Spinal Pain Patients' Beliefs about Pain and Physiotherapy
The lay public's medical knowledge is acquired from three sources: the lay consultation and referral service, the media, and the practitioner. Satisfaction with and continued utilization of a health care service may depend on congruence between patients' beliefs about the cause of illness and practitioners' conditions of care. The results of a recent survey indicate that the information to which patients with spinal pain had access, was inadequate for them to acquire accurate knowledge of the basis for their pain and physiotherapists' conditions of care. It is suggested that more accurate information on the mechanisms of spinal pain, volunteered by physiotherapists during the encounter, would be in the interests of the lay pUblic and the physiotherapy profession.
The professional relationship is classically defined as a situation where the patient, lacking specialized knowledge in a particular field, is unable to diagnose his or her problems with any precision or to discriminate among the range of possibilities for meeting such problems (Maddison 1980) and therefore seeks the expertise of one who is trained to do so_ It can also be said that the patient is limited when it comes to assessing the competence of professionals from whom assistance is soughtToday, scientifically trained health care professionals are being asked to recognize that patients' satisfaction with a particular area of care (and hence their continued utilization of the service) may depend on factors other than the practitioner's specialized knowledge and competence. One of these factors which has received attention in the literature is the extent to which the professional appears to be prepared to recognize the patient as a 'whole person'. Insistence on the whole person approach is interpreted by some authors as being part of a national revolt against any form of
MAX ZUSMAN
Max Zusman, B.App.Sc. (Physio), Grad.Dip.Hth.Sc., is a private practitioner in Mount Hawthorn, Western Australia.
elitism (Tracy 1980), and by others as an index of humanity (Breslau 1981). Attempts to denigrate applied science by attributing all sorts of inhumane qualities to the scientifically trained professional are not new. The 'disappearance of the humane, wholeperson orientated physician' was reported with regret in the popular press at the turn of the century (Singh 1982, p. 18). More recently it has been said that it is commonplace for humanity to be trained out of clinicians in pursuit of scientific objectivity (Thomas 1979). However, it has been shown that not only do patients tend to estimate professional competence by the nature of the affective tone of the encounter (whole person) (Ben-Sira 1982), but will, if this is not satisfactory, equate the frequently necessary emphasis on objectivity with a lack of humanity (Tracy 1981). Other studies have shown that even patients making incomplete recoveries express satisfaction with the treatment they receive so long as they feel it is empathetic (Wooley et aI1978). This same general level of satisfaction response appears
to apply equally to those in less developed countries where reliance is, to a large degree, on IDpre traditional forms of medicine (Kuman et a11979). It appears that protests of inhumanity may often be dismissed as being little more than an inability or reluctance on the part of the professional to employ certain skills in order to influence the encounter. Also, outcome and approach are not always reliable predictors of satisfaction with the care received. What then might be the basis for satisfaction (or otherwise) with various forms of health care? The work oJ Fox and Storms (1981) suggests that satisfaction with health care universally is directly related to what patients believe to be the causes of illness, and to care providers' 'conditions of care' including an explanation of the cause of the problem, the method of treatment and the expected outcome. If these are congruent then, in the majority of cases, the foundation for 'satisfaction' exists; if they are not, then it is unlikely to develop. The form patients' beliefs take is the product of why and how they come into existence. The why
The Australian Journal of Physiotherapy. Vol. 30, No.5, October, 1984
145
Spinal Pain Patients' Beliefs
and how are in turn a product of personal experience and information. Information in this context is the theme of this paper.
Information Sources
The three major sources of health care information available to the lay public are the lay consultation and referral service, the media and the practitioners. Over the past decade or so, the general disillusionment many members of Western societies have with what Yankelovich (1981, p 36) terms 'the scientific/technological world view' has had a profound influence in the area of health. A growing suspicion of orthodox medicine has been accompanied in certain circles by a newfound enchantment with a variety of pseudoscientific practices (Maddison 1980). Spread of the egalitarian ethic has been responsible for the rise of numerous self-professed experts on health (Tracy 1980). Personal responsibility for health, said to be the last bastion of individuality in todays society (Reubenstein 1982) is being eagerly endorsed by government (AlIegrante and Green 1981)~ This responsibility frequently leads to selfdiagnosis, and self-prescription hasbecome one tenet of a general lifestyle now assuming the proportions of a social movement (Cassileth 1982, Wangfield et a1 1979). Information disseminated by certain practices and cults is being relayed, endorsed and espoused by members of all socioeconomic classes (Darby 1979, Reiman 1979). And while this and more is happening in the field of alternative health care, orthodox medicine appears to lack a response. Perhaps as Singh (1982, p 18) has suggested, modern medicine's explanations and treatments are 'not magical enough' for many people today, who would rather continue to seek simple and naive explanations for their ills and the treatment they receive. To a certain extent this is probably true. However, it is also possible that 148
at least part of the reason for this apparent preference is that inadequate explanations of orthodox theory and treatment have been forthcoming from informed sources. Leventhal (1982) points out that in the absence of suitable information, patients will make what are to them commonsense assumptions concerning illness and treatment. For instance, the opthalmologist who, when asked about iridology simply shrugs and then proceeds to look into the patient's eyes with an opthalmoscope, may be committing a grave error (Stark 1981). In addition to laying the foundation for encouraging the patient to seek alternative care, a dearth of information has led to the accusation that this is a deliberate attempt on the part of the scientifically trained practitioner to preserve control in the professionalpatient encounter (Waitzkin and Stoelke 1976). Significantly, studies such as that by Faden et al (1981) have shown that patients tend to express greater dissatisfaction with the information they receive from professionals during the encounter than with any other feature of their medical care.
