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Therapeutic approaches to fibromyalgia syndrome in the United Kingdom: a survey of occupational therapists and physical therapists
European Journal of Pain 7 (2003) 173–180 www.EuropeanJournalPain.com
Therapeutic approaches to fibromyalgia syndrome in the United Kingdom: a survey of occupational therapists and physical therapists Julius Sima,*, Nicola Adamsb b
a Primary Care Sciences Research Centre, Keele University, Keele, Staffordshire ST5 5BG, UK Faculty of Health and Applied Social Sciences, John Moores University, 79 Tithebarn Street, Liverpool L2 2ER, UK
Received 22 April 2002; accepted 14 August 2002
Abstract Background and purpose. This study sought information from occupational therapists (OTs) and physical therapists (PTs) working in rheumatology in the UK on their usual methods of treatment and management of patients with fibromyalgia syndrome (FMS). Methods. Data were gathered by self-completion questionnaire on: work setting; referrals of FMS patients; usual treatment objectives; assessment and treatment approaches; perceived responsiveness of patients; and other perceptions of the management of FMS. Most data were in the form of frequency counts, with some ordinal scales and open responses. Results. Responses were obtained from 142 therapists (71% response rate), of whom 47 OTs and 39 PTs managed patients with FMS. The foremost therapeutic objective was increased functional ability for OTs, and increased exercise tolerance and general fitness for PTs. Pain reduction or management was rated as the second objective for both groups. An endurance-based exercise program and energy conservation techniques were the most frequently utilized interventions. Patients with FMS were thought to be Ômoderately responsiveÕ to physical management. Predictors of outcome were considered to be largely psychosocial, rather than physical, in nature. Conclusion. These data provide a preliminary profile of current practice in the management of FMS among UK therapists and indicate certain differences in approach between OTs and PTs. 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd. All rights reserved. Keywords: Fibromyalgia; Occupational therapy; Physical therapy; Rehabilitation; Survey
1. Introduction Fibromyalgia syndrome (FMS) is a disorder defined by chronic diffuse muscular pain and low pain thresholds at 11 or more of 18 anatomic sites termed tender points (Wolfe et al., 1990). Patients also report symptoms such as chronic fatigue, unrefreshing sleep, morning stiffness, and low exercise tolerance (McCain and Scudds, 1988; Yunus et al., 1981). FMS is widely documented in North America (McCain, 1993; Scudds and Li, 1997; White et al., 1999; Yunus et al., 1981), with an estimated prevalence in the population of approximately 2% (Carmona et al., 2001; Wolfe et al., *
Corresponding author. E-mail address: [email protected] (J. Sim).
1995). Kennedy and Felson (1996) report that 14–20% of patients in rheumatology practices in the USA have FMS as their primary diagnosis. However, there still exists controversy over its existence in the United Kingdom (Bohr, 1995), and the diagnosis seems to be made less commonly than in the USA. The optimum medical management of FMS is a matter of debate (Reilly, 1999). Nonetheless, a very large number of patients with diffuse musculoskeletal pain are referred for occupational therapy (OT) and physical therapy (PT) assessment and management and, in view of prevalence figures for FMS, it is reasonable to assume that a considerable proportion of these patients would fulfil the diagnostic criteria for FMS (Scudds et al., 1996). Despite this, and although there has been a recent focus on FMS in rehabilitation journals
1090-3801/02/$30 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd. All rights reserved. PII: S 1 0 9 0 - 3 8 0 1 ( 0 2 ) 0 0 0 9 5 - 2
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(Adams and Sim, 1998; Krsnich-Shriwise, 1997; Mengshoel, 2000; Scudds and Li, 1997), there is little published literature on the rehabilitation management of FMS, and little clear guidance on appropriate nonpharmacological interventions (Sim and Adams, 1999, 2002). Moreover, although some authors have indicated potential means of managing and treating FMS within a rehabilitation context (Adams and Sim, 1998; KrsnichShriwise, 1997; Rosen, 1994; Scudds and Li, 1997), the practices of OTs and PTs in relation to fibromyalgia, and ways in which these may differ, have not hitherto been documented. Accordingly, physicians wishing to refer these patients for rehabilitation are likely to have little information on the basis on which they will be treated. Further, a lack of clarity as to the specific interventions that are likely to be employed by each type of practitioner may present difficulties regarding appropriate referral to these professional groups. The aim of this study was therefore to identify and describe current assessment and management of FMS patients as reported by OTs and PTs in the UK, and to examine possible differences in practice between these two groups. The study also sought to obtain information on therapistsÕ perceptions of the clinical responsiveness of FMS and factors that they consider predictive of therapeutic outcome. No attempt was made, however, to gain an objective measure of treatment effectiveness within this study.
We anticipated that respondents would treat patients with FMS who had been referred under a variety of diagnostic labels. Therefore, to establish a case definition for the purpose of the survey, we included a definition of FMS in the questionnaire. This definition was based on that of Wolfe et al. (1990) and read: ÔA chronic, non-articular rheumatological condition characterized by widespread pain, fatigue, poor quality sleep, and bilateral tender pointsÕ. The tender points were illustrated in a diagram of anterior and posterior aspects of the body. Respondents were asked to base their responses on this definition, rather than on particular diagnostic labels that may already have been applied to individual patients, as this was felt to constitute a more consistent case definition for the purposes of the survey. The questionnaire was piloted on a convenience sample ðn ¼ 10Þ of therapists (who were not included in the final sample), and we made changes to its structure and content as appropriate. Following this, the questionnaire was sent to all current members of two professional interest groups in rheumatology—the National Association of Rheumatology Occupational Therapists ðn ¼ 140Þ and the Rheumatic Care Association of Chartered Physiotherapists (n ¼ 61). These groups represented a clearly defined sampling frame and were considered by us to be the most informed source of information on current therapy practice in the UK. The same questionnaire was sent to both groups. 2.1. Data analysis
2. Method Data were collected by means of an anonymous postal questionnaire, containing both closed- and open-ended questions, and tapping both quantitative and qualitative data. Most quantitative data were gathered in the form of frequency counts. The degree of use of specific practices was measured on ordinal rating scales, and attitudinal data were gathered by means of five-point Likert items (Oppenheim, 1992). The content of the questionnaire was based upon a review of the literature on FMS, including the small amount of literature available on the physical management of the condition, and on discussions with OTs and PTs experienced in the management of rheumatological conditions. The principal categories of information sought in the final questionnaire were as follows: • Occupation and area of work. • Frequency and source of referrals. • Usual management objectives. • Specific interventions adopted. • Perceived responsiveness of patients to physical management. • Attitudes and beliefs regarding the nature of FMS and its management.
Quantitative data were analysed by means of appropriate descriptive statistics and nonparametric statistical tests (v2 and Wilcoxon rank sum tests), with statistical significance set at p 6 0:05 (two-tailed), except where stated otherwise. Qualitative data were sorted according to themes and categories, and frequency counts were performed on recurring responses where appropriate.
