Alexithymia is highly prevalent among chronic pain patients. Pain is a remarkable cause for high levels of chronic anxiety. The purpose of this study was to investigate the prevalence of alexithymia and to determine anxiety levels among DSM-IV somatoform pain disorder (chronic pain) female patients and to examine the relationship between alexithymia and the self-reporting of pain.Thirty adult females , who applied to the outpatient psychiatry clinic at a public hospital with the diagnosis of chronic pain disorder (DSM-IV), were included in the study. Thirty seven healthy females , who matched for sociodemographic features with the patient group, consisted the control group. A sociodemographic data form, 26-item Toronto Alexithymia Scale (TAS-26), Spielberger Trait Anxiety Inventory (STAI) were administered to each subject and information was obtained on several aspects of the patients' pain, including intensity (measured by VAS), and duration.Chronic pain patients were found significantly more alexithymic than controls. There was a positive correlation between TAS-26 scores and the duration of pain. The alexithymic and nonalexithymic group did not differ in their perception of pain. Neither positive correlation nor significant difference was found between alexithymia and trait anxiety in pain patients.Alexithymia may be important in addressing the diversity of subjective factors involved in pain. The conceptualization of alexithymia as a personality trait as well as a secondary state reaction is underlined by our data. The original definition of alexithymia is the inability to identify and use verbal language to describe feelings ,2. AlexiSeveral studies have found a high prevalence of alexithymia in pain patients. Chronic pain patients frequently exhibit many of the core features of alexithymia, such as problems in identifying and describing subjective feelings, impoverished imaginative abilities, and excessive preoccupation with physical symptoms and external events. Although several studies have found a high prevalence of alexithymia in pain patients, the way alexithymia may possibly influence pain experience is still unclear ,13.DSM-IV-TR defines pain disorder as the presence of pain that is "the predominant focus of clinical attention" . In chroThe alexithymic person's difficulty in identifying and describing feelings may increase symptom reporting by several mechanisms. Consequently, due to the difficulty to experience and express emotions, alexithymia has been linked with somatosensory amplification, which is the tendency to focus on benign somatic sensations. Alexithymic subjects are considered to focus on somatic manifestations of emotional arousal, resulting in misinterpretation of somatic sensations as signs of physical illness ,13,16. ABased on previous findings, these factors are worth receiving more attention in terms of clinical research. The purpose of the present study was to investigate the prevalence of alexithymia among DSM-IV somatoform pain disorder (chronic pain) female patients and to examine the relationship between alexithymia and the self-reporting of pain in this group of patients. Besides, the study searched for the anxiety levels of chronic pain patients with or without alexithymia.The sample consisted of 30 females who applied to the outpatient psychiatry clinic at a public hospital and who met DSM-IV diagnostic criteria for chronic pain disorder. Patients with concomitant psychiatric disorders, such as major depression, anxiety disorders and somatoform disorders other than pain disorder were excluded.Patients either directly applied to the psychiatry clinic themselves or were referred for psychiatric assessment from another outpatient clinic, mainly physical medicine and rehabilitation. After complete description of the study, written informed consent was obtained from each subject.The control group was 37 healthy females, who matched for age, and education with the subjects. All subjects participated voluntarily in the study and gave consent after the procedure had been fully explained to them.t = 0,79, df = 65, P > 0,05), educational level , and marital status .The mean age of the patients and the healthy controls was 34,63 ± 10,62 (range: 16–62) and 34,46 ± 7,43 (range: 22–57) years and the educational level was 6,13 ± 3,03 (range: 5–11) and 6,59 ± 2,9 (range: 5–14) years, respectively. There were no significant differences between the two groups with respect to age  , TurkishThe psychometric scales used in the study were the 26-item Toronto Alexithymia Scale (TAS-26] and the Trait Anxiety Inventory (STAI), which were both validated in Turkish population studies -28. TAS In order to determine the relative importance of a number of factors in pain disorders, we used both correlation analyses. The alexithymic and nonalexithymic groups were compared using the independent sample t-tests on scores of psychological tests. The statistical procedure, which was carried out by a SPSS package program for Windows using Chi-square, Fisher's exact test, two tailed t test and Pearson correlation coefficients, was also used to determine group differences  in sociodemographic variables and various aspects of pain.2 = 0,27, df = 1, p > 0,87) were not associated with alexithymia  had a score greater than 11 on the TAS-26, and were considered alexithymic. The mean TAS-26 score of the alexithymic group (n = 17) was 17.88 ± 3.43 and the nonalexithymic group (n = 13) was 8.39 ± 2.02. Age , education  and marital status  or anxiety levels in the control subjects  were alexithymic according to TAS-26. The mean TAS-26 score of the alexithymic group (n = 9) was 13,82 ± 1,93 and the nonalexithymic group (n = 28) was 10,33 ± 0,86. Alexithymia was not associated with age , educational level , or marital status . STAI (trait) scores of the alexithymics in the pain group did not significantly differ from the nonlalexithymics  and besides, TAS-26 and STAI scores were not correlated .In summary, there are three points to be emphasized. First, chronic pain patients were found significantly more alexithymic than controls . Second, a positive correlation was observed between TAS-26 scores and duration of pain. Third, neither positive correlation nor significant difference was found between alexithymia and trait anxiety in pain patients.The results of the present study suggest that patients with chronic pain disorder are more alexithymic than individuals with no pain. This finding is consistent with results obtained with earlier measures of alexithymia -13. AlthThere were no significant differences between alexithymic and nonalexitymic patients on self reports of current pain severity. This is in accordance with Cox's study [1994] in which it was further pointed out that alexithymic patients were found to use significantly more verbal descriptors of pain compared to nonalexithymic patients . In our The positive correlation between alexithymia and the duration of pain in this sample supports the assumption of a two-way hypothesis. It is often assumed that pain can be caused by alexithymic personality traits and also that severe and chronic pain may cause emotional change. One of the limitations of this study is that because of the cross-sectional design, we are unable to draw conclusions about the direction of causality between alexithymia and pain. The duration of the patients' pain could approximately be determined, yet the preexisting level of alexithymia was not known. In the usual absence of internal stimuli, alexithymic person may be expected to maintain an external focus of attention, such as pain. Symptom chronicity may force the alexithymic person to attent to and amplify this somatic sensation.Difficulties in the ability to identify and differentiate emotions and somatic experiences are core features of the alexithymic construct. Therefore, alexithymic patients might be expected to differ from nonalexithymic ones in their anxiety levels. Yet, in our pain group alexithymic patients showed no significant difference from the nonalexithymics on trait anxiety. Besides, alexithymia and anxiety were not correlated at all. The reasons may be lying in the specific characteristics of this patient group itself.The study included patients suffering from chronic symptoms; with an average of 7,44 ± 6,82 years of pain in the alexithymic and 3,31 ± 2,79 years in the nonalexithymic groups. Persistency of any physical symptom may bring along alexithymia as a coping strategy. In their paper, Crook and Tunks (1988) examined the types of coping strategies used by persistent pain sufferers and addressed to the importance to alter their attitudes and behavior that tend toward catastrophizing, avoidance and withdrawal, rather than simply concentrate on trying to teach them techniques for 'coping with stress' to help persistent pain sufferers . SuffereAlexithymia may be important in addressing the diversity of subjective factors involved in pain . It is n


Pain is highly prevalent in nursing homes (NH) in several countries. Data about pain in Dutch NH's, where medical care is delivered by specifically trained NH-physicians, are not available. The aim of the present study is to determine prevalence, course, correlates, recognition and treatment of pain among Dutch NH-patients and to make a comparison with international data.The study-population consisted of 350 elderly NH-patients from 14 Dutch NH's. Pain  and clinical characteristics  were measured at baseline and at six months.Association of pain (baseline and six months) with clinical characteristics was assessed with chi-square and multiple logistic regression analyses.Pain-prevalence was 68.0% . 80% of the patients with pain at baseline still experienced pain at six months. Serious pain at baseline was significantly associated with depression  and anxiety . Serious pain at six months was associated with pain at baseline  and depression at baseline . Recognition of pain by NH-physicians varied (35% to 69.7%) depending on measurement instrument and severity of pain. Analgesics were received by 64.5% (paracetamol (acetaminophen), NSAIDs, opioids). Paracetamol (acetaminophen) and opioids frequently were prescribed below daily defined doses. Pain occurred frequently also among Dutch NH-patients and was associated with depression and anxiety. Recognition and treatment by NH-physicians proved sub-optimal. Future studies should focus on interventions to improve recognition and treatment of pain. One of the main goals of nursing home care is preservation of the best possible quality of life. A very important aspect of quality of life is being free of pain. Prompt recognition and adequate treatment is therefore requested when nursing home patients are suffering from pain.Previous studies in several countries showed that pain is a common problem in the long-term care setting -3. PrevaFor the Netherlands, in which nursing home physicians are employed by nursing homes for medical care and in which nursing home medicine is an independent medical specialism with its own specific training programme ,9, epideThe aim of the present study was therefore (a) to determine prevalence, course, correlates, recognition and treatment of pain in Dutch nursing home patients and (b) to make a comparison with international data.This study is based on data collected in the Amsterdam Groningen Elderly Depression (AGED) study . FourteePatients with at baseline an expected stay of less than 6 months were excluded. All eligible patients were informed verbally and in writing. Written informed consent was obtained from all respondents prior to inclusion. The study received approval from the Medical Ethics Committee of the VU University Medical Center.Between November 1999 and May 2001, data were collected. All measurements were administered twice in a face to face interview: at baseline and six months later. Sampling procedures are described in detail elsewhere .From the source population (696 nursing home patients who met inclusion criteria) eventually an active sample of 350 patients remained who participated in the baseline data-collection. 