Pain
One of the most frequent symptoms of sickness, and the one said to be the strongest source of motivation or incentive in seeking and demanding medical treatment, is pain (Caterinicchio 1979 p83). When present, perceived pain and its severity are powerful predictors of what will be done about symptoms and the promptness with which this will be done (Safer et a1 1979). In the United States of America, the cost of pain has been estimated to be around 10 per cent of the National Budget annually; the per capita figure for Australia is believed to be equivalent (Rose 1981). One third of all pain in Western societies is said to arise from the spine (Bonica 1980). In Western countries, pain of spinal origin has become the single most expensive health care item today
The Australian Journal of PhYSiotherapy. Vol 30, No 5, October, 1984
(Rose 1981). Of the estimated 80 percent of the members of these societies who will experience pain of spinal origin at some stage during their lifetime, the majority will seek some form of treatment including physiotherapy (Nachemson 1979). The extremely high prevalence rate and less than optimal management make pain of spinal origin a frequent symptom in patients presenting at physiotherapy practices. Therefore, in order to examine Fox and Storms' (1981) suggestion in relation to satisfaction with and hence continued utilization of physiotherapy for the mangement of spinal pain, a survey was undertaken to determine if these patients' beliefs and responses were congruent with physiotherapists theoretical and practical conditions of care.
Method
Ninety-six patients (44 males, 52 females) answered a questionnaire designed to determine their beliefs and responses to pain of spinal origin. The sample was randomly selected from six private physiotherapy practices which, due to location, were representative of a cross-section of this community (Perth, Western Australia). The sample was adjusted for age and sex in accordance with information supplied by the Bureau of Census and Statistics. No consideration was given to aetiology, proposed pathology, site and severity of pain or duration of symptoms. The questionaire consisted of multiple choice questions (for a number of which more than one choice was permitted) relating to patients' beliefs concerning the basis for their pain and the mechanisms by which relief was afforded with physiotherapy. Also requested were experience with and opinions of physiotherapy and other providers and expectations of the amount of treatment necessary for recovery.
Results
Fifty-one patients (53.12070), 24 males and 27 females, thought the
Spinal Pain Patients' Beliefs
pain that they were experiencing was due to either a muscle, disc or joint out of place and the same group felt physiotherapy treatment relieved this pain by putting these structures back in place. Thirty patients (31.25070), 10 males and 20 females, thought that their pain was due to torn muscles or ligaments (11), arthritis, fibrositis or rheumatism (11), or inflamation (14) or some combination of these. The relief that was obtained with physiotherapy treatment was believed to be due to its assisting in the repair of these muscles or ligaments (13), soothing the symptoms of arthritis, fibrositis or rheumatism (12) or by helping to reduce inflamation (14). Included in this group were three patients who felt that they had, in addition, a muscle, disc or joint out of place. Four thought that none of the choices offered explained the basis for their pain, two said they did not know how physiotherapy treatment relieved their pain and one felt relief was due to none of the choices offered. Of the fifteen patients (11.4610, 10 males, 5 females) who did not know the basis for their pain, four nevertheless aaded some possible cause (one arthritis, fibrositis or rheumatism, one stiffness, one inflammation, and one torn muscle or ligaments, and inflammation). Four of the remaining 11 replied with 'don't know' to the question on how physiotherapy treatment relieved their pain. Two others said physiotherapy operated via none of the choices offered. The remainder felt that it did so by putting muscles back in place (two), repairing muscles and ligaments (one) and putting joints back in place (one). One patient felt relief was achieved by a combination of repairing muscles or ligaments, putting muscles and ligaments back in place, soothing the symptoms of arthritis, fibrositis or rheumatism and reducing inflammation. Seventy-five patients (78.12070) had had previous experience with physioth-
erapy. Twenty-four (25070) felt that from one to three treatments would be needed for recovery, 43 (44.790/0) felt they would require from four to eight treatments and 29 (30.2070) thought nine or more visits would be necessary. Seventy-six patients expected to get eventual relief with treatment, 38 thought they would experience immediate partial relief and two anticipated immediate complete relief from their pain. In the opinion of 69 patients (71.87070) physiotherapy was the best treatment for their condition. Fortyfour (45.8070) thought this was because physiotherapists were the best qualified practitioners to treat them, 39 (40.65070) because previous experience of their own or others indicated that it was, and 28 (29.16070) thought it must be, otherwise the doctor would not have referred them to a physiotherapist. Six felt physiotherapy was better than nothing. Twenty-one respondents (21.87070) thought chiropractic, osteopathy or acupuncture was of comparable efficacy. Twentysix (27010) out of all respondents had previously sought the services of the stated alternative providers.
