Wrong Problem, Wrong Treatment
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Physiotherapy December 1999/vol 85/no 12
Waddell, G, Main, C J, Morris, E W, Paola, M D, and Gray, I (1984). 'Chroniclow back pain, psychological distress, and illness behaviour', Spine, 9, 2, 209-213.
Waddell, G (1996). Low back pain: Atwentieth century health care enigma',Spine, 21, 24, 2820-25.
Whitney, C W and Von Korff, M (1992).Regression to the mean in treated versus untreated chronic pain, Pain, 50, 281-285.
WE are delighted by the level of responseto our paper (Rose et al, 1999). Given therange and importance of issues raised byyour correspondents, it is possible for usto respond only in general terms.
Our argument recognises thatmusculoskeletal physiotherapy is held inhigh esteem. However, this may lead to aninability to meet demand and it is timelyfor the profession to consider its purposeand practice. It is around this point thatthe views of your correspondents seem todiverge.
We do, of course, recognise thecomplex interplay between psychosocialand physical factors in the context of illhealth and we challenge the view that ourpaper, if read carefully, suggests that weare dualistic. Of course, the nature ofthe relationships between these factors isstill poorly understood and we are still, tosome extent, limited in debate by adualistic language that distinguishespsychological from physical factors.However, it is neither unfair norinaccurate to state that physiotherapy hasa traditional allegiance to biomechanicalexplanatory models that assume a causalrelationship between tissue damage andsymptoms. Furthermore, some of yourcorrespondents provide further evidencethat many physiotherapists, if not themajority, continue to practise within thisexplanatory framework.
Our paper provided evidence for theview that a significant proportion ofmusculoskeletal patients referred tophysiotherapy might also havepsychological problems that, if notprimary, may at least interfere withtreatment based upon a biomechanicalmodel. Furthermore, we proposed that
such treatment might worsen thecondition of recipients. We also aimed topresent a potential mechanism by whichreferral pathways could be rationalisedand resources focused upon those whowere most likely to benefit.
We acknowledge that there is a movetowards bio-psychosocial explanatorymodels within physiotherapy generallyand specifically within pain managementand rehabilitation. However, the findingspresented in our paper and the reactionsof some of your correspondents suggestthe continued need for re-appraisal of thepurpose and practice of traditionallyorganised musculoskeletal physiotherapy.
Our aim, in which we have apparentlybeen successful, was to stimulate debateabout these issues and we thank,wholeheartedly, those colleagues whohave contributed to this debate throughtheir correspondence.
Michael Rose PhD MCSPUniversity of Keele
Ian Stanley FRCGPSarah Peters MAPeter Salmon PhDUniversity of Liverpool
Rachel Stott MCSPPat Tebbitt MCSPWhiston Hospital NHS Trust
ReferenceRose, M, Stanley, I, Peters, S, Salmon, P,Stott, R and Tebbitt, P (1999). Wrongproblem, wrong treatment: Unrecognisedinappropriate referrals to physiotherapy,Physiotherapy, 85, 6, 322-328.
This correspondence is now closed. Editor
IN reply to the Hare Association forPhysical Ability (Letters, November) we doindeed recognise that Noreen Haresoriginal work on the Physical Ability Scale(PAS) was an early influence on our work.The majority of our publications whichdescribe our work on the Chailey Levels ofAbility acknowledge this and referenceNoreens work. We have had manydiscussions with Noreen during the earlystages of our research and we appreciateand have benefited from her insights intomotor ability.
Since the 1988 publication in which wedescribed an early version of the sittingability scale, which was indeed anacknowledged adaptation of the PAS, we have not pursued further adaptation of the PAS and instead have undertaken a great deal of research funded by Action Research.
Now the Chailey Levels of Ability inlying, sitting and standing are based on astudy of the neurological andbiomechanical factors of normal infantdevelopment and describe in detail the effect of these on motor skill. Thesescales represent a much more in-depthdevelopmental and biomechanical analysisof postural ability at low ability levels thanwas previously available. It is these levelsof ability that were validated and notNoreens original work, which was not,therefore, acknowledged.
Perhaps this was an oversight, but ourfocus for this publication was on thevalidation of what we had researched andused in clinical practice rather than ouroriginal adaptation of PAS.
We did not intend to ignore or discountNoreens invaluable work in the field ofpostural assessment and, through theHare Association for Physical Ability, herongoing contribution to understandingthe complex needs of severely disabledpeople. We also acknowledge the ongoingsupport from the Hare Association forPhysical Ability expressed in this letter.
Teresa E Pountney MA MCSPElizabeth Green MD BA DCHCatharine Mulcahy BSc DipCOT DipCounsRoy Nelham BEng CEng FISPOChailey Heritage Clinical Services
Wrong Problem, Wrong Treatment
Chailey Levels of Ability
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Wrong Problem, Wrong TreatmentReference