When Traditional Physical Therapy Isn’t Enough

Using Complementary Therapies to Treat Patients with Chronic Pain

Meryle Richman, PT, MS, CST

As the use of and demand for complementary medicine continues to rise, PTPN member Meryle Richman, PT, finds that her pioneering work to integrate complementary techniques into traditional physical therapy has put her at the forefront of that trend.

Richman, owner of two physical therapy clinics in New York state, began using complementary therapies in their very early stages. "I found that the usual treatment methods were often not enough to help my patients who have chronic pain, including many fibromyalgia patients."

To better assist those patients, Richman created the Fibromyalgia Empowerment Program, a first-of-its-kind endeavor that incorporates the use of complementary therapies such as:

• Myofascial Release™, a whole-body, hands-on approach for evaluation and treatment to reduce and eliminate soft tissue restrictions and pain caused by trauma, inflammation, postural changes or scar tissue.
• CranioSacral Therapy, a gentle, hands-on method of evaluating and enhancing the functioning of the craniosacral system.
• The Alexander Technique, a method to change unconscious movement habits that contribute to recurring difficulties.
• The Feldenkrais Technique, a supportive therapy that helps people relearn good posture and body movements to relieve pain and improve balance, coordination and mobility.
• Other complementary techniques such as yoga, meditation, diaphragmatic breathing and Tai Chi.

The use of complementary therapies in physical therapy practices is becoming more prevalent as therapists add non-traditional techniques and disciplines like yoga, Tai Chi and deep tissue massage to their therapeutic repertoire. The trend is echoed in the larger healthcare environment: A recent survey by the Centers for Disease Control revealed that 36 percent of U.S. adults use some form of complementary and alternative medicine (CAM)¹. Americans are spending over $27 billion a year, mostly out of pocket, for CAM interventions², and a growing number of health insurers are offering coverage for the services to meet the demands of their plan members.

Richman’s Fibromyalgia Empowerment Program consists of 12 sessions, beginning with an evaluation session, 3 sessions of myofascial work, and 8 group sessions, with 4 to 6 patients, focusing on education, relaxation, stretching and therapeutic exercises. An education session might be on proper body mechanics. A relaxation session might be learning meditation or yoga, and a workout session might incorporate the pool or proper instruction in exercising. After completing the 12 sessions, some patients continue with weekly exercise classes, such as modified Tai Chi/yoga or aerobics.

Richman offers an exercise program for fibromyalgia patients with the goals of enhancing overall fitness to combat fatigue, improving body mechanics and posture, improving sleep patterns and increasing feelings of well-being and confidence. She introduces patients to workouts in the manner and sequence outlined below to ensure a reduction of tension and increased flexibility and strength.

1. Breathing Awareness. Prior to exercise, train patients in relaxed diaphragmatic breathing. Once exercise begins, include stretching, gradual strengthening and instruction in a modified cardiovascular program, directing patients to breathe diaphragmatically throughout the exercise routine. Deep, even breathing should be a priority to ensure that patients don’t overstrain or use inappropriate muscles in their exercise routines.
2. Stretching. Patients’ exercise programs should begin and end with gentle stretching, all of which should be performed against a background of diaphragmatic breathing. Patients with fibromyalgia tend to have multiple fascial restrictions and to brace excessively in movement, and these patterns reduce bodily sensitivity and sensory feedback mechanisms. For these reasons, patients should move through stretches very slowly, and focus on making these movements as soft and smooth as possible.
3. Strengthening. Once the patient has effectively integrated a stretching routine with diaphragmatic breathing, she can begin a strengthening program. Therapists guide patients to maintain proper alignment of the feet and spine; avoid excessive involvement of the torso when using weights; and scan the body continually to release excess tension from the shoulders, neck, back, etc. Patients start with active movements in the mid-range and progress from 0- to 3-pound weights as tolerated. They begin with a 5 to 10 minute program, doing 3 to 5 repetitions, and gradually progress to 20 to 40 minutes, doing 10 repetitions and integrating 2 to 3 rest periods.
4. Cardiovascular. Introducing a cardiovascular program in conjunction with stretching and strengthening should be determined based on the patient’s symptoms and preference for aerobic conditioning. Patients should begin with a two-minute warm-up and perform 2-3 minutes of minimal to moderate cardiovascular exercise, gradually increasing the time (up to 30 minutes), speed and intensity of exercise, while maintaining the workout at a perceived exertion rate of very light to fairly light. When patients are comfortable with a light workout combined with diaphragmatic breathing and alignment, they are trained to identify and gradually work toward their target heart rates. They must minimize any muscle bracing throughout the cardiovascular workout and finish the aerobic component with a two-minute or longer cool-down.