Discussion
The time, effort and money that is being spent on informing the medical profession about physiotherapists' areas of competence are warranted. However, it cannot, nor should it be expected that this information, which defines physiotherapy, will necessarily be passed on to the public. The fact that only four patients in the entire sample felt that they were unaware of the means by which physiotherapy helped relieve their pain is small consolation in view of the opinions held by the rest. Obviously it is impossible to define the functions of physiotherapy with relation to spinal pain management in terms of a single, simple belief. It is possible, however, for physiotherapy to function and be identified as being accurately informative. As might be
expected, the patients in this sample had no detailed knowledge of the basis for their pain. By focusing on the mechanisms of pain, with emphasis on the known mechanisms of spinal pain, physiotherapists may take the opportunity afforded them during the encounter to at least begin by informing patients as to what is not the actual basis for their pain. This is considered to be valuable for the following reason. It would appear that a significant proportion of patients in this sample have beliefs regarding the basis for their pain and the mechanism for its relief, which stem from what will be referred to here as manipulation propaganda. 'Manipulation propaganda' is defined as being that information, derived from the three earlier mentioned major sources of health care information, which is interpreted by members of the lay public to mean that pain of spinal origin is the result of some tissue or structure associated with the spine not being in its correct anatomical position. The implication is that relief from this pain may be effected by the intervention of an individual who identifies to the community as purporting to be capable of non-invasive manual manipulation of this tissue or structure back into its correct place. It is further evident that these same patients believe physiotherapists to be among those individuals, despite the fact that physiotherapy has never identified itself to the public as endorsing this concept. Assuming that a porportion 0 f these patients are satisfied with physiotherapy, there exists an apparent contradiction with Fox and Storms' (1981) proposal that this satisfaction depends fundamentally on congruence between the patients' beliefs and responses and providers' theoretical and practical conditions of care. This apparent contradiction may be resolved by conceding that physiotherapists have been excessively inclined to accept that some of the mechanisms for the basis (White and Gordon 1982)
The Australian Journal of Physiotherapy Vol 30 No.5, October, 1984 1
149
Spinal Pain Patients' Beliefs
and especially the management of spinal pain by non-invasive means are currently uncertain (Grieve 1981). Therefore, having been encouraged to remain objective in their approach (Cyriax 1978, Maitland 1977) and to refrain from making what may be unsubstantiatable claims (Cyriax 1978), physiotherapists operating in this area may have become reticent about volunteering information on this topic to members of the lay public. As a result those members who have been offered and have embraced the manipulation propaganda concept take congruence for granted. If spinal pain requires the intervention of physiotherapy, then physiotherapists' conditions of care must include putting something which is 'out' back into its correct place in some way. This assumption is considered to be evidence of the pervasive and deep-rooted nature of these beliefs, reflecting the potency of the information endorsing this concept. In the absence of sufficient and appropriate information, physiotherapists' hands-on methods would serve to reinforce this impression. Believers have generally extended the concept to assuming that the something (disc, joint, muscle) which is thought to be in an incorrect anatomical position, causes pain by compromising neural tissue (Still 1910). This belief was reinforced by the hopefully now moribund legacy of a disc protrusion being considered to be the basis for lumbago and sciatica (Mixter and Barr 1934). Relief from pain is believed to follow non-invasive manual decompression (Cyriax 1978). However, should the pain not disappear within a suitable period of time following intervention, as it frequently does not (in this writer's experience different patients have varying expectations as to the period for various reasons), patients espousing this concept are obliged to come to the following conclusions: (a) compromise and pain remain because the something has not been restored to its 150
correct anatomical position, (b) the remaining pain is due to some sinister, possibly incurable, pathology. In the first situation the provider's efforts are seen as being unsuccessful (incompetence) resulting in the unproductive switching of providers (Fox and Storms 1981). In time, faith in the capabilities of all providers, regardless of discipline, is lost. The second situation may follow the first. It is suggested that this sequence, influenced by specific socio-cultural patterned reactions to the presence of pain per se (Jones et al 1981), is an unnecessary accompaniment of certain cases of unmanageable, chronic spi~al pain. Physiotherapy has always justified its position by the unremitting commitment to furnish acceptable documented evidence for the mechanisms of specific modalities. Aligned as such with the theory and obligations of orthodox practice, it should make the effort to project this image and not permit itself to become identified with alternative philosphies, particularly by default. Physiotherapists are now sufficiently well trained to volunteer to the lay public accurate information on the known mechanisms of spinal pain, and in so doing dissociate the profession from the aspirations and claims of alternative practice (Baer 1981, Hildebrandt 1982).
