Address Fibromyalgia with Confidence

Assessment and Intake Key to Good Work

By Cara McGuinness

Despite the increasing number of sufferers diagnosed in North America, fibromyalgia is a condition that has left many MTs wading through a plethora of conflicting information and feeling a resulting anxiety about treating fibromyalgia clients. One of the best ways MTs can overcome these challenges is to focus on their client communication, which includes a thoughtful intake and assessment process.

MTs should not make the assumption that every client will fall into the profile of a “typical” fibromyalgia sufferer found in massage therapy textbooks and classroom lectures. The majority of fibromyalgia clients seeking treatment are women in their 30s or older who have suffered from the condition for quite some time, but men and children can be afflicted, too. Many of these clients have gone through a long process of visiting numerous health-care professionals, undergoing various diagnostic tests, and seeking out viable treatment options. This is due in part to a lack of knowledge and experience with fibromyalgia, and widely varying attitudes regarding the condition among those in the health-care community.

Health History

Clients with fibromyalgia tend to have more information on their health history form than the average client, primarily because of common accompanying conditions, such as bursitis and carpal tunnel, and the number of medications they are taking. It can be helpful to keep (or include in all health history packages) an additional information form in which clients can add any details they could not fit onto your standard health history form.

The amount of medication listed on the health intake of a fibromyalgia client can be overwhelming. Many are on multiple prescriptions for pain and inflammation in widely varying strengths and doses. Keeping an up-to-date reference guide for prescription medications can be helpful in determining the side effects of each drug. If clients give fibromyalgia as the reason for booking their initial appointment, it can be beneficial to request that they email a list of their current medications to ensure you have sufficient time to research each one and its effect on the upcoming treatment.

Client Interview

Spending too much time focused on the client’s day-to-day pain and other issues related to their fibromyalgia (instead of their current flare-up issues), and attempting to make their symptoms and experiences fit into the accepted definition of a fibromyalgia sufferer should be avoided during the interview. Most clients with fibromyalgia have done a great deal of their own research and may belong to online or community support groups. These are clients who have explored many avenues of treatment and home remedies for their symptoms. While they understand the importance of discussing their most common symptoms and factors involved in their flare-ups, they do not want to spend long periods of time going into every minute detail. Many feel they have already spent too much of their time explaining themselves to health-care professionals who don’t thoroughly understand their condition. It is best to keep your initial interview focused on the client’s current symptoms. Some specific questions that can assist in attaining the pertinent information include:

• Are you in flare-up? If so, how long have you been in flare-up?

• Was there any event or activity that triggered your current flare-up?

• How has your pain changed your daily activities?

• What prescription and/or over-the-counter medications have you taken today to help manage your pain?

• What home remedies have you been using to alleviate the pain and inflammation?

Client Assessments

Basic orthopedic testing will be as beneficial in assessing a client with fibromyalgia as it is with any other client. It is important to note, however, that the results of these tests should not necessarily be integrated into the initial treatment plan while the client is in flare-up. The pain experienced during a flare-up often occurs in a specific, predictable area that the client will be aware of and will have little difficulty in pinpointing for the MT. These areas of pain and inflammation are often unrelated to areas of chronic hypertension, shortening, or other muscular concerns discovered during orthopedic testing.

Postural evaluation can be particularly important to perform and track as the client moves from the initial visit to ongoing treatment for chronic pain and maintenance. Many clients will have noticeable postural changes before, during, and after flare-ups that, over time, can help predict and possibly avoid or minimize future recurrences.

Approaching Treatment

When fibromyalgia is discussed in texts and the classroom, the point of sensitivity to pain and pressure is stressed repeatedly. For many MTs, this creates anxiety in performing anything but a light treatment, which many of these clients find frustrating. Like any other clients, fibromyalgia sufferers vary in their sensitivity, pain threshold, and treatment preferences. Although it is true many sufferers are hypersensitive to pain and pressure during treatment, there are just as many clients who will find greater benefit from a moderate pressure, and some who will even request and benefit from deeper treatment.