58 patients (8.3%) died before the interview could be started and 46 patients (6.6%) could not be interviewed because they were suffering from acute illness, terminal illness or coma. 235 patients (33.8%) refused to participate in this study and 7 patients (1.0%) were not included for other reasons.In the second wave at six months 229  patients participated; 43 (12.3%) patients died; 16 (4.6%) patients had severe cognitive impairment; 9 (2.6%) patients were unable to communicate; 15 (4.3%) patients were hospitalised or moved; 35 (10%) patients refused and 3 (0.9%) patients were lost to follow-up for other reasons.Perceived pain was measured with the pain subscale of the Dutch version of the Nottingham Health Profile, which measures pain by selfreport . The paiThe items of the pain subscale concern pain intensity as well as situations in which pain occurs , was assessed by chart review and was classified according to the Anatomical Therapeutic Chemical (ATC) classification system . The PDDPrescription of antidepressants and of anxiolytics/hypnosedatives (mainly bezodiazepines) was also registrated.Demographic characteristics like age and gender were gathered by chart review. Cognitive functioning was assessed with the Mini-Mental State Examination (MMSE) . Sum scoDepressive symptoms were measured with the Geriatric Depression Scale . A scoreAnxiety was measured with the Schedules for Clinical Assessment in Neuropsychiatry . AnxietySleep was also measured with the SCAN. Presence of impaired sleep was defined as having troubles falling asleep or being awake in the night  or waking up early .Information about the presence of physical illnesses was obtained from the attending physician using a questionnaire containing thirteen main groups of somatic diseases. The total number of physical illnesses was dichotomized on the median.Data on functional limitations were supplied by care personnel involved in direct daily care, using the Groningen Activity Restriction Scale (GARS): 11 items concerning Activities of Daily Living . Sum scoAnalysis of attrition was done by comparing baseline characteristics  of patients who could be interviewed at baseline and at six months with baseline characteristics of patients who could only be interviewed at baseline.Prevalence of pain was calculated at baseline and at six months. The relations between pain at baseline and demographic and clinical characteristics were evaluated by calculating crude odds ratios (OR) and corresponding 95% confidence intervals (CI). As a next step multiple logistic regression was used to calculate adjusted odds ratios. Only variables with a statistically significant (p < 0.05) crude odds ratio were entered in the multiple logistic regression model.To identify baseline characteristics that were associated with presence of pain at six months the same analyses were done with pain at six months as dependent variable. Presence of pain at baseline was entered in these analyses also as an independent variable.The course of pain was described in two ways. Firstly, at NHP symptom level. For all eight NPH items the course of the symptom over six months was assessed  had mild pain symptoms and 27.5% (n = 94) had serious pain symptoms.Table Presence of serious pain symptoms at six months was in multiple logistic regression analysis statistically significant associated with presence of pain  and depressive symptoms  at baseline. Presence of mild pain symptoms at six months was only statistically significant associated with presence of pain at baseline .Data about the course of pain over six months were available for 216 patients. Especially 'unbearable pain' (58.6%) and 'constant pain' (66.0%) are persistent over time table .Presence of mild pain symptoms was recognized in 34.4% and presence of serious pain symptoms was recognized in 38.2% of the patients, when measured by interviewing the attending physician.Pain-recognition was also measured by assessing prescription of analgesics  between patients with pain (mild pain symptoms and serious pain symptoms) and without pain were statistically significant . Further analyses showed no significant difference in analgesic therapy between patients with mild pain symptoms and serious pain symptoms .The majority of analgesic users at baseline still reported pain. Only 31 (19.6%) of them were free of pain, 74 (46.8%) still experienced mild pain symptoms and 53 (33.5%) still experienced serious pain symptoms.Data of analgesic use at six months depicted similar results (data not shown).Considering the adequacy of dosing, opioid-presciptions had in 12.5% a PDD/DDD-ratio of 1 and in 69.2% a PDD/DDD-ratio lower than 2/3. Paracetamol (acetaminophen) prescriptions showed in 15.5% a PDD/DDD ratio of 1 and in 30.8% a PDD/DDD-ratio lower than 2/3. NSAIDs were prescribed in 84.0% with a PDD/DDD-ratio of >= 1 and in 16.0% with a PDD/DDD-ratio below 1.Combinations of analgesics were prescribed to 12.1–15.8% of the patients with pain at baseline.There was no significant difference in antidepressants prescription  between patients with pain (mild pain symptoms and serious pain symptoms) and without pain, but patients with pain (mild pain symptoms and serious pain symptoms) used significantly more frequently anxiolytics/hypnosedatives than patients without pain . Further analyses showed no significant difference in prescription of anxiolytics/hypnosedatives between patients with mild pain symptoms and patients with serious pain symptoms .The prevalence of self-reported pain was high in this population of nursing home patients: 40.5% of the patients reported mild pain symptoms and an additional 27.5% serious pain symptoms at baseline. Only 32.0% was free of pain. This was in line with previous studies which used self-reported pain as method of pain measurement -22. PainImportant associated characteristics with serious pain symptoms at baseline were presence of depressive symptoms and presence of anxiety symptoms. Serious pain symptoms at six months were associated with pain at baseline and with presence of depressive symptoms.The observed association with depressive symptoms and anxiety symptoms was also found in previous investigations . In a loContrary to previous studies, no association of self-reported pain with cognitive functioning was observed ,24. ThisRecognition of pain measured by interview and recognition of pain measured by prescription of analgesics resulted in different recognition rates: 35–40% vs. 61.2–69.7%, presumably because they reflect two ways of defining pain recognition. Analgesics prescription as measurement for pain recognition indicates that at some moment (before or after admission to the nursing home) a physician diagnosed pain and prescribed an analgesic.A positive interview-answer as measurement for pain recognition indicates that the physician recognized that the patient experienced pain at the time of the interview.Both methods of measuring pain recognition made clear that presence of pain in many patients remained undetected. Previous studies showed similar results, not only for recognition of pain by physicians but also for recognition by nursing staff .False attitudes about pain and age among elderly patients and their caregivers and non-communication about pain between patients and caregivers were held responsible for this underdetection .Treatment with analgesics occurred frequently in the present population: 54.5%. Analgesic prescription rate was the highest among patients who reported pain . Paracetamol (acetaminophen) was used the most frequently, followed by NSAIDs and opioids. In spite of use of analgesics many patients still reported pain. Underdosing of analgesics and a restrained prescription of combinations of analgesics and of opioids could be potential causes.Underdosing, for which a PDD/DDD-ratio below 1 is indicative, was indeed observed, especially for opioids (PDD/DDD-ratio < 2/3: 69.2%) and to a lesser extent also for paracetamol (acetaminophen) (PDD/DDD-ratio < 2/3: 30.8%). PDD/DDD-ratio for NSAIDs on the other hand was relatively high (84% PDD/DDD-ratio >=1) in view of the risk of renal failure and hypertension for older patients . A similCombinations of analgesics were prescribed to 12.1–15.8% of the patients with pain at baseline. Given the fact that these patients still had pain, one would expect a higher rate of combinations of analgesics.Opioids were prescribed to 11.7% of the patients with pain at baseline and about half of the opioid-prescriptions were given as monotherapy. This seems not in line with pain-guidelines which advise opioids to be added to NSAIDs and paracetamol (acetaminophen) as a next step in analgesic treatment .The high prevalence of pain in the present study and the observations made about recognition and treatment of pain suggest that in nursing homes in the Netherlands, pain-management is suboptimal just as was found in studies among nursing home populations in other countries, despite the deliverance of medical care by specifically trained nursing home physicians.Assessment of pain by a standardized instrument at regular times, which is uncommon in the Netherlands , speech and language problems, severe physical illness and expected discharge within six months were important exclusion criteria.Secondly, attrition was considerable as could be expected among the frail population of elderly patients residing in nursing homes. Nevertheless, analysis of attrition showed no differences in distribution of baseline-characteristics between patients who remained in the study and patients who dropped out.Thirdly, pain was measured with the NHP-pain subscale which contains items concerning different aspects of pain (pain-intensity as well as items concerning situations in which pain is present). We therefore constructed an ordinal pain variable, that in our opinion has satisfying clinical face validity by using intensity and long lasting presence of pain for defining more severe pain.Pain is a common and usually persistent problem among nursing home patients.Important associations are observed with depressive and anxiety symptoms.Recognition by nursing home physicians in the Netherlands is comparable to recognition in other countries and open for improvement.Despite a high prescription rate of analgesics, many patients still report pain. This may be caused by underdosing and restrained use of analgesic combination therapy.To warrant optimal quality of life of nursing home patients improvement of pain recognition and treatment is needed. Introduction of standardized pain assessments at regular times, treatment according to pain guidelines and interdisciplinary discussion of the assessment results and treatment effects, may help to establish this.The author(s) declare that they have no competing interests.All authors contributed to the study conception and design. MS participated in the data analysis and drafting of the manuscript, LJ participated in the data collection, AP participated in the data analysis, AB participated in the data analysis, JE participated in the data analysis. All authors critically reviewed the manuscript, read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