3. Results Fig. 1 shows the initial sample, the number who responded, and the number of respondents who indicated that they have been involved in the management of any FMS patients in the last 12 months. All data reported henceforth will relate to this last category of 86 respondents. Findings of the survey should be interpreted in the context of the 71% response rate. Seventy-three (87%) respondents reported that they see 1–5 new FMS patients a month. Twenty-six (30%) respondents said that half or fewer of these patients are referred under the diagnostic label of FMS. The most common alternative diagnostic labels for patients whom respondents considered to have FMS were generalized arthritis (14 occurrences), chronic pain syndrome (11),
J. Sim, N. Adams / European Journal of Pain 7 (2003) 173–180
Fig. 1. Initial sample and respondents. Therapists classified as managing FMS patients were defined as those who had seen any patients in the preceding 12 months fitting the description of FMS provided in the questionnaire. Figures in parentheses are percentages, based on the values in the previous row in the figure.
and generalized aches and pains (10); a further 12 diagnostic labels were identified. For both professional groups, the most common source of referral for FMS patients was rheumatologists, followed by general medical practitioners and other therapists. Forty-four (51%) respondents indicated that they never or almost never receive self-referrals from patients. Data were gathered on which clinical feature, in the respondentsÕ view, was most often reported by patients as their primary problem. The highest endorsement was given to pain (49%), followed by fatigue (28%), loss of function (7%), depression (2%), and stiffness (2%); 11% of responses referred to a combination of features (e.g., Ôpain and stiffnessÕ). Of those respondents who ranked either pain or fatigue as the foremost problem, PTs were more likely to select pain and OTs more likely to select fatigue ðv2 ¼ 4:190, df ¼ 1, p ¼ :041Þ. Respondents were asked which methods they use to measure the intensity of patientsÕ pain. The most commonly identified methods were, in descending order of frequency: Ôverbal rating scale (e.g., severe, moderate....)Õ, Ôvisual analogue scaleÕ, and Ônumerical rating scale (e.g., 1–10)Õ. Approximately 24% of respondents responded Ônot applicableÕ to this question, on the grounds that they do not routinely measure pain intensity in these patients. In response to an open-ended question that sought respondentsÕ three most commonly identified treatment/ management objectives, the objectives presented in
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Table 1 were found to be the six most commonly utilized by each professional group. These were identified within each professional group by subsuming responses from individual respondents into broader categories. These categories were derived inductively from the data, and were not established a priori. Slight differences in descriptions of apparently similar items in Table 1 reflect differences in the typical terminology used by respondents from the two professional groups. To elucidate customary clinical practice, respondents were asked to indicate their use of a range of therapeutic interventions on a five-point frequency scale ranging from Ônever/almost neverÕ to Ôalways/nearly alwaysÕ. Table 2 shows median ratings for those interventions on which at least 20% of respondents in each profession gave a response. In view of the large number of ratings in this part of the questionnaire, alpha was reduced to 6 :005 to restrict the Type 1 error rate. Most differences were of a single-scale point, and none were greater than two scale points. Statistically significant differences were found in respect of ergonomic evaluation ðW ¼ 511; n1 ¼ 27, n2 ¼ 26; p < :0005Þ, passive mobilization ðW ¼ 680:5; n1 ¼ 17, n2 ¼ 33; p < :0005Þ and endurance exercise (W ¼ 445; n1 ¼ 21, n2 ¼ 37; p ¼ :002). For a further nine interventions (Table 3), fewer than 20% of the OT respondents gave a rating. As ratings for interventions that are unavailable to a large majority of a profession are unlikely to be informative on that professionÕs perspective, Table 3 includes only the PT ratings for these interventions. Respondents were asked whether or not they operated a treatment/management program for FMS patients, and if so whether this was a generic program for chronic pain patients or one specific to FMS patients. Of the 84 responders to this question, 54 (64%) do not operate such a program, 13 (16%) have a general program, and 17 (20%) offer a program specifically for FMS patients. Fig. 2 shows the responses to this question by profession. There is a difference in the practice of OTs and PTs in respect of this issue (v2 ¼ 8:084, df ¼ 2; p ¼ :018Þ. Inspection of Fig. 2 and examination of the standardized residuals from the v2 analysis reveal that the differential use of programs tailored specifically for FMS patients contributes markedly to the overall difference.
Table 1 Treatment/management objectives most frequently identified by respondents Occupational therapists
n
Physical therapists
n
Increase functional activities Pain management Fatigue management Assist relaxation Patient education and advice Encourage coping skills
29 20 17 17 12 10
Increase exercise tolerance and fitness Reduce pain Improve functional ability Encourage coping skills Patient education and advice Relaxation
29 21 14 11 13 8
The n value represents the number of occurrences.
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Table 2 Median ranking, for total sample and for each professional group, for interventions on which at least 20% of respondents in each profession gave a response Total
Fatigue management Exercise-endurance Functional activity re-education Postural education Relaxation Exercise-strength Heat therapy Ergonomic evaluation Cognitive/behavioural therapy Group exercise program Ice therapy Biofeedback Passive joint mobilization
Occupational therapists
Physical therapists
Rank
n/86
Rank
n/47
Rank
n/39
5 5 4 4 4 4 3 3 3 3 2.5 2 1.5
76 58 81 67 81 56 43 53 57 47 40 37 50
5 4 5 4 4 3 4 4 3 1.5 3 2 3
45 (96) 21 (45) 45 (96) 28 (60) 45 (96) 20 (43) 9 (19) 27 (57) 32 (68) 14 (30) 8 (17) 17 (36) 17 (36)
4 5 4 4 4 4 3 2 3 3 2 1.5 1
31 (79) 37 (95) 36 (92) 39 (100) 36 (92) 36 (92) 34 (87) 26 (67) 25 (64) 33 (85) 32 (82) 20 (51) 33 (85)
(88) (67) (94) (78) (94) (65) (50) (62) (66) (55) (47) (43) (58)
p value
.009 .002 .092 .206 .137 .240 .037 <.0005 .882 .227 .056 .793 <.0005
Scale values are: 1 ¼ Ônever/almost neverÕ; 2 ¼ ÔseldomÕ; 3 ¼ ÔsometimesÕ; 4 ¼ ÔoftenÕ; 5 ¼ Ôalways/nearly alwaysÕ. Figures in parentheses are percentages. The n value corresponding to each median score excludes respondents who indicated that the intervention was not available to them (e.g., because they were not trained in its use) and any missing values. The p value is from a Wilcoxon rank sum test of the between-group difference in median ranking.
