The power of language

As a physio I hear from approximately 20-30 patients per day.  Most of whom are in pain.  This is a traumatic thing and places the person in a vulnerable position.  They come to see people they trust to help them.  However, when I speak to these patients, I find some of the things they repeat to me are anywhere from slightly misguided to downright wrong.  This is by no means the responsibility of the patient, but instead can be, the fault of us as clinicians.

What do the words wear and tear, bone on bone, slipped disc all mean to you?  Or my favourite, I was out of alignment and my therapist put my bone back in place.  It is so difficult to start to unpick what patients think when they say these things to me.

We have all hear about placebo effect.  You take a sugar pill when you believe you might be taking a real medicine and you still get better.  The brain has the amazing ability to make you feel better.  It’s so clever.  So, if it can make you feel better, can it make you feel worse?  Yes, the term is nocebo.  

If we take an MRI scan of someone with simple low back pain, early in the episode, we have the potential to make that person feel worse.  But how?  Surely MRI scans see everything and tell you what is wrong.  MRI and other scans are brilliant, they see many things in detail.  But do they see pain.  No, they see structure.  They see what is there and what isn’t.  We cannot scan for pain.  I have seen many scans of people and their spines.  Can I tell you if someone is in pain or how much pain, absolutely not.

Saying to a patient they have a disc that has slipped, might make them more protective of their back, cautious in using it and means they might not go back to doing what they were before as they are scared!  This over protection is not always a conscious effort either.  Sometimes when the brain is deciding on whether we should do a task, it asks itself is there a risk?  Sometimes pain can be so severe it seems like we should never do that task again.  Ever had a paper cut and put alcohol gel on your hand, nips a bit doesn’t it!  However, we have to do the same thing again, we can see its only a small paper cut, and we have had one before, so the brain rationalises it as a risk worth taking.

We cannot see what is in our backs, sometimes the pain is severe, sometimes not.  Stories from friends and lack of knowledge can cause fear.  Fear in the brain leads to avoiding activity, avoiding activity leads to poop muscle strength and function. The language we use to describe things can be a difficult minefield to work through.  Making sure you are open and honest and using appropriate language for the person sat across from you is key.  I like to use analogies.  Not everybody understands medical language, we use it so easily and forget it has taken us years to understand it.  

Analogies

I use analogies daily as do we all.  I have heard countless stories from patients about getting discs put back in place, that they have bone on bone, their scan is the worst the Dr has ever seen.  These words and stories matter.  But they are not always helpful.  A careful clinician needs to be aware of what they are saying and how they are saying it.  

I like to use analogies the help my patients understand what is going on and why.  One of my favourites is regarding scans.  A patient comes to me demanding a scan, so I know how to treat their back.  I mean how can I possibly know what disc is out of place if I haven’t seen their scan!  I like to give patients the comparison about a broken-down car.  Imagine you are driving; you are miles from home and family and friends, and your car breaks down.  What do you do?  You phone the AA/RAC etc.  Imagine instead of a lovely bright yellow van coming to meet you, the mechanic sat in his van 20 miles away and asked you to take a photo of your car and he would tell you what is wrong.  Great if a wheel has fallen off.  Not so great for most other modern-day car problems.  The problem lies not in what is or isn’t there but in how it is working!  The same is true of our bodies.

Another analogy I use a lot comes from when I first qualified as a physio.  I had done 4 years of training and thought I could help anything.  Massage from my hands would break up scar tissue and tight muscles like kneading out dough. I used to think I was like structural engineer, changing things at will as the patient needed! Years later I realised this wasn’t true.  A therapist's hands cannot alter our bodies in that dramatic a fashion.  We are far too strong for that.  Instead I now believe we are more akin to a software engineer/computer programmer.  I can change how you move and show you how to get stronger/more flexible, but I cannot do it for you.

This is one of the reasons why language is so important and patient understanding is at the heart of what we do.  One of the things I like to do, and should do more often, is to get the patient to explain back to me what they think I just told them in the session.  Get them to explain to me as they would once, they got home, what is wrong, and what is needed to get better.  Here we can see what the patient has heard and understood.

Pain is not always to be trusted!  Ask a professional.  Also look for strong recommendations, not every sore back needs a scan, sometimes they need a scan quickly but that is what a well-qualified and reputable clinician will do.  If you are not seeing progress within 6-10 sessions, I would be questioning what the treatment is and if it is working.  Most of all be curious, question and query what someone is doing and why and if there are alternatives.