Conclusion
It has been suggested (Oppenheim 1980) that one of the principal reasons why people value and should be offered detailed information during the health care encounter today, is that for the first time in history they are paying professionals when they are not sick. As they struggle to meet the rising cost of government health programmes and private insurance plans~ patients feel they have a right to know more about what they are getting for their money when they become sick and seek treatment. The lay public uses Information in order to form opinions and make
The Australian Journal of PhySiotherapy Vol 30, No 5, October, 1984
decisions with regard to the meaning and proposed management of their symptoms. The results of this survey indicate that none of the sample could be considered to be able to do so with any degree of accuracy with respect to physiotherapy. Boreham and Gibson (1978) have shown that while desirous of specific details, patients are frequently reluctant to ask about these during the professional encounter. They further point out that an association exists between the amount and type of information made available to the patient during the encounter, and such health care outcomes as satisfaction with the service, compliance and subsequent well-being. Other research indicates that patients wish to be given even that information which might be thought to distress them or raise their levels 0 f anxiety (Faden et aJ 1981). Furthermore, a number of studies by Ley cited by Garrity (1981 p 216) indicate that the capacity patients have for absorbing and comprehending medical terminology, placed in familiar contexts, is generally underestimated by professionals. Finally, physiotherapists functioning in the field of spinal pain management are in the situation to ensure that their patients will be the recipients of accurate information and not have to rely for this aspect of their medical knowledge on what Bareham and Gibson (1978 p 415) consider to be 'the vagaries of media inspired social change.' References Allegrante JP and Green LW (1981); When health policy becomes victim blamIng, The New England Journal of Medicme, 305; 1528-1529 Baer HA (1981), The orgamzatIOnal reJuvmatlon of osteopathy' a reflectIOn of the decline of professlOnal dommance In medlcme; SOCIal Suence and Medlcme, ISA, 701-71 I. Ben-Sira Z (1982), Lay evaluatIOn of medical treatment and competence development of a model of the functIOn of the phYSICian's affectlve behavIOur, SOCIal SCIence and MedIcine,
16, 10]3-1019 Bonica 1J (1980), Pam, Raven, New York. Boreham P and Gibson D (1978), The mformatlve process In pnvate medical consultatIOns: a prelim mary investigation, SOCIal SCience and MedlCme, 12,409-416.
Spinal Pain Patients' Beliefs
Beslau N (1981), W hat do patients statements regardmg doctors and medical care slgmfy? Medical Care, 19, 1069-1070. Cassileth BR (1982), After Laetrile, what? The New England Journal of MedIcine, 306. 14821484 CatenmcchlO RP (1979), Testmg plausible path models of mter-personal trust in patient-phySICian treatment relationships SOCIal Science and Med1CIne, 13A, 81-99. Cynax 1 (1978), Textbook of orthopaedIc medicine, Ballhere Tmdall, London. Darby W J (1979), EtIology of nutntlonal fads, Cancer, 43, 2121-2124. Faden RR, Becker C, LeWIS C, Freeman 1 and Faden A I (1981), DIsclosure of mformation to patients in medical care, Medical Care, 19 718733. Fox 1G and Storms DM (1981), A dIfferent approach to soclodemographic predictors of satisfactiOn With health care, SOCIal SCIence and Medlcme, 15A, 557-564. GarrIty TF (1981), Medical compliance and the chmcIan-patient relatiOnshIp. a reView, SOCIal Science and Medlcme, 15E, 215-222. Gneve GP (1981), Common vertebral Jomt problems, Churchill LIvIngstone, Edmburgh Hildebrandt RW (1982), ObservatIOns of hope Journal of Manipulative and PhYSIOlogical Therapeutics,S, 105-106 Jones RA, Wiese HJ, Moore RW and Haley JV (1981), On the perceived meanmg of symptoms, Medical Care, 19, 710-717.