Table 3 Median rankings (in descending order) from PT respondents, for those interventions on which fewer than 20% of OTs provided a response
Hydrotherapy (Electro)-acupuncture TENS Ultrasound Aromatherapy Connective tissue massage Laser therapy Other massage techniques Pulsed shortwave/PEME
Ranking
n/39
4 3 3 2 1 1 1 1 1
34 22 37 33 14 25 18 29 32
(87) (56) (95) (85) (36) (64) (46) (74) (82)
Scale values are: 1 ¼ Ônever/almost neverÕ; 2 ¼ ÔseldomÕ; 3 ¼ ÔsometimesÕ; 4 ¼ ÔoftenÕ; 5 ¼ Ôalways/nearly alwaysÕ. Figures in parentheses are percentages. The n value corresponding to each median score excludes respondents who indicated that the intervention was not available to them (e.g., because they were not trained in its use) and any missing values. Fig. 2. The use of pain management programs for FMS patients. OTs ¼ occupational therapists, PTs ¼ physical therapists.
Respondents were asked to indicate their perception of the responsiveness of FMS patients to OT or PT management on a five-point scale (1 ¼ ÔExtremely unresponsiveÕ; 5 ¼ ÔExtremely responsiveÕ). The median score for both professional groups was 3 (ÔModerately responsiveÕ); 59% of respondents gave this response. There was no difference between groups ðW ¼ 728:5; n1 ¼ 44, n2 ¼ 38; p ¼ :248Þ. A number of Likert items were included in the questionnaire to elicit respondentsÕ attitudes and beliefs regarding certain aspects of FMS; Table 4 shows the results for these items. Both groups felt equally that FMS patients are not well informed on their condition (W ¼ 855:5; n1 ¼ 45, n2 ¼ 39; p ¼ :829). OTs were more likely than PTs to agree that treatment should not
aggravate the patientÕs pain (W ¼ 1290:5; n1 ¼ 44, n2 ¼ 37; p ¼ :022). Conversely, PTs were more likely to agree that it is more important to restore function than to treat pain (W ¼ 1535; n1 ¼ 45, n2 ¼ 39; p < :0005). The respondents were neutral as to whether FMS is of psychological origin, and OTs and PTs did not differ on this belief (W ¼ 1717:5; n1 ¼ 43, n2 ¼ 38; p ¼ :651). Finally, respondents were asked by means of an open-ended question to identify factors relating to the patientÕs condition that, in their opinion, were associated with either a good or a poor therapeutic outcome. Table 5 shows those factors that emerged most strongly from the responses.
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Table 4 Median ratings for items on attitudes and beliefs Total
PatientsÕ symptoms are largely psychological in origin These patients are generally well informed on their condition Treatment should not aggravate the patientÕs pain Restoring function is more important than treating pain
Occupational therapists
Physical therapists
p value
Rating
n/86
Rating
n/47
Rating
n/39
3
81 (94)
3
43 (92)
3
38 (97)
.651
2
84 (98)
2
45 (96)
2
39 (100)
.829
3
81 (94)
4
44 (94)
2
37 (95)
.022
3
84 (98)
3
45 (96)
4
39 (100)
<.0005
Scale values are: 1 ¼ Ôstrongly disagreeÕ; 2 ¼ ÔdisagreeÕ; 3 ¼ ÔneitherÕ; 4 ¼ ÔagreeÕ; 5 ¼ Ôstrongly agreeÕ. Figures in parentheses are percentages. The p value is from a Wilcoxon rank sum test for between-group differences in median ranking.
Table 5 Principal factors identified by respondents as being associated with good or poor therapeutic outcome in FMS patients Associated with good outcome
Associated with poor outcome
Good rapport with patient Education of patient and family Early diagnosis and referral Fewer and less severe tender points Positive attitude Motivation Social support
Late diagnosis and chronicity Psychological problems Poor motivation Negative attitudes and beliefs Social problems/lack of social support Maladaptive illness behaviour
4. Discussion A number of conclusions can be drawn from these findings. A substantial proportion of respondents (30%) indicated that half or fewer of the patients whom they consider to have FMS are referred under other diagnostic labels. It seems that, when classifying patients with FMS, some UK therapists employ different criteria or focus on different clinical features from those used by medical practitioners. In relation to the problems that the therapists considered to be most important from the patientÕs perspective, the OTs and PTs diverged somewhat. Among those who nominated either pain or fatigue, the PTs were more likely to nominate pain, while the OTs were more likely to nominate fatigue. Interpretation of this finding must to some extent be speculative, but it may suggest that PTs and OTs in the UK perceive their patientsÕ complaints differently, in terms of the complaint that each profession feels best equipped to address. Alternatively, it may reflect the referral process. Physicians, or patients themselves, may select an OT or a PT according to which profession they believe can better manage the primary complaint. There was a substantial difference in the percentage of OTs and PTs that routinely manage FMS patients (49% vs 85%; Fig. 1), which may indicate that physicians refer these patients more often to PTs. Rush & Shore (1994) found that physiciansÕ preferences were for an active programme of management incorporating physical exercise for musculoskeletal disorders. It may also be
conjectured that physicians are fully aware of the therapeutic strategies offered by OTs in the management of FMS. In the attitude section, whereas the PT respondents agreed that restoration of function is more important than pain relief, OT respondents were overall undecided on this question; the difference between the professionsÕ responses was highly significant (Table 4). Interpretation of this finding is not, however, straightforward. A belief among PTs that restoration of function is a more important goal than that of pain relief may reflect an underlying view that relief of pain is not pursued for its own sake, but as a means to gain improved physical functioning. Similarly, a failure to prioritize function over pain on the part of OTs may indicate that these objectives are not readily separable. Moreover, it is possible that the two groups of practitioners have a somewhat different definition of what restoration of function entails. Hence, despite the difference in ratings, no clear contrast in approach between the two groups emerges in terms of a focus on function. A considerable minority of respondents (approximately 24%) reported that they do not routinely measure pain intensity in assessing patients with FMS. Some authors (e.g., Turner et al., 1996) believe that a failure to assess pain is remiss in conditions where it is a major clinical feature. Alternatively, this omission is in line with the belief that restoration of function is a more important goal than relief of pain, and may reflect certain contemporary approaches to chronic pain man-
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agement. These characteristically focus upon active coping strategies and seek to elicit active involvement from patients through education, to assist them in managing their symptoms more effectively; for example, by focusing on normal ÔwellÕ behaviours, such as engaging in normal everyday activities, rather than being controlled by their pain. Overall, the treatment objectives reported (Table 1) span both physical and psychosocial domains of clinical management. Although the most frequently nominated objective differs between the two professions—with the OTs emphasizing a functional aim related to daily activities and the PTs focusing on a more physiological capacity—if the relative frequency of nomination is ignored, the objectives identified by the two groups are fairly similar. Despite having identified pain as the foremost problem for patients, PTs identified increased fitness more often than pain relief as a treatment objective. This parallels advice given in some of the FMS literature, to the effect that exercise and restoration of function are more important than pain relief, and that pain should not be a reason to avoid or curtail exercise (Rosen, 1994). The fact that PT respondents disagreed with the statement that treatment should not aggravate the patientÕs pain (Table 4) is compatible with this view. Alternatively, it may represent a belief that a short-term increase in pain is an inevitable side-effect of an exercise programme that will lead to a long-term diminution in pain as fitness, strength, and flexibility improve. Both groups identified, as predictors of good or poor outcome, factors that are largely psychosocial in nature rather than physical or purely sensory (Table 5). This is in line with the findings of Macfarlane et al.