This paper comments on the role and emergence of the biopsychosocial model in modern medical literature and health care settings. The evolution of the biopsychosocial model and its close association with modern pain theory is also examined. This paper seeks to discuss the place of this model with respect to the management of hypothyroidism. This discussion represents a forerunner to a randomised control trial that will seek to investigate the effect of a biopsychosocial-based treatment regime on hypothyroidism. A search through Medline, Meditext, PubMed, OVID, Science direct, Austats, CINAHL, Expanded Academic ASAP was performed using the key words: Biopsychosocial model, hypothyroidism, treatment, levothyroxine, thyroid.soma, resulting from infection, injury or inheritance [The biopsychosocial model depicts a health care concept that has evolved in close association with current pain theory. It has sought coexistence with the dominant biomedical model of health care, which describes 'disease' as a failure of or within the eritance . The bioeritance .In 1977, Engel described a crisis that modern medicine and psychiatry were facing. Disease, from a biomedical perspective was described in somatic parameters alone, there was little or no room for psychological, social and behavioural dimensions of illness within this model. This made adherence to this framework very difficult. There were somatic and mental disorders that simply did not fit the biomedical model, and hence it was no longer sufficient for the scientific and social responsibilities of either medicine or psychiatry ,3. EngelThe biopsychosocial model states that ill health and disease are the result of an interaction between biological, psychological and social factors. The biopsychosocial model makes the distinction between pathophysiological processes that cause disease and the client's perception of their health and the effects on it, called the illness . It seekSituations paradoxically arise in medicine in which a person who feels well is described biochemically, as having 'disease'. In contrast, a client's laboratory findings may reveal no 'disease', however the client still feels unwell. The biopsychosocial model provides a conceptual framework for dealing with such situations .Of late, a great deal of attention has been given to the factors involved in chronic pain and depression. It is research like this that has highlighted the need for a paradigm such as the biopsychosocial model in the management of conditions other than chronic pain. Following the success of various psychological and cognitive interventions in the reduction of somatic signs and symptoms associated with certain conditions such as irritable bowel syndrome (IBS), non-cardiac chest pain, fibromyalgia and rheumatoid arthritis (RA), research has set out to explore the role of psychosocial factors in the disease process ,7,8.The biopsychosocial model avoids a strong 'disease' focus and seeks to address the client and his or her illness . ClientsThe biopsychosocial model represents the evolution of the biomedical model, and aligns favourably with recent ideas in pain theory and pathophysiology .Early theories concerning pain were consistent with the specificity theory, which described pain as the result of noxious stimuli or somatic pathology alone . There wThe mid nineteen sixties saw the emergence of the gate control theory of pain ,12. The Melzack through his study of phantom limb pain  developeThe end product is the cyclic processing of neural information into a characteristic pattern, known as the neurosignature. Melzack postulates that a neurosignature exists for all types of pain, mood and psychological states ,14. The Put into context, this model suggests that neurosignatures for pain and depression exist throughout the neuromatrix. These signatures cannot be erased, but can be altered if changes are made to the entire network ,11,14.The biopsychosocial model has emerged over the past two decades and has sought to expand upon disease paradigms and complement pain models. It states that in order to understand and manage ill health, pain and disease, one must take into account the influence of biological, psychological and social factors .It is acknowledged that there are many conditions (eg osteoarthritis and rheumatoid arthritis) in whichIn contrast, the existence of pain and discomfort in conditions such as fibromyalgia, irritable bowel syndrome (IBS) and noncardiac chest pain is strongly linked to central nervous system (CNS) disturbance  and psychosocial factors ,7,8. FroResearch into chronic pain and depression has revealed a number of significant psychological factors . ClientsPsychological intervention  aimed at these maladaptive patterns and behaviours has demonstrated high rates of success in reducing symptomatology and disease progression in certain chronic pain conditions ,10,20.One area pain researchers are currently exploring is the differences in information processing and recall bias between chronic pain sufferers who present with comorbid depression and those non-depressed pain groups. It appears that clients with chronic pain demonstrate a propensity for recalling the negative information regarding their condition, in the presence of co-morbid depression. Clients without depression demonstrate a recall bias for positive illness related information. These studies suggest that depressed patients with chronic pain may be processing information differently to the non-depressed groups .pain schema encompass sensory intensity, along with spatial and temporal features of pain. The schema accounts for the immediate properties of the pain experience. They depict the interruption of ongoing behaviour and the commencement of pain avoidance and recuperative behaviours.Pincus and Morley propose a model to account for the bias in information processing  demonstrated in chronic pain sufferers . It is pillness schema depict information relating to affective and behavioural consequences of illness . The identity, timeframe, perceived causes and consequences along with control of a particular illness, make up the schema.The self is described in a number of ways. The self can be explained as 'an organized cognitive structure within long-term memory, which may incorporate both general trait like information about the self, as well as specific behaviours' [The schema representing aviours' . The selaviours' .It is stated that contemporary individuals are striving to meet their positive goals and avoid unwanted outcomes . This isenmeshment. Consequently, the activation of one schema via a relatively innocuous stimulus following enmeshment, can elicit unwanted effects (eg illness behaviour associated with pain syndromes) [Variations in the state of a person may be explained by the interaction of these schema. Activation of elements from one particular schema has the potential to simultaneously activate components of another schema, in a process known as ndromes) .Recent studies performed by Buer and Linton describe the importance of cognitions (fear-avoidance beliefs and catastrophizing) in chronic pain situations . The modThere exists a considerable amount of data on the social determinants of ill health and disease. One of the contributors to this body of knowledge has been the Whitehall studies. The Whitehall I study initiated in the late 1960's, examined mortality rates over 10 years among male British Civil Servants aged 20–64 . The WhiThe Whitehall II study was set up to investigate the effect of social gradient on morbidity and mortality, including determinants such as, work characteristics and social support . MeasureThere are various social factors that have gained recognition in recent years with respect to influences on depression among pain patients. Patients who report high family conflict and low family cohesion often display higher depression levels. Likewise, patients with low socio-economic status and lower levels of education also exhibit higher depression scores. Research into this area highlights a number of studies in which psychological intervention involving spouses or caregivers resulted in reduced pain and psychological distress .et al describes a diagnostic protocol for irritable bowel syndrome (IBS), encompassing social factors such as, break up of a close relationship, early life experience, familial dysfunctions and family environment. It is postulated that these factors may influence the development of symptoms, clinical expression, course of the disorder and the utilization of health services [In a recent review, Truchon describes a set of socio-demographic factors that have featured in chronic disability (related to low back pain) studies over the last decade . These iservices .Hypothyroidism refers to any metabolic state that results from a decrease in the amount of circulating thyroid hormones in the body. Hypothyroidism can be classified based on its time of onset , severity , and the degree of endocrine aberration (primary or secondary) . PrimaryAccording to the 1995 report from the Australian Bureau of Statistics (ABS) 5.3/1000 males and 27.3/1000 females experience thyroid dysfunction in Australia . This fiHypothyroidism is caused by a variety of different states and conditions. Autoimmune and iatrogenic causes constitute the most common sources of reduced thyroid hormone levels  see tab.Hypothyroidism manifests in a variety of different forms . Young iOvert hypothyroidism refers to patients with elevated thyroid stimulating hormone (TSH) levels and low free thyroxine (T4) levels. The term 'subclinical hypothyroidism' has featured repeatedly in the literature in recent years. Subclinical hypothyroidism is characterised by elevated TSH concentrations associated with normal thyroxine (T4) and triiodothyronine (T3) serum levels. Subclinical hypothyroidism is further categorized with respect to the following guidelines: ,38 see .A relatively exhaustive index of signs and symptoms is listed below. However, it is important to keep in mind that the manifestation of hypothyroidism is often far from the textbook presentation. The symptoms of hypothyroidism can be subtle and are often confused with the signs of aging ,40 see .The current treatment of choice for individuals suffering from hypothyroidism is supplementation using the synthetic thyroid hormone, levothyroxine. Levothyroxine is an artificial version of the naturally occurring thyroid hormone, thyroxine (T4). Patients are required to take 50–150 μg of levothyroxine daily for the rest of their lives ,34. ThyrDepression is one of the major symptoms associated with hypothyroidism. According to the DSM-IV, a person presenting with depression (major depressive episode) must either have a depressed mood or interest for two or more weeks . This moWhile depression is strongly associated with hypothyroidism, the exact mechanisms are not yet known -45. HaggResearch has sought to explain the above findings via the concept of central and peripheral hypothyroidism . It is pet al suggests that biological correlates may exist for some of the depressive symptoms of hypothyroidism [Gunnarsson yroidism . These iyroidism .It has been suggested that central serotonergic activity is reduced in hypothyroid patients. It is also postulated that comparatively higher thyroid stimulating hormone (TSH) levels may be a predictor of lower serotonin mediated endocrine responses and the presence of clinical depression . DepressSullivan states that transthyretin, a thyroid carrier protein, exists in differing forms both centrally and peripherally . This caet al suggested that acute stress may alter the levels of thyroid hormone T3, but not T4 in the rat brain [et al researched the effects of chronic stress on hormone secretion in human subjects [et al analysed the effects of chronic stress on the thyroid axis and its influence on the immune response in animals. The results showed that the thyroid hormones could be influenced by chronic stress, in particular T3 concentrations. Furthermore it was postulated that changes in thyroid axis function may play a role in regulation of the immune response [Research into stress, immunity and the HPT axis has demonstrated some interesting findings. In a recent study investigating the effects of stress on rat brains, Friedman at brain . Bauer esubjects . Thyroidsubjects . Cremascresponse .et al describe a study in which a significant number of patients with prophylaxis resistant affective disorders  improved after being given supra-physiological doses of synthetic thyroid hormone [Bauer  hormone . It was  hormone .et al describe a study of a large randomly selected population group examining the risk of anxiety disorders or depression in individuals with thyroid dysfunction. The results of this study showed a higher prevalence of depression in groups with previously known thyroid disorders, with lower prevalence in those with more recently diagnosed thyroid dysfunction. This study demonstrated a weak association between thyroid disorder and symptoms of anxiety and depression. Based on the results of their study Engum et al suggests that when depression and anxiety disorders are diagnosed in thyroid dysfunction sufferers, they should be treated as separate entities, and considered that these common conditions can occur and coexist without influencing each other [et al described similar findings in a study of psychopathology and subclinical hypothyroidism. It was stated that when interfering factors related to individual vulnerability to depression and perception of disease were excluded, there was no direct correlation between subclinical hypothyroidism and mood disorders [There is a multitude of evidence highlighting the importance of the HPT axis in depression ,49. Altech other . Baldiniisorders .et al suggests that the information available on