Battered child and unwanted pregnancy To the editor: In the exchange (Can Med Assoc J 112: 279, 1975) between Tompkins and the authors of the paper "The unwanted pregnancy" (Can Med Assoc J 111: 1093, 1974) Scott and Stone state "there certainly are, then, sufficient numbers of unwanted pregnancies resulting in unwanted infants to presume that they may make up the majority of the beaten and neglected children". In a study of over 600 abused children, Dr. E.F. Lenoski, assistant professor of pediatrics and emergency medicine, University of Southern California School of Medicine, Los Angeles, reported that 90% of the children's parents stated that they had wanted the pregnancy. B.E. BROSSEAU, MD
Bonnyville, Alta.
Results of acupuncture To the editor: The report on the 1975 annual meeting of the Royal College (Can Med Assoc J 112: 356, 1975) is misleading in the account given of the results of the, acupuncture studies performed at The Arthritis Centre in Vancouver. The report quotes me as stating that "analysis of subjective pain and tenderness did not reveal significant difference between the experimental and control group". This statement is true for only a part of one of the three experiments that were performed. The report of three controlled trials on the influence of acupuncture on the pain of rheumatic disease will be published in full in due course but the results reported at the meeting indicated a significant effect of acupuncture in each of three experiments (rheumatoid arthritis affecting the Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double spaced and should not exceed 1½ pages in length.
hands, painful shoulder syndrome without arthritis and rheumatoid arthritis affecting the knees). Acupuncture does do something and the observations we have made are compatible with the relief of pain. L.H. TRUELOVE, BM, FRCP[C]
The Arthritis Centre 895 West 10th Ave. Vancouver, BC
Painful shoulder syndrome
uncover the temporal relation between PSS and depression retrospectively, but this approach is open to many errors, particularly if the patients were depressed at the time of interview. Dr. Tyber's findings are collected in Table I. He interprets these figures as indicating that "depression preceded or was simultaneous with the development of PSS in 50% (13/26) of patients", and this interpretation led him to speculate that depression might be etiologically implicated in PSS. By the same process one could say that PSS preceded or was simultaneous with the development of depression in 62% (16/26) of patients, leading to the speculation that PSS might be causally related to depression. However, considering the inaccuracy of the approach (as well as of the figures themselves) it is difficult to draw any conclusion. If one does consider the possibility of PSS causing depression, a simpler explanation for the association, as well as of the nocturnal exacerbation of pain, can be suggested. The pain of this syndrome is known to be positionally related (this aspect was used in the clinical grading), so the worsening of pain at night may well be related to the position in which the patient sleeps. This has in fact been commented on by patients; they may, for example, wake up with an intense pain after having rolled over from a painfree position onto their shoulder. The reason why the exacerbation of pain at Table I-Relation between depression and the painful shoulder syndrome in the test group
To the editor: The article "Treatment of the painful shoulder syndrome with amitriptyline and lithium carbonate" by M.A. Tyber (Can Med Assoc J 111: 137, 1974) highlights a number of problems that can arise if patients who have been instrumental in their own selection (to a hospital, clinic or private practice) are used for the study of disease interrelations. It also illustrates some of the difficulties encountered when therapeutic measures are evaluated. In commenting on Dr. Sullivan.s subsequent suggestion of an association between the painful shoulder syndrome (PSS) and diabetes,1 Dr. Chaiton2 discussed "Berkson's fallacy": when hospital, clinic or private patients are used for studying disease interrelations spurious associations can arise through the interplay of various selection factors at work on the different diseases. This phenomenon must also be considered in relation to Dr. Tyber's study. For example, patients with both P55 and depression may be more likely to reach Dr. Tyber than those with P55 alone. If the selection of other types of patients (i.e. those used as controls) is in any way different, then PSS and Tb. of patients depression may appear more strongly related than they in fact are. Patients with depression and PSS Depression preceded PSS 4 An association between two diseases Depression and PSS simultaneous 9 found by prevalence data does not reDepression followed PSS 7 veal whether disease A caused disease Indeterminate 6 B, B caused A, or whether they were Total 26 8 both caused by another factor. In Dr. Patients with PSS only Tyber's study an attempt was made to All patients in test group 34
CMA JOURNAL/MAY 3, 1975/VOL. 112 1039
night occurred only in PSS and not in the diseases involving other joints may therefore be that particular stress was placed on the shoulder joint in certain recumbent positions. The occurrence of an agonizing pain that disrupts sleep in this way would be enough in itself to produce mood changes scored as depression. (The effects of loss of sleep can be devastating, ranging from loss of ability to sustain attention to disturbing visual hallucinations.3) PSS is a clinical entity arising from a number of different lesions (a textbook of orthopedics4 lists five primary lesions). In fact, 34% of Dr. Tyber's treatment group were given one of a number of radiologic diagnoses, including calcific tendinitis, calcific subdeltoid bursitis and glenohumeral osteoarthritis. If PSS is found to be associated with depression regardless of the underlying lesion, then the hypothesis that a painful shoulder can make a patient depressed seems more likely than the hypothesis that depression is etiologically implicated in the lesions that give rise to PSS. Because PSS tends to have a fluctuating course, it is most important to establish that the improvement noted after therapy is not just a phenomenon of the natural history of the disease.