Õs (1996) community-based epidemiological study, which found that associated psychological problems were among factors predictive of poor resolution of chronic widespread pain, and Masi (1994), who similarly identifies negative outcome factors to be psychological distress, current depression, feelings of helplessness, disability and inability to work, and pending litigation. More broadly, it parallels the growing acknowledgement that the prognosis for chronic musculoskeletal pain is more strongly related to such Ôpsychosocial yellow flagsÕ than to physical factors (CSAG, 1994; Martin et al., 1996b; Watson and Kendall, 2000). The findings relating to respondentsÕ reported use of therapeutic interventions (Table 2) are necessarily an indirect indication of their actual practice. Nonetheless, some informative points emerge. Exercise emerged as a primary treatment intervention, and the fact that it was PTs who particularly favoured this reflects the findings of Turner and WhitfieldÕs (1997) survey of 230 UK physical therapists. The use of exercise in FMS also supports the views of Clark (1994), McCain (1996), and Martin et al. (1996a). Electroacupuncture, EMG biofeedback, hypnotherapy, and laser therapy were not
favoured, despite some evidence from randomized controlled trials of their effectiveness in the management of FMS (Deluze et al., 1992; Ferraccioli et al., 1987; G€ ur et al., 2002; Haanen et al., 1991). Similarly, although cognitive behavioural therapy was identified as an intervention, it was not highly favoured. It is probable that UK therapists do not feel sufficiently skilled to implement some of these interventions. Additionally, in respect of cognitive-behavioural therapy there may be uncertainty among therapists as to what techniques this approach embraces, and hence a reluctance to claim to practice it. The OT respondents reported a higher frequency of use of ergonomic evaluation than did the PTs. This is in keeping with the emphasis on functional and occupational performance within OT (Hagedorn, 2001; Nelson, 1996). The fact that OTs give a higher priority to passive joint mobilization is not as might be expected, though it may be that the two professions understood rather different things by this description. The PTs may have envisaged a specific form of manual therapy, whereas the OTs may have interpreted this description more in terms of general mobility exercises performed within a functional context. Overall, however, little difference in ranking of interventions was observed for the two professions. The ranking profile shows a strong pattern in favour of active coping strategies and active involvement from patients, which is supported by current scientific evidence (e.g., Morley et al., 1999; Sim & Adams, 2002; van Tulder et al., 2000). Further, Rush & Shore (1994) report that physicians display a preference for active exercise rather than the use of electrophysical modalities in the treatment of musculoskeletal disease, though FMS was not specifically addressed in their study. This may reflect an overall shift in rehabilitation practice—for both physicians and therapists—from passive to active approaches to clinical management. At present, there are no clear consensus statements or standards of care for the rehabilitation of patients with FMS, with which the reported therapeutic interventions might be compared. Patient preferences remain to be investigated. The treatment objectives reported by the sample (Table 1) and the varieties of intervention generally utilized by respondents (Table 2) are generally consonant. One feature is, however, worthy of note. More than 50% of respondents identified cognitive-behavioural therapy as an intervention, but it only received a median rating of three, from both groups. Given the psychosocial emphasis in the treatment objectives in Table 1 and the predictors of therapeutic outcome in Table 5, one might have expected a higher reported frequency of use of this form of treatment. The underlying reason for this apparent discrepancy may be that whereas therapists recognize the relevance and importance of psychosocial factors in the context of patient management, they see their specific role in terms of
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techniques and interventions which are primarily directed at aspects of physical functioning. Further, they may not classify certain aspects of psychological care that they provide to patients as constituting cognitive behavioural therapy. As noted earlier, some therapists may lack confidence in psychological intervention and may prefer to remain on Ôhome territoryÕ. Therapists considered that patients were not well informed about their condition (Table 4), which serves to emphasize the role of patient education in the management of FMS (Burckhardt & Bjelle, 1994). There may, therefore, be scope for augmenting physical management with psychological approaches such as patient education, stress management and the teaching of coping behaviour, and thereby adopting a multidimensional approach to the rehabilitation of patients with FMS (Masi, 1994). Finally, most respondents (64%) do not manage FMS patients within a chronic pain program. PTs seem more likely than OTs to be involved in a specific management program for FMS patients (Fig. 2), which suggests that there may be a different context for intervention between the two professions, though it is not clear precisely what this constitutes.
5. Conclusion Although it cannot be claimed that its findings are necessarily representative of UK therapists in general, or indeed those in other countries, this study has provided a preliminary profile of the current practice of OTs and PTs in respect of FMS, based on an authoritative sample of practitioners. It would seem that some therapists classify patients as having FMS in a different way from referring physicians, suggesting that there is a need for greater interprofessional agreement on the diagnostic criteria to be used. Treatment objectives were fairly similar across OTs and PTs, and there was little difference in ranking of interventions, in terms of the frequency of their use, by the two professions. Where differences in practice emerged between the two professional groups, some of these are explicable in terms of what may be assumed to be their respective philosophies of care. Others may reflect differences in terminology applied to fundamentally similar approaches or techniques. Respondents identified a variety of treatment approaches and interventions, but this might be expected in view of the multifactorial pathogenesis of FMS (Zimmermann, 1991). However, it also underlines the need for further research into the methods and processes of assessment and management of this syndrome by OTs and PTs, and their clinical effectiveness. These findings may provide the basis for a more detailed examination of the rationale for clinical decision-
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making in this area of practice. The study did not seek to gain an objective measure of treatment effectiveness, but by profiling the therapeutic approaches of OTs and PTs, it may provide a starting point for further randomized controlled trials of the physical management of FMS.
Acknowledgments This study was funded by the West Midlands Regional Office of the National Health Service Executive. Thanks are due to the National Association of Rheumatology Occupational Therapists and the Rheumatic Care Association of Chartered Physiotherapists for providing their membership lists. Krysia Dziedzic, Mary Wade and Jackie Waterfield provided advice on the survey.
