Manual therapy can worsen symptoms for people with fibromyalgia syndrome, new guidelines warn
Physiotherapists and other clinicians have been warned that offering manual therapy to patients with fibromyalgia syndrome (FMS) may worsen their symptoms.
The warning appears in guidelines – titled ‘The diagnosis of fibromyalgia syndrome’ – that were published last week (17 March) by the Royal College of Physicians.
The guidelines, which were drawn up by 30 members of a guideline development group that included clinicians such as Nadia Loftus from the Chartered Society of Physiotherapy – as well as patients and carers of those with FMS – include the following statement: ‘Rehabilitation focusing solely on manual therapy, including mobilisation or soft tissue techniques (for example massage) or vigorous exercises can be ineffective and may even increase pain.’
The college hopes that the guidelines will help to speed up the process that leads to people receiving a diagnosis of FMS and assist diagnosticians, including physiotherapists, in making accurate diagnoses. In the past, rheumatologists often took the lead in making diagnoses, the guidelines note.
Established pain medications or normal musculoskeletal physiotherapy are often not effective or can even cause harm – the patient should be advised accordingly [Royal College of Physicians guidelines]
In a section titled ‘Clinical management’, the guidelines suggest that:
any discussion regarding treatment should be a shared decision between patient and healthcare provider
clinicians offering advice should aim to do this with a knowledge of the current evidence
treatments can be based on a working diagnosis – even in cases of diagnostic uncertainty (though some patients will ‘find it challenging’ to accept treatment in this situation)
The guidelines note that interventions involving education, self-management and connecting with support groups for non-clinical support can play an important role. Patients might be signposted to local or virtual resources or given advice on gentle rehabilitation (aerobic exercises and group-based treatments in the community such as Pilates and mindfulness classes).
Professional treatment options include pain-specialised physiotherapy, psychology, occupational therapy-led pain management programmes and medication.
But the guidelines stress: ‘Established pain medications or normal musculoskeletal physiotherapy are often not effective or can even cause harm – the patient should be advised accordingly.’
If patients require blood screening tests, physios and other clinicians who cannot arrange these directly should refer patients to the primary physician involved in their care, usually their GP, the guidelines point out.
FMS is a long-term condition, sometimes requiring planned reviews in primary or secondary care settings. ‘Thus, the primary or secondary care team should support and facilitate the development of a therapeutic relationship. This is crucial if expertise from both clinician and patient is to be effectively utilised in a shared management plan.’
Some patients experience a range of symptoms that can result in disability and feeling distressed. This situation ‘can be difficult to understand and may lead to a patient feeling overwhelmed’. The guidelines note that this ‘can be articulated in many ways’.
Clinicians should aware that such a complex presentation may represent FMS. ‘Healthcare professionals often reflect on the interaction between themselves and their patient and how it makes them feel. It is not unusual for consultations to invoke feelings of being overwhelmed, even for the most experienced clinician. This can also be useful information in itself and point towards FMS.’
In a section tackling diversity topics, the guidelines state that while FMS is most commonly found in women aged from 40-60, men, young people and older people can also be affected.
‘Work on how fibromyalgia and chronic pain affect different ethnicities is ongoing. Most research into different ethnicities has taken place in the USA and involves people from African-American and Hispanic backgrounds. There is a lack of research into how fibromyalgia affects the South-Asian population in the UK.
‘Research suggests that people from ethnic minority backgrounds may be less likely to receive a diagnosis of fibromyalgia than White individuals. Patients with FMS from ethnic minority backgrounds may also be more affected by mood disturbances including depression, and sleep disturbances than White patients with FMS.’
To download copies of ‘The diagnosis of fibromyalgia syndrome’ and related guidance, visit: https://www.rcplondon.ac.uk/guidelines-policy/diagnosis-fibromyalgia-syndrome
Author: Ian A McMillan