An audit of treatments for fibromyalgia at the Royal London Hospital for Integrated Medicine - Esther Odetunde, Chartered Physiotherapist.

Esther is a specialist physiotherapist working at the Royal London Hospital for Integrated Medicine (RLHIM) known for the high number of patients she treats, the vast majority of whom must feel well looked after given her very high attendance rate. Esther treats a challenging group of patients, those diagnosed with fibromyalgia. She is part of a small team offering a programme of care for those suffering with this potentially debilitating chronic pain condition. The team is multidisciplinary in nature and also comprises a physician, psychologist, dietician and occupational therapist.

Referred patients with fibromyalgia enter a care pathway based on the Eular fibromyalgia treatment guidelines (2007) and are selected either for group or individualized treatment. The care pathway also determines which part of programme is most applicable for the patient. For example if depression is the main issue, the patient would receive a course of CBT, in the case reduced function, pain and mobility issues physiotherapy would be offered. Different types of treatment may be offered concurrently.

Now I’m talking about stripped down back to basics yoga, no candles and incense!

As a system of exercise which promotes flexibility, power and strength it’s terrific. Yoga places an emphasis on integrated and functional movement, moving with fluidity and grace.

Done correctly a nice balance can be achieved between strength and flexibility. Going too far in either direction can cause problems. This has been the downfall of the ‘core strengthening’ approach. If not done correctly or applied to the wrong body type, core strengthening can promote rigidity, tension and stiffness which can actually promote pain and injury rather than relieve it as would be the conventional wisdom.

My client was referred to me by his GP with a 6 month history of ‘rotator cuff’, vague yes, but a starting point perhaps.

Indeed he showed and arc of pain raising the shoulder into abduction. He had a positive Jobes empty can test, but as we know this type of test lacks validity and reliability. Nonetheless the test indicated that some shoulder structure or other did not like to be stressed in this way. But did Jobe's test reproduce my clients pain? - no, and neither did the other impingement tests which appeared positive. So was the possible impingement a secondary issue?

My client's shoulder was ‘stiff’ and generally restricted in all directions. His pain was more accurately reproduced when he actively raised his arm into about 90 degrees of abduction and then outwardly rotated at the shoulder. This reproduced ‘his pain’ which was located at the upper long head of biceps brachii region. The biceps muscle, possibly tendon is the problem? No, only mildly tender to palpate and the biceps provocations tests were negative. However when I applied a gentle anteroposterior glide to the head of the humerus his pain eased immediately and he was able to move without pain further into range.

Physiotherapy, like most professions is subject to trends and fads. Big names in research will on occasion hit upon an idea that starts to gain traction in research circles and then may filter down to clinical practice.

Most of us in clinical practice want to get better and what we do so that we can help our clients get better more quickly. Others get bored with using the same techniques and love an opportunity to do it differently. For this reason physiotherapists seem ever open to new approaches and techniques.

Medical acupuncture which may include dry needling often gets criticised by other healthcare practitioners as being too ‘passive’. The concern seems to be that you as clients will develop a reliance when the emphasis should be on self management, exercise, movement and lifestyle modification etc.

I fully understand the concern and the importance promoting active involvement on the part of the client. We as physiotherapists know that some of the best evidence for the long term management of pain is with exercise. Lifestyle adjustments as well as an understanding of how thoughts, attitudes and beliefs towards pain is now better understood and should also be addressed by your physiotherapist if needed.

My view if that medical acupuncture is most effective when combined with exercise and lifestyle adjustments and this is how I practice. No session with me would be complete without getting you moving afterwards. My aim is to facilitate movement and function which is free and easy, comfortable and relaxed, I want you to trust your body and let it work for you without fear and concern. The type of movement and exercises I will recommend will be tailored to your needs and based on what I find on assessment.