Apologies for not blogging for so long but I am back with a few more perspectives on physiotherapy. Following my first blog on concepts and the importance of their clarity, I thought that I would reflect on the meaning and perception of words from both the clinicians’ and patients’ viewpoints, specifically the words used to convey information to patients with low back pain (LBP).
Did you know that it may take just 39 milliseconds to form a first impression of somebody? (Bar, Neta and Linz, 2006) A bad first impression may take some time to change and communication affects every clinical encounter (Roberts et al, 2013)– definitely worth pondering!
The issues of language in regards to LBP are known to be problematic and the literature recognises a need for shared use of language to enhance both patient and therapist satisfaction (Cedrashi et al, 1998). An insightful qualitative study explored the use of language by health professionals treating LBP and found distinct areas where there were different uses of language (Barker, Reid and Minns Lowe, 2009). The health care practitioners involved in the study were Chiropractors, GPs, Osteopaths and Physiotherapists. The findings showed terms fell into three categories: 1. Potentially leading to problematic misunderstandings, 2. Having unintended meanings but few negative repercussions, and 3. Meeting the expectation and intention of understanding. This is summarised below in Table 1.
Table 1 – A summary of responses that members of the public discussed in focus groups on LBP (Barker, Reid and Minns Lowe, 2009)
|Speaking a different language- terms that could lead to problematic misunderstandings||Speaking a different language – terms with unintended meanings but few negative repercussions||Speaking a common language – term which the public appeared to understand as intended|
|Acute||(Low) back pain/ache||Muscle spasm|
|Chronic||Mechanical back pain/ache||Sensation|
|Muscle weakness||Muscle strain||Mobilisation|
|Instability||Sciatica||Soft tissue technique|
|Non-specific back pain||Radiated||Rehabilitation|
|Neurological involvement||Muscle imbalance|
|Trapped nerve||Nerve root pain|
|Parasesthesia||Disc – prolapsed, slipped, herniated, ruptured|
|Managing your back pain||Facet joint|
|Wear and tear||Spondylitis|
Surprisingly, for me, the responses that were felt to have good agreement were on areas that appear to be “therapy” specific. Examples of these terms are ‘mobilisation’, ‘manipulation’ and ‘soft tissue technique’. However, it appears that biomedical terms such as ‘neurological involvement’, ‘arthritis’, ‘instability’ and ‘non-specific LBP’ were problematic. This is in keeping with an excellent metasynthesis of qualitative studies by Bunzli et al (2013) which identified tensions between the clinician and patient when discussing, through the biomedical paradigm, the ligitimisation of pain and suffering, uncertainty, fear and anxiety for the future. The paper highlights key areas that require a shift in thinking across the medical profession in the management of chronic LBP.
Of interest, terms such as ‘managing your back pain’, ‘coping’ and ‘activity’ were also seen as problematic in the study by Barker, Reid and Minns Lowe (2009). This strikes me as concerning, as these are key areas for patient education, understanding and engagement for rehabilitation. On twitter I discussed the use of words with Peter Moore (@paintoolkit2), co-author of Pain Toolkit, who felt that more appropriate language could be used, as it would be more helpful. The word “coping” can be interpreted as “making do” whereas “active self-managers” or “active self-learners” are more empowering.
The issues surrounding connotations of words are very interesting. How many times in my career have I used words that seem very benign and non-threatening to me, but are potentially frightening and even harmful for the patient? Table 2 captures some perceptions of common terms that we use in clinical practice.
Table 2 – Summary of participant respondents. Adapted from Barker, Reid and Minns Lowe (2009)
|Term||Patient perception||What the clinician meant||How therapists feel about the term|
|Non-specific low back pain||Clinicians do not understand the cause of the pain or how to treat it
All in head
|No specific cause for the symptoms could be found following diagnostic investigations||The patient may feel that they do not know what they are doing
Letting the patient down
Severe pain on a specific point
|Pain of recent onset relating to timeframes||The patient may misunderstand the term as it might be seen as a quantifying factor
Try not to use it
Couple of steps from a wheel chair
Never going to go away
|Pain of duration longer than six weeks or three months||Although used in clinical notes the patient may interpret it in alternative ways|
Comes in waves
|Symptoms that are likely to recur or have a history of recurring||Felt that part of their role was to prevent recurrence|
|Muscle weakness||Muscles not exercised and giving adequate support
Permanent and may progressively get worse
|Weak manual muscle testing||A goal of physiotherapy is to strengthen weak muscles|
|Instability||Back could ‘go’ at any time
Something loose and likely to pop out
Worrying as may not be able to relax and permanent problem
|Referring to the mechanical type of symptom response to movement
Catching symptom “extension catch”
|Concerned about the term as may increase alarm to the patient|
|Neurological Involvement||Something about the nerves
Something going wrong in the brain
Could be a tumor
|Findings that involve the function of the nervous system||Aware that the term could be misinterpreted as is vague|
|Trapped nerve||Nerves stuck between bones or vertebral discs
A cause of low back pain
|Nerve root related symptoms||Prefer the term nerve root irritation as trapped nerve seems permanent|
|Wear and tear||Wearing out
No treatment available
Likely to get progressively worse
Relief as something not serious
|Normal process of aging||Prefer term than degenerative change|
|Arthritis||Serious and worrying
Associated with the elderly
|Joint inflammatory change||Feel that ‘wear and tear’ and ‘degeneration’ preferable but with education on the term|
|Exercise and activity||Exercise = planned and organised where physical activity normal movement||Good agreement||Prescribed exercise for back pain
Exercise such as walking and swimming
Activity = anything else apart from sitting in a chair or lying down – normal
Even with the very best of intentions, what we tell our patients may be perceived as something completely different and in some ways extremely harmful.