Kuman S. Ramalah TJ, Katana M. Gupta JP and Rao KJ (1979), Repeat evaluatIOn of communIty health volunteers scheme - 1979), Nallonal InstItute of Health and FamIly Welfare, New Delhi Leventhal H (1982), Wrongheaded ideas about Illness, Psychology Today, 16 (1), 48-73. Maddison D (1980), ProfeSSiOnalIsm and community responsIbIlity, SOCIal Science and MedIcme, 14A, 91-96. Maitland GD (1977), Vertebral manipulation, Butterworths, London. MIxter W J and Barr JS (1934), Rupture of mtervertebral disc with mvolvement of spmal canal, New England Journal of MedIcine, 211, 210-215. Nachemson A (1979), A cntlcal look at the treatment for IQw back pain, ScandmavIan Journal of Rehabll1tatlOn MedIcme, 11, 143147. OppenheIm M (1980), Healers, The New England Journal of MedICIne, 303, 1117-1120. ReIman AS (1979), HolIstiC medIcme, The New England Journal of MedIcme, 300, 312-313. Reubenstem C (1982), Wellness IS all, Psychology Today, 16. (10), 28-37. Rose L (1981), Pam problems in general practice, The medical Journal of Australia, 1. 703-705. Safer MA, Tharps QJ, Jackson TC and Leventhal H (1979), DetermInants of three stages of delay III seekIng care at a medical clIme, MedIcal Care, 17, 11-29.
Singh B (1982), Magic and magIcians: some Implications for doctors. New Doctor, 23, 1618. Stark DJ (1981), Look into my eyes, The Medical Journal of AustrafJa, 2, 676-679. Still A (1910), Osteopathic research and practIce. pp. 12-15. Tracy OD (1980), Evolution of responsibilities In the care of health. The Medical Journal of Australia, 2, 591-596. Tracy GO (1981), DRS forum: personal canng and/or high technology, New Doctor. 20, 1316. Waltzkm Hand Stoelke 1D (1976), InformatIon control and the micropolltics of health care: summary of an ongomg research project, SOCIal Science and Medicme, 10, 263-276. Wangfleld MO, Vissing YM, Markle GE and Petersen JC (1979), Notes from the cancer underground: health attitudes and practices of participants m the laetnle movement, Social Science and MedIcme, 13A. 483-485. White AA and Gordon SL (1982), Synopsis: workshop on IdlOpatl'uc low back pam, Spine, 7, 141-149. Wooley FR, Kane RL, Hughes CC and Wright DD (1978), The effects of doctor-patient commUnIcation on satisfactIOn and outcome of care, SOCIal Science and Medicine, 12, Yankelovich D 1981. New rules in Amencan life: searchmg for self-fulfIlment in a world turned upSide down. Psychology Today, 15. (4), 3591
The Australian Journal of Physiotherapy. Vol. 30, No.5, October, 1984
151
The lay public's medical knowledge is acquired from three sources: the lay consultation and referral service, the media, and the practitioner. Satisfaction with and continued utilization of a health care service may depend on congruence between patients' beliefs about the cause of illness and practitioners' conditions of care. The results of a recent survey indicate that the information to which patients with spinal pain had access, was inadequate for them to acquire accurate knowledge of the basis for their pain and physiotherapists' conditions of care. It is suggested that more accurate information on the mechanisms of spinal pain, volunteered by physiotherapists during the encounter, would be in the interests of the lay pUblic and the physiotherapy profession.
The professional relationship is classically defined as a situation where the patient, lacking specialized knowledge in a particular field, is unable to diagnose his or her problems with any precision or to discriminate among the range of possibilities for meeting such problems (Maddison 1980) and therefore seeks the expertise of one who is trained to do so_ It can also be said that the patient is limited when it comes to assessing the competence of professionals from whom assistance is soughtToday, scientifically trained health care professionals are being asked to recognize that patients' satisfaction with a particular area of care (and hence their continued utilization of the service) may depend on factors other than the practitioner's specialized knowledge and competence. One of these factors which has received attention in the literature is the extent to which the professional appears to be prepared to recognize the patient as a 'whole person'. Insistence on the whole person approach is interpreted by some authors as being part of a national revolt against any form of
MAX ZUSMAN
Max Zusman, B.App.Sc. (Physio), Grad.Dip.Hth.Sc., is a private practitioner in Mount Hawthorn, Western Australia.
