Explaining persistent physical symptoms to patients in general practice: can tests to measure central sensitisation add value? 2024, den Boer et al

Abstract

Introduction
General practitioners (GPs) often face challenges in explaining to patients with persistent physical symptoms (PPS) why their symptoms persist. Providing an explanation of the central sensitisation (CS) mechanism to patients could be helpful, yet GPs do not routinely test for signs of CS in these patients. The aim of this study was to explore the value of applying a test to assess CS in enhancing explanations provided to patients.

Methods
In this prospective study, 25 GPs applied three tests, selected through a Delphi study, to assess CS-related symptoms: (1) the Central Sensitisation Inventory (CSI); (2) an algometer for measuring pressure pain thresholds (PPT); and (3) a monofilament for assessing temporal summation. Following the tests, both the GP and the patient completed a short questionnaire. Subsequently, GPs shared their experiences in focus groups and interviews, while a sample of patients was interviewed individually. The questionnaires were analysed quantitatively, and the focus groups and interviews were analysed qualitatively.

Results
GPs reported that all tests were feasible to perform during consultations; testing took less than 5 min in 25% of cases and between 5 and 10 min in 60% of cases. In approximately 50% of cases, an additional consultation was required to perform the test. The results of the CSI confirmed CS-related symptoms more frequently (74%) than the algometer (46%) and the monofilament (43%). Consequently, many GPs preferred the CSI. Patients did not show a preference for any specific test; two-third found the tests valuable and approximately 50% reported that the explanation of CS was clearer when a test was used.

Conclusions
Testing during the consultation was feasible, although an additional consultation was required in 50% of the cases. GPs preferred the CSI because its results confirmed CS-related symptoms more frequently than those from the algometer and monofilament.

Open access, https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-024-02686-w

 

Introduction
Persistent physical symptoms (PPS) such as low back pain, headache or dizziness, and syndromes like fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome, have a high prevalence in both general practice and hospital care [1,2,3]. PPS are physical symptoms that last for at least three months, cause distress, or interfere with daily functioning [4, 5]. A clear medical explanation for these symptoms may be lacking. However, symptoms can also persist in well-understood disorders despite adequate treatment or may not correspond to the severity of the underlying disease [6]. The societal burden of these patients – such as medical costs, disability and work absenteeism- is substantial, and their quality of life is generally low [7,8,9,10,11].

Patients with PPS oftens seek a diagnosis and recognition for extended periods, sometimes for up to two years. Understanding why their symptoms persist could help them initiate recovery earlier. Therefore, providing clear explanations may be crucial in guiding these patients [12]. GPs frequently struggle to explain to patients with PPS why symptoms persist in the absence of a specific disease or in case of an adequately treated disease [13, 14]. Explaining the central sensitisation (CS) mechanism underlying PPS may be helpful for GPs [15].

 

Isn’t “central sensitisation” in it’s broad sense a symptom of all sorts of neurological diseases. Ie. being more sensitive to stimuli.

The CSI looks like it leads to anyone with ME to be flagged. In fact, one of the questions is “I have chronic fatigue syndrome”. It looks to be a mix of a pain/anxiety questionnaire.

See PDF

Is the concept of central sensitisation part of the psychosomatic paradigm?

Their inventory looks a lot like those depression questionnaires who flag up anyone who is chronically ill.

 

I had to double check on central sensitisation. Found this video.

https://www.youtube.com/watch?v=DrNnv5QN318

Just keep telling the patient it's their maladaptive beliefs are the sole cause of their problems!

 

Here's a metaphor right back at them from The Four Principles of Biomedical Ethics — Healthcare Ethics and Law

 

Agreed. It's exactly that type of advice which could end up in a late diagnosis of cancer, endometriosis, all sorts. Just because we are diagnosed with CFS doesn't mean we don't have other illnesses.

 

The reason GPs face challenges in explaining to patients is that we basically don’t know. Central sensitisation is an unproved hypothesis, not an explanation. GPs don’t currently have any tests to identify central sensitisation, they can only observe presenting symptoms whose assumed cause is central sensitisation in a meaninglessly circular argument to prove the presence of central sensitisation.

 

The standardization of fake tests is such a rotten idea. It will backfire so hard. Especially when it's on top of the standardization of fake models and fake treatments. I just noticed a BMJ review on IBS treatments boasting how CBT and gut-directed hypnosis are now part of all major IBS guidelines, which is basically as worthy of boasting as a restaurant that boasts of rat droppings in every plate. The death of expertise continues to accelerate.

Meanwhile you look on social media and every post about Long Covid is filled with people saying it's the vaccines. No one has ever worked so hard in history to so loudly lose credibility as the medical profession. Absolutely baffling.

Ah, right, we're all just dumbasses who never thought of "initiating" recovery. Silly us.

Notable that those two have no relation to one another. It's normal to struggle to explain something that isn't understood by anyone, but it seems well-recognized that this isn't such an explanation, just a convenient way of dropping the ball without feeling guilty about it. See, it's helpful to GPs. Not patients. Also "may be", which is the standard language for "very likely doesn't, but wink nod".

All in all it can really be said that this is the main goal of the psychobehavioral ideology: it gives permission to physicians to fail at their job, but it makes them feel good about it. Which is just about the worst possible combination, and the complete lack of progress is thus easy to explain.

 

The concept of central sensitisation had its origins in some interesting research out of UCL in the 1980s, beginning with the paper "Evidence for a central component of post-injury pain hypersensitivity" (Nature, 1983). A review article in 2009 by the same author - "Central Sensitization: A Generator of Pain Hypersensitivity by Central Neural Plasticity" (J Pain 10;9:895-926) showed how the concept evolved over time as a model of pain.

The problem is that the concept made its way into the fibromyalgia and psychosomatic literature and started to be applied with reference to all manner of psychological factors, and in a very woolly and overbroad way that is not adequately supported by the evidence.

 

This is my sense as well. My understanding, and I could be wrong, is that there the concept has some credibility in certain kinds of pain but that it has metastasized to be applied to the range of "medically unexplained symptoms." It became a more medical-sounding extension of the psychsomatic paradigm and is also appealing because gradual exposure to whatever has become centrally sensitized seems to be the treatment. Hence, gradual increases in activity can be justified under the psychosomatic hypotheses as well as under the CS hypothesis.

 

I was going to check it out. I assume it's like the "catastrophizing" questionnaires and all the others that presume nothing is wrong with the person, and on which anyone who is actually sick would score very high--and then presumed to be "catastrophizing."

 

Actually, the CSI turns out to be a questionnaire designed to assess the severity of CS-related symptoms. In other words, it presumes the symptoms themselves are related to CS. All it's saying is, this person has a high degree of symptoms that we say are CS. It doesn't actually show that the symptoms have anything to do with CS. So it's confirming for the doctor that the person has high levels of anxiety, bad sleep, etc. that's all.

 

After which they give up in despair.

 

Yep, amazing. It almost perfectly recapitulates the various ME/CFS consensus criteria (minus any recognition of PEM) with the coup de grâce being: