human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The purpose of this study was to compare the effects of aerobic training with a muscle-strengthening program in patients with fibromyalgia . Thirty women with fibromyalgia were r and omized to either an aerobic exercise ( AE ) program or a strengthening exercise ( SE ) program for 8 weeks . Outcome measures included the intensity of fibromyalgia-related symptoms , tender point count , fitness ( 6-min walk distance ) , hospital anxiety and depression ( HAD ) scale , and short-form health survey ( SF-36 ) . There were significant improvements in both groups regarding pain , sleep , fatigue , tender point count , and fitness after treatment . HAD-depression scores improved significantly in both groups while no significant change occurred in HAD-anxiety scores . Bodily pain subscale of SF-36 and physical component summary improved significantly in the AE group , whereas seven subscales of SF-36 , physical component summary , and mental component summary improved significantly in the SE group . When the groups were compared after treatment , there were no significant differences in pain , sleep , fatigue , tender point count , fitness , HAD scores , and SF-36 scores . AE and SE are similarly effective at improving symptoms , tender point count , fitness , depression , and quality of life in fibromyalgia Objective : Assess the efficacy of  duloxetine 60/120 mg ( N = 162 ) once daily compared with  placebo ( N = 168 ) in the treatment of patients with fibromyalgia , during six months of treatment . Methods : This was a phase-III , r and omized , double-blind , placebo-controlled , parallel-group study assessing the efficacy and safety of duloxetine . Results : There were no significant differences between treatment groups on the co- primary efficacy outcome measures , change in the Brief Pain Inventory ( BPI ) average pain severity from baseline to endpoint ( P = 0.053 ) and the Patient ’s Global Impressions of Improvement ( PGI-I ) at endpoint ( P = 0.073 ) . Duloxetine-treated patients improved significantly more than placebo-treated patients on the Fibromyalgia Impact Question naire pain score , BPI least pain score and average interference score , Clinical Global Impressions of Severity scale , area under the curve of pain relief , Multidimensional Fatigue Inventory mental fatigue dimension , Beck Depression Inventory-II total score , and 36-item Short Form Health Survey mental component summary and mental health score . Nausea was the most common treatment-emergent adverse event in the duloxetine group . Overall discontinuation rates were similar between groups . Conclusions : Although duloxetine 60/120 mg/day failed to demonstrate significant improvement over placebo on the co- primary outcome measures , in this supportive study , duloxetine demonstrated significant improvement compared with placebo on numerous secondary measures OBJECTIVE A subset of fibromyalgia ( FM ) patients have a dysfunctional hypothalamic-pituitary-insulin-like growth factor 1 ( IGF-1 ) axis , as evidence d by low serum levels of IGF-1 and a reduced growth hormone ( GH ) response to physiologic stimuli . There is evidence that pyridostigmine ( PYD ) improves the acute response of GH to exercise in FM patients . The purpose of this study was to evaluate the clinical effectiveness of 6 months of PYD and group exercise on FM symptoms . METHODS FM patients were r and omized to 1 of the following 4 groups : PYD plus exercise , PYD plus diet recall but no exercise , placebo plus exercise , and placebo plus diet recall but no exercise . The primary outcome measures were the visual analog scale ( VAS ) score for pain , tender point count , and total myalgic score . Secondary outcome measures were the total score on the Fibromyalgia Impact Question naire ( FIQ ) and FIQ VAS scores for individual symptoms ( fatigue , poor sleep , stiffness , and anxiety ) , as well as quality of life ( QOL ) and physical fitness ( lower body strength/endurance , upper and lower body flexibility , balance , and time on the treadmill ) . RESULTS A total of 165 FM patients completed baseline measurements ; 154 ( 93.3 % ) completed the study . The combination of PYD and exercise did not improve pain scores .  PYD groups showed a significant improvement in sleep and anxiety in those who completed the study and in QOL in those who complied with the therapeutic regimen as compared with the placebo groups . Compared with the nonexercise groups , the 2 exercise groups demonstrated improvement in fatigue and fitness .  