hypothyroidism and depression does not demonstrate a causal relationship [Fountoulakis tionship . Statingtionship .The biopsychosocial model represents a health concept. It depicts a treatment paradigm that acknowledges the contribution of biological, psychological and social factors in the disease process . Alonso et al it was stated that approximately one fifth of hypothyroid patients are receiving an inadequate thyroxine dose and a fifth are given an excess of the synthetic thyroid hormone. Reasons for this are postulated in table Hypothyroidism is a disease that has been treated relatively successfully using pharmacological agents for many years. However, the treatment and management of this disease has been approached purely from a biomedical standpoint. Thyroid hormone levels that are considered inappropriate are restored using pharmacological supplementation. This management requires a life long commitment to drug therapy. In addition to this, significant proportions of patients under the current management protocol continue to experience the plethora of signs and symptoms associated with hypothyroidism, even though their thyroid hormone levels are returned to normal ,27. In aAnother important issue that has been raised within the current literature is the suitability of modern treatment strategies for the elderly. Elderly patients often present with an extensive list of different medications that they are taking in combination. In prescribing an additional long-term pharmacological agent to the patient presenting with reduced thyroid hormone levels, practitioners must consider the issue of drug interaction. This debate is especially relevant as this group of patients makes up a substantial proportion of the hypothyroid population .It is essential that thyroid hormone levels be monitored at prescribed intervals in those patients undergoing levothyroxine therapy . WeetmanResearch suggests that is it important to provide multidisciplinary care in chronic diseases (eg rheumatoid arthritis). It is further postulated that the implementation of programmes of this nature, may not only improve functioning, but may lead to improvement in disease activity . The WorIt seems that while current treatment protocols for hypothyroidism are quick and relatively cost efficient, there is a strong influence in form, from the biomedical model. The reductionist thinking associated with this model may be the cause of the inherent problems associated with the current treatment. As the biopsychosocial model gains credibility, it seems plausible that there may be a place for this paradigm in the management of hypothyroidism. If this disease were to be approached from a more wholistic standpoint, solutions to current management problems may be revealed. It is also feasible that if this disease were approached using a different model, factors in addition to pure biological influences may be discovered. Research into thyroid hormones and mood disorders further highlights the need for investigation in this area. A framework such as the biopsychosocial model seems to be a plausible model of inquiry.The biopsychosocial model represents the latest ideas in chronic illness management and compliments recent ideas in pain theory. It states that in order to rationalise and contend with chronic conditions, one must take into account the influence of biological, psychological and social factors. The biopsychosocial model is gaining acceptance within educational institutions and medical fields and is proving very successful in the areas in which it is applied . HypothyBTB wrote the manuscript. All authors took part in researching for, reading and approving the final manuscript.


In the context of finite health resources, encouraging self-management of chronic conditions is important. Indeed, it is a key priority in the UK. An increasing number of self-management programmes are becoming available. However, patients may not always choose to participate in them. Some will prefer a more directed or medically orientated treatment. The acceptability of self-management programmes for patients suffering from chronic pain is an important issue. Few measures exist that examine the process of change to a self-management approach. The Pain Stages of Change Questionnaire (PSOCQ) was evaluated for this purpose in the present study. Hypotheses were centred around criterion and construct validity of the PSOCQ.A sample of pain patients was surveyed about their interest in participating in a lay-led self-management programme ('the Expert Patients Programme'). In addition, participants completed two psychometric measures: the Pain Stages of Change Questionnaire (PSOCQ) together with the Chronic Pain Acceptance Questionnaire (CPAQ). This is the first study as far as we are aware to examine these two scales together. The psychometric properties of the PSOCQ were examined. Analyses focused on the associations between the PSOCQ scores and interest in participating in the self-management programme. Further associations were examined between the PSOCQ and the Chronic Pain Acceptance Questionnaire.The results demonstrated qualified support for the PSOCQ, in particular the Contemplation sub-scale. There was a significant positive association between interest and likelihood of joining the self-management programme and contemplation scores. The action and maintenance sub-scales appeared to be measuring a unitary dimension. The associations between the PSOCQ and the Chronic Pain Acceptance Questionnaire were in the directions predicted. The limitations of the study were discussed.The results showed some support for the PSOCQ as a potentially useful tool in assessing who may or may not be likely to join a self-management course. Self-management is increasingly emphasised as a key component in chronic disease treatment, including chronic pain management. Most psychological programmes designed to help patients alter behavioural and perceptual patterns surrounding pain also aim to foster self-reliance and reduce medical intervention. The effectiveness of cognitive behavioural programmes where self-management skills training is incorporated is well documented ,2. CBT pIt is inevitable that some patients will adapt well to this approach while others will be less able to do so. Patients may be included in a self-management programme before they are ready and able to cope with it and it may thus be unhelpful both for the patients and from a resource management perspective. It is difficult to know who may or may not respond and there are few measures in existence that examine patients' orientation towards a self-management approach. Typically psychometric measures tend to be outcome focused rather than process focused.precontemplation is a stage in which little action is being considered. The second stage contemplation is one in which there is an intention to change and the third and fourth stages (action and maintenance) are involved with achieving and maintaining change. The Pain Stages of Change Questionnaire is likewise based on similar stages of change  for use in pain self-management [One potential measure that has been developed is the Pain Stages of Change Questionnaire . This isnagement ,8,9. Thenagement . There inagement .What has been proposed as a possible precursor of change to a self-management approach is acceptance of some level of pain . SeveralIntuitively if adaptation to pain is seen to be largely a product of acceptance and change then there should be an association between scores on pain acceptance and scores on readiness to change. This is the first study as far as we are aware to examine the relationship between these two concepts based on the Pain Stages of Change Questionnaire and the Chronic Pain Acceptance Questionnaire.pre-contemplation sub-scale would be negatively associated with interest in a self-management programme; (ii) Scores on the contemplation sub-scale would be positively associated with interest in participating in a self-management programme; (iii) Patients scoring high on action and maintenance subscales would be oriented towards joining the self-help programme; (iv) Significant associations between acceptance and change would be found. Specifically, that scores on pain acceptance would be negatively associated with scores on the pre-contemplation sub-scale and positively correlated with scores on the contemplation, action and maintenance sub-scales.The following hypotheses were tested: (i) Scores on the All patients registered at a Pain clinic during a 4-week period (including new attendees and follow-up patients) were invited to participate in the study. The majority were suffering from chronic non-malignant pain, mostly involving the musculoskeletal system. Most interventions at the clinic were pharmacological in nature.Patients received a leaflet about a self-management programme with a covering letter, together with a number of questionnaires. The aim was to ascertain their views about self-management and the likelihood of their attending the course. The self-management course was not part of the pain clinic's psychological or educational based programmes. It was a generic course in its pilot stage developed for the benefit of people with chronic conditions called the Expert Patients Programme (EPP). This is a nationally based self-management training initiative based on the chronic disease self-management programme (CDSMP) developed originally at Stanford University USA . The proExpert Patients' Programme). In this leaflet the programme was described as "a course where you take control of your condition and make a difference to your life". It provides a list of what the course offers, e.g.: "manage your symptoms, deal with stress, depression and low self-image, manage pain, develop coping skills, relax, eat healthily, work more closely with those caring for you, plan for the future".This was the generic leaflet for the national pilot programme of the self-management programme, , "How likely are you to join this course?" , and "when might you consider joining this course" .pre-contemplation; representing a stage whereby the pain sufferer is not considering changing behaviour, contemplation; whereby changes in behaviour are being considered , action; whereby active steps are being taken to change behaviour, and maintenance: whereby attempts to maintain those changes are evident. The questionnaire was based on a 5-point likert type scale from 'strongly disagree' (1) to 'strongly agree' (5). The PSOCQ was examined for the ability to classify patients into a distinct stage. In accordance with Jensen et al [The Pain Stages of Change Coping Questionnaire (PSOCQ) was the measure chosen to examine patients' readiness to adopt a self-management approach to chronic pain. It was developed by Kerns et al  and is ben et al  patientsactivity engagement and pain willingness. Questions are based on a 7- point scale from 'never true' (0) to 'always true' (6). Acceptance of chronic pain has been shown to be negatively associated with avoidance of pain and positively associated with better mental well being, fewer visits for professional help, and fewer analgesics [The Chronic Pain Acceptance Questionnaire (CPAQ revised method) was used to measure patients' acceptance of pain . This isalgesics . It has algesics . Psychomalgesics .Of the 320 or more patients who were sent a leaflet about the self-management programme and questionnaire only 98 were returned (31%), of which 96 were complete. The majority of respondents were female (68%). The mean age was 53 (range 21 to 82). More than a third of the sample had chronic pain lasting more than 10 years, with 34% reporting between 2–5 years, 26% reporting 5–10 years with only 4% having had the pain for 1–2 years and 2% having had the pain for less than a year. A majority had been registered at the Centre for Pain Medicine for more than a year (65%). Approximately 17% had been registered for between 6 months and 1 year and around 18% had been registered for less than 6 months, (approximately 3% were newly registered patients). Participants were recipients of largely passive interventions for pain control.Of those who responded to questions on educational attainment, a large proportion (66%) had gained some educational certificates, 60% of whom had professional or vocational qualifications and around 10% had a