If the course of a disease consists of alternating exacerbations and remissions, and patients are assessed at their worst time, then on a probability basis alone they are likely to be better when next assessed. In a condition like PSS, then, it is important to evaluate new therapy with a clinical trial in which patients are randomly assigned to one of two treatment groups. Clinical grading (range of painless abduction) does not appear to have been carried out blind. If this is so, then there is room for observer bias (where knowledge of the desired outcome may affect assessments) or bias resulting from the patient's awareness of the expected results. Use of a control group would allow the grading to be completed on a double-blind basis. If the therapy is effective, it does not necessarily mean that PSS and depression are etiologically related. Drugs are usually widely distributed throughout the body and can influence cellular mechanisms of different tissues. If a drug can affect disease processes in different parts of the body, a causal relation need not be assumed (e.g. amitriptyline has antiasthmatic properties;5 salbutamol is effective in bronchial asthma and in the inhibition of premature labour). Amitriptyline may provide night-time sedation (possibly mild analgesia as well) and lithium may
have a specific biochemical effect on the lesion. As in many physical conditions conventionally described as psychogenic, the psychologic basis of PSS is at the moment no more than an assumption. We are still left with more questions than answers: What is the biologic gradient and natural history of the condition? What are the attributes of those who reach a particular medical facility? Are other disorders of the shoulder associated with nocturnal exacerbation of pain? What is the most effective therapy, and does the presence of a specific radiologic lesion determine the response? DAVID P. GOLDBLATr, MB, CH B
Department of epidemiology and health McGill University Montr6al, QuE.
References 1. SULLIVAN JD: Painful shoulder syndrome. Can Med Assoc 1 111: 505, 1974 2. CHAITON A: Painful shoulder syndrome. Ibid, p 1299 3. Harrison's Principles of Internal Medicine, sixth ed, edited by WINTROBE MM, et al, New York, McGraw, 1970, pp 158-159 4. ADAMS JC: Outline of Orthopaedics, sixth ed. London, LiVingstone, 1967, p p 231-235 5. WILsori RCD: Antiasthmatic effect of amitriptyline. Can Med Assoc 1 111: 212, 1974
Jo the editor: In reply to Dr. Goldblatt I would like to say that the subjects in the test and control groups in my study were all derived from my own practice. They were subject to the pre-
The University of Toronto Continuing Education Program in Health Administration announces THREE ADVANCED SEMINAR - WORKSHOPS Spring, 1975 CITIZEN INVOLVEMENT IN HEALTH SERVICES PROVISION: the pitfalls and the potentials May 12-16 HEALTH SERVICES AND SOCIAL SERVICES: destructive conflict or dynamic relationship? June 2-6 CONTINUITY OF CARE: a meaningless concept or an achievable goal? June 23 - 27 These Seminar-Workshops are designed for individuals with experience and administrative responsibility in the health services field. The workshops will require each participant to present a problem he or she is currently facing for discussion by the group and expert resource personnel. The seminars will be led by senior faculty members of the health administration program and invited experts from key health institutions and academic and government agencies. Enrolment will be limited to assure active participation by all. The fee for each seminar - workshop ($250) will cover tuition costs and the preparation of course materials which will be sent to participants in advance, additional information, detailed programs and registration forms may be obtained by writing Professor J. W. Browne, continuing Education Program, Department of Health Administration, School of Hygiene, UNIVERSITY OF TORONTO, Toronto, Ontario, M5S lAl. The Advanced Seminars are part of the Continuing Education Program in Health Administration which gratefully acknowledges the support of the W. K. Kellogg Foundation.