This all makes sense when you consider the mature organism model that was conceptualised by the late, great Louis Gifford (1998). An important aspect of the model is the focus on pain and its relationship to stress biology. By that, I mean that a stress response is aimed at motivating the person to alter their behaviour in order to recover and survive. This, in the short term, is an extremely helpful and desirable quality to have. However, in the long term, the response may facilitate maladaptive and non-helpful behaviours that affect the nervous system, the motor system, the endocrine system and the immune system, to name a few, in an adverse way.
In figure 1, we can see how sensory information is processed within the spinal cord and is scrutinized by the brain. In response, a person will perform a protective action, dependent on their prior experiences, beliefs, thoughts and feelings. The protective action becomes embedded as an associated memory. Then the cycle has the ability to repeat itself.
Figure 1 – The mature organism model (Gifford, 1998)
The words therapists use can be the sensory input that can start this cycle again in the mature organism model, resulting in altered behaviour and physiology (see figure 2). Examples of negative altered behaviour could include the effect on the motor system through guarding and breath-holding to protect from pain. An increased sensitivity of the nervous system could occur and result in central sensitisation where a non-noxious stimulus is perceived as painful (allodynia and secondary hyperalgesia). The ongoing stress of pain may increase levels of adrenaline and nor-adrenaline and affect multiple organs via the autonomic nervous system. Levels of cortisol may increase to maintain a sense of homeostasis and the immune system can become impaired and have a negative effect on recovery. This may maintain ongoing sensitivity of the nervous system and so the cycle continues: more threat, more sensitivity, reduced tolerance, poor sleep and recovery, altered physiology, altered behaviour and mood, reduced self-management strategies and ongoing pain.
By no means is this blog intended to be comprehensive, particularly on such a large topic as pain. But I hope that it highlights the importance that communication has on our therapeutic encounters. As much as it can hinder, or arguably harm, progress, it has the capacity to be able to change people’s lives for the better. It is of fundamental importance to build relationships with our patients and their values (link to blog on EBP) and to move towards helpful behavioural change.
An excellent video showing Peter O’Sullivan demonstrating this clearly:
So, as I reflect on language, concepts and evidence-based practice, I realise that being a physiotherapist is such a fulfilling job as it has so many complexities and components to ponder. All of them require ongoing reflection particularly on my ability to communicate. This is the tip of the iceberg ….just the beginning of reflection on communicating with patients! It begs the question, how well do I communicate with other therapists? That may be an entirely different post all together!
Bar M, Neta M, Linz H. (2006) Very First Impressions. Emotions; 6: 269-278
Barker K, Reid M, Minns Lowe J. (2009) Divided By A Common Language? A Qualitative Study Exploring The use Of Language By Health Professionals Treating Back Pain. BMC Musculoskeletal Disorders 123, (10); 1-10.
Bunzli S, Watkins R, Smith A, Schutze, O’Sullivan P. (2013) A Qualitative Synthesis Exploring The Experience Of Chronic Low Back Pain. Clinical Journal Of Pain. 29; (10). 907-916.
Cedraschi C, Nordin M, Nachemson A, Vischer T. (1998) Health Care Providers Should Use A Common Language In Relation To Low Back Pain Patients. Ballieres Clinical Rheumatology; 12, (1): 1–15.
Gifford L (1998) Pain, The Tissues And The Nervous System: A Conceptual Model. Physiotherapy 84 (1): 27-36.
Roberts L, Whittle C, Cleland J, Wald M. (2013) Measuring Verbal Communication in Initial Physical Therapy Encounters. Physical Therapy; 93: 479-491.