elitism (Tracy 1980), and by others as an index of humanity (Breslau 1981). Attempts to denigrate applied science by attributing all sorts of inhumane qualities to the scientifically trained professional are not new. The 'disappearance of the humane, wholeperson orientated physician' was reported with regret in the popular press at the turn of the century (Singh 1982, p. 18). More recently it has been said that it is commonplace for humanity to be trained out of clinicians in pursuit of scientific objectivity (Thomas 1979). However, it has been shown that not only do patients tend to estimate professional competence by the nature of the affective tone of the encounter (whole person) (Ben-Sira 1982), but will, if this is not satisfactory, equate the frequently necessary emphasis on objectivity with a lack of humanity (Tracy 1981). Other studies have shown that even patients making incomplete recoveries express satisfaction with the treatment they receive so long as they feel it is empathetic (Wooley et aI1978). This same general level of satisfaction response appears
to apply equally to those in less developed countries where reliance is, to a large degree, on IDpre traditional forms of medicine (Kuman et a11979). It appears that protests of inhumanity may often be dismissed as being little more than an inability or reluctance on the part of the professional to employ certain skills in order to influence the encounter. Also, outcome and approach are not always reliable predictors of satisfaction with the care received. What then might be the basis for satisfaction (or otherwise) with various forms of health care? The work oJ Fox and Storms (1981) suggests that satisfaction with health care universally is directly related to what patients believe to be the causes of illness, and to care providers' 'conditions of care' including an explanation of the cause of the problem, the method of treatment and the expected outcome. If these are congruent then, in the majority of cases, the foundation for 'satisfaction' exists; if they are not, then it is unlikely to develop. The form patients' beliefs take is the product of why and how they come into existence. The why
The Australian Journal of Physiotherapy. Vol. 30, No.5, October, 1984
145
Spinal Pain Patients' Beliefs
and how are in turn a product of personal experience and information. Information in this context is the theme of this paper.
Information Sources
The three major sources of health care information available to the lay public are the lay consultation and referral service, the media and the practitioners. Over the past decade or so, the general disillusionment many members of Western societies have with what Yankelovich (1981, p 36) terms 'the scientific/technological world view' has had a profound influence in the area of health. A growing suspicion of orthodox medicine has been accompanied in certain circles by a newfound enchantment with a variety of pseudoscientific practices (Maddison 1980). Spread of the egalitarian ethic has been responsible for the rise of numerous self-professed experts on health (Tracy 1980). Personal responsibility for health, said to be the last bastion of individuality in todays society (Reubenstein 1982) is being eagerly endorsed by government (AlIegrante and Green 1981)~ This responsibility frequently leads to selfdiagnosis, and self-prescription hasbecome one tenet of a general lifestyle now assuming the proportions of a social movement (Cassileth 1982, Wangfield et a1 1979). Information disseminated by certain practices and cults is being relayed, endorsed and espoused by members of all socioeconomic classes (Darby 1979, Reiman 1979). And while this and more is happening in the field of alternative health care, orthodox medicine appears to lack a response. Perhaps as Singh (1982, p 18) has suggested, modern medicine's explanations and treatments are 'not magical enough' for many people today, who would rather continue to seek simple and naive explanations for their ills and the treatment they receive. To a certain extent this is probably true. However, it is also possible that 148
at least part of the reason for this apparent preference is that inadequate explanations of orthodox theory and treatment have been forthcoming from informed sources. Leventhal (1982) points out that in the absence of suitable information, patients will make what are to them commonsense assumptions concerning illness and treatment. For instance, the opthalmologist who, when asked about iridology simply shrugs and then proceeds to look into the patient's eyes with an opthalmoscope, may be committing a grave error (Stark 1981). In addition to laying the foundation for encouraging the patient to seek alternative care, a dearth of information has led to the accusation that this is a deliberate attempt on the part of the scientifically trained practitioner to preserve control in the professionalpatient encounter (Waitzkin and Stoelke 1976). Significantly, studies such as that by Faden et al (1981) have shown that patients tend to express greater dissatisfaction with the information they receive from professionals during the encounter than with any other feature of their medical care.
Pain
One of the most frequent symptoms of sickness, and the one said to be the strongest source of motivation or incentive in seeking and demanding medical treatment, is pain (Caterinicchio 1979 p83). When present, perceived pain and its severity are powerful predictors of what will be done about symptoms and the promptness with which this will be done (Safer et a1 1979). In the United States of America, the cost of pain has been estimated to be around 10 per cent of the National Budget annually; the per capita figure for Australia is believed to be equivalent (Rose 1981). One third of all pain in Western societies is said to arise from the spine (Bonica 1980). In Western countries, pain of spinal origin has become the single most expensive health care item today
The Australian Journal of PhYSiotherapy. Vol 30, No 5, October, 1984
(Rose 1981). Of the estimated 80 percent of the members of these societies who will experience pain of spinal origin at some stage during their lifetime, the majority will seek some form of treatment including physiotherapy (Nachemson 1979). The extremely high prevalence rate and less than optimal management make pain of spinal origin a frequent symptom in patients presenting at physiotherapy practices. Therefore, in order to examine Fox and Storms' (1981) suggestion in relation to satisfaction with and hence continued utilization of physiotherapy for the mangement of spinal pain, a survey was undertaken to determine if these patients' beliefs and responses were congruent with physiotherapists theoretical and practical conditions of care.