CMA JOURNAL/MAY 3, 1975/VOL. 112 1041
Bonnyville, Alta.
Results of acupuncture To the editor: The report on the 1975 annual meeting of the Royal College (Can Med Assoc J 112: 356, 1975) is misleading in the account given of the results of the, acupuncture studies performed at The Arthritis Centre in Vancouver. The report quotes me as stating that "analysis of subjective pain and tenderness did not reveal significant difference between the experimental and control group". This statement is true for only a part of one of the three experiments that were performed. The report of three controlled trials on the influence of acupuncture on the pain of rheumatic disease will be published in full in due course but the results reported at the meeting indicated a significant effect of acupuncture in each of three experiments (rheumatoid arthritis affecting the Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double spaced and should not exceed 1½ pages in length.
hands, painful shoulder syndrome without arthritis and rheumatoid arthritis affecting the knees). Acupuncture does do something and the observations we have made are compatible with the relief of pain. L.H. TRUELOVE, BM, FRCP[C]
The Arthritis Centre 895 West 10th Ave. Vancouver, BC
Painful shoulder syndrome
uncover the temporal relation between PSS and depression retrospectively, but this approach is open to many errors, particularly if the patients were depressed at the time of interview. Dr. Tyber's findings are collected in Table I. He interprets these figures as indicating that "depression preceded or was simultaneous with the development of PSS in 50% (13/26) of patients", and this interpretation led him to speculate that depression might be etiologically implicated in PSS. By the same process one could say that PSS preceded or was simultaneous with the development of depression in 62% (16/26) of patients, leading to the speculation that PSS might be causally related to depression. However, considering the inaccuracy of the approach (as well as of the figures themselves) it is difficult to draw any conclusion. If one does consider the possibility of PSS causing depression, a simpler explanation for the association, as well as of the nocturnal exacerbation of pain, can be suggested. The pain of this syndrome is known to be positionally related (this aspect was used in the clinical grading), so the worsening of pain at night may well be related to the position in which the patient sleeps. This has in fact been commented on by patients; they may, for example, wake up with an intense pain after having rolled over from a painfree position onto their shoulder. The reason why the exacerbation of pain at Table I-Relation between depression and the painful shoulder syndrome in the test group
To the editor: The article "Treatment of the painful shoulder syndrome with amitriptyline and lithium carbonate" by M.A. Tyber (Can Med Assoc J 111: 137, 1974) highlights a number of problems that can arise if patients who have been instrumental in their own selection (to a hospital, clinic or private practice) are used for the study of disease interrelations. It also illustrates some of the difficulties encountered when therapeutic measures are evaluated. In commenting on Dr. Sullivan.s subsequent suggestion of an association between the painful shoulder syndrome (PSS) and diabetes,1 Dr. Chaiton2 discussed "Berkson's fallacy": when hospital, clinic or private patients are used for studying disease interrelations spurious associations can arise through the interplay of various selection factors at work on the different diseases. This phenomenon must also be considered in relation to Dr. Tyber's study. For example, patients with both P55 and depression may be more likely to reach Dr. Tyber than those with P55 alone. If the selection of other types of patients (i.e. those used as controls) is in any way different, then PSS and Tb. of patients depression may appear more strongly related than they in fact are. Patients with depression and PSS Depression preceded PSS 4 An association between two diseases Depression and PSS simultaneous 9 found by prevalence data does not reDepression followed PSS 7 veal whether disease A caused disease Indeterminate 6 B, B caused A, or whether they were Total 26 8 both caused by another factor. In Dr. Patients with PSS only Tyber's study an attempt was made to All patients in test group 34
CMA JOURNAL/MAY 3, 1975/VOL. 112 1039
night occurred only in PSS and not in the diseases involving other joints may therefore be that particular stress was placed on the shoulder joint in certain recumbent positions. The occurrence of an agonizing pain that disrupts sleep in this way would be enough in itself to produce mood changes scored as depression. (The effects of loss of sleep can be devastating, ranging from loss of ability to sustain attention to disturbing visual hallucinations.3) PSS is a clinical entity arising from a number of different lesions (a textbook of orthopedics4 lists five primary lesions). In fact, 34% of Dr. Tyber's treatment group were given one of a number of radiologic diagnoses, including calcific tendinitis, calcific subdeltoid bursitis and glenohumeral osteoarthritis. If PSS is found to be associated with depression regardless of the underlying lesion, then the hypothesis that a painful shoulder can make a patient depressed seems more likely than the hypothesis that depression is etiologically implicated in the lesions that give rise to PSS. Because PSS tends to have a fluctuating course, it is most important to establish that the improvement noted after therapy is not just a phenomenon of the natural history of the disease.
