The Importance of Language
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 misunderstandingsSpeaking a different language – terms with unintended meanings but few negative repercussionsSpeaking a common language – term which the public appeared to understand as intendedAcute(Low) back pain/acheMuscle spasmChronicMechanical back pain/acheSensationRecurrentMuscle sprainManipulationMuscle weaknessMuscle strainMobilisationInstabilitySciaticaSoft tissue techniqueNon-specific back painRadiatedRehabilitationNeurological involvementMuscle imbalanceTrapped nerveNerve root painParasesthesiaDisc – prolapsed, slipped, herniated, rupturedManaging your back painFacet jointCopingAlignmentPsychological painPostureWear and tearSpondylitisArthritisStenosisExerciseActivityDisability
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)TermPatient perceptionWhat the clinician meantHow therapists feel about the termNon-specific low back painClinicians do not understand the cause of the pain or how to treat it Non existent All in headNo specific cause for the symptoms could be found following diagnostic investigationsThe patient may feel that they do not know what they are doing Letting the patient down AcuteMild pain Severe pain on a specific pointPain of recent onset relating to timeframesThe patient may misunderstand the term as it might be seen as a quantifying factor Try not to use it ChronicSevere pain Couple of steps from a wheel chair Never going to go awayPain of duration longer than six weeks or three monthsAlthough used in clinical notes the patient may interpret it in alternative ways RecurrentLess severe Comes in waves EpisodicSymptoms that are likely to recur or have a history of recurringFelt that part of their role was to prevent recurrence Muscle weaknessMuscles not exercised and giving adequate support Permanent and may progressively get worseWeak manual muscle testingA goal of physiotherapy is to strengthen weak musclesInstabilityBack could ‘go’ at any time Something loose and likely to pop out Worrying as may not be able to relax and permanent problemReferring 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 InvolvementSomething about the nerves Something going wrong in the brain Could be a tumorFindings that involve the function of the nervous systemAware that the term could be misinterpreted as is vague Trapped nerveNerves stuck between bones or vertebral discs Inflammation A cause of low back painNerve root related symptomsPrefer the term nerve root irritation as trapped nerve seems permanent Wear and tearWearing out General disintegration Rotting away No treatment available Likely to get progressively worse Relief as something not serious “Fobbed off”Normal process of agingPrefer term than degenerative change ArthritisSerious and worrying Associated with the elderlyJoint inflammatory changeFeel that ‘wear and tear’ and ‘degeneration’ preferable but with education on the termExercise and activityExercise = planned and organised where physical activity normal movementGood agreementPrescribed 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.