degree or the equivalent of a degree. Approximately a third of respondents did not have any educational certificates.Table precontemplation' and 'contemplation' subscales. All items from the contemplation subscale, except item 9 ('I have been thinking that doctors can only help so much in managing my pain...') loaded onto factor 1 and accounted for 22% of the variance. Factor 3, the precontemplation subscale had loadings of 0.5 or greater for all of the items listed on this dimension, except item 3 ('everybody I speak with tells me I have to learn to live with my pain....'). This item loaded independently onto factor 7. The items representing the 'action' and 'maintenance' subscales each loaded onto factor 2 and accounted for 18% of the variance. Only 1 item from these two subscales had a loading of less than 0.35 ('I am learning to help myself control my pain without doctors'), which loaded onto factor 5.Principal components analysis, with varimax rotation produced a 7 factor solution using the eigenvalues >1 criteria. This explained 65% of the variance, although a 3-factor solution seemed more appropriate following examination of the scree plot and in view of the small number of items loading onto the other factors. Approximately 47% of the variance was explained by the 3-factor solution. The factor structure shown in Table Overall there was considerable support for the structure of the PSOSQ with the exception of the 2 separate subscales of 'action' and 'maintenance', which appeared, in this sample, to be measuring a unitary dimension.There was a significant positive association between expressed interest and likelihood of joining the self-management programme and contemplation scores as shown in Table Pain patients who expressed a likely intent to join an EPP class scored significantly higher on the contemplation scale (mean = 37.26) compared with those who expressed uncertainty or said they were unlikely to join (mean = 31.78), (CI = 2.51 to 8.45). No significant differences were found for the other sub-scales.contemplation stage (forty three per cent), thirty seven per cent were in the action/maintenance stage and twenty per cent were in the pre-contemplation stage. There was some support for the classification of patients in this way. Table Most patients were in the pre-contemplation and pain acceptance and a similar but weaker association between contemplation and pain acceptance. Action/maintenance was positively associated with pain acceptance. Pre-contemplation was negatively associated with pain willingness and, to a lesser degree but in the same direction, with activities engagement, contemplation was also significantly negatively associated with pain willingness (to a lesser degree) but not with activities engagement. Action/maintenance was positively associated with activities engagement but not with pain willingness.Table The results of this study provide some support for the PSOCQ in a UK sample. The contemplation scale may have particular value in predicting who may or may not be ready to participate in a self-management programme. This finding is consistent with previous studies ,22. Furtpre-contemplation subscale was also found. Unlike previous studies however this sub-scale failed to predict level of interest in the self-management class. There may be several reasons for this. A relatively low proportion of patients were classified as being in this stage. In addition, it could have reflected some ambivalence (for some patients) about how the course was going to help them. Lay-led self-management courses are a fairly novel trend in the UK and patients only had the leaflet for reference purposes.Psychometric support for the action and maintenance scales did not show any pattern of association with expressed interest and likely up-take of the self-management programme. This is consistent with previous findings [The unacceptably high correlations observed between action and maintenance scales were in line with previous findings ,10,24. Pfindings . Action In general the associations found between the PSOCQ and the CPAQ were in the hypothesised direction. As expected, scores on pre-contemplation were negatively associated both with pain willingness and with engagement in activity. This is consistent with the idea that people in the pre-contemplation stage are seeking a medical cure, are less active and are less willing to accept some level of pain ,9. The nOne of the problems raised about the PSOCQ is the scale's lack of a strong relationship with adaptive behaviours ,23-25. HValidation studies on the PSOCQ have often been based on samples demonstrating good to high levels of education ,9,22. ThThere are several limitations to this study. The results are constrained by the sample size. Other studies have been equally constrained ,22. The Despite the limitations the results of this study found some support for the PSOCQ as a useful tool in assessing who may or may not be likely to join a self-management course. The associations found in relation to the Chronic Pain Acceptance Questionnaire were consistent with the hypothesised nature of readiness to change and add overall strength to the validity of the PSOCQ.The author(s) declare that they have no competing interests.JLC and JAKM conceived the study and participated in its design. JLC carried out the statistical analyses and wrote the first draft and successive drafts of the manuscript JLC, together with DMS and JAKM interpreted the findings and produced successive drafts. DRH participated in the design of the study. All authors read and approved the manuscript.The pre-publication history for this paper can be accessed here:


Pain drawings are widely used as an assessment of patients' subjective pain in low back pain patients being considered for surgery. Less work has been done on primary health care patients. Moreover, the possible correlation between pain drawing modalities and other pain assessment methods, such as pain score and functional variables needs to be described. Thus, the objectives were to describe the course of pain drawings during treatment in primary health care for low back pain patients.160 primary health care outpatients with acute or sub-acute low back pain were studied during 10 weeks of a stay active concept versus manual therapy in addition to the stay active concept. The patients filled out 3 pain drawings each, at baseline and after 5 and 10 weeks of treatment. In addition the patients also reported pain and functional variables during the 3 measurement periods.The proportion of areas marked, the mean number of areas marked (pain drawing score), mean number of modalities used (area score), and the proportion of patients with pain radiation all decreased during the 10-week treatment period. Most of the improvement occurred during the first half of the period. The seven different pain modalities in the pain drawing were correlated to pain and functional variables. In case of no radiation some modalities were associated with more pain and disability than others, a finding that grew stronger over time. For patients with pain radiation, the modality differences were smaller and inconsistent.Pain modalities are significantly correlated with pain and functional variables. There is a shift from painful modalities to less painful ones over time. Low-back pain is a major diagnostic and therapeutic problem, which causes a great deal of suffering and is a major expense to society ,2. Ever Pain drawings have also been shown to be associated with both pain and functional variables or pain related disability -9. For eWe performed a randomized controlled trial in primary health care outpatients, where the alternative treatments were a stay active concept versus manual treatment in addition to the stay active concept. Some of the main results have been reported previously . The objThe sampling procedure and the methods used have been described in detail elsewhere ,12. Brie- Acute or sub-acute low back pain (i.e. back pain below the level of the seventh thoracic vertebra) with or without pain radiating to one or both legs, not requiring surgical or rheumatologic care. Patients with demonstrated or suspected herniated disc were included if surgery was not being considered. Low back pain was to dominate the clinical condition but other musculoskeletal symptoms, not requiring sick leave, were allowed.- Symptom duration of 3 months or less, preceded by at least 2 months of relative freedom from symptoms.- Consent to treatment and follow up for ten weeks.- Agreement not to consult therapists other than those participating in the study during the ten weeks.- Absence of other conditions or circumstances that might jeopardize completion of treatment and follow up .- No previous treatment of current complaints with specific mobilization or manipulation.- No previous participation in the study.All patients preliminarily fulfilling the inclusion criteria were referred by general practitioners (GPs) at primary health care centres or by physicians at Visby hospital to the recruiting physician in the study. In addition, in order to secure an unselected study population the National Social Insurance Office, a government agent that handles all sick leave compensation for periods two weeks or longer, was engaged to refer all patients that were filing sick leave applications for low back pain. The recruiting physician examined all patients and made the final assessment of whether or not they fulfilled the inclusion criteria.Of the 316 patients referred, 111 did not fulfil the inclusion criteria, and 45 declined to participate. The remaining 160 patients were included after informed consent was obtained, and were allocated to the treatment groups, using sealed pre-prepared envelopes with group assignment derived from a random table.The treatments given have been described in detail elsewhere . BrieflyTwo orthopaedic surgeons at Visby Hospital and eight physiotherapists treated the reference patients. In accordance with the study design, muscle stretching was a treatment option in 51% of the reference group, and 41% actually received muscle stretching. Two GPs based at primary health care centres in Visby and nine physiotherapists treated the experimental patients. They received the full reference treatment, plus specific mobilization, spinal manipulation, and auto-traction when indicated. According to the study design steroid injections were a treatment option in 52% of the experimental group, but less than half of these patients received injections.Data on patient characteristics were recorded at baseline and data on pain, pain drawings, disability index and other variables measuring the course of the disease were measured using a questionnaire answered on location at baseline, and with postal questionnaires after 5 and 10 weeks of treatment.The pain drawing sketch contained 34 anatomical areas, 8 dorsal and 8 frontal areas below the waistline and the same numbers above the waistline, Figure The average pain experience during the previous week was used as the pain score. The disability rating index  is the mData were analyzed with the JMP  and SAS The patients were on average 41 years old (range 20–55), 44% were females, and 44% were cigarette smokers. 