PYD was generally well tolerated . CONCLUSION Neither the combination of PYD plus supervised exercise nor either treatment alone yielded improvement in most FM symptoms . However , PYD did improve anxiety and sleep , and exercise improved fatigue and fitness . We speculate that PYD may have improved vagal tone , thus benefiting sleep and anxiety ; this notion warrants further study OBJECTIVE To evaluate the effects of using a gamma-hydroxybutyrate ( GHB ) administered in divided doses at night in 11 patients previously diagnosed with fibromyalgia ( FM ) . METHODS Subjects completed daily diaries assessing their pain and fatigue levels and slept in the sleep laboratory before and one month after initiating GHB treatment . Polysomnographic recordings were evaluated for sleep stages , sleep efficiency and the presence of the alpha anomaly in non-REM sleep . RESULTS There was a significant improvement in both fatigue and pain , with an increase in slow wave sleep and a decrease in the severity of the alpha anomaly . CONCLUSION Further controlled studies are needed to characterize the clinical improvement and the polysomnographic changes we observed This article describes an ongoing , long-term clinical exercise program for women with fibromyalgia syndrome ( FMS ) , some of whom also have chronic fatigue and immune dysfunction syndrome ( CFIDS ) . The recorded outcomes from the most recent year of the program also are reported . Participants engaged in sessions lasting 50 - 70 minutes , 5 days per week ; each session involved aerobic activity , resistance training , and other dynamic exercise . One group was in the program for 3 years and another group was in the program for 2 years . Program outcomes for the year ( comparing beginning and end-of-year results ) are presented for both groups on physical fitness , psychosocial , and FMS/CFIDS symptoms . The outcomes support that all of the women appear to have benefited from the program in numerous ways , suggesting that the program works . Also , those outcomes are in agreement with past research reported in this journal . Implication s for clinical nurse specialists working with FMS/CFIDS patients are discussed OBJECTIVE Fibromyalgia ( FMS ) is a chronic syndrome characterized by widespread pain , troubled sleep , disturbed mood , and fatigue . Several analgesic strategies have been evaluated but the results are moderate and inconsistent . Antidepressant agents are now considered the treatment of choice in most patients . It has been recently suggested that FMS may be associated with metabolic alterations including a deficit of carnitine . In this multicenter r and omized clinical trial we evaluated the efficacy of acetyl L-carnitine ( LAC ) in patients with overt FMS . METHODS One hundred and two patients meeting the American College of Rheumatology criteria for FMS were r and omized into the study . The treatment consisted of 2 capsules/day of 500 mg LAC or placebo plus one intramuscular ( i.m . ) injection of either 500 mg LAC or placebo for 2 weeks . During the following 8 weeks the patients took 3 capsules daily containing either 500 mg LAC or placebo . The patients were seen during treatment after 2 ( visit 3 ) , 6 ( visit 4 ) and 10 weeks ( visit 5 ) . The patients were also visited 4 weeks after treatment discontinuation ( follow-up visit ) . Outcome measures included the number of positive tender points , the sum of pain threshold ( kg/cm2 or " total myalgic score " ) , the Short Form 36 ( SF36 ) , a 100 mm visual analog scale ( VAS ) for self-perceived stiffness , fatigue , tiredness on awakening , sleep , work status , depression , and muscular-skeletal pain , and the Hamilton depression scale . RESULTS The " total myalgic score " and the number of positive tender points declined significantly and equally in both groups until the 6th week of treatment . At the 10th week both parameters remained unchanged in the placebo group but they continued to improve in the LAC group with a statistically significant between-group difference . Most VAS scores significantly improved in both groups . A statistically significant between-group difference was observed for depression and musculo-skeletal pain . Significantly larger improvements in SF36 question naire were observed in LAC than in placebo group for most parameters . Treatment was well-tolerated . CONCLUSION Although this experience deserves further studies , these results indicate that LAC may be of benefit in patients with FMS , providing improvement in pain as well as the general and mental health of these patients OBJECTIVE Fibromyalgia ( FM ) syndrome is a chronic pain condition characterized by diffuse muscle pain , increased negative mood , and sleep disturbance . Until recently , sleep disturbance in persons with FM has been modeled as the result of the disease process or its associated pain . The current study examined sleep disturbance ( i.e. , sleep duration and sleep quality ) as a predictor of daily affect , stress reactivity , and stress recovery . DESIGN AND MEASURES A hybrid of daily diary and ecological momentary assessment methodology was used to evaluate the psychosocial functioning of 89 women with FM . Participants recorded numeric ratings of pain , fatigue , and positive and negative affect 3 times throughout the day