Physiotherapy September 1999/vol 85/no 9

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Letters

Wrong Evaluation,Wrong ConclusionWE wish to express our deep concern thatsome physiotherapists might concludefrom the article by Rose et al (1999) that itis possible to classify patients as having a‘mental illness’ of somatisation by usingthe Hospital Anxiety and Depression(HAD) scale. It is our contention that wecannot decide that patients areinappropriate referrals and exclude themfrom physiotherapy management basedon scores on such a questionnaire. Wethink this would be unethical and outsidethe scope of practice of physiotherapists.

Furthermore, there are a number offlaws in the understanding of the conceptof somatisation and in the methodology.This comes at a time when there is anincreasing interest among physiotherapistsin the role of psychological factors in thedevelopment and maintenance of chronicincapacity. The main problems areoutlined below.

The authors appear to make a numberof assumptions:1. That the cause of chronic pain can

always be identified and all causes of pain are understood.

2. Anxiety, depression and somatisation are interchangeable terms.

3. Anxiety about bodily sensations in the absence of a clearly defined pathology isindicative of mental illness.The corollary of point 1 is that we need

no longer conduct research into chronicpain and its remediation. We should take

a sobering lesson from history; phantomlimb pain was unrecognised untilrelatively recently, and those reportingpain in the absent limb were previouslydeemed to be psychologically disturbed,demonstrating a conversion hysteria inresponse to the loss of the leg. Evenearlier, angina was considered to be aform of neurosis. We now know that thereare clear physiological changes that occurafter amputation which explain thepresence of pain in the absence of a limb,and we have identified the pathology ofmyocardial hypoxia. To assume that wecurrently know all there is to know aboutback pain is at best unwise and at worstmedical arrogance.

In 1965 Melzack and Wall firstsuggested the Pain Gate Theory. Thisexploded the Labelled Line theory ofnociception and the previously held belief of a direct linear relationshipbetween pain, pain perception, painreport and behaviour. This landmarkpaper, supported since by a considerablebody of research, demonstrated the clearinteraction between nociceptive,psychological factors and behaviouralresponses. Since that time a host of

psychophysiological studies havedemonstrated the relationship betweenaltered pain thresholds, pain responses,behavioural responses and psychologicalfactors, in particular anxiety and lowmood, in chronic pain patients andhealthy controls that are too numerousand too complex to discuss in a letter.

Our first methodological concern is thatthe way in which the presence or absenceof medical pathology was investigated inthis study is not reported: we are asked toassume that this had been controlled anddone systematically and appropriately ineach case.

Secondly, anxiety and depressioncannot be used as synonyms forsomatisation. Anxiety is characterised byimpaired concentration, worry, irritabilityand poor sleep. In addition there isheightened arousal and altered thinking.Anxiety is common in those with chronicpain problems. Indeed it has beenestimated that one in four patientsconsulting their general practitioner forall conditions can be described as havingan anxiety state of some sort.

Patients with chronic pain arefrequently demoralised or depressed.

Wrong Problem, Wrong Treatment --

and the Wrong Way to Deal with PainReaders respond to an article on inappropriate referral to physiotherapy

The subject of debate:

Rose, M, Stanley, I, Peters, S, Salmon, P, Stott, T and Crook, P (1999).‘Wrong problem, wrong treatment: Unrecognised inappropriatereferral to physiotherapy’, Physiotherapy, 85, 6, 322-328.

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Many studies have demonstrated thatdepression is a consequence of ratherthan an antecedent to chronic pain (VonKorff et al, 1993; Hassenbring et al, 1994:Hansen et al, 1995; Averill et al, 1996).It would be considered abnormal forindividuals not to be depressed if theysuffered pain over a prolonged period.Current mood does however appear to beinfluential in whether a person with painconsults a GP (Croft et al, 1995).

Heightened awareness of all sorts ofsymptoms is characteristic of some painpatients. This heightened somaticawareness can be indicative of somaticanxiety. The process of somatisation hasbeen defined in a number of ways but isperhaps best understood as a normalphenomenon rather than as apsychopathological one. According toSullivan and Katon (1993): ‘A primarycare perspective on somatisation reveals itto be a ubiquitous and diverse processlinking the physiology of distress and thepsychology of symptom perception’ (page 141).

The experience of somatically focusedanxiety is a common feature of chronicpain sufferers and it is perhaps bestunderstood as a cognitive distortion ormisperception. Cioffi (1991) reviewedevidence supporting the view that themeaning patients assign to physicalsymptoms is profoundly influenced bytheir beliefs, assumptions and ‘common-sense’ explanation (causal attributions)and that of other influential individuals(doctors and physiotherapists). Thesepsychosocial processes and cognitivestyles, in turn, guide behaviour. The roleof these factors appears to have beenmissed in this study. In chronic painpatients, somatic anxiety should be viewedas a pain-associated psychologicaldysfunction leading to up-rating of painperception rather than a primarypsychiatric disorder; it is certainly not‘mental illness’.