69% were on sick leave at baseline. In addition, 74% had been on sick leave due to low back pain in the last two years, approximately 80% of these for one month or less.At baseline, the proportion of patients with marked areas ranged from 85.6% in the left lower back/buttock area to 3.1% in the right dorsal foot area, Table The mean number of pain modalities, the area score, is shown in Table There was a shift of dominating pain modality prevalence in the lower back/buttock areas during the follow up, Figure There was an association between, on the one hand, mean number of areas marked, i.e. the pain drawing score, and pain score during the previous week , and the disability rating index  on the other, across the study period. Pain radiation was present in 149 (34.2%) of the 436 pain drawings with no marks above the waistline. Among the latter, 'stabbing pain' was the most frequently used dominating pain modality (45.6%) followed by 'dull aching' (30.2%), 'stiffness' (12.1%), 'burning' (6.0%), 'numbness' (2.7%), 'pins and needles' (2.0%) and finally 'cramps' (1.4%).Among the pain drawings with no pain radiation, there were no significant differences in pain score or disability rating index between the various pain modalities at baseline (p = 0.25 for the whole model). However, during the course of the study strong associations developed between pain modalities and pain score or disability rating (p < 0.0001 for the whole model at 5 and at 10 weeks). In Figure The pain drawings were improved over time, an improvement that mainly occurred during the first half of the period. Also, in the pain drawings with no pain radiation some pain modalities were associated with more pain and disability than others, a finding that grew stronger over time. For the pain drawings with pain radiation, the differences were smaller and less consistent than for those with no radiation.The study population was population based and the methods used are all well established and evaluated. All patient with low back pain seeking medical attention or receiving sick leave compensation in the area were assessed regarding inclusion in the study. The study population is therefore most certainly representative for this type of low back patients. There were no drop outs and the data loss owing to missing values or non-completed questionnaires or pain drawing sketches was minimal. We therefore have no reason to believe that the data would be biased to an extent affecting the conclusions.To assess the pain drawing we used the pain drawing score, a frequently used method first described in 1986 by Margolis , and latSeveral studies on the validity and reproducibility of pain drawings have been published. It has been asserted that the instrument is sufficiently well-evaluated with regard to validity ,20, thatAmong pain drawing sketch variants available we chose Margolis', containing 43 areas all within the body contour. However, we moderated the anatomical areas size and number to a total of 34 areas for the present study population since the lower body has a higher impact and the area regions are more relevant for the purposes of our study. This system allows the pain to be scored using clinically reported pain patterns  and the The pain drawings were completed in the same way at all three measurement points. Two pain drawing patterns were prominent: the left side dominated the drawings, and there was a more substantial rate of improvement during the first period than the second. The left side domination has not previously been reported, and therefore remains to be replicated in other studies. The improvement manifested itself as fewer marked areas, fewer marks in the areas, fewer used modalities and more proximal marking, i.e., fewer marks in the leg areas. The early improvement is probably attributable to the fact that the majority of treatments were given in the first half of the 10-week treatment period . The effThe 'pain modality shift' as described by McKenzie , was seeIn the present report there was a strong correlation (p < 0.0001) between self-rated pain, functional score and pain drawing score. These results are in line with the literature both for the disability rating -9 and thAmong patients who had no pain radiation there was a clear change towards fewer pain modalities and an emerging difference between modalities in pain score and disability index during the course of the study. This was not found among those who had pain radiation, a finding not described elsewhere to our knowledge. A possible explanation might be that since various pain modalities communicate with the brain through different type of fibres, patients who use a number of modalities to describe their pain might have difficulties in grading the sensations, and the addition of pain radiation makes the distinction between pain modalities too complex . Thus, iThe results from this study emphasize that the pain drawings should be part of the clinical practice when assessing sub-acute low back pain, as recommended in the biopsychosocial pain analyze for chronic pain . Pain drThe patients tended to use fewer pain modalities in their pain drawings over time and there was a shift from painful modalities to less painful ones. Most of the changes occurred during the first half of the study course. In the pain drawings of patients with no pain radiation the description of low back pain quality and extent was associated with both pain score and disability rating index. In patients with radiation the differences in pain score and disability index between modalities were smaller and inconsistent.The author(s) declare that they have no competing interests.SB designed the study and coordinated the data collection. SB, MG, JB and HD prepared the data before analysis. the statistical analysis and drafted the manuscript. participated in the data preparation. MG and KS performed the statistical analyses and drafted the manuscript. All authors participated in the manuscript revisions and read and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:


Despite much research, an immediately available, instantly effective and harmless pain relief technique has not been discovered. This study describes a new manipulation: a "2-minute sciatic nerve press", for rapid short-term relief of pain brought on by various dental and renal diseases.This randomized, single-blind, placebo-controlled trial ran in three hospitals in Anhui Province, China, with an enrollment of 66 out of 111 solicited patients aged 16 to 74 years. Patients were recruited sequentially, by specific participating physicians at their clinic visits to three independent hospitals. The diseases in enrolled dental patients included dental caries, periodontal diseases and dental trauma. Renal diseases in recruits included kidney infections, stones and some other conditions. Patients were randomly assigned to receive the "2-minute sciatic nerve press" or the "placebo press". For the "2-minute sciatic nerve press", pressure was applied simultaneously to the sciatic nerves at the back of the thighs, using the fists while patients lay prone. For the "placebo press", pressure was applied simultaneously to a parallel spot on the front of the thighs, using the fists while patients lay supine. Each fist applied a pressure of 11 to 20 kg for 2 minutes, after which, patients arose to rate pain.The "2-minute sciatic nerve press" produced greater pain relief than the "placebo press". Within the first 10 minutes after sciatic pressure, immediate pain relief ratings averaged 66.4% (p < 0.001) for the dental patients, versus pain relief of 20% for the placebo press, and, 52.2% (p < 0.01) for the renal patients, versus relief of 14% for the placebo press, in median. The method worked excellently for dental caries and periodontal diseases, but poorly for dental trauma. Forty percent of renal patients with renal colic did not report any pain relief after the treatment.Two minutes of pressure on both sciatic nerves can produce immediate significant conduction analgesia, providing a convenient, safe and powerful way to overcome clinical pain brought on by dental diseases and renal diseases for short term purposes.ACTR 12606000439549 At any given time, people may experience the pain of disease. In most cases, pain cannot be rapidly relieved. Overcoming pain in a fast and convenient way, therefore, is a worthwhile goal that has yet to be achieved despite considerable research into the subject. Presently, the analgesics available to patients are not satisfactory. For patients with acute initial pain, the time necessary to acquire appropriate pharmaceuticals, as well as, for drugs to reach effective levels, can mean hours or days of sustained pain before relief. Furthermore, many commonly used drugs, both over-the-counter and prescription, have well known serious side effects. For example, commonly prescribed NSAIDs can cause ulcers, gastrointestinal bleeding and renal impairment. Opioids can cause, among other things, constipation, nausea, vomiting, sedation, dependency, and addiction -4.Many non-drug analgesics have been used to help manage pain: acupuncture, cryoanalgesia, transcutaneous electrical nerve stimulation (TENS), interferential stimulation (IFS), exercise, massage, music therapy, etc -7. CurreWhile applying traditional Chinese medicine by finger pressure stimulation of 'Chengfu' points located on the upper-back of the legs, we were surprised to find rapid relief of pain by the pressure stimulation. Because the 'Chengfu' point is anatomically associated with the sciatic nerve, further pilot studies were undertaken applying pressure along the sciatic nerves, but separate from the 'Chengfu' point, and, these produced the same results. Then, to evaluate the exciting finding, we designed the study reported here.The clinical tests on renal patients were conducted between October 17, 2005 and January 24, 2006 in Anhui Province Hospital, Anhui Medical University, China. The clinical tests on dental patients were conducted between October 28, 2005 and January 24, 2006 in Tongling Hospital, Tongling, China, and between November 23, 2005 and April 12, 2006 in Chuzou Zhongxiyi Hospital, Chuzou, China. The study was separately approved by the ethic committees of each participating hospital – Anhui Province Hospital, Hefei, 230001, China ; Chuzou Zhongxiyi Hospital, Chuzou, 239000, China  and Tongling People Hospital, Tongling, 244000, China .This was a randomized, single-blind and placebo-controlled clinical trial on 66 participants out of 111 solicited patients. All the instructions and explanations were extended to patients of the "sciatic press" and "placebo press" groups equally. All the patients were told that the experiments were designed to test whether the method works for pain relief or not. All were advised that they could discontinue the experiment at any time without penalty, and their healthcare treatment would not be affected. After informed consent was obtained, the doctor or his assistant taught the patients how to evaluate pain using a visual analogue scale (VAS), with pain scaled from "0" for no pain to "10" for most pain. Thereafter, randomization of patients to the "sciatic press" group or the "placebo press" group was performed using Random Permuted Blocks. The three steps of the test were described to each patient, including: the baseline pain rating step, the leg pressure step for 2 minutes while lying down and, the post-pressure pain rating step for 10 min. In this context, the '0 minute' point indicated that the pain was estimated within one minute of discontinuing the leg pressure.The location of the classic 'Chengfu' point, the sciatic nerve pressure area, and the fist gesture for pressure application used are shown in Figure Two minutes of pressure with the dorsal, proximal phalangeal surface of the fists was applied simultaneously to the sciatic, or the placebo location on both legs. Pain was then rated by patients, and, the value was recorded on a visual analogue scale table.All patients in pain from their respective pathologies during a clinic visit to Dental and Renal Clinics were eligible for the trial. Any patients who were younger than 15 years old, emotionally unstable, or receiving any analgesic within 12 hours of the test were ineligible for the study. All patients in the study had not been previously exposed to the method. Written informed consent was obtained from each participating patient.Table The diseases in enrolled dental patients included dental caries, periodontal diseases and dental trauma. Renal diseases in recruits included kidney infections, stones and some other conditions.t-tests, both for the "sciatic press" groups, and, the "placebo press" groups. Comparisons to the "placebo press" groups were performed using an analysis of covariance procedure, with adjustment for baseline VAS score, sex and age. All tests were two-sided, and, a p-value of < 0.05 was considered as statistically significant. All statistical analyses were performed with the use of SPSS statistical software (release 13.0).The baseline VAS scores and age of the participants were compared between the "sciatic press" groups and the "placebo press" groups by using t-tests. Categorical data were analyzed by using chi-square tests, or Fisher Exact tests. Changes, from the baseline for pain relief, were assessed by using paired Figure Next, we report that the sciatic press also produced rapid pain relief in patients with varying renal diseases. Figure