Method
Ninety-six patients (44 males, 52 females) answered a questionnaire designed to determine their beliefs and responses to pain of spinal origin. The sample was randomly selected from six private physiotherapy practices which, due to location, were representative of a cross-section of this community (Perth, Western Australia). The sample was adjusted for age and sex in accordance with information supplied by the Bureau of Census and Statistics. No consideration was given to aetiology, proposed pathology, site and severity of pain or duration of symptoms. The questionaire consisted of multiple choice questions (for a number of which more than one choice was permitted) relating to patients' beliefs concerning the basis for their pain and the mechanisms by which relief was afforded with physiotherapy. Also requested were experience with and opinions of physiotherapy and other providers and expectations of the amount of treatment necessary for recovery.
Results
Fifty-one patients (53.12070), 24 males and 27 females, thought the
Spinal Pain Patients' Beliefs
pain that they were experiencing was due to either a muscle, disc or joint out of place and the same group felt physiotherapy treatment relieved this pain by putting these structures back in place. Thirty patients (31.25070), 10 males and 20 females, thought that their pain was due to torn muscles or ligaments (11), arthritis, fibrositis or rheumatism (11), or inflamation (14) or some combination of these. The relief that was obtained with physiotherapy treatment was believed to be due to its assisting in the repair of these muscles or ligaments (13), soothing the symptoms of arthritis, fibrositis or rheumatism (12) or by helping to reduce inflamation (14). Included in this group were three patients who felt that they had, in addition, a muscle, disc or joint out of place. Four thought that none of the choices offered explained the basis for their pain, two said they did not know how physiotherapy treatment relieved their pain and one felt relief was due to none of the choices offered. Of the fifteen patients (11.4610, 10 males, 5 females) who did not know the basis for their pain, four nevertheless aaded some possible cause (one arthritis, fibrositis or rheumatism, one stiffness, one inflammation, and one torn muscle or ligaments, and inflammation). Four of the remaining 11 replied with 'don't know' to the question on how physiotherapy treatment relieved their pain. Two others said physiotherapy operated via none of the choices offered. The remainder felt that it did so by putting muscles back in place (two), repairing muscles and ligaments (one) and putting joints back in place (one). One patient felt relief was achieved by a combination of repairing muscles or ligaments, putting muscles and ligaments back in place, soothing the symptoms of arthritis, fibrositis or rheumatism and reducing inflammation. Seventy-five patients (78.12070) had had previous experience with physioth-
erapy. Twenty-four (25070) felt that from one to three treatments would be needed for recovery, 43 (44.790/0) felt they would require from four to eight treatments and 29 (30.2070) thought nine or more visits would be necessary. Seventy-six patients expected to get eventual relief with treatment, 38 thought they would experience immediate partial relief and two anticipated immediate complete relief from their pain. In the opinion of 69 patients (71.87070) physiotherapy was the best treatment for their condition. Fortyfour (45.8070) thought this was because physiotherapists were the best qualified practitioners to treat them, 39 (40.65070) because previous experience of their own or others indicated that it was, and 28 (29.16070) thought it must be, otherwise the doctor would not have referred them to a physiotherapist. Six felt physiotherapy was better than nothing. Twenty-one respondents (21.87070) thought chiropractic, osteopathy or acupuncture was of comparable efficacy. Twentysix (27010) out of all respondents had previously sought the services of the stated alternative providers.
Discussion
The time, effort and money that is being spent on informing the medical profession about physiotherapists' areas of competence are warranted. However, it cannot, nor should it be expected that this information, which defines physiotherapy, will necessarily be passed on to the public. The fact that only four patients in the entire sample felt that they were unaware of the means by which physiotherapy helped relieve their pain is small consolation in view of the opinions held by the rest. Obviously it is impossible to define the functions of physiotherapy with relation to spinal pain management in terms of a single, simple belief. It is possible, however, for physiotherapy to function and be identified as being accurately informative. As might be
expected, the patients in this sample had no detailed knowledge of the basis for their pain. By focusing on the mechanisms of pain, with emphasis on the known mechanisms of spinal pain, physiotherapists may take the opportunity afforded them during the encounter to at least begin by informing patients as to what is not the actual basis for their pain. This is considered to be valuable for the following reason. It would appear that a significant proportion of patients in this sample have beliefs regarding the basis for their pain and the mechanism for its relief, which stem from what will be referred to here as manipulation propaganda. 'Manipulation propaganda' is defined as being that information, derived from the three earlier mentioned major sources of health care information, which is interpreted by members of the lay public to mean that pain of spinal origin is the result of some tissue or structure associated with the spine not being in its correct anatomical position. The implication is that relief from this pain may be effected by the intervention of an individual who identifies to the community as purporting to be capable of non-invasive manual manipulation of this tissue or structure back into its correct place. It is further evident that these same patients believe physiotherapists to be among those individuals, despite the fact that physiotherapy has never identified itself to the public as endorsing this concept. Assuming that a porportion 0 f these patients are satisfied with physiotherapy, there exists an apparent contradiction with Fox and Storms' (1981) proposal that this satisfaction depends fundamentally on congruence between the patients' beliefs and responses and providers' theoretical and practical conditions of care. This apparent contradiction may be resolved by conceding that physiotherapists have been excessively inclined to accept that some of the mechanisms for the basis (White and Gordon 1982)