The Fibromyalgia Empowerment Program is offered about four times a year in Richman’s clinics, each located within a fitness center. When asked how she decided on a fitness center location, Richman recalls, "In the early 1970s when I was a new practitioner working in a rehabilitation hospital and doing home care, I thought it would be great for patients to continue after their treatment to exercise in a wellness environment." When she decided to start her own practice, she approached the Club Fit Fitness Center in Jefferson Valley, New York, about opening an office within the facility. In 1983 Physical Therapy at Jefferson Valley was born.

Opening physical therapy offices within fitness centers was a new concept at that time, and a gym setting was ideal for physical therapy, says Richman, who opened a second clinic in 1985 within the Club Fit Fitness Center in Briarcliff Manor, New York, a 20-minute drive from the first clinic. Richman and her staff are able to use the pools at the fitness centers for aquatic programs and use exercise equipment for one-on-one sessions. "It was always my goal to have a ‘pain facility’ within this type of setting because it allows me to provide services such as the Fibromyalgia Empowerment Program."

Richman’s two clinics have grown to include: ten full-time PTs (two of whom are assistant directors at each location), five part-time PTs, 3 full-time aides, 9 part-time aides, two administrative managers, four full-time secretaries, and two full-time billing collectors. "If you’re an owner who wants to successfully operate your practice, you must be willing to work long hours and learn to delegate." Richman devotes a large portion of her time to marketing efforts -- visiting physicians, distributing marketing packets and flyers, giving community talks on anything from osteoporosis to the prevention of golf injuries wellness, and offering free postural screenings at the fitness centers.

When asked how a PT can thrive in the current healthcare environment with declining reimbursement and restrictions on therapy visits, Richman advises, "Ask yourself, ‘What are the needs of my clients?’ Then find your passion for what you really like in the field, and develop a specialty niche because it’s advantageous in terms of a marketing approach." Richman joined PTPN 10 years ago to participate in more managed care contracts, and now finds other benefits as well. "Being a PTPN member is a good way of feeling united with other PTs, and I know I can turn to Mary Gannon [Executive Director in PTPN’s New York regional office] when I have business questions," says Richman.

A firm believer in giving back to her community, Richman has helped organize an aquatic program and runs a monthly Fibromyalgia Support Group on behalf of the Arthritis Foundation New York Chapter. She encourages her support group to focus on the positive, rather than the negative, and conducts a Q & A sharing session in which participants talk about techniques that have been helpful for them. Richman brings in speakers to address various aspects of the syndrome, such as a nutritionist who explains special diet strategies, and a mental health provider who talks about the emotional sources of pain.

Richman is a guest lecturer on complementary therapies at the New York Medical College and Columbia University Physical Therapy programs, and she has also spoken at her local APTA chapter on Myofascial Release. She integrates the use of Myofascial Release and CranioSacral Therapy in her work in treating women recuperating from breast cancer and reconstructive surgery.

Richman and co-author Ingrid Bacci, PhD, CST, wrote a series of five articles on fibromyalgia that appeared in ADVANCE for Physical Therapists (from December 2001 to February 2003), in which they define causes of fibromyalgia, including chronic sympathetic nervous system over-activation, skeletal misalignments and connective tissue adhesions. They recommend the use of manual therapies that soften tissues and education that assists patients in changing patterns of bodily misuse.

She makes the most of every day by getting up at dawn to meditate and then work out. And in her spare time? She combines community work with her penchant for fitness -- she’s an avid bicycle rider always up for cycling fundraiser events.

Contact Meryle Richman at 914-762-2222, ext.157 or Meryle@ptrehab.com.


¹Barnes P, Powell-Griner E, McFann K, Nahin R. CDC Advance Data Report #343. Complementary and Alternative Medicine Use Among Adults: United States, 2002. May 27, 2004.

²Eisenberg, D., et al. (1998). Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. Journal of the American Medical Association, 280(18), 1569-1575.