Combined rheumatologist-exercise physiologist consult on trial

4 minute read

While logistically challenging for the practice, fibromyalgia patients appreciated our “combined consult”.

While logistically challenging for the practice, fibromyalgia patients appreciated our “combined consult”.

“Managing fibromyalgia in daily clinical practice is often difficult, unglamourous work. Indeed, fibromyalgia has been shown to occupy the bottom rung of a hierarchy of ‘disease prestige’. Therefore, it can be of great benefit for both the clinician and the patient to have a robust and functional mental model of what it is that we are actually managing. 

“The answer is that we are managing a whole person who experiences a set of symptoms that we recognise (and name) as fibromyalgia. The act of naming in itself can be therapeutic. And by invoking the name fibromyalgia, we enter into a language-game with our patient – a process of creating shared meaning that, if done well, promotes genuine shared decision-making in the clinic.”

                                                   Sam Whittle, Rheumatology Republic 2018

Whether you’re a rheumatologist or an allied health professional, navigating the initial consultation with someone with suspected or confirmed diagnosis of fibromyalgia can be tricky.

Patient expectations can vary.

Symptoms and functional limitations can vary.

The need for further investigations and referrals can also vary.

At our private practice, we wanted to try something different. Over a 12-month period, we decided to try combining an initial rheumatology consultation with an exercise physiology appointment.


We wondered whether having the patient interacting with two clinicians from the beginning of their journey would improve the progress and outcomes achieved by the patient. A rheumatologist and exercise physiologist together might (?) be better able to discuss important lifestyle concepts such as sleep, stress, movement and nutrition, and potentially start to work on managing these right from the first appointment.

We also wondered whether having a longer interaction with the health professionals on the first visit would improve the patient’s experience. Would a longer consultation time allow more time for the patient to share their story, and for the practitioners to explain their recommendations on how to move forward?

How did we do it?

Patients were informed in advance of this “combined consult” by our reception staff. It was available only for those whose main reason for presenting was fibromyalgia. Initially, as we were piloting this style of initial assessment, the patient was charged only for the consultation with the rheumatologist. The rheumatologist would see the patient first, and then the exercise physiology session would happen thereafter. We included some time for cross-over between the two clinicians, when the rheumatologist would summarise their findings and management plan.

So, what did we learn?

Screening the suitability of the patient was tricky

Ensuring that the patient’s main presenting problem was fibromyalgia was tricky. Patients often presented with multiple issues, with fibromyalgia being one of numerous concerns that might have needed attention and management. It was necessary to work closely with our reception team to ensure appropriate screening took place, and that referrals were received before the consultation took place.

Patients liked it (we think)

All patients were given the option to attend the combined consult and given the option to not attend if they didn’t want to see the exercise physiologist. Only 5% of patients chose not to. The exercise physiologist was able to see many of the patients immediately after the appointment with the rheumatologist, and could start discussing pacing principles, activity modifications and, where suitable, prescribe an exercise program. Many clients continued working with the exercise physiologist after this initial appointment.

It was challenging (but rewarding) work

Logistically, ensuring the rheumatologist and exercise physiologist diaries were available to work in this manner was a challenge in our private practice set-up. However, the patients who engaged seemed to appreciate getting a longer consult with two clinicians that understood their condition. It required the rheumatologist and exercise physiologist to work very closely together, with an appreciation and shared respect for what their colleague could provide for the patient.

Although we have since ceased this style of clinic, we learnt significantly from it. We will continue considering different models of care and how we can best utilise a multi-disciplinary approach to achieve the best patient outcomes.

Sarah Comensoli is an accredited exercise physiologist based in Sydney and certified strength and conditioning coach. She works at BJC Health.

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