for 30 consecutive days . At the end of each day , participants completed daily diary records of positive and negative life events . In addition , participants reported on their sleep duration and sleep quality each morning . RESULTS After accounting for the effects of positive events , negative events , and pain on daily affect scores , it was found that sleep duration and quality were prospect ively related to affect and fatigue . Furthermore , the effects of inadequate sleep on negative affect were cumulative . In addition , an inadequate amount of sleep prevented affective recovery from days with a high number of negative events . CONCLUSIONS These results lend support to the hypothesis that sleep is a component of allostatic load and has an upstream role in daily functioning Objective : To determine the incidence and duration of response of clinical ly meaningful improvements with pregabalin across several key symptoms of fibromyalgia ( FM ) . Methods : This was a post hoc analysis of data from a multicenter , double-blind , placebo-controlled , r and omized , withdrawal study , originally design ed to evaluate the efficacy of pregabalin monotherapy for durability of effect on FM pain based on pain and Patient Global Impression of Change ( PGIC ) criteria . Responder criteria for Fibromyalgia Impact Question naire total score ( ≥16-point change ) , Medical Outcomes Study Sleep Scale Sleep Disturbance subscale ( ≥15.8-point change ) , and the 36-item Short-Form Health Survey Vitality scale ( ≥10-point change ) were used to evaluate the incidence and duration of improvements in function , sleep , and fatigue  for pregabalin versus placebo among pain and PGIC responders . A composite responder index consisting of pain , PGIC , function , and sleep endpoints was used to explore multidimensional response . Results : Approximately 80 % of patients meeting pain and PGIC improvement criteria at r and omization had clinical ly meaningful improvement in fatigue , sleep , or function . Higher proportions of patients in the pregabalin group maintained a clinical ly meaningful response , and pregabalin-treated patients had a significantly longer time to loss of therapeutic response  compared with the placebo group . Composite responder Kaplan-Meier analysis , performed with patients demonstrating clinical ly meaningful improvements in pain , PGIC , function , and sleep at r and omization showed a significantly longer median time to loss of therapeutic response for pregabalin-treated patients . Discussion : The results from this post hoc analysis indicate that pregabalin provides long-term effects across multiple domains of FM ( Clinical Trials.gov registry ID : NCT00151489 ) In two investigations , we studied vulnerability to the negative effects of stress among women in chronic pain from 2 types of musculoskeletal illnesses , fibromyalgia syndrome ( FMS ) and osteoarthritis ( OA ) . In Study 1 , there were 101 female participants 50 to 78 years old : 50 had FMS , 29 had OA knee pain and were scheduled for knee surgery , and 22 had OA but were not planning surgery . Cross-sectional analyses showed that the three groups were comparable on demographic variables , personality attributes , negative affect , active coping , and perceived social support . As expected , FMS  and  OA surgery women reported similar levels of bodily pain , and both groups scored higher than OA nonsurgery women . However , women with FMS reported poorer emotional and physical health , lower positive affect , a poorer quality social milieu , and more frequent use of avoidant coping with pain than did both groups of women with OA . Moreover , the perception and use of social support were closely tied to perceived social stress only among the FMS group . In Study 2 , we experimentally manipulated negative mood and stress in 41 women 37 to 74 years old : 20 women had FMS , and 21 women had OA . Participants from each group were r and omly assigned to either a negative mood induction or a neutral mood ( control ) condition , and then all participants discussed a stressful interpersonal event for 30 min . Stress-related increases in pain were exacerbated by negative mood induction among women with FMS but not women with OA , and pain during stress was associated with decreases in positive affect in women with FMS but not women with OA . These findings suggest that among women with chronic pain , those with FMS may be particularly vulnerable to the negative effects of social stress . They have fewer positive affective re sources , use less effective pain-coping strategies , and have more constrained social networks than their counterparts with OA , particularly those who experience similar levels of pain . They also seem to experience more prolonged stress-related increases 
    Output:
    
agent
