U test and χ(2) test. RESULTS: Compared with the control group, subjects in the intervention group reported significantly greater improvement in total and subscale scores of the Constipation Severity Instrument and Patient Assessment of Constipation Quality of Life Questionnaire (P < .05). Based on the results from bowel diaries, the improvements in the number of bowel movements, duration of defecation, stool consistency, and the feeling of incomplete evacuation in the intervention group were also significantly more than the control group (P < .05). CONCLUSION: This study showed that CTM and lifestyle advice were superior to reducing symptoms of constipation and quality of life compared with lifestyle advice alone for patients with chronic constipation.

Comparison of different treatment protocols in the treatment of idiopathic detrusor overactivity: a randomized controlled trial.

OBJECTIVE: To investigate and compare the effectiveness of various treatment protocols for the treatment of women with idiopathic detrusor overactivity. DESIGN: Prospective, randomized controlled trial. SETTING: Departments of Physiotherapy and Rehabilitation and Obstetrics and Gynaecology, Hacettepe University. SUBJECTS: Forty-six subjects were randomized to three groups. INTERVENTIONS: The first group received only pharmacotherapy, the second group received only physiotherapy and in the third group pharmacotherapy was combined with physiotherapy (combined therapy group). MAIN MEASURES: All patients were evaluated at the beginning and at the end of treatment. Assessment parameters were maximum cystometric capacity, electromyographic activity of pelvic floor muscles, voiding diary parameters, the amount of urine leakage and the quality of life score. RESULTS: The maximum cystometric capacity and the electromyographic activity of pelvic floor muscles increased significantly and the number of voids/day and incontinence episodes/day, and the amount of urine leakage reduced significantly (P < 0.05) in both physiotherapy and combined therapy groups while there was no significant difference in the pharmacotherapy group. After treatment, the number of voids/day increased by 0.3 ± 3.4 in the pharmacotherapy group (P > 0.05) and decreased by 5.1 ± 5.5 and 4.7 ± 5.6 in the physiotherapy and combined therapy groups, respectively (P < 0.05). Statistically significant improvements were observed in all groups according to the number of voids/night and the quality of life scores at the end of the treatment. CONCLUSION: The physiotherapy protocol we introduced in the present study with or without anticholinergic therapy has a substantial positive impact on the treatment of female patients with idiopathic detrusor overactivity.

Comparison of manual lymph drainage therapy and connective tissue massage in women with fibromyalgia: a randomized controlled trial.

OBJECTIVE: This study analyzed and compared the effects of manual lymph drainage therapy (MLDT) and connective tissue massage (CTM) in women with primary fibromyalgia (PFM). METHODS: The study design was a randomized controlled trial. Fifty women with PFM completed the study. The patients were divided randomly into 2 groups. Whereas 25 of them received MLDT, the other 25 underwent CTM. The treatment program was carried out 5 times a week for 3 weeks in each group. Pain was evaluated by a visual analogue scale and algometry. The Fibromyalgia Impact Questionnaire (FIQ) and Nottingham Health Profile were used to describe health status and health-related quality of life (HRQoL). Wilcoxon signed rank test and Mann-Whitney U test were used to analyze the data. RESULTS: In both groups, significant improvements were found regarding pain intensity, pain pressure threshold, and HRQoL (P < .05). However, the scores of FIQ-7 (P = .006), FIQ-9 (P = .006), and FIQ-total (P = .010) were significantly lower in the MLDT group than they were in the CTM group at the end of treatment. CONCLUSIONS: For this particular group of patients, both MLDT and CTM appear to yield improvements in terms of pain, health status, and HRQoL. The results indicate that these manual therapy techniques might be used in the treatment of PFM. However, MLDT was found to be more effective than CTM according to some subitems of FIQ (morning tiredness and anxiety) and FIQ total score. Manual lymph drainage therapy might be preferred; however, further long-term follow-up studies are needed.

Interferential current versus biofeedback results in urinary stress incontinence.