For the inexperienced MT, determining just how much pressure to use and how to weigh client preferences against professional judgment and training can be tricky. Working with a fibromyalgia client for the first time can make this decision even more difficult, since there is a lack of reference available on which to base decisions. There is often a greater temptation to make decisions based on the experiences and requests of clients, since they have more knowledge of their condition. Many clients who come in for an initial visit will use their previous MTs as a reference point for ongoing treatments. This can be both positive and negative. A client who has had a number of treatments with one or more MTs in the past will most likely be very aware of what she needs, and what does or doesn’t work for her. She will likely be aware of her pain tolerance during a treatment and can direct you accordingly. Unfortunately, this can also create problems during treatments. Clients who have been with one—or very few—MTs in the past may not be aware that pressure, to a certain degree, is subjective. For example, her previous MT may have been a “lightweight,” whose deep pressure is only considered moderate by her new MT’s standards. She may come in requesting a deep treatment, insisting that it is the type of treatment she is accustomed to, only to discover that the pressure is too much for her to bear. It is an experience that can cause frustration and irritation for both the client and the MT, and one that can create an unpleasant environment during the client’s next visit. Avoid this experience by implementing specific treatment guidelines for all fibromyalgia clients and using it consistently.

When treating a client with fibromyalgia, be upfront and explain to her that the initial visit will be a learning experience for both of you, and that you will be working cautiously, using light to moderate pressure, and that no deep techniques—such as trigger-point release—will be used at any point. Clients will be much more understanding about necessary adjustments to their treatment plan when their MT is upfront about the fact that they will be learning together. Make it clear to the client that each therapist and each client is different, and new treatment plans cannot be based on experiences with past MTs. Clients who are accustomed to deeper treatments or specific techniques may not be happy, but most will understand your reasoning once it is explained to them that this will help ensure that the appropriate amount of pressure and specific techniques will be effectively adjusted and applied in future sessions based on the client’s reaction to their initial treatment.

Communication during the treatment session is vital. It is important that the client is aware she should speak up when pressure is either too deep or the treatment becomes painful. No matter what philosophy a therapist or client has toward the role of pain in an effective treatment, fibromyalgia is not a condition that allows for the “no-pain, no-gain” attitude during treatment. MTs should also be extremely aware of signs of increased inflammation to areas of focus during the treatment. An area that seems to increase in the amount of visible edema or exhibits significant hyperemia can become very painful during or after a treatment. These areas should be treated with a lighter pressure for a longer time; ideally hydrotherapy can be used to combat the inflammation.

Take-Home Work

Offering effective remedial exercises to a fibromyalgia client is an important part of their treatment.1 It is best to initially focus on stretches the client can use during flare-up to help reduce hypertension and increase mobility in affected areas. Among other health benefits, regular cardiovascular exercise can also aid in managing the pain and hypertension associated with fibromyalgia. It should be noted, however, that the inflammation and joint issues associated with the condition will alter the types of exercise clients should consider engaging in. MTs can safely suggest activities such as swimming/water aerobics, low-impact aerobic classes, yoga, and the use of machines like elliptical trainers and stationary bikes. High-impact activities like step aerobics or running and jogging on a treadmill should be avoided. Clients who express an interest in weight training to improve muscle tone and strength should be advised to do so only if they are willing to work with an accredited and experienced personal trainer who can guide them in the appropriate exercises, form, and weight limitations.

Following a client’s progress after treatment is an important tool when treating fibromyalgia sufferers. Day-after calls will allow an MT to get more accurate feedback on the client’s level of pain, feelings about the effectiveness of the treatment, and any questions or concerns the client may have, rather than relying on the client’s memory of this information on her next visit.

Overcoming the Intimidation Factor

The unique challenges presented by a fibromyalgia sufferer can be intimidating when first presented to inexperienced MTs. With the implementation of minor adjustments to the treatment routine as outlined above, and thoughtful communication before, during, and after the session, MTs can dissipate their anxiety and treat their fibromyalgia clients with more confidence and effectiveness.

 Cara McGuinness is a registered massage therapist, reflexologist, and aromatherapist. Her hope is to use her knowledge and experience to open up new avenues of treatment in chronic pain disorders. Contact her through her website:


1. Exercises or stretches should be intended as a take-home resource and should not be performed within massage sessions or progressed by massage therapists, in order to comply with state laws and maintain scope of practice.