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Scudds RA, Li L. Fibromyalgia: a ÔmodelÕ chronic pain syndrome. Physiother Theory Pract 1997;13:81–8. Sim J, Adams N. Physical and other non-pharmacological interventions for fibromyalgia. BailliereÕs Clin Rheumatol 1999;13:507–23. Sim J, Adams N. Systematic review of randomized controlled trials of non-pharmacological interventions for fibromyalgia. Clin J Pain 2002;18:324–36. Turner P, Whitfield A, Bewster S, Halligan M, Kennedy J. The assessment of pain: an audit of physiotherapy practice. Aust J Physiother 1996;42:55–62. Turner P, Whitfield TWA. A multidimensional scaling analysis of the techniques that physiotherapists use. Physiother Res Int 1997;2:237–54. van Tulder MW, Ostelo R, Vlaeyen JW, Linton SJ, Morley SJ, Assendelft WJ. Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine 2000;25:2688–99. Watson P, Kendall N. Assessing psychosocial yellow flags. In: Gifford L, editor. Topical issues in pain 2: biopyschosocial assessment and management—relationships and pain. Falmouth: CNS Press; 2000. p. 111–29. White KP, Speechley M, Harth M, Ostbye T. The London fibromyalgia epidemiology study: the prevalence of fibromyalgia syndrome in London, Ontario. J Rheumatol 1999;26:1570–6. Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995;38:19–28. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160–72. Yunus M, Masi AT, Calabro JJ, Miller KA, Feigenbaum SL. Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched controls. Semin Arthritis Rheum 1981;11:151–71. Zimmermann M. Pathophysiological mechanisms of fibromyalgia. Clin J Pain 1991;7(Suppl. 1):S8–S15.
Therapeutic approaches to fibromyalgia syndrome in the United Kingdom: a survey of occupational therapists and physical therapists Julius Sima,*, Nicola Adamsb b
a Primary Care Sciences Research Centre, Keele University, Keele, Staffordshire ST5 5BG, UK Faculty of Health and Applied Social Sciences, John Moores University, 79 Tithebarn Street, Liverpool L2 2ER, UK
Received 22 April 2002; accepted 14 August 2002
Abstract Background and purpose. This study sought information from occupational therapists (OTs) and physical therapists (PTs) working in rheumatology in the UK on their usual methods of treatment and management of patients with fibromyalgia syndrome (FMS). Methods. Data were gathered by self-completion questionnaire on: work setting; referrals of FMS patients; usual treatment objectives; assessment and treatment approaches; perceived responsiveness of patients; and other perceptions of the management of FMS. Most data were in the form of frequency counts, with some ordinal scales and open responses. Results. Responses were obtained from 142 therapists (71% response rate), of whom 47 OTs and 39 PTs managed patients with FMS. The foremost therapeutic objective was increased functional ability for OTs, and increased exercise tolerance and general fitness for PTs. Pain reduction or management was rated as the second objective for both groups. An endurance-based exercise program and energy conservation techniques were the most frequently utilized interventions. Patients with FMS were thought to be Ômoderately responsiveÕ to physical management. Predictors of outcome were considered to be largely psychosocial, rather than physical, in nature. Conclusion. These data provide a preliminary profile of current practice in the management of FMS among UK therapists and indicate certain differences in approach between OTs and PTs. 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd. All rights reserved. Keywords: Fibromyalgia; Occupational therapy; Physical therapy; Rehabilitation; Survey
1. Introduction Fibromyalgia syndrome (FMS) is a disorder defined by chronic diffuse muscular pain and low pain thresholds at 11 or more of 18 anatomic sites termed tender points (Wolfe et al., 1990). Patients also report symptoms such as chronic fatigue, unrefreshing sleep, morning stiffness, and low exercise tolerance (McCain and Scudds, 1988; Yunus et al., 1981). FMS is widely documented in North America (McCain, 1993; Scudds and Li, 1997; White et al., 1999; Yunus et al., 1981), with an estimated prevalence in the population of approximately 2% (Carmona et al., 2001; Wolfe et al., *
Corresponding author. E-mail address: [email protected] (J. Sim).
1995). Kennedy and Felson (1996) report that 14–20% of patients in rheumatology practices in the USA have FMS as their primary diagnosis. However, there still exists controversy over its existence in the United Kingdom (Bohr, 1995), and the diagnosis seems to be made less commonly than in the USA. The optimum medical management of FMS is a matter of debate (Reilly, 1999). Nonetheless, a very large number of patients with diffuse musculoskeletal pain are referred for occupational therapy (OT) and physical therapy (PT) assessment and management and, in view of prevalence figures for FMS, it is reasonable to assume that a considerable proportion of these patients would fulfil the diagnostic criteria for FMS (Scudds et al., 1996). Despite this, and although there has been a recent focus on FMS in rehabilitation journals
1090-3801/02/$30 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd. All rights reserved. PII: S 1 0 9 0 - 3 8 0 1 ( 0 2 ) 0 0 0 9 5 - 2
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(Adams and Sim, 1998; Krsnich-Shriwise, 1997; Mengshoel, 2000; Scudds and Li, 1997), there is little published literature on the rehabilitation management of FMS, and little clear guidance on appropriate nonpharmacological interventions (Sim and Adams, 1999, 2002). Moreover, although some authors have indicated potential means of managing and treating FMS within a rehabilitation context (Adams and Sim, 1998; KrsnichShriwise, 1997; Rosen, 1994; Scudds and Li, 1997), the practices of OTs and PTs in relation to fibromyalgia, and ways in which these may differ, have not hitherto been documented. Accordingly, physicians wishing to refer these patients for rehabilitation are likely to have little information on the basis on which they will be treated. Further, a lack of clarity as to the specific interventions that are likely to be employed by each type of practitioner may present difficulties regarding appropriate referral to these professional groups. The aim of this study was therefore to identify and describe current assessment and management of FMS patients as reported by OTs and PTs in the UK, and to examine possible differences in practice between these two groups. The study also sought to obtain information on therapistsÕ perceptions of the clinical responsiveness of FMS and factors that they consider predictive of therapeutic outcome. No attempt was made, however, to gain an objective measure of treatment effectiveness within this study.
We anticipated that respondents would treat patients with FMS who had been referred under a variety of diagnostic labels. Therefore, to establish a case definition for the purpose of the survey, we included a definition of FMS in the questionnaire. This definition was based on that of Wolfe et al. (1990) and read: ÔA chronic, non-articular rheumatological condition characterized by widespread pain, fatigue, poor quality sleep, and bilateral tender pointsÕ. The tender points were illustrated in a diagram of anterior and posterior aspects of the body. Respondents were asked to base their responses on this definition, rather than on particular diagnostic labels that may already have been applied to individual patients, as this was felt to constitute a more consistent case definition for the purposes of the survey. The questionnaire was piloted on a convenience sample ðn ¼ 10Þ of therapists (who were not included in the final sample), and we made changes to its structure and content as appropriate. Following this, the questionnaire was sent to all current members of two professional interest groups in rheumatology—the National Association of Rheumatology Occupational Therapists ðn ¼ 140Þ and the Rheumatic Care Association of Chartered Physiotherapists (n ¼ 61). These groups represented a clearly defined sampling frame and were considered by us to be the most informed source of information on current therapy practice in the UK. The same questionnaire was sent to both groups. 2.1. Data analysis
2. Method Data were collected by means of an anonymous postal questionnaire, containing both closed- and open-ended questions, and tapping both quantitative and qualitative data. Most quantitative data were gathered in the form of frequency counts. The degree of use of specific practices was measured on ordinal rating scales, and attitudinal data were gathered by means of five-point Likert items (Oppenheim, 1992). The content of the questionnaire was based upon a review of the literature on FMS, including the small amount of literature available on the physical management of the condition, and on discussions with OTs and PTs experienced in the management of rheumatological conditions. The principal categories of information sought in the final questionnaire were as follows: • Occupation and area of work. • Frequency and source of referrals. • Usual management objectives. • Specific interventions adopted. • Perceived responsiveness of patients to physical management. • Attitudes and beliefs regarding the nature of FMS and its management.