While no clinical trial to date has specifically targeted fatigue , r and omized controlled trials , systematic review s , and meta-analyses indicate that treatment modalities studied in the context of other fibromyalgia symptoms could also improve fatigue .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The purpose of this study was to compare the effects of aerobic training with a muscle-strengthening program in patients with fibromyalgia . Thirty women with fibromyalgia were r and omized to either an aerobic exercise ( AE ) program or a strengthening exercise ( SE ) program for 8 weeks . Outcome measures included the intensity of fibromyalgia-related symptoms , tender point count , fitness ( 6-min walk distance ) , hospital anxiety and depression ( HAD ) scale , and short-form health survey ( SF-36 ) . There were significant improvements in both groups regarding pain , sleep , fatigue , tender point count , and fitness after treatment . HAD-depression scores improved significantly in both groups while no significant change occurred in HAD-anxiety scores . Bodily pain subscale of SF-36 and physical component summary improved significantly in the AE group , whereas seven subscales of SF-36 , physical component summary , and mental component summary improved significantly in the SE group . When the groups were compared after treatment , there were no significant differences in pain , sleep , fatigue , tender point count , fitness , HAD scores , and SF-36 scores . AE and SE are similarly effective at improving symptoms , tender point count , fitness , depression , and quality of life in fibromyalgia Objective : Assess the efficacy of  duloxetine 60/120 mg ( N = 162 ) once daily compared with  placebo ( N = 168 ) in the treatment of patients with fibromyalgia , during six months of treatment . Methods : This was a phase-III , r and omized , double-blind , placebo-controlled , parallel-group study assessing the efficacy and safety of duloxetine . Results : There were no significant differences between treatment groups on the co- primary efficacy outcome measures , change in the Brief Pain Inventory ( BPI ) average pain severity from baseline to endpoint ( P = 0.053 ) and the Patient ’s Global Impressions of Improvement ( PGI-I ) at endpoint ( P = 0.073 ) . Duloxetine-treated patients improved significantly more than placebo-treated patients on the Fibromyalgia Impact Question naire pain score , BPI least pain score and average interference score , Clinical Global Impressions of Severity scale , area under the curve of pain relief , Multidimensional Fatigue Inventory mental fatigue dimension , Beck Depression Inventory-II total score , and 36-item Short Form Health Survey mental component summary and mental health score . Nausea was the most common treatment-emergent adverse event in the duloxetine group . Overall discontinuation rates were similar between groups . Conclusions : Although duloxetine 60/120 mg/day failed to demonstrate significant improvement over placebo on the co- primary outcome measures , in this supportive study , duloxetine demonstrated significant improvement compared with placebo on numerous secondary measures OBJECTIVE A subset of fibromyalgia ( FM ) patients have a dysfunctional hypothalamic-pituitary-insulin-like growth factor 1 ( IGF-1 ) axis , as evidence d by low serum levels of IGF-1 and a reduced growth hormone ( GH ) response to physiologic stimuli . There is evidence that pyridostigmine ( PYD ) improves the acute response of GH to exercise in FM patients . The purpose of this study was to evaluate the clinical effectiveness of 6 months of PYD and group exercise on FM symptoms . METHODS FM patients were r and omized to 1 of the following 4 groups : PYD plus exercise , PYD plus diet recall but no exercise , placebo plus exercise , and placebo plus diet recall but no exercise . The primary outcome measures were the visual analog scale ( VAS ) score for pain , tender point count , and total myalgic score . Secondary outcome measures were the total score on the Fibromyalgia Impact Question naire ( FIQ ) and FIQ VAS scores for individual symptoms ( fatigue , poor sleep , stiffness , and anxiety ) , as well as quality of life ( QOL ) and physical fitness ( lower body strength/endurance , upper and lower body flexibility , balance , and time on the treadmill ) . RESULTS A total of 165 FM patients completed baseline measurements ; 154 ( 93.3 % ) completed the study . The combination of PYD and exercise did not improve pain scores .  PYD groups showed a significant improvement in sleep and anxiety in those who completed the study and in QOL in those who complied with the therapeutic regimen as compared with the placebo groups . Compared with the nonexercise groups , the 2 exercise groups demonstrated improvement in fatigue and fitness .  