Physiotherapy November 1999/vol 85/no 11

639Letters

Physiotherapists should question whetheror why only one-way modulation exists intheir ‘traditional’ reasoning?

The paper by Rose et al has raised a veryimportant issue in noting the prevalenceof ‘somatisation’ in a physiotherapypopulation. This has long been ignored inresearch and debate. However, theconclusions of James (1999), Skelly (1999)and Watson et al (1999) are correct; this isnot inappropriate referral butinappropriate professional reasoning andtreatment approaches.

The training of physiotherapists and theclinical reasoning of physiotherapy mustchange to reduce the dichotomousdualism inherent in practice.Additionally, the provision of data thatsupport (or refute) the notion thatphysiotherapy can be effective in cases ofsomatisation should become an essentialrequirement of the debate. Without thisour practice remains, at best, speculative,and at worst, unfounded.

Richard Stephenson MCSPUniversity of East Anglia

References

Bagby, M, Parker, J and Taylor, G

(1994a). ‘The 20-item TorontoAlexithymia Scale – 1. Item selection andcross-validation of the factor structure’,Journal of Psychosomatic Research, 38, 23-32.

Bagby, M, Taylor, G, and Parker, J(1994b). ‘The 20-item TorontoAlexithymia Scale -- 2. Convergent,discriminant, and concurrent validity’,Journal of Psychosomatic Research, 38, 33-40.

Berrios, G (1985). ‘The psychopathologyof affectivity: Conceptual and historicalaspects’, Psychological Medicine, 15, 745-758.

Gifford, l (1998). ‘Pain, the tissues andthe nervous system: A conceptual model’,Physiotherapy, 84, 1, 27-36.

Hutton, S et al (1999). ‘Physiotherapyrole’ (letter) Physiotherapy, 85, 9, 525-526.

James, T (1999). ‘How can we help?’(letter) Physiotherapy, 85, 9, 525.

Kirmayer, L and Robbins, J (1991).‘Three forms of somatization in primarycare: Prevalence, co-occurrence, andsociodemographic characteristics’, Journalof Nervous and Mental Disease, 179, 647-655.

Kirmayer, L, Robbins, J and Paris, J(1994). ‘Somatoform disorders:Personality and the social matrix ofsomatic distress’, Journal of AbnormalPsychology, 103, 125-136.

Lipowski, Z J (1987). ‘Somatisation:Medicine’s unsolved problem’,Psychosomatics, 28, 294-297.

Lipowski, Z J (1988). ‘Somatisation: Theconcept and its clinical application’,American Journal of Psychiatry, 145, 1358-68.

Mayou, R (1993). ‘Somatisation’,Psychotherapy and Psychosomatics, 59, 69-83.

Rose, M, Stanley, I, Peters, S, Salmon, P,Scott, T and Crook, P (1999). ‘Wrongproblem, wrong treatment: Unrecognisedinappropriate referral to physiotherapy’,Physiotherapy, 85, 6, 322-328.

Skelly, M (1999). ‘Explore ouralternatives’ (letter) Physiotherapy, 85, 9,526.

Stephenson, R (1996). ‘Introducingalexithymia: A concept within thepsychosomatic process’, Disability andRehabilitation, 18, 209-214.

Stephenson, R (1999a). ‘The complexityof pain: Part 1. No pain without gain: Theaugmentation of nociception in the CNS’,Physical Therapy Reviews, 4, 2, 105-116.

Stephenson, R (1999b). ‘The complexityof pain: Part 2. Pain as a complexadaptive system’, Physical Therapy Reviews,4, 3, in press.

Stephenson, R and Royce, J (1999). ‘Theincidence of alexithymia in peoplereferred to a physiotherapy outpatientdepartment’, Physiotherapy Theory andPractice, in press.

Stoudemire, A (1991). ‘Somatothymia,Parts 1 and 2’, Psychosomatics, 32, 365-381.

Taylor, G J, Bagby, R M and Parker, J D A(eds) (1997). Disorders of Affect Regulation,Cambridge University Press.

Watson, P J et al (1999). ‘Wrongevaluation, wrong conclusion’ (letter)Physiotherapy, 85, 9, 522-524.

Stimulating DiscussionTHANKS to the Journal for the timely andinformative article by Jayne Dalley‘Evaluation of clinical practice’(Physiotherapy, September) which provideduseful discussion material for staffmeetings, managers’ meetings and audit

meetings. Surely we will get into IndexMedicus now?

Secondly, I was heartened by the articleon inapproprate referrals by Rose et al inthe previous issue and the massiveresponse in the letters pages of theSeptember issue. No one can say that weare an apathetic profession after that!

At last one of the most fundamentalissues in physiotherapy is being discussed– that of somatisation. Since Descartessplit mind and body, the health system inthe West has been slightly out of balance.We are in a key position to bridge the gap.

Let us keep arguing on the importantissues of definition and interpretation, butespecially let us keep an awareness of howthe body is used to express distress.

Thank you Rose et al for stirring this upand reminding us that because we havethe privilege of working with the body, wecan help patients to heal themselvesthrough mind and body together.

Alexandra HoughMSc MCSPHailsham, East Sussex

Physiotherapy Fights FearMAY I congratulate Hope and Forshaw(1999) on their excellent article analysingthe relationship between depression andtreatment outcome in low back pain. Thelinks they make between the fear of pain,increasing depression, and increasedchronicity are important. A largeproportion of patients who fall into thiscategory are repeatedly and unsuccessfullyre-referred for physiotherapy. Normallythey receive the approach based onphysical pathology that the authorsdescribe – assess, mobilise, exercise andadvise.

However, I am unhappy with theirstatements that physiotherapy cannot dealwith these patients. It can. It all dependson the physiotherapy approach used.

In 1989, Physiotherapy published anarticle ‘Illness behaviour to wellnessbehaviour’ which described an approachbased on reducing the fear of pain inprecisely this depressed chronic patientgroup. The approach was developed in