Quantitative data were analysed by means of appropriate descriptive statistics and nonparametric statistical tests (v2 and Wilcoxon rank sum tests), with statistical significance set at p 6 0:05 (two-tailed), except where stated otherwise. Qualitative data were sorted according to themes and categories, and frequency counts were performed on recurring responses where appropriate.
3. Results Fig. 1 shows the initial sample, the number who responded, and the number of respondents who indicated that they have been involved in the management of any FMS patients in the last 12 months. All data reported henceforth will relate to this last category of 86 respondents. Findings of the survey should be interpreted in the context of the 71% response rate. Seventy-three (87%) respondents reported that they see 1–5 new FMS patients a month. Twenty-six (30%) respondents said that half or fewer of these patients are referred under the diagnostic label of FMS. The most common alternative diagnostic labels for patients whom respondents considered to have FMS were generalized arthritis (14 occurrences), chronic pain syndrome (11),
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Fig. 1. Initial sample and respondents. Therapists classified as managing FMS patients were defined as those who had seen any patients in the preceding 12 months fitting the description of FMS provided in the questionnaire. Figures in parentheses are percentages, based on the values in the previous row in the figure.
and generalized aches and pains (10); a further 12 diagnostic labels were identified. For both professional groups, the most common source of referral for FMS patients was rheumatologists, followed by general medical practitioners and other therapists. Forty-four (51%) respondents indicated that they never or almost never receive self-referrals from patients. Data were gathered on which clinical feature, in the respondentsÕ view, was most often reported by patients as their primary problem. The highest endorsement was given to pain (49%), followed by fatigue (28%), loss of function (7%), depression (2%), and stiffness (2%); 11% of responses referred to a combination of features (e.g., Ôpain and stiffnessÕ). Of those respondents who ranked either pain or fatigue as the foremost problem, PTs were more likely to select pain and OTs more likely to select fatigue ðv2 ¼ 4:190, df ¼ 1, p ¼ :041Þ. Respondents were asked which methods they use to measure the intensity of patientsÕ pain. The most commonly identified methods were, in descending order of frequency: Ôverbal rating scale (e.g., severe, moderate....)Õ, Ôvisual analogue scaleÕ, and Ônumerical rating scale (e.g., 1–10)Õ. Approximately 24% of respondents responded Ônot applicableÕ to this question, on the grounds that they do not routinely measure pain intensity in these patients. In response to an open-ended question that sought respondentsÕ three most commonly identified treatment/ management objectives, the objectives presented in
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Table 1 were found to be the six most commonly utilized by each professional group. These were identified within each professional group by subsuming responses from individual respondents into broader categories. These categories were derived inductively from the data, and were not established a priori. Slight differences in descriptions of apparently similar items in Table 1 reflect differences in the typical terminology used by respondents from the two professional groups. To elucidate customary clinical practice, respondents were asked to indicate their use of a range of therapeutic interventions on a five-point frequency scale ranging from Ônever/almost neverÕ to Ôalways/nearly alwaysÕ. Table 2 shows median ratings for those interventions on which at least 20% of respondents in each profession gave a response. In view of the large number of ratings in this part of the questionnaire, alpha was reduced to 6 :005 to restrict the Type 1 error rate. Most differences were of a single-scale point, and none were greater than two scale points. Statistically significant differences were found in respect of ergonomic evaluation ðW ¼ 511; n1 ¼ 27, n2 ¼ 26; p < :0005Þ, passive mobilization ðW ¼ 680:5; n1 ¼ 17, n2 ¼ 33; p < :0005Þ and endurance exercise (W ¼ 445; n1 ¼ 21, n2 ¼ 37; p ¼ :002). For a further nine interventions (Table 3), fewer than 20% of the OT respondents gave a rating. As ratings for interventions that are unavailable to a large majority of a profession are unlikely to be informative on that professionÕs perspective, Table 3 includes only the PT ratings for these interventions. Respondents were asked whether or not they operated a treatment/management program for FMS patients, and if so whether this was a generic program for chronic pain patients or one specific to FMS patients. Of the 84 responders to this question, 54 (64%) do not operate such a program, 13 (16%) have a general program, and 17 (20%) offer a program specifically for FMS patients. Fig. 2 shows the responses to this question by profession. There is a difference in the practice of OTs and PTs in respect of this issue (v2 ¼ 8:084, df ¼ 2; p ¼ :018Þ. Inspection of Fig. 2 and examination of the standardized residuals from the v2 analysis reveal that the differential use of programs tailored specifically for FMS patients contributes markedly to the overall difference.
Table 1 Treatment/management objectives most frequently identified by respondents Occupational therapists
n
Physical therapists
n
Increase functional activities Pain management Fatigue management Assist relaxation Patient education and advice Encourage coping skills
29 20 17 17 12 10
Increase exercise tolerance and fitness Reduce pain Improve functional ability Encourage coping skills Patient education and advice Relaxation
29 21 14 11 13 8
The n value represents the number of occurrences.
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Table 2 Median ranking, for total sample and for each professional group, for interventions on which at least 20% of respondents in each profession gave a response Total
Fatigue management Exercise-endurance Functional activity re-education Postural education Relaxation Exercise-strength Heat therapy Ergonomic evaluation Cognitive/behavioural therapy Group exercise program Ice therapy Biofeedback Passive joint mobilization
Occupational therapists
Physical therapists
Rank
n/86
Rank
n/47
Rank
n/39
5 5 4 4 4 4 3 3 3 3 2.5 2 1.5
76 58 81 67 81 56 43 53 57 47 40 37 50
5 4 5 4 4 3 4 4 3 1.5 3 2 3
45 (96) 21 (45) 45 (96) 28 (60) 45 (96) 20 (43) 9 (19) 27 (57) 32 (68) 14 (30) 8 (17) 17 (36) 17 (36)
4 5 4 4 4 4 3 2 3 3 2 1.5 1
31 (79) 37 (95) 36 (92) 39 (100) 36 (92) 36 (92) 34 (87) 26 (67) 25 (64) 33 (85) 32 (82) 20 (51) 33 (85)
(88) (67) (94) (78) (94) (65) (50) (62) (66) (55) (47) (43) (58)
p value
.009 .002 .092 .206 .137 .240 .037 <.0005 .882 .227 .056 .793 <.0005
Scale values are: 1 ¼ Ônever/almost neverÕ; 2 ¼ ÔseldomÕ; 3 ¼ ÔsometimesÕ; 4 ¼ ÔoftenÕ; 5 ¼ Ôalways/nearly alwaysÕ. Figures in parentheses are percentages. The n value corresponding to each median score excludes respondents who indicated that the intervention was not available to them (e.g., because they were not trained in its use) and any missing values. The p value is from a Wilcoxon rank sum test of the between-group difference in median ranking.