More worryingly, the measure ofsomatisation in this study was the HADscale. This is not a recognised measure ofsomatisation; by the authors' ownadmission ‘the HAD sub-scales aredesigned to exclude [our italics] physicalsymptoms of anxiety and depression’.

The HAD was developed to detectanxiety and depression in a hospital

population who, by the nature of thesetting, were likely to have somaticconcerns, so these were factored out inthe development of the scale. Wetherefore have no good evidence ofsomatisation in this group of patients.

From the paper it appears the data on referral to physiotherapy wereretrospective and the data on the HADwere prospective. The assumption is madethat the subjects were either anxious,depressed or both at the time of thereferral to physiotherapy and thereforethe referral was inappropriate. There is nocontemporaneous evidence to supportthis.

The authors also suggest that where GPsdiagnosed depression the patients wereless likely to be referred to physiotherapyand suggest that this is evidence that thedepression preceded the pain andtherefore supports the evidence forsomatisation. We see no evidence in thepaper that the patients were depressedprior to the onset of their pain, or for thecriteria upon which the GPs made thediagnosis.

This brings us to the point of whetherthese patients reporting pain wereinappropriately referred to physiotherapy.Physiotherapy is a rehabilitationprofession; symptomatic treatment aloneis not rehabilitation. Reduction of pain isonly one aim; the main problem inchronic pain is pain-related incapacity(Waddell, 1998). These patients gave areport of pain, so are likely todemonstrate levels of incapacity anddeconditioning as well as fear of certainactivities and distress. It is, in our opinion,the role of the physiotherapist to managepain-associated incapacity. Likewise it isthe physiotherapist’s role to help patientsmanage their anxiety and distress where itis directly attributable to the experienceof pain and incapacity. It is unacceptableto refer these people back to their GPssimply because they are challenging tomanage.

Furthermore, less than 1% of those withchronic pain will be referred to a specialistpain management programme (Smithet al, 1996).

Physiotherapists need to be equippedwith the skills to manage these patientsmore effectively through an improvementin their training in the recognition of

psychosocial barriers to progress inrehabilitation and how to manage thesesuccessfully..

Somatic anxiety is not a categoricalconstruct or a diagnosis, it is better viewedas a continuum. However, the morepeople focus on their pain problems themore incapacitated they are likely to be.The problem with somatisation models,when badly applied, is that they discreditthe veracity of a patient's condition.

Rose et al have clearly demonstratedthat those patients who have persistentpain, for which we currently are unable togive a diagnosis, are anxious anddepressed. Although not new, this is veryuseful information which should be usedto call for an improvement in the trainingof physiotherapists and not encourage agame of pass-the-patient.

Paul J Watson MSc MCSPChair of the Physiotherapy Pain AssociationUniversity of Manchester

Vicky Harding MCSPEmma Hollyman MCSPCarol Sweet MSc MCSPLondon

Louis Gifford BSc MAppSc MCSPFalmouth

Sue Mickleburgh BA MCSPTruro

Heather Muncey BA GradDipPhys MCSP MAC RMNBristol

References

Averill, P M, Novy, D M, Nelson, D V andBerry, L A (1996). ‘Correlates ofdepression in chronic pain patients: A comprehensive examination’, Pain, 65,93-100.

Cioffi, D (1991). ‘Beyond attentionalstrategies: A cognitive perceptual model ofsomatic interpretation’, PsychologicalBulletin, 109, 25-41.

Croft, P R, Papageorgiou, A C, Ferry, S,Thomas, E, Jayson, MIV and Silman, A J(1995). ‘Psychologic distress and low backpain: Evidence from a prospective study inthe general population’, Spine, 20, 2731-37.

Hansen, F R, Biering Sorensen, F andSchroll, M (1995). ‘Minnesota MultiphasicPersonality Inventory profiles in personswith or without low back pain. A 20-yearfollow-up study’, Spine, 20, 2716-20.

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Pathology of SufferingWE were very concerned to read a paperin the June issue of Physiotherapy (Rose etal, 1999), by recognised authorities in thepain field, which appeared to discouragephysiotherapists from offering valuableskills to chronic pain sufferers, andinstead pathologised the suffering oftenassociated with chronic pain in a mostunhelpful way.