BACKGROUND: Urinary stress incontinence is a common, disruptive and potentially disabling condition in which the subject complains of involuntary leakage on effort or exertion or on sneezing or coughing. AIM: This study was performed in order to compare the effects of interferential current and biofeedback applications on incontinence severity in patients with urinary stress incontinence. In addition, pelvic muscle strength and quality of life as important parameters in these subjects were investigated. METHODS: In this prospective, randomised, controlled study, forty women with moderate intensity of urinary stress incontinence as determined by one-hour pad test were included. Pelvic muscle strength was evaluated by a biofeedback device and quality of life was assessed by a 28-itemed questionnaire. All of the parameters were evaluated before and after the treatments. Twenty cases underwent interferential current therapy, while pelvic floor exercises via biofeedback were applied in the remaining cases. The treatments lasted 15 minutes per session, three times a week for a total of 15 sessions. RESULTS: All of the parameters improved after the treatments in each group (p <0.05) and both treatment modalities seemed to have similar effects on pad test (95% CI: -1.48 - 4.59), pelvic muscle strength (95% CI: -9.29 -1.78) and quality of life (95% CI: -11.91 - 5.31) outcomes. CONCLUSIONS: Physical therapy modalities used in this trial are applied easily and non invasive. Also, when the finding that no adverse effects were observed during the study period is taken into consideration, it can be concluded that both methods can be used effectively in patients with urinary stress incontinence.

Effectiveness of transcutaneous electrical nerve stimulation and interferential current in primary dysmenorrhea.

OBJECTIVE: To compare the effectiveness of transcutaneous electrical nerve stimulation and interferential current in primary dysmenorrhea. DESIGN: A prospective, randomized, and controlled study. SETTING: Hacettepe University School of Physical Therapy and Rehabilitation. PATIENTS: Thirty-four volunteer subjects with primary dysmenorrhea (mean age: 21.35 +/- 1.70 years) were included. Statistical analyses were performed in 32 subjects who completed all measures. INTERVENTIONS: Fifteen subjects received interferential current application for 20 minutes and 17 subjects received transcutaneous electrical nerve stimulation for 20 minutes when they were experiencing dysmenorrhea. OUTCOME MEASURES: Physical characteristics, years since menarche, length of menstrual cycle (days), and duration of menstruation (days) were recorded. Visual analog scale ( VAS) intensities of menstrual pain, referred lower limb pain, and low back pain were recorded before treatment, and immediately, 8 hours, and 24 hours after treatment. RESULTS: Intensities of the evaluated parameters decreased beginning from just after the applications in both groups (P<0.05). Intensity of referring low back pain in first three measurement times was different between the groups (P<0.05), but this difference is thought to be due to the baseline values of the groups. So, it can be said that no superiority existed between the methods (P>0.05). CONCLUSION: Both transcutaneous electrical nerve stimulation and interferential current appear to be effective in primary dysmenorrhea. As they are free from the potentially adverse effects of analgesics, and no adverse effects are reported in the literature nor observed in this study, a clinical trial of their effectiveness in comparison with untreated and placebo-treated control groups is warranted.

Short and long-term results of connective tissue manipulation and combined ultrasound therapy in patients with fibromyalgia.

OBJECTIVE: The aim of the study was to evaluate the short-term and 1-year follow-up results of connective tissue manipulation and combined ultrasound (US) therapy (US and high-voltage pulsed galvanic stimulation) in terms of pain, complaint of nonrestorative sleep, and impact on the functional activities in patients with fibromyalgia (FM). METHODS: This is an observational prospective cohort study of 20 female patients with FM. Intensity of pain, complaint of nonrestorative sleep, and impact of FM on functional activities were evaluated by visual analogue scales. All evaluations were performed before and after 20 sessions of treatment, which included connective tissue manipulation of the back daily, for a total of 20 sessions, and combined US therapy of the upper back region every other session. One-year follow-up evaluations were performed on 14 subjects. Friedman test was used to analyze time-dependent changes. RESULTS: Statistical analyses revealed that pain intensity, impact of FM on functional activities, and complaints of nonrestorative sleep improved after the treatment program (P < .05). CONCLUSION: Methods used in this study seemed to be helpful in improving pain intensity, complaints of nonrestorative sleep, and impact on functional activities in patients with FM.