Table 3 Median rankings (in descending order) from PT respondents, for those interventions on which fewer than 20% of OTs provided a response
Hydrotherapy (Electro)-acupuncture TENS Ultrasound Aromatherapy Connective tissue massage Laser therapy Other massage techniques Pulsed shortwave/PEME
Ranking
n/39
4 3 3 2 1 1 1 1 1
34 22 37 33 14 25 18 29 32
(87) (56) (95) (85) (36) (64) (46) (74) (82)
Scale values are: 1 ¼ Ônever/almost neverÕ; 2 ¼ ÔseldomÕ; 3 ¼ ÔsometimesÕ; 4 ¼ ÔoftenÕ; 5 ¼ Ôalways/nearly alwaysÕ. Figures in parentheses are percentages. The n value corresponding to each median score excludes respondents who indicated that the intervention was not available to them (e.g., because they were not trained in its use) and any missing values. Fig. 2. The use of pain management programs for FMS patients. OTs ¼ occupational therapists, PTs ¼ physical therapists.
Respondents were asked to indicate their perception of the responsiveness of FMS patients to OT or PT management on a five-point scale (1 ¼ ÔExtremely unresponsiveÕ; 5 ¼ ÔExtremely responsiveÕ). The median score for both professional groups was 3 (ÔModerately responsiveÕ); 59% of respondents gave this response. There was no difference between groups ðW ¼ 728:5; n1 ¼ 44, n2 ¼ 38; p ¼ :248Þ. A number of Likert items were included in the questionnaire to elicit respondentsÕ attitudes and beliefs regarding certain aspects of FMS; Table 4 shows the results for these items. Both groups felt equally that FMS patients are not well informed on their condition (W ¼ 855:5; n1 ¼ 45, n2 ¼ 39; p ¼ :829). OTs were more likely than PTs to agree that treatment should not
aggravate the patientÕs pain (W ¼ 1290:5; n1 ¼ 44, n2 ¼ 37; p ¼ :022). Conversely, PTs were more likely to agree that it is more important to restore function than to treat pain (W ¼ 1535; n1 ¼ 45, n2 ¼ 39; p < :0005). The respondents were neutral as to whether FMS is of psychological origin, and OTs and PTs did not differ on this belief (W ¼ 1717:5; n1 ¼ 43, n2 ¼ 38; p ¼ :651). Finally, respondents were asked by means of an open-ended question to identify factors relating to the patientÕs condition that, in their opinion, were associated with either a good or a poor therapeutic outcome. Table 5 shows those factors that emerged most strongly from the responses.
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Table 4 Median ratings for items on attitudes and beliefs Total
PatientsÕ symptoms are largely psychological in origin These patients are generally well informed on their condition Treatment should not aggravate the patientÕs pain Restoring function is more important than treating pain
Occupational therapists
Physical therapists
p value
Rating
n/86
Rating
n/47
Rating
n/39
3
81 (94)
3
43 (92)
3
38 (97)
.651
2
84 (98)
2
45 (96)
2
39 (100)
.829
3
81 (94)
4
44 (94)
2
37 (95)
.022
3
84 (98)
3
45 (96)
4
39 (100)
<.0005
Scale values are: 1 ¼ Ôstrongly disagreeÕ; 2 ¼ ÔdisagreeÕ; 3 ¼ ÔneitherÕ; 4 ¼ ÔagreeÕ; 5 ¼ Ôstrongly agreeÕ. Figures in parentheses are percentages. The p value is from a Wilcoxon rank sum test for between-group differences in median ranking.
Table 5 Principal factors identified by respondents as being associated with good or poor therapeutic outcome in FMS patients Associated with good outcome
Associated with poor outcome
Good rapport with patient Education of patient and family Early diagnosis and referral Fewer and less severe tender points Positive attitude Motivation Social support
Late diagnosis and chronicity Psychological problems Poor motivation Negative attitudes and beliefs Social problems/lack of social support Maladaptive illness behaviour
4. Discussion A number of conclusions can be drawn from these findings. A substantial proportion of respondents (30%) indicated that half or fewer of the patients whom they consider to have FMS are referred under other diagnostic labels. It seems that, when classifying patients with FMS, some UK therapists employ different criteria or focus on different clinical features from those used by medical practitioners. In relation to the problems that the therapists considered to be most important from the patientÕs perspective, the OTs and PTs diverged somewhat. Among those who nominated either pain or fatigue, the PTs were more likely to nominate pain, while the OTs were more likely to nominate fatigue. Interpretation of this finding must to some extent be speculative, but it may suggest that PTs and OTs in the UK perceive their patientsÕ complaints differently, in terms of the complaint that each profession feels best equipped to address. Alternatively, it may reflect the referral process. Physicians, or patients themselves, may select an OT or a PT according to which profession they believe can better manage the primary complaint. There was a substantial difference in the percentage of OTs and PTs that routinely manage FMS patients (49% vs 85%; Fig. 1), which may indicate that physicians refer these patients more often to PTs. Rush & Shore (1994) found that physiciansÕ preferences were for an active programme of management incorporating physical exercise for musculoskeletal disorders. It may also be
conjectured that physicians are fully aware of the therapeutic strategies offered by OTs in the management of FMS. In the attitude section, whereas the PT respondents agreed that restoration of function is more important than pain relief, OT respondents were overall undecided on this question; the difference between the professionsÕ responses was highly significant (Table 4). Interpretation of this finding is not, however, straightforward. A belief among PTs that restoration of function is a more important goal than that of pain relief may reflect an underlying view that relief of pain is not pursued for its own sake, but as a means to gain improved physical functioning. Similarly, a failure to prioritize function over pain on the part of OTs may indicate that these objectives are not readily separable. Moreover, it is possible that the two groups of practitioners have a somewhat different definition of what restoration of function entails. Hence, despite the difference in ratings, no clear contrast in approach between the two groups emerges in terms of a focus on function. A considerable minority of respondents (approximately 24%) reported that they do not routinely measure pain intensity in assessing patients with FMS. Some authors (e.g., Turner et al., 1996) believe that a failure to assess pain is remiss in conditions where it is a major clinical feature. Alternatively, this omission is in line with the belief that restoration of function is a more important goal than relief of pain, and may reflect certain contemporary approaches to chronic pain man-
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agement. These characteristically focus upon active coping strategies and seek to elicit active involvement from patients through education, to assist them in managing their symptoms more effectively; for example, by focusing on normal ÔwellÕ behaviours, such as engaging in normal everyday activities, rather than being controlled by their pain. Overall, the treatment objectives reported (Table 1) span both physical and psychosocial domains of clinical management. Although the most frequently nominated objective differs between the two professions—with the OTs emphasizing a functional aim related to daily activities and the PTs focusing on a more physiological capacity—if the relative frequency of nomination is ignored, the objectives identified by the two groups are fairly similar. Despite having identified pain as the foremost problem for patients, PTs identified increased fitness more often than pain relief as a treatment objective. This parallels advice given in some of the FMS literature, to the effect that exercise and restoration of function are more important than pain relief, and that pain should not be a reason to avoid or curtail exercise (Rosen, 1994). The fact that PT respondents disagreed with the statement that treatment should not aggravate the patientÕs pain (Table 4) is compatible with this view. Alternatively, it may represent a belief that a short-term increase in pain is an inevitable side-effect of an exercise programme that will lead to a long-term diminution in pain as fitness, strength, and flexibility improve. Both groups identified, as predictors of good or poor outcome, factors that are largely psychosocial in nature rather than physical or purely sensory (Table 5). This is in line with the findings of Macfarlane et al.