The study was designed as a single blind rather than a double blind experiment; because, the method is highly effective in pain relief, and, doctors could easily identify the placebo or the actively treated during the test. The "Chengfu" point, located on the back of thigh just below the juncture of the hip Figure , is recoThis method worked excellently on clinical pain from dental diseases, and part of renal diseases. The rapid pain relief in other diseases by the sciatic nerve press has been demonstrated in our further studies (manuscript soon to be submitted). No side effects were revealed in our study. Of those who declined to participate in the study, one of the most common reasons offered was skepticism of the method's simplicity. Some doctors participating in this study were also skeptical of the efficacy before the test.Nearly 40% of renal patients did not report any pain relief after the "sciatic press"; these were all patients with the intense pain of kidney colic before the treatment. Similarly, the tests in dental patients showed excellent relief of pain for dental caries and periodontal diseases, but poor relief for dental trauma. However, limited by the small number of patients in this study, we can not assert whether the method works less effectively in intense pain states, or, if the loss of effect is related to the diseases' origin, or, to some other factor. To clarify this question, further systematic studies with a larger number of patients are needed.Three critical factors determined the success of this method: the precise location, the total time, and, the suitable force for the applied pressure. Fists produced better results than finger tips in this method; because, is difficult to apply sufficient pressure for two minutes with finger tips, and, finger tips miss the precise sciatic nerve too easily. Pressure application was two minutes for all patients in this study. In our pilot study, for those patients who obtained pain relief with the method, 25% patients obtained relief within 30 to 60 second of the press, 54.7% patients between 60 to 90 seconds' after the press, and, the rest needed pressure for a longer time. Time shorter than 90 seconds of pressure for the press decreased the rate of success, and, the duration of pain relief declined proportionally. The third qualitative factor of importance is the amount of pressure applied. Insufficient force led to a failure of relief. The force used for the press was 11 to 20 kg from each fist.This manipulation gave very distinct pain relief results in pilot studies and the clinical studies reported here. Based on the pilot studies, we did a prospective power analysis for dental diseases which gave a minimum sample size of 2 × 12 for the 10 min test. We didn't use the sample size as a strict limit for these two studies; because, pain relief with this method differed greatly between different diseases. The minimum sample size increased when the test period was lengthened. The result confirmed that the minimum sample size could be smaller for this method with some diseases for the 10 minutes observation period.Stimulation of peripheral nerves elevated the pain threshold -22. The The pinch press of rat sciatic nerve with a vascular clip (pinch force 120 g) caused attenuation of the WDR neurons' responses to various innocuous and noxious stimuli . HoweverThe Gate Control Theory of Pain can explain the rapid relief of pain by this method. However, the pain relief by this method is not limited to the segmental level only. Also, pain relief lasted only briefly for a small number of patients, while, more patients obtained longer relief periods, more than 30 minutes for a single two minute press (data not shown in this preliminary report). These observations suggest possible activation of multiple inhibitory systems. Another mechanism possibly involved is activation of the endogenous opioid system. In studying the effect of low frequency stimulation of rat sciatic nerve on long-lasting cardiovascular depression and pain threshold, Yao found that the pain threshold was increased by 50%. The analgesic effect he observed was antagonized by Naloxone suggesting the activation of the opioid system in the stimulation of the sciatic nerve .The press stimulation, by itself, might cause pain, and such pain could activate a special form of descending pain inhibition called diffuse noxious inhibitory control (DNIC) -36, so cThis study reports a simple, immediately available and rapidly effective manipulation, hand stimulation of the sciatic nerve, to relieve pain of dental diseases and renal diseases. Anybody can apply it any time, any place, without a hospital setting.Two minutes of pressure on both sciatic nerves can produce rapid significant conduction analgesia, providing a convenient, safe and powerful way to overcome clinical pain brought on by dental diseases and renal diseases for short term purposes.The author(s) declare that they have no competing interests.JH had full access to all of the data in the study and takes responsibility for the integrity of the data and the decision to submit for publication. BW collaborated in the study design, participated in renal clinical tests and data analysis; WZ collaborated in clinical tests on dental patients and the data interpretation; GT collaborated in the study design, technical direction in the study and administrative support in dental clinical tests. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The choice of an evaluative instrument has been hampered by the lack of head-to-head comparisons of responsiveness and the minimal clinically important difference (MCID) in subpopulations of low back pain (LBP). The objective of this study was to concurrently compare responsiveness and MCID for commonly used pain scales and functional instruments in four subpopulations of LBP patients.The Danish versions of the Oswestry Disability Index (ODI), the 23-item Roland Morris Disability Questionnaire (RMQ), the physical function and bodily pain subscales of the SF36, the Low Back Pain Rating Scale (LBPRS) and a numerical rating scale for pain (0–10) were completed by 191 patients from the primary and secondary sectors of the Danish health care system. Clinical change was estimated using a 7-point transition question and a numeric rating scale for importance. Responsiveness was operationalised using standardardised response mean (SRM), area under the receiver operating characteristic curve (ROC), and cut-point analysis. Subpopulation analyses were carried out on primary and secondary sector patients with LBP only or leg pain +/- LBP.RMQ was the most responsive instrument in primary and secondary sector patients with LBP only  whereas ODI and RMQ showed almost similar responsiveness in primary and secondary sector patients with leg pain . In improved patients, the RMQ was more responsive in primary and secondary sector patients and LBP only patients (SRM = 1.3–1.7) while the RMQ and ODI were equally responsive in leg pain patients (SRM = 1.3 and 1.2 respectively). All pain measures demonstrated almost equal responsiveness. The MCID increased with increasing baseline score in primary sector and LBP only patients but was only marginally affected by patient entry point and pain location. The MCID of the percentage change score remained constant for the ODI (51%) and RMQ (38%) specifically and differed in the subpopulations.RMQ is suitable for measuring change in LBP only patients and both ODI and RMQ are suitable for leg pain patients irrespectively of patient entry point. The MCID is baseline score dependent but only in certain subpopulations. Relative change measured using the ODI and RMQ was not affected by baseline score when patients quantified an important improvement. As clinicians and researchers we often wish to address change in a patient's condition as a result of an intervention or to distinguish individual differences in response to treatment . A prereSeveral approaches to classifying clinically meaningful change (responsiveness) have been proposed based on study design and the construct of change being quantified -16. One Apart from the type of responsiveness index, other factors affect the size of the responsiveness index such as type of intervention, patient population under study, and timing of data collection ,21,22. TThe purpose of this study was therefore twofold: 1) to determine and compare the responsiveness of four frequently used functional status questionnaires and three pain scales when applied to four different subpopulations of low back pain patients, and 2) to determine MCID using optimal cut-points for each instrument and its dependency on baseline entry score, pain location and patient entry point.The study was not reported to the local ethics committee as this is not required according to the rules and regulations of the Danish scientific ethical committee. However, the study was reported to and accepted by The Danish Data Protection Agency.e.g., fractures, spinal infections, malignancy or inflammatory diseases). All patients received oral and written information about the project and gave their informed consent to participate in the study.This study is a secondary analysis of data from a large validation study of the Oswestry Disability Index in Danish ,57. PatiA prospective cohort study design with follow-up at one week, eight weeks and nine weeks. At baseline, one week and eight weeks follow-up, a questionnaire booklet containing sociodemographic data, medical status and outcome measures was administered to all patients. Responders at the eight weeks follow-up received a telephone interview 3–5 days after (week nine) by a specially trained professional interviewer from the Danish National Institute of Social Research. The purpose of the telephone interview was to obtain patient ratings of improvement/deterioration and the importance of such change. A detailed description of the study design can be found elsewhere .The Oswestry Disability Index (ODI) version 2.1 is a self-administered questionnaire measuring "back-specific function" with reference to "today" on a 10 item scale with six response categories each. Each item scores from 0 to 5 and the score is subsequently transformed into 0–100 [to 0–100 ,60,60.The 23-item version of the Roland Morris Disability Questionnaire (RMQ) was developed specifically to target LBP patients with radicular symptoms and is a modification of the original RMQ [inal RMQ . We chosinal RMQ  for two inal RMQ . Each itThe Low Back Pain Rating Scale (LBPRS) was developed to measure the dimensions of pain, disability and physical impairment for patients with LBP [pain) is measured on 0 to 10 numerical scales with 0 representing no pain and 10 representing worst possible pain. There were three 11-box numeric rating scales  for back pain and leg pain separately. Each response scale score is added giving a scale range of 0–60 points. The disability index (LBPRSdisability) comprises 15 items scaled as yes = 0 points, can be a problem = 1 points, no = 2 points, giving a total score of 0–30 points.with LBP . The paiThe SF36 is a generic 36-item questionnaire compiled from the Rand Health Insurance Long Form Health Status Scale [us Scale . Of the us Scale .Back and/or leg pain was scored on an 11-box numeric rating scale (pain now) from 0 (no pain) to 10 (worst possible pain) [le pain) ,68.The patients' global retrospective assessment of treatment effect (transition question) was used to assess the patients' perception of their overall change in their back condition. A 7-point Likert scale transition question (TQ) ranging from "much better" to "much worse" was used [imp) with "very important" and "not at all important" at the extremes.was used . Furtherpain) before answering the TQ to ensure optimal patient focus on the change in health rather than the present health state [This information was collected by telephone interviews which followed a carefully planned protocol. First, all patients were told their baseline global rating of pain severity  was restricted to patients who had changed and calculated as the ratio of the mean raw change score and the standard deviation of that raw change score [raw were estimated using 200,000 bootstrap samples with replacement [raw of the different questionnaires within each subpopulation, we first estimated the SRMraw using