Words Will Never Hurt Me… Or Will They?

Words matter. It’s amazing how often patients share stories about how other providers have explained their condition in horrific terms. “Your arthritis is terrible” or “your back is a mess.”

The “placebo” effect is well-known, but its counterpart, the “nocebo” effect is just as strong (if not stronger), and perhaps even more relevant for the healthcare industry. When patients are told that something will hurt, then it will likely hurt, whereas without this verbal suggestion, there is often much less pain. Many studies have been conducted related to drawing blood and/or giving injections, finding a strong effect of verbal suggestion on increased pain with the stimulus.

In this issue of the Physio Weekly, we discuss the role of our words in the clinic.

Sticks and Stones

I can’t imagine the thought of healthcare providers looking at imaging and suggesting that patients should be in pain because of their imaging. If you’ve spent any time researching imaging studies with respect to pain, then you have surely found how images aren’t stellar at predicting pain.

In this month’s issue of JOSPT is one of my favorite papers ever , written by Stewart and Loftus. In the paper, the authors make the case for changing the words that we use in order to avoid creating harm. Stewart and Loftus argue that many biomedical terms reinforce negative beliefs, and the authors provide some alternative options instead of common terms that we hear or say in the clinic. For example:

Instead of “wear and tear,” say “normal age changes

Instead of “damage,” say “reparable harm

Instead of “trapped nerve,” say “tight, but can be stretched

Instead of “bulge/herniation,” say “bump/swelling

Instead of lordosis or kyphosis, say “the normal curve in your back

I am often the one to interpret imaging findings for patients, because even though they are provided the radiologist’s impression, the jargon is overwhelming. The alternative phrases above are some ways to translate the imaging findings into non-threatening terms.

When More Treatment Isn’t Better

What happens if we suggest to patients that their bodies are messed up and that we need to correct everything? What if we explain that if we use some gadgets to mend their imperfections, and yet we only to arrive at a disappointing outcome for the patient?

I’m afraid that when we explain symptoms in terms of pathology, then we may contribute to overmedicalization and even harm to patients. The STarT Back Trial is one study that offers evidence that some patients don’t really need much treatment; they just need to know that it’s okay to move, to exercise, and to keep working. In the trial, physios in the group using the STarT Back tool provided only 1 session of treatment to those who score as low risk for poor prognosis, whereas the physios provided an average of 5 visits to those not in the group using the STarT Back tool.

Despite these differences in number of visits, the patients’ outcomes were not significantly different between the groups. This finding tells me the value of reassurance, encouragement, and education when prognosis is good.

When Words Hurt

Healthcare providers, though, could do something entirely different: They could look at how patients move or how their joints move and say something like, “No wonder you’re in pain, I see some problems with you.” What’s the possibility that such an assessment could actually create more pain? The research about nocebo responses is fascinating, and I believe that this 1-page paper about nocebo should be required reading for anyone who works with people in pain. As the paper mentions, merely suggesting that something could be painful actually leads to people experiencing pain.

I’ve been choosing my words a bit more carefully after seeing this research. What about you?

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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