First, no definition or explanation wasoffered for the key concept ofsomatisation, which was equated withmental illness and with depression. Theseare by no means identical. Further, theauthors used the Hospital Anxiety andDepression (HAD) scale to classifypatients, yet the depression subscale isexplicitly based on a model of anhedonia(Zigmond and Snaith, 1983): that is, itexcludes cognitive and somatic elementsof what is defined as depression withinpsychiatry, and has not been validatedagainst DSM or other recognised criteria(Silverstone, 1991). It is therefore hardlysurprising to find poor agreementbetween HAD-based classification and GPjudgement, which is likely to be closer tothat of psychiatrists and their diagnosticschedules.

In addition, a cutpoint of 8 is usuallyinterpreted as indicating borderlineclinical ‘caseness’, not, as in the paper, toindicate ‘high probability of clinicallysignificant anxiety or depression’.Without information (for instance, onsensitivity or specificity) to support thisdecision rule, findings such as prevalencewhich are based on it must be treated withcaution.

Secondly, the model implied isprofoundly dualistic, associatingphysiotherapy by ‘traditional allegiance’with disease models, with no mention ofthe skills and practices used byphysiotherapists in the pain field to goodeffect: work on habits of movement andposture, restoring wasted muscle, dealingpractically with fears about movement andits implications for pain.

The authors imply that if apsychological cause is identified for aproblem, only a psychological solution isappropriate, and that for a physical cause,only a physical solution is appropriate -- an assumption which is contradicted bycountless effective physiotherapeutic andpsychological treatments. Since thismistaken belief in patients often presentsa barrier to engagement in treatment,health professionals who propagate it do aserious disservice to patients.

Thirdly, the model proposed by theauthors instantiates a stigmatisingapproach to patients’ problems, referringto ‘legitimisation’ of somatic symptoms, asif some physical problems (presumablythose backed up by X-ray or examinationfindings) are real and the remainder arenot. This betrays a woefulmisunderstanding of pain problems, manyof which are not accessible to currentimaging or diagnostic techniques (Wall,1994). But that is hardly the patients’fault, and to encourage physiotherapiststo embrace such an anachronistic andpotentially blaming approach todistressed patients is very regrettable.

It is helpful for all health professionalsto learn better to recognise distress and

depression in patients, and how best tohelp, whether by referral elsewhere, jointwork, or taking a psychologist’s orpsychiatrist’s advice in applying theirpractical skills. That may have been theintention of the authors, but their paper ismore likely to lead to confusion amongphysiotherapists and rejection of patientsfor whom physiotherapy is the treatmentof choice.

Amanda C de C Williams PhDConsultant clinical psychologist

Kathryn Nicholson Perry

Katherine O’Neill

Clare Daniel

Jannie van de MeuweChartered clinical psychologists

Input Pain Management UnitGuy’s and St Thomas’ Hospital NHS TrustLondon

References

Silverstone, P H (1991). ‘Measuringdepression in the physically ill’,International Journal of Methods in PsychiatricResearch, 1, 3-12.

Wall, P D (1994). ‘Introduction’ in Wall, P D and Melzack, R (eds)’, Textbookof Pain, Churchill Livingstone, Edinburgh,3rd edn, pages 1-7.

Zigmond, A S and Snaith, R P (1983).‘The Hospital Anxiety and Depressionscale’, Acta Psychiatrica Scandinavica,67, 361--370.

Hassenbring, M, Marienfeld, G,Kuhlendahl, D and Soyka, D (1994). ‘Risk factors of chronicity in lumbar discpatients. A prospective investigation ofbiologic, psychologic, and social predictorsof therapy outcome’, Spine, 19, 2759-65.

Melzack and Wall, P D (1965).‘Pain mechanism: A new theory’, Science,150, 971-979.

Smith, B, Chambers, W and Smith, W ,(1996). ‘Chronic pain: ‘Time forepidemiology’, Journal of the Royal Societyof Medicine, 8, 181-183.

Sullivan, M and Katon, W (1993).‘Somatisation: The path between distressand somatic symptoms?’ American PainSociety Journal, 2, 141-149.

Von Korff, M, Le Resche, L and Dworkin, S F (1993). ‘First onset ofcommon pain symptoms: A prospectivestudy of depression as a risk factor’, Pain, 55, 251-258.

Waddell, G (1998). The Back PainRevolution, Churchill Livingstone,Edinburgh.

The subject of debate:

Rose, M, Stanley, I, Peters, S,Salmon, P, Stott, T and Crook, P(1999).‘Wrong problem, wrong treatment:Unrecognised inappropriatereferral to physiotherapy’,

Physiotherapy, 85, 6, 322-328.