If the course of a disease consists of alternating exacerbations and remissions, and patients are assessed at their worst time, then on a probability basis alone they are likely to be better when next assessed. In a condition like PSS, then, it is important to evaluate new therapy with a clinical trial in which patients are randomly assigned to one of two treatment groups. Clinical grading (range of painless abduction) does not appear to have been carried out blind. If this is so, then there is room for observer bias (where knowledge of the desired outcome may affect assessments) or bias resulting from the patient's awareness of the expected results. Use of a control group would allow the grading to be completed on a double-blind basis. If the therapy is effective, it does not necessarily mean that PSS and depression are etiologically related. Drugs are usually widely distributed throughout the body and can influence cellular mechanisms of different tissues. If a drug can affect disease processes in different parts of the body, a causal relation need not be assumed (e.g. amitriptyline has antiasthmatic properties;5 salbutamol is effective in bronchial asthma and in the inhibition of premature labour). Amitriptyline may provide night-time sedation (possibly mild analgesia as well) and lithium may
have a specific biochemical effect on the lesion. As in many physical conditions conventionally described as psychogenic, the psychologic basis of PSS is at the moment no more than an assumption. We are still left with more questions than answers: What is the biologic gradient and natural history of the condition? What are the attributes of those who reach a particular medical facility? Are other disorders of the shoulder associated with nocturnal exacerbation of pain? What is the most effective therapy, and does the presence of a specific radiologic lesion determine the response? DAVID P. GOLDBLATr, MB, CH B
Department of epidemiology and health McGill University Montr6al, QuE.
References 1. SULLIVAN JD: Painful shoulder syndrome. Can Med Assoc 1 111: 505, 1974 2. CHAITON A: Painful shoulder syndrome. Ibid, p 1299 3. Harrison's Principles of Internal Medicine, sixth ed, edited by WINTROBE MM, et al, New York, McGraw, 1970, pp 158-159 4. ADAMS JC: Outline of Orthopaedics, sixth ed. London, LiVingstone, 1967, p p 231-235 5. WILsori RCD: Antiasthmatic effect of amitriptyline. Can Med Assoc 1 111: 212, 1974
Jo the editor: In reply to Dr. Goldblatt I would like to say that the subjects in the test and control groups in my study were all derived from my own practice. They were subject to the pre-
The University of Toronto Continuing Education Program in Health Administration announces THREE ADVANCED SEMINAR - WORKSHOPS Spring, 1975 CITIZEN INVOLVEMENT IN HEALTH SERVICES PROVISION: the pitfalls and the potentials May 12-16 HEALTH SERVICES AND SOCIAL SERVICES: destructive conflict or dynamic relationship? June 2-6 CONTINUITY OF CARE: a meaningless concept or an achievable goal? June 23 - 27 These Seminar-Workshops are designed for individuals with experience and administrative responsibility in the health services field. The workshops will require each participant to present a problem he or she is currently facing for discussion by the group and expert resource personnel. The seminars will be led by senior faculty members of the health administration program and invited experts from key health institutions and academic and government agencies. Enrolment will be limited to assure active participation by all. The fee for each seminar - workshop ($250) will cover tuition costs and the preparation of course materials which will be sent to participants in advance, additional information, detailed programs and registration forms may be obtained by writing Professor J. W. Browne, continuing Education Program, Department of Health Administration, School of Hygiene, UNIVERSITY OF TORONTO, Toronto, Ontario, M5S lAl. The Advanced Seminars are part of the Continuing Education Program in Health Administration which gratefully acknowledges the support of the W. K. Kellogg Foundation.
CMA JOURNAL/MAY 3, 1975/VOL. 112 1041
