Fibromyalgia is one of the most dreadful pain syndromes involving myofascia of different anatomical sites. Although, its features are similar to Myofascial Pain Syndrome (MFPS) and overlaps with other pain conditions but it has a clear diagnostic criteria and treatment of fibromyalgia is started soon after the case is diagnosed. Similarly physiotherapy in fibromyalgia syndrome must be extensive, long- term and multi- faceted. Here is a detail discussion on the physiotherapy aspects of this condition along with the possible outcomes after the physiotherapy treatment in fibromyalgia syndrome.
Here we want to make a point that physiotherapy in fibromyalgia syndrome is just one aspect of treatment of fibromyalgia syndrome and the management should involves a client- centered multi- disciplinary approach to the problem. The article will be divided in three parts namely:
- Physiotherapy in Fibromyalgia
- Patient referral to other specialists
- Treatment outcomes.
Physiotherapy in Fibromyalgia
The Physiotherapy treatment in fibromyalgia involves three parts:
The physical modalities that show good results in the treatment of fibromyalgia are:
Moist packs help in relieving pain, improving blood supply and muscle relaxation. This in terms helps in further application of manual therapy. The moist pack should be directly applied on the involved parts with a wrapped towel. On similar lines, use of hot shower is also recommended for the relaxation of muscles and relief from pain in cases of fibromyalgia.
Transcutaneous Electrical Nerve Stimulation (TENS) works by acting on Melzack and Wall’s “Gait control.” It shows good results in controlling the pain in fibromyalgia syndrome. This can be learned to be use at home also. Long term uses have not shown any dependence. So it is a good alternative to analgesic medicine.
The therapeutic ultrasound shows good results in the deactivation of Myofascial trigger points that are associated with myofascial pain syndromes as well as fibromyalgia. The effects include pain relief, relaxation in muscle spasm etc.
The manual therapy should also and always accompany the physical modalities in the treatment of fibromyalgia.
Soft Tissue Elongation
Muscles harboring the trigger points must be stretched to gain the full length of the muscle and enhancing the complete range of motion. Travell & Simons also recommended the use of stretch and spray technique in releasing trigger points but later due to the environmental effects of aerosols has taken it back.
It is the most important treatment modality in helping the cases of Myofascial pain and providing physiotherapy in fibromyalgia. It involves the release of myofascia using local pressure and guided movements. Self MFRs should be learned by the patient to help in releasing the stiffer muscles at home also.
Intramuscular Manual Therapy
- Also known as Dry Needling/ Western Acupuncture/ Percutaneous manual therapy
It is the latest and most effective treatment modality available for the trigger point release in cases of Myofascial Pain Syndrome or Fibromyalgia. In this therapy, the Needles are directly applied to the taut myofascial bands as well as trigger points for its de- activation. There are different sizes of needles available and the use depends on the region on which dry needling is applied. Some researches have shown that Dry Needling is equally effective as compared to steroid or local anesthetic injections in relieving the pain of radiating from trigger points. This is cost effective as compared to Injection therapy.
Fibromyalgia is a chronic problem and the pathology involves the presence of trigger points n the muscles, ligaments and tendons. But the secondary changes in the joints also have a far fetched effect in dissipating pain and inability to correct the posture. Thus spine mobilization as well as peripheral mobilization helps in correcting the posture and long- term relief or prevention.
Proprioceptive Neuromuscular Facilitation (PNF) helps in gaining or rather experiencing the functional movements in the painful body parts. This helps in developing neuronal circuits for pain free movements and decreasing central sensitization that is strongly associated with fibromyalgia syndrome. This includes set of movements based on the clients functional problems and can be- active, active assisted and/or passive.
This technique helps in movement of nerves that got struck at tension points. This will lead to overall relaxation of the involved extremity or part. This is of two types- sliders and tensioners.
It is sometimes not possible for the patient to see the psychologist each and everyday while taking physiotherapy sessions for fibromyalgia. So its physiotherapist responsibility to guide the patient about the mechanism of pain development, making him learn the coping strategies (for difficult cases) and motivating to continue the treatment even when it looks less effective in short term. This is as important as applying physical modalities or manual therapy because the biggest problem the clients with fibromyalgia syndrome faces is the indifferent attitude of the physician towards his pain, non- diagnosis, unclear diagnosis and the associated anxiousness.
Patient referral to other specialists
As it is already mentioned that treating the fibromyalgia requires a client- centered multi- disciplinary approach, here is a mention of other health care professionals to whom a referral at right time can help the client in getting relief from some of the associated symptoms as well as the hastening the process of rehabilitation or functional independence.
The foremost person to refer is a rheumatologist, if there is a client coming to the center with symptoms similar to fibromyalgia. Well defined diagnostic criteria have been developed by the American College of Rheumatology, based on which the diagnosis of the fibromyalgia symptoms can be made. There after the rheumatologist should refer back to a physiotherapy center or pain management center as per the requirements of the client. The main reason for referral is not that they are prime member in developing treatment strategies but that they help in excluding other rheumatologic and systemic condition that have similar symptoms.
Generally, the pain management centers are headed by anesthesiologists and helps in providing relief from pain and anxiousness. This is especially true for people having long term pain and is unable to do even the activities of daily living. But the pain management must not be restricted to the pharmacologic management of pain and must involve other specialist too.
In severe cases, the patient must attend psychologist to get rid of psychological effects of pain and associated anxiety. Indian social structure provide a good family support specially in joint families, so the number of cases requiring pain counseling is less as compared to other countries with more of nuclear families.
For associated symptoms
- Sleep disturbance, depression, drug abuse: Psychiatric referral may be required.
- Irritable bowel syndrome, Gastric ulcers due to prolonged use of NSAIDs: Gastroenterologist referral may be required.
Following the regular physiotherapy sessions and other treatment method, the client can expect a complete or near complete gain in the activities of daily living as well as complete functional independence. At the same time, it is expected from the client that always remain in touch with the primary care provider so that any complication arising will be able to be treated at the earliest.