Reply: Symptoms without pathology

P. Croft

Primary Care Sciences, Keele University, Keele, Staffordshire STS 5BG, UK

Correspondence to: E-mail: p.r.croft{at}cphc.keele.ac.uk

I accept George Ehrlich's gentle censure that the ACR criteria were intended to help standardize reporting and research and not to provide the basis for a clinical diagnosis.

My understanding of Professor Ehrlich's concerns, both from his letter and the referenced articles, is that ‘labelling’ the real distress of chronic pain sufferers as fibromyalgia has created a false sense of biological, pathological and aetiological certainty, which is not justified by the evidence and has done more harm than good.

I do not feel qualified to enter this particular debate, but, as my editorial indicated, I certainly believe that (i) current evidence suggests that tender points are not uniquely part of a chronic pain syndrome, and (ii) there is little evidence yet that eliciting tender points is a clinically useful exercise. The status of fibromyalgia as a syndrome of chronic pain and high tender point counts is, from this perspective, yet to be established.

More problematic for me is the question of whether getting rid of a label would make the treatment of ‘the very real physical and psychological symptoms that characterize chronic pain’ any easier or any more detached from the social and cultural influences that surround the experience and treatment of chronic pain in modern society.

In the 1970s, for example, the most widely used label in British general practice for the presenting symptom of low back pain was ‘spinal osteoarthritis’. In the next decade or two, British general practitioners were persuaded of the spurious nature of this pathological label for most patients, and they reverted to the currently most frequently favoured label—namely ‘low back pain’. However, during those same two decades, work absence and invalidity payments for back symptoms and conditions accelerated exponentially. Taking the pathology out of the label did not convert the problem to an acceptable part of everyday life.

Professor Ehrlich highlights an important problem. More empirical research on the influence of labels on patients’ well-being and clinical outcome would be welcome.

Accepted 30 September 2003





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