PYD was generally well tolerated . CONCLUSION Neither the combination of PYD plus supervised exercise nor either treatment alone yielded improvement in most FM symptoms . However , PYD did improve anxiety and sleep , and exercise improved fatigue and fitness . We speculate that PYD may have improved vagal tone , thus benefiting sleep and anxiety ; this notion warrants further study OBJECTIVE To evaluate the effects of using a gamma-hydroxybutyrate ( GHB ) administered in divided doses at night in 11 patients previously diagnosed with fibromyalgia ( FM ) . METHODS Subjects completed daily diaries assessing their pain and fatigue levels and slept in the sleep laboratory before and one month after initiating GHB treatment . Polysomnographic recordings were evaluated for sleep stages , sleep efficiency and the presence of the alpha anomaly in non-REM sleep . RESULTS There was a significant improvement in both fatigue and pain , with an increase in slow wave sleep and a decrease in the severity of the alpha anomaly . CONCLUSION Further controlled studies are needed to characterize the clinical improvement and the polysomnographic changes we observed This article describes an ongoing , long-term clinical exercise program for women with fibromyalgia syndrome ( FMS ) , some of whom also have chronic fatigue and immune dysfunction syndrome ( CFIDS ) . The recorded outcomes from the most recent year of the program also are reported . Participants engaged in sessions lasting 50 - 70 minutes , 5 days per week ; each session involved aerobic activity , resistance training , and other dynamic exercise . One group was in the program for 3 years and another group was in the program for 2 years . Program outcomes for the year ( comparing beginning and end-of-year results ) are presented for both groups on physical fitness , psychosocial , and FMS/CFIDS symptoms . The outcomes support that all of the women appear to have benefited from the program in numerous ways , suggesting that the program works . Also , those outcomes are in agreement with past research reported in this journal . Implication s for clinical nurse specialists working with FMS/CFIDS patients are discussed OBJECTIVE Fibromyalgia ( FMS ) is a chronic syndrome characterized by widespread pain , troubled sleep , disturbed mood , and fatigue . Several analgesic strategies have been evaluated but the results are moderate and inconsistent . Antidepressant agents are now considered the treatment of choice in most patients . It has been recently suggested that FMS may be associated with metabolic alterations including a deficit of carnitine . In this multicenter r and omized clinical trial we evaluated the efficacy of acetyl L-carnitine ( LAC ) in patients with overt FMS . METHODS One hundred and two patients meeting the American College of Rheumatology criteria for FMS were r and omized into the study . The treatment consisted of 2 capsules/day of 500 mg LAC or placebo plus one intramuscular ( i.m . ) injection of either 500 mg LAC or placebo for 2 weeks . During the following 8 weeks the patients took 3 capsules daily containing either 500 mg LAC or placebo . The patients were seen during treatment after 2 ( visit 3 ) , 6 ( visit 4 ) and 10 weeks ( visit 5 ) . The patients were also visited 4 weeks after treatment discontinuation ( follow-up visit ) . Outcome measures included the number of positive tender points , the sum of pain threshold ( kg/cm2 or " total myalgic score " ) , the Short Form 36 ( SF36 ) , a 100 mm visual analog scale ( VAS ) for self-perceived stiffness , fatigue , tiredness on awakening , sleep , work status , depression , and muscular-skeletal pain , and the Hamilton depression scale . RESULTS The " total myalgic score " and the number of positive tender points declined significantly and equally in both groups until the 6th week of treatment . At the 10th week both parameters remained unchanged in the placebo group but they continued to improve in the LAC group with a statistically significant between-group difference . Most VAS scores significantly improved in both groups . A statistically significant between-group difference was observed for depression and musculo-skeletal pain . Significantly larger improvements in SF36 question naire were observed in LAC than in placebo group for most parameters . Treatment was well-tolerated . CONCLUSION Although this experience deserves further studies , these results indicate that LAC may be of benefit in patients with FMS , providing improvement in pain as well as the general and mental health of these patients OBJECTIVE Fibromyalgia ( FM ) syndrome is a chronic pain condition characterized by diffuse muscle pain , increased negative mood , and sleep disturbance . Until recently , sleep disturbance in persons with FM has been modeled as the result of the disease process or its associated pain . The current study examined sleep disturbance ( i.e. , sleep duration and sleep quality ) as a predictor of daily affect , stress reactivity , and stress recovery . DESIGN AND MEASURES A hybrid of daily diary and ecological momentary assessment methodology was used to evaluate the psychosocial functioning of 89 women with FM . Participants recorded numeric ratings of pain , fatigue , and positive and negative affect 3 times throughout the day for 30 consecutive days . At the end of each day , participants completed daily diary records of positive and negative life events . In addition , participants reported on their sleep duration and sleep quality each morning . RESULTS After accounting for the effects of positive events , negative events , and pain on daily affect scores , it was found that sleep duration and quality were prospect ively related to affect and fatigue . Furthermore , the effects of inadequate sleep on negative affect were cumulative . In addition , an inadequate amount of sleep prevented affective recovery from days with a high number of negative events . CONCLUSIONS These results lend support to the hypothesis that sleep is a component of allostatic load and has an upstream role in daily functioning Objective : To determine the incidence and duration of response of clinical ly meaningful improvements with pregabalin across several key symptoms of fibromyalgia ( FM ) . Methods : This was a post hoc analysis of data from a multicenter , double-blind , placebo-controlled , r and omized , withdrawal study , originally design ed to evaluate the efficacy of pregabalin monotherapy for durability of effect on FM pain based on pain and Patient Global Impression of Change ( PGIC ) criteria . Responder criteria for Fibromyalgia Impact Question naire total score ( ≥16-point change ) , Medical Outcomes Study Sleep Scale Sleep Disturbance subscale ( ≥15.8-point change ) , and the 36-item Short-Form Health Survey Vitality scale ( ≥10-point change ) were used to evaluate the incidence and duration of improvements in function , sleep , and fatigue  for pregabalin versus placebo among pain and PGIC responders . A composite responder index consisting of pain , PGIC , function , and sleep endpoints was used to explore multidimensional response . Results : Approximately 80 % of patients meeting pain and PGIC improvement criteria at r and omization had clinical ly meaningful improvement in fatigue , sleep , or function . Higher proportions of patients in the pregabalin group maintained a clinical ly meaningful response , and pregabalin-treated patients had a significantly longer time to loss of therapeutic response  compared with the placebo group . Composite responder Kaplan-Meier analysis , performed with patients demonstrating clinical ly meaningful improvements in pain , PGIC , function , and sleep at r and omization showed a significantly longer median time to loss of therapeutic response for pregabalin-treated patients . Discussion : The results from this post hoc analysis indicate that pregabalin provides long-term effects across multiple domains of FM ( Clinical Trials.gov registry ID : NCT00151489 ) In two investigations , we studied vulnerability to the negative effects of stress among women in chronic pain from 2 types of musculoskeletal illnesses , fibromyalgia syndrome ( FMS ) and osteoarthritis ( OA ) . In Study 1 , there were 101 female participants 50 to 78 years old : 50 had FMS , 29 had OA knee pain and were scheduled for knee surgery , and 22 had OA but were not planning surgery . Cross-sectional analyses showed that the three groups were comparable on demographic variables , personality attributes , negative affect , active coping , and perceived social support . As expected , FMS  and  OA surgery women reported similar levels of bodily pain , and both groups scored higher than OA nonsurgery women . However , women with FMS reported poorer emotional and physical health , lower positive affect , a poorer quality social milieu , and more frequent use of avoidant coping with pain than did both groups of women with OA . Moreover , the perception and use of social support were closely tied to perceived social stress only among the FMS group . In Study 2 , we experimentally manipulated negative mood and stress in 41 women 37 to 74 years old : 20 women had FMS , and 21 women had OA . Participants from each group were r and omly assigned to either a negative mood induction or a neutral mood ( control ) condition , and then all participants discussed a stressful interpersonal event for 30 min . Stress-related increases in pain were exacerbated by negative mood induction among women with FMS but not women with OA , and pain during stress was associated with decreases in positive affect in women with FMS but not women with OA . These findings suggest that among women with chronic pain , those with FMS may be particularly vulnerable to the negative effects of social stress . They have fewer positive affective re sources , use less effective pain-coping strategies , and have more constrained social networks than their counterparts with OA , particularly those who experience similar levels of pain . They also seem to experience more prolonged stress-related increases 
    Output:
    