PhysioUpdate 29th March 2022

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.’

Sharing expertise

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.’

Feeling ‘overwhelmed’

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.’

Diversity issues

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

New ways of encouraging certain patients to lie face down in prone positions for longer periods are urgently needed, according to researchers who led a study involving patients with Covid-19 in intensive care settings.

The results of a trial, which had to be aborted, appear in today’s edition of The BMJ (24 March). The trial, titled COVID-PRONE was conducted by a team based in Canada and the USA and led by Michael Fralick, from the division of general internal medicine, Sinai Health in Toronto.

After it became clear that patients would not make sufficient improvements, researchers stopped the trail. They argue that innovative approaches are needed to enable patients to adopt prone positions for more than a few hours each day.

Physiotherapists, district nurses and other NHS staff who have to drive hundreds of miles to treat home-bound vulnerable patients face a cost of living crisis that has been exacerbated by rising petrol rises.

The NHS Confederation and NHS Providers have warned that fuel costs – which now stand at an average of £1.67 for a litre of petrol – mean the government must act to alleviate the financial pressures being heaped on community staff. The organisations argue that mileage rate reimbursements should reflect the price of fuel, along with levels of business tax relief.

The current mileage reimbursement rate for health staff on standard NHS employment contracts is set by the Treasury, in agreement with trade unions and NHS employers. Rates are reviewed twice a year, with the next review due next month (April).