Following on from Assessing Fibromyalgia Is Not An Exercise In Pain this blog aims to provide some practical tips on how to go about treating a Fibromyalgia (FM) patient after successfully assessing them.
“For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance.” (1)
Clearly there is no direct effect to reducing pain from this approach. There are however significant less tangible effects reducing the fear or perception of pain which leads to a reduction.
My advice is to teach your FM patients as much as you are able to about pain in as much depth as possible. I have received excellent feedback immediately following the education and they continue to quote me months down the line appropriately as we introduce new interventions. There is an overview here:
Treat the Biomechanical Issues
Assuming you have found the biomechanical issues, treat them. Treat them as you normally would.
Graded exercise program (Hydrotherapy?)
There is evidence that exercise therapy works in FM patients to decrease pain, improve function and reduce disability (2). You can read a bit more about how here:
The real crux of the problem here though is how we get FM patients participating in regular exercise when walking up the stairs increases their pain significantly. One answer lies in the treatment of the Biomechanics issues uncovered in the assessment. If a muscle is weak it clearly needs strengthening and exercise is usually the most effective way of doing that, patients can relate to this easily. I use these exercises to build into more general exercises and aerobic work.
Aerobic work is always tolerated better with minimal impact so cross-trainer and static bike are my first port of call. There is evidence to suggest that light-moderate Aerobic exercise is tolerated better than higher intensity exercise with regards to post exercise symptom increases.
Hydrotherapy is often a mainstay of treatment for FM patients in Physio departments and there is certainly evidence to suggest its effectiveness in the short term. I use it sparingly. I stay away from Hydrotherapy in patients that have no interest in keeping it up outside of the hospital setting. 1 session per week for 6 weeks is going to have had zero effect 6 months after it finishes unless the patient keeps it up. Patients sometimes arrive at appointments expecting it and unless they give signs to indicate keeping it up they don’t get referred. Harsh? Maybe. My advice on Hydro for FM is think carefully about what you are trying to achieve. If you need it to best treat a biomechanical issue or the patient wants to carry it on then it is a good treatment option. If they won’t carry it on and it is not the best treatment option for a biomechanical issue, don’t refer.
What I do in Hydro is treat it like a water gym. Strengthening, CV and stretching/mobility work in all programs to optimize performance. Remember that the patient will likely feel great in the water but will still have the short term adverse reaction to exercise so be careful with the time/intensity of the first few sessions.
Teach the patient how to pace activities, use specific examples of their activities and get them to focus on one at a time. When they improve at the skill they will either naturally adapt or can take on more activity change at a time.
This is the way I teach patients to pace:
Activity X causes or increases pain after 20 mins. Do Activity X for 20% less time (16 mins) then stop. After 1 week add 10% (18 mins) if no increase in pain continue for one week then add 10%. Continue. If a stage is reached where pain increases again then return to previous time and continue for a while, maybe a month and try increasing it by 10% again.
N.B.1 dependent on the frequency of the activity you may need to leave increases longer than a week.
N.B.2 If you never do too much how do you know what you can do?
Focus away from pain
Try and give strategies or interventions to improve the patients other symptoms. For example: Fatigue – Sleep hygiene or relaxation techniques. General education regarding diet, smoking or alcohol for example can also help to improve energy levels and overall health. As said previously you can make a lot of improvements in function without affecting the patients pain levels.
Don’t expect smooth sailing
- Short term response to exercise in FM patients increases their pain levels
- The variable nature of FM means patients will peak and trough despite interventions provided
- Biomechanical issues may occur or worsen just as with populations without FM
- Be patient, lifestyle changes don’t happen overnight
If you have any questions, feedback or just want to hear more of my ideas you can follow me on Twitter (@physiojack).
1. Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine & Rehabilitation, 92(12), 2041-2056
2. Busch AJ, Barber KA, Overend TJ, Peloso PMJ, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD003786. DOI: 10.1002/14651858.CD003786.pub2.