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

[Andy]

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

 

[Andy]

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].

 

[Yann04]

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.

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

GPs preferred the CSI because its results confirmed CS-related symptoms more frequently than those from the algometer and monofilament.

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.

 

[Trish]

Additionally, GPs reported occasional confusion regarding negative test results, particularly when they assumed that the patient had CS-related symptoms but the patients exhibited very high PPTs. [pressure pain threshold]

The assumption throughout is that all the conditions mentioned, including ME/CFS are caused by central sensitisation.

Use of the questionnaire:

The CSI assisted GPs in initiating conversations about the symptoms associated with CS and how CS is explained. Patients reported feeling more understood as they recognized their symptoms reflected in the CSI’s questions. The CSI proved beneficial in enhancing both patients’ and GPs’ understanding of the symptoms.

 

[Trish]

GPs reported that some patients found it challenging to accept CS. These patients often wanted more diagnostics and proposed alternative explanations for their symptoms. While the tests sometimes facilitated acceptance of CS, there were instances where they did not.

GPs needed to believe in the explanatory model of CS to effectively convince the patients. Although some GPs questioned the model’s validity, most GPs regarded CS as a useful explanation for patients with PPS.

So the GP's didn't always believe what they were telling patients, but they mostly were happy to fob off patients with lies, metaphors and nonsense.

 

[Maat]

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



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

 

[Maat]

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

Now let us consider Person B. In this second scenario, they push Person C into the lake knowing that they would be faitily harm by this action. Person B can be said in this example to have a negative duty not to harm the individual by pushing them into the lake. In other words, they have a duty to refrain from an action which will cause harm to Person C. In healthcare, we have negative duties not to harm our patients. For example, we should not give them medications which could harm them or worsen their condition. Another example would be that a surgeon has a duty to remove a diseased right kidney instead of a healthy left kidney during a surgery.

Therefore, to summarise.

A negative duty requires you to refrain from an action that could cause some form of harm. This relates to non-maleficence in which we have this same negative duty to refrain from actions which could harm our patients.

 

[Trish]

The question of harm bothers me here. Persuade a patient that they are ovesensitive to pain, and they will do their best to ignore all pain, including pain that needs urgent medical attention. And that's compounded if their GP thinks they are over reacting to all pain, so doesn't investigate new pains.

 

[Maat]

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.

 

[Peter T]

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.

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.

 

[rvallee]

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.

Understanding why their symptoms persist could help them initiate recovery earlier.

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

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].

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.

 

[Sean]

The question of harm bothers me here. Persuade a patient that they are ovesensitive to pain, and they will do their best to ignore all pain, including pain that needs urgent medical attention. And that's compounded if their GP thinks they are over reacting to all pain, so doesn't investigate new pains.

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.

That is exactly what is going to happen. It will delay diagnosis and treatment of other diseases, which is going to increase morbidity and mortality for patients. Did they discuss that blindingly obvious risk certainty?

It is incredibly reckless and callous of them. All just so they can having to admit that they don't have an answer. Are their egos really that fragile?

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.

This.

Explaining the central sensitisation (CS) mechanism underlying PPS may be helpful for GPs [15].

There is their real motive.

 

[Nightsong]

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.

 

[dave30th]

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.

 

[dave30th]

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.

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."

 

[dave30th]

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.

 

[SNT Gatchaman]

Patients with PPS oftens [sic] seek a diagnosis and recognition for extended periods, sometimes for up to two years.

After which they give up in despair.

 

[SNT Gatchaman]

The CSI looks like it leads to anyone with ME to be flagged.

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.

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

24. I suffered trauma as a child.

 

[NelliePledge]

Would be interesting to get the opinion of their oncology colleagues on this paper.

 

[Hutan]

Yes, the survey is circular nonsense.
1."Central sensitisation" (having symptoms without any identifiable pathology) has this set of symptoms with no identifiable medical cause,
2. You have these symptoms and I haven't identified any medical cause,
3. Therefore you have central sensitisation.
I don't understand why people don't immediately see through it. I guess a lot of patients do. Certainly it's a way to erode trust in a GP's professional competence.

On the method for determining pain thresholds:

2.a experiences with the algometer
GPs reported both positive and negative experiences with the algometer. They appreciated the precise scale of the device, as it facilitated the explanation of hypersensitivity when a positive test result was obtained. The test was relatively easy to perform and required less than 10 min in 78% of cases. However, they expressed that they sometimes lacked experience in performance of the test and were occasionally uncertain about the reference values. They also found the pressure pain threshold (PPT) to be subjective; patients were sometimes unsure when to indicate that the feeling of pressure changed into pain.

Additionally, GPs reported occasional confusion regarding negative test results, particularly when they assumed that the patient had CS-related symptoms but the patients exhibited very high PPTs.

"patients were sometimes unsure where to indicate that the feeling of pressure changed into pain"
We've seen a study recently, where women were found to indicate feeling pain with less noxious exposure than men did, but they rated the pain at lower levels than the men did when they reported feeling pain. So, just as an example, a person can report feeling pain with a mild to moderately painful stimulus, but they report the pain severity is only of 3/10, whereas another person can wait until the stimulus is moderately painful, but report the pain severity is 5/10. It's extremely subjective as to when a person reports feeling pain. It tells you little about their pain thresholds, but rather more about what they have been taught about what is appropriate when acknowledging pain.

"GPs reported occasional confusion regarding negative test results, particularly when they assumed the patient had CS-related symptoms but the patients exhibited very high [pressure pain thresholds]"
Yes, I can see that would be rather difficult. A performative test aiming to convince patients that they have central sensitisation that doesn't actually work. Perhaps that's why the ridiculous circular survey turned out to be the test of choice - nothing else worked.