stata's regression command with group indicators and the cluster option to account for intra individual correlation between responses. The differences between SMRraw were examined with a non-linear Wald test [Responsiveness was operationalised using two strategies; standardised response mean of the raw change scores (distribution-based method) and receiver operating characteristic (ROC) curves (anchor-based method). The standardised response mean of the raw change scores . The SRMraw for the "important improvement" group addresses the sensitivity to change. On the other hand, the SRMraw for the "no change" patients addresses the important issue of specificity to change where change without clinical relevance may occur in instrument scores.SRMimp equal to or more than 7. The "no change" patients rated themselves as either "a little better", "about the same" or "a little worse" or with a rating of the importance of the change less than 7. Because of the low number of patients (n = 13) reporting deterioration, a "worse" sample was not included. The ROC curve is the sensitivity plotted against 1-specificity  and shows the trade-off between the true-positive successes and the false-positive errors as each of several cut-off points in the change score is assessed [auc) can be interpreted as the ability of an instrument to discriminate between "important improvement" and "no change" patients. An area of 0.5 is interpreted as no discriminatory accuracy and 1.0 as complete accuracy [In the second strategy we used ROC curve analyses to determine sensitivity and specificity for classifying patients as having experienced an "important improvement" or "no change" and defined "important improvement" patients from two criteria: 1) had to rate themselves as either "much better" or "better" on the TQ, and 2) had to rate the importance of the change on NRSassessed ,86. The accuracy . An omniaccuracy .%) change scores. The optimal cut-off change score was identified as the cut-point with equally balanced sensitivity and specificity [The MCID was determined by an optimal cut-point analysis using both the raw (MCID) and percentage .Second, ODI and RMQ quarter-specific MCID® v. 9.2 SE (StataCorp) and statistical significance was accepted at the P < 0.05 level.All statistical calculations were analysed using the statistical package STATATwo-hundred-and-thirty-three patients with low back pain and/or leg pain were entered at baseline. At 8-weeks follow-up the response rate was 82% leaving 191 patients for analyses . Age and sex distributions were similar in the two patient populations and patients from the PrS had mostly low back pain only, shorter duration of the current LBP episode and used less medication compared to SeS patients. Three out of 4 disability questionnaires demonstrated significantly higher disability in the SeS patients whereas 2 out of 3 pain measures showed no difference in pain intensity levels between the two groups (Table raw for the two study samples stratified according to pain location are shown in Table The mean raw change scores and SRMP < 0.001). For patients with leg pain the ODI and RMQ was equally responsive in PrS patients (P = 0.2) as was the case between the disability measures in the SeS patients. Of the 3 pain measures, the SF36 (bp) had the highest responsiveness in all subpopulations. This was statistically significant in the LBP only subgroup for both PrS and SeS patients (P < 0.002).The RMQ proved to be the most responsive disability measure for patients with LBP only (both PrS and SeS samples) and this was statistically significantly different from the other disability measures in the PrS patients (P < 0.001) and in patients with LBP only compared to leg pain patients . The "important improvement" and "no change" groups had similar baseline scores except for a significantly higher mean baseline score in the improved group for: 1) RMQ in SeS patients (P = 0.04), 2) LBPRSpain (P = 0.04) and NRSpain (P = 0.01) in patients with leg pain.The proportion of patients reporting an "important improvement" was statistically higher in PrS compared to SeS patients .The mean raw change scores between the "important improvement" and "no change" groups showed a significant difference for all instruments except for SF36 (pf) in leg pain patients and LBPRSraw for patients reporting an "important improvement" and patients reporting "no change" are shown in Table raw (0.7 – 2.1) were found in the "important improvement" group regardless of entry point (PrS or SeS) and pain location. As expected this was somewhat smaller in the "no change" group (0.2 – 0.9). The RMQ showed the largest difference in SRMraw between the "important improvement" and "no change" groups in all subpopulations when compared to the other disability measures. For the pain measures, the SF36 (bp) demonstrated the largest difference in all subpopulations except the leg pain +/- LBP patients where it was equal to the NRSpain.The SRMauc with 95% CIs for all included instruments. The RMQ showed superior discriminative abilities in LBP only patients (both PrS and SeS) whereas the ODI was marginally superior in the leg pain patients, again these differences were not statistically significant. For the pain measures, the LBPRSpain was the superior instrument in the LBP only patients and this was statistically significant in the SeS patients (P = 0.04). Similar discriminative abilities were observed in the other subpopulations.Figure The overall and baseline-specific MCIDs for PrS, SeS, LBP and leg pain patients are presented in Table disability), 18 points (SF36 (pf)), 6 points (LBPRSpain), 13 points (SF36 (bp)), and 1 point for the NRSpain.For each 25% increase in baseline entry score , the MCID for all patients increased by: 12 points (ODI), 2 points (RMQ), 5 points  and this was irrespective of where in the health care system they were seen. However, the ODI seemed marginally superior to the RMQ in patients with leg pain +/- LBP corresponding to the more chronic conditions (66% had pain > 30 days) in both PrS and SeS patients. The LBPRSFor the pain measures, we found comparably higher SRMs for the SF36 (bp) in all subpopulations (range: 0.6 – 1.4) which is somewhat higher than previously published values (0.7–1.0) [pain is the most responsive pain scale [0.7–1.0) ,37,92. Tin scale ,67. Howepain showed differing sensitivity to change according to which responsiveness index was used. Using SRMs the LBPRSpain was equally responsive to the NRSpain; however, using ROCauc it was the most responsive pain instrument in LBP only patients. Thus, we conclude that the LBPRSpain scale is responsive and probably preferable to the NRSpain as it provides more information about the pain dimension.The LBPRSpain as it is easy to use and provides more information about the patients' pain.In summary, we found that all pain measures demonstrate similar responsiveness and this was in turn comparable to the disability measures. We recommend using the LBPRSrepeat, and our inclusion of SRMs may therefore seem obsolete. We have chosen to include both analyses as most researchers and clinicians are familiar with interpretation and application of effect sizes in comparison to ROC curves. Furthermore, the overall conclusions about responsiveness would not change  using the ROC curve analysis alone.The optimal design and analytic strategies for a responsiveness study are topics of much debate with little or no consensus ,95-98. HThe concept of the MCID defines the smallest meaningful change score for outcome measures. An assumption behind this concept is that the instruments can indeed detect this change. Ultimately, one may question the ability of well established outcome measures to determine the smallest meaningful change as the "true" MCID is unknown. Further, the variability of the MCID is large as it is context-specific and not a fixed attribute .pain [Published MCID values for the included instruments range from: 4 – 16 points (ODI) ,92,100, pain ,102,103.pain .% was more or less independent of the baseline entry score for all subpopulations  and pain location (LBP vs. leg pain +/- LBP) with the two subscales of the SF36 as an exception. Furthermore, increasing baseline entry scores resulted in greatly increased MCIDs in PrS patients and patients with LBP only. However, the dependence on baseline entry score was not monotonous for all measures in the SeS and for patients with leg pain.disability which partly measures pain related function (33% of the items) and function of daily living may be problematic. Second, we reported overall responsiveness and MCIDs for a broad spectrum of care-seeking LBP patients' receiving treatments ranging from simple advice to intensive multidisciplinary rehabilitation. Consequently, responsiveness and MCIDs for specific subgroups of LBP patients are likely to vary depending on such factors as entry point into the health care system, pain location, treatment received and possibly psychosocial factors, as indicated by our subgroup analyses. Statistical power issues prevented us from further sub-dividing the sample, and estimates presented are to be regarded as an overall guideline. Therefore, we recommend that researchers calculate MCIDs relevant for their individual study populations and use this when reporting the proportion of improved patients and numbers needed to treat in a clinical trial [and importance is central to the concept of the MCID. Further, the cut-point used to describe who has improved or stayed the same was arbitrarily set for both dimensions. However, our results showed correlation coefficients greater than 0.63  declare that they have no competing interests.HHL and JH conceived the study and participated in its design and the planning of analyses. HHL drafted the manuscript, and HHL and JH revised the manuscript several times. HHL and LK made the statistical analyses. NGN and CM participated in the design of the study. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Patients increasingly use the Internet to solicit "tele-advice" via email from physicians. In two different studies we evaluated the quality of the advice given and determined the attitude of physicians and the ethical codes towards giving such tele-advice.In both studies, we posed as a patient describing a medical problem (herpes zoster under immunosuppresion) in lay terms and asked physicians for their advice via email. In the first study, we contacted 17 professional cyberdocs who explicitly offered to give tele-advice. In the second study, we sent an "unsolicited" patient email to 58 physicians who did not offer tele-advice to evaluate their reaction. The second study was also complemented by a questionnaire asking them for their attitude towards answering medical questions via email. Finally, we conducted a review of the ethical, legal and professional codes in the US, Germany, Switzerland to investigate differences in the ethical assessment of giving advice via telecommunication in the absence of a pre-existing patient-physician relationship.From the 17 professional "cyberdocs", only 7 replied giving detailed advice, 2 of the responses were medically wrong. In the second study with the "unsolicited email", 29 (50%) responded to the fictitious patient request; 9 respondents (31%) refused to give advice without having seen the lesion, 27 (93%) recommended that the patient see a physician, and 17 (59%) explicitly mentioned the correct "diagnosis" in their reply. In response to the questionnaire, 8 (28%) of the 29 respondents said that they tended not to answer any patient e-mail, 7 (24%) said they usually reply with a standard e-mail message, and 7 (24%) said they answer each request individually. Slight differences in the professional codes between the US, Germany and Switzerland exist: While the US AMA ethical guidelines only warn to make a diagnosis and considers drug prescriptions unethical, the German code disallows any advice via mail or email in the absence of a physician-patient relationship.These pioneering studies give important hints on the possible economics, problems and ethics of patient-physician communication via email. Responses of physicians and Web masters to e-mail requests for medical advice vary as do approaches to handling unsolicited e-mail. International standards for physician response to unsolicited patient e-mail are needed.