Õs (1996) community-based epidemiological study, which found that associated psychological problems were among factors predictive of poor resolution of chronic widespread pain, and Masi (1994), who similarly identifies negative outcome factors to be psychological distress, current depression, feelings of helplessness, disability and inability to work, and pending litigation. More broadly, it parallels the growing acknowledgement that the prognosis for chronic musculoskeletal pain is more strongly related to such Ôpsychosocial yellow flagsÕ than to physical factors (CSAG, 1994; Martin et al., 1996b; Watson and Kendall, 2000). The findings relating to respondentsÕ reported use of therapeutic interventions (Table 2) are necessarily an indirect indication of their actual practice. Nonetheless, some informative points emerge. Exercise emerged as a primary treatment intervention, and the fact that it was PTs who particularly favoured this reflects the findings of Turner and WhitfieldÕs (1997) survey of 230 UK physical therapists. The use of exercise in FMS also supports the views of Clark (1994), McCain (1996), and Martin et al. (1996a). Electroacupuncture, EMG biofeedback, hypnotherapy, and laser therapy were not
favoured, despite some evidence from randomized controlled trials of their effectiveness in the management of FMS (Deluze et al., 1992; Ferraccioli et al., 1987; G€ ur et al., 2002; Haanen et al., 1991). Similarly, although cognitive behavioural therapy was identified as an intervention, it was not highly favoured. It is probable that UK therapists do not feel sufficiently skilled to implement some of these interventions. Additionally, in respect of cognitive-behavioural therapy there may be uncertainty among therapists as to what techniques this approach embraces, and hence a reluctance to claim to practice it. The OT respondents reported a higher frequency of use of ergonomic evaluation than did the PTs. This is in keeping with the emphasis on functional and occupational performance within OT (Hagedorn, 2001; Nelson, 1996). The fact that OTs give a higher priority to passive joint mobilization is not as might be expected, though it may be that the two professions understood rather different things by this description. The PTs may have envisaged a specific form of manual therapy, whereas the OTs may have interpreted this description more in terms of general mobility exercises performed within a functional context. Overall, however, little difference in ranking of interventions was observed for the two professions. The ranking profile shows a strong pattern in favour of active coping strategies and active involvement from patients, which is supported by current scientific evidence (e.g., Morley et al., 1999; Sim & Adams, 2002; van Tulder et al., 2000). Further, Rush & Shore (1994) report that physicians display a preference for active exercise rather than the use of electrophysical modalities in the treatment of musculoskeletal disease, though FMS was not specifically addressed in their study. This may reflect an overall shift in rehabilitation practice—for both physicians and therapists—from passive to active approaches to clinical management. At present, there are no clear consensus statements or standards of care for the rehabilitation of patients with FMS, with which the reported therapeutic interventions might be compared. Patient preferences remain to be investigated. The treatment objectives reported by the sample (Table 1) and the varieties of intervention generally utilized by respondents (Table 2) are generally consonant. One feature is, however, worthy of note. More than 50% of respondents identified cognitive-behavioural therapy as an intervention, but it only received a median rating of three, from both groups. Given the psychosocial emphasis in the treatment objectives in Table 1 and the predictors of therapeutic outcome in Table 5, one might have expected a higher reported frequency of use of this form of treatment. The underlying reason for this apparent discrepancy may be that whereas therapists recognize the relevance and importance of psychosocial factors in the context of patient management, they see their specific role in terms of
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techniques and interventions which are primarily directed at aspects of physical functioning. Further, they may not classify certain aspects of psychological care that they provide to patients as constituting cognitive behavioural therapy. As noted earlier, some therapists may lack confidence in psychological intervention and may prefer to remain on Ôhome territoryÕ. Therapists considered that patients were not well informed about their condition (Table 4), which serves to emphasize the role of patient education in the management of FMS (Burckhardt & Bjelle, 1994). There may, therefore, be scope for augmenting physical management with psychological approaches such as patient education, stress management and the teaching of coping behaviour, and thereby adopting a multidimensional approach to the rehabilitation of patients with FMS (Masi, 1994). Finally, most respondents (64%) do not manage FMS patients within a chronic pain program. PTs seem more likely than OTs to be involved in a specific management program for FMS patients (Fig. 2), which suggests that there may be a different context for intervention between the two professions, though it is not clear precisely what this constitutes.
5. Conclusion Although it cannot be claimed that its findings are necessarily representative of UK therapists in general, or indeed those in other countries, this study has provided a preliminary profile of the current practice of OTs and PTs in respect of FMS, based on an authoritative sample of practitioners. It would seem that some therapists classify patients as having FMS in a different way from referring physicians, suggesting that there is a need for greater interprofessional agreement on the diagnostic criteria to be used. Treatment objectives were fairly similar across OTs and PTs, and there was little difference in ranking of interventions, in terms of the frequency of their use, by the two professions. Where differences in practice emerged between the two professional groups, some of these are explicable in terms of what may be assumed to be their respective philosophies of care. Others may reflect differences in terminology applied to fundamentally similar approaches or techniques. Respondents identified a variety of treatment approaches and interventions, but this might be expected in view of the multifactorial pathogenesis of FMS (Zimmermann, 1991). However, it also underlines the need for further research into the methods and processes of assessment and management of this syndrome by OTs and PTs, and their clinical effectiveness. These findings may provide the basis for a more detailed examination of the rationale for clinical decision-
179
making in this area of practice. The study did not seek to gain an objective measure of treatment effectiveness, but by profiling the therapeutic approaches of OTs and PTs, it may provide a starting point for further randomized controlled trials of the physical management of FMS.
Acknowledgments This study was funded by the West Midlands Regional Office of the National Health Service Executive. Thanks are due to the National Association of Rheumatology Occupational Therapists and the Rheumatic Care Association of Chartered Physiotherapists for providing their membership lists. Krysia Dziedzic, Mary Wade and Jackie Waterfield provided advice on the survey.
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