The words we use to describe musculoskeletal pain matter
Sticks and stones may break my bones, but words will never hurt me.
Although it may not be used today as much as in the past, the saying is a famous way to teach that we don’t have to be upset by the things others say. This rhyme is generally used to combat the harsh words of a playground bully or a disgruntled coworker, so we usually don’t think to employ it when discussing musculoskeletal pain with a healthcare provider.
We may need to rethink this notion.
When people think of musculoskeletal conditions, they tend to picture problems affecting muscles, ligaments, joints, and other tissues. While knowledge of the physical body is vital in the management of such conditions, the way providers communicate this information can also have a profound impact on recovery.
Take the term "spinal degeneration." While this phrase sounds straightforward to a clinician who understands that spinal degeneration is often a very normal process of aging, it may be catastrophic to a patient. They may believe their spine is crumbling, which sounds frightening and something that requires urgent intervention. Although it’s the provider’s duty to help the patient reconceptualize this information, that can be a bit like putting toothpaste back in the tube.
In an aptly named article from the Journal of Orthopaedic & Sports Physical Therapy, "Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation," the authors included a list of words that healthcare providers should avoid, along with some helpful alternatives. Because language contains the capacity to heal or cause devastating harm, they recommended replacing provocative terms such as "bone on bone" with the word "narrowing," or "chronic degenerative changes" with "normal age-related changes."
For example, when someone is told that their knee pain is because their joint is "bone on bone," it all but implies their problem is unfixable short of surgery. On the other hand, calling it "joint space narrowing," coupled with the explanation that imaging findings often don’t correlate to the severity of pain or that patients with similar findings have positive responses to conservative care, the outlook would almost certainly be different.
And it’s not just healthcare providers that are at fault. Society at large is also to blame. Many people are led to believe that for their pain to get better, they need a label. As a result, it’s not unusual for doctors to go the extra mile to help satisfy their patients’ desire for an answer, which often means ordering advanced imaging such as MRI.
Research has shown that this course of action may not actually achieve its intended purpose. Studies have looked explicitly at a sense of well-being in patients when their imaging findings are disclosed to them compared to when this information is withheld. Interestingly, those blinded to the results from their imaging had a better sense of well-being related to their condition.
One paper took a group of people with low back pain, all of whom had a confirmed L4-L5 disc herniation, and divided them into two groups. In the first group, patients were told their diagnosis (L4-L5 disc herniation), while those in the second group were simply told they had low back pain. Not surprisingly, the second group had better outcomes.
This may seem a bit counterintuitive. Shouldn’t an accurate diagnosis on imaging lead to more precise treatment and a better outcome? Unless the image revealed a fracture or a serious pathology such as cancer or infection, the answer is often no. In most musculoskeletal pain cases, imaging alone doesn’t make great treatment decisions and can lead to more confusion.
This was evident in a patient who recently presented to my office with sciatica that radiated from her lower back to her right calf. In the previous half-decade, she had received two separate MRIs, which, in her words, showed "bad discs" in her lumbar spine. My assessment revealed that as a result of moving her spine in a specific way, the pain in her leg was abolished and became more localized to her lower back. This response is termed centralization, which I explained is a strong indicator of an excellent prognosis. Unfortunately, the findings from her MRIs created a bit of a mental roadblock. The fact that her pain had become more predominant in her lower back, where her "bad discs" were located, was of great concern to her. She believed that she should stop treatment and get another MRI. It took a great deal of coaching to get this patient back on track, and after another week of performing this centralizing movement, her remaining lower back pain was also abolished.
This doesn’t mean that information should be withheld from patients. Instead, it should be offered to them in a way that fosters the best possible outcome. Cognitive and contextual factors play an important role in the management of musculoskeletal pain, as beliefs, expectations, and the perception of one’s condition can significantly impact recovery. For this reason, other authors and I have recommended that radiology reports for several common diagnoses come with an explanation: "Finding may be unrelated to symptoms, further investigation necessary." As it pertains to the case described above, it’s likely that this patient’s MRI findings did not change despite her full resolution.
As medical providers, we must ask ourselves questions such as, “What does this mean to the patient?” and “How can I help them find a positive outlook in this situation?” Ultimately, this involves being very mindful of the language we use. While sticks and stones can break bones, the words we use have the potential to heal or cause great harm.
Dr. Jordan Duncan was born and raised in Kitsap County and graduated from the University of Western States in 2011 with a Doctor of Chiropractic Degree. He practices at Silverdale Sport and Spine. He is one of a small handful of chiropractors in Washington state to be credentialed in the McKenzie Method.
This article originally appeared on Kitsap Sun: How we talk about pain makes a difference in recovery