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and especially the management of spinal pain by non-invasive means are currently uncertain (Grieve 1981). Therefore, having been encouraged to remain objective in their approach (Cyriax 1978, Maitland 1977) and to refrain from making what may be unsubstantiatable claims (Cyriax 1978), physiotherapists operating in this area may have become reticent about volunteering information on this topic to members of the lay public. As a result those members who have been offered and have embraced the manipulation propaganda concept take congruence for granted. If spinal pain requires the intervention of physiotherapy, then physiotherapists' conditions of care must include putting something which is 'out' back into its correct place in some way. This assumption is considered to be evidence of the pervasive and deep-rooted nature of these beliefs, reflecting the potency of the information endorsing this concept. In the absence of sufficient and appropriate information, physiotherapists' hands-on methods would serve to reinforce this impression. Believers have generally extended the concept to assuming that the something (disc, joint, muscle) which is thought to be in an incorrect anatomical position, causes pain by compromising neural tissue (Still 1910). This belief was reinforced by the hopefully now moribund legacy of a disc protrusion being considered to be the basis for lumbago and sciatica (Mixter and Barr 1934). Relief from pain is believed to follow non-invasive manual decompression (Cyriax 1978). However, should the pain not disappear within a suitable period of time following intervention, as it frequently does not (in this writer's experience different patients have varying expectations as to the period for various reasons), patients espousing this concept are obliged to come to the following conclusions: (a) compromise and pain remain because the something has not been restored to its 150
correct anatomical position, (b) the remaining pain is due to some sinister, possibly incurable, pathology. In the first situation the provider's efforts are seen as being unsuccessful (incompetence) resulting in the unproductive switching of providers (Fox and Storms 1981). In time, faith in the capabilities of all providers, regardless of discipline, is lost. The second situation may follow the first. It is suggested that this sequence, influenced by specific socio-cultural patterned reactions to the presence of pain per se (Jones et al 1981), is an unnecessary accompaniment of certain cases of unmanageable, chronic spi~al pain. Physiotherapy has always justified its position by the unremitting commitment to furnish acceptable documented evidence for the mechanisms of specific modalities. Aligned as such with the theory and obligations of orthodox practice, it should make the effort to project this image and not permit itself to become identified with alternative philosphies, particularly by default. Physiotherapists are now sufficiently well trained to volunteer to the lay public accurate information on the known mechanisms of spinal pain, and in so doing dissociate the profession from the aspirations and claims of alternative practice (Baer 1981, Hildebrandt 1982).
Conclusion
It has been suggested (Oppenheim 1980) that one of the principal reasons why people value and should be offered detailed information during the health care encounter today, is that for the first time in history they are paying professionals when they are not sick. As they struggle to meet the rising cost of government health programmes and private insurance plans~ patients feel they have a right to know more about what they are getting for their money when they become sick and seek treatment. The lay public uses Information in order to form opinions and make
The Australian Journal of PhySiotherapy Vol 30, No 5, October, 1984
decisions with regard to the meaning and proposed management of their symptoms. The results of this survey indicate that none of the sample could be considered to be able to do so with any degree of accuracy with respect to physiotherapy. Boreham and Gibson (1978) have shown that while desirous of specific details, patients are frequently reluctant to ask about these during the professional encounter. They further point out that an association exists between the amount and type of information made available to the patient during the encounter, and such health care outcomes as satisfaction with the service, compliance and subsequent well-being. Other research indicates that patients wish to be given even that information which might be thought to distress them or raise their levels 0 f anxiety (Faden et aJ 1981). Furthermore, a number of studies by Ley cited by Garrity (1981 p 216) indicate that the capacity patients have for absorbing and comprehending medical terminology, placed in familiar contexts, is generally underestimated by professionals. Finally, physiotherapists functioning in the field of spinal pain management are in the situation to ensure that their patients will be the recipients of accurate information and not have to rely for this aspect of their medical knowledge on what Bareham and Gibson (1978 p 415) consider to be 'the vagaries of media inspired social change.' References Allegrante JP and Green LW (1981); When health policy becomes victim blamIng, The New England Journal of Medicme, 305; 1528-1529 Baer HA (1981), The orgamzatIOnal reJuvmatlon of osteopathy' a reflectIOn of the decline of professlOnal dommance In medlcme; SOCIal Suence and Medlcme, ISA, 701-71 I. Ben-Sira Z (1982), Lay evaluatIOn of medical treatment and competence development of a model of the functIOn of the phYSICian's affectlve behavIOur, SOCIal SCIence and MedIcine,
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