Words Can Hurt, or Help

Many publications have been put out into the public space and in the scientific research on how the nocebo effect is generated from patient-provider interactions, and there are some really important things to read about how words, which we, as clinicians, might consider really innocuous, could in fact directly influence somebody’s experience of pain and change the way they think about their bodies or their capacity to move or engage in things and certainly their future. I have directly noticed a change in the language used when referring patients to my clinic. Whereas before it was “Diagnosis: Chronic low back pain or idiopathic low back pain, needs core stabilization,” now it’s something like “Please help the patient with beliefs and fear avoidance; they could benefit from some pain neuroscience education.” The old language suggests to a patient that they have a stability problem, and that by itself can lead to fear avoidance and worry for the patient. Now, referrals might say the diagnostic code associated with the referral is low back pain, but the reason for the referral was the patient is afraid to move and they need to be coached and guided into getting more active. Another way to help people understand complex issues—and pain is always complex and always will be—is to use metaphors. Metaphors are a really effective way to help people understand when you’re trying to explain a treatment intervention or a recommendation or help somebody understand why they hurt. They’re a good way to communicate something that otherwise would be hard to grasp. Remember that something as simple to a clinician as stenosis… that word “stenosis” has a negative association with it especially if you look up what that means online. Anatomical pictures can be scary. People use language interchangeable with stenosis like pinched nerves or narrowing of the canals, and that evokes an image that can be really frightening especially when you hurt. I use a metaphor to help patients understand why it is possible for a large number of people to have stenosis or degenerative disk disease or degenerative joint disease of other types and have no pain, why those things co-exist: it’s because our bodies are adaptable and because we can adjust. Our nerves can adjust to smaller and smaller houses, and that’s a metaphor I use to describe stenosis. It’s no different. If you choose to move from a large house to a small house, if you do it in stages, you adjust to each stage, and once you get to the tiny house, you’re fine. If you move directly from one place to another and you have to suddenly get adjusted to a smaller space, it’s harder, and nerves have that problem, too. So if there is traumatic injury and there’s a sudden change in the internal space for a nerve, it’s going to tell you about it, it will hurt, or you’ll feel pain. By contrast, if that process happened slow and steady, the nerve is fine and it can adjust.