Reflecting on the Language We Use
Listen for a moment in a busy clinic. We usually can hear bits and pieces of our colleague’s conversations with their patients. Some are about the news, what’s going on in their lives, or patient education. Communicating with our patients is a must in order to set up a strong therapeutic alliance. (Ferreria- 2012) This can happen both verbally and non-verbally. For this post, I will focus my attention on the verbal aspect of our communication with the patients we treat.
Many of us encounter patients who are downright scared to move. They have been told by their doctor or other referring healthcare practitioner that they have diagnosis X and bulging this or degenerative that on their imaging. As many of us know, there is little correlation between findings on one’s imaging and one’s symptoms. This only goes on to cause fear avoidant behavior or pain catastrophizing.
Now we have seen this circumstance time and time again and most of us have our ways to talk the patient away from their fearful thoughts, but it is the language that we use day in and day out that may feed into future fear generating thoughts or dependency. I have several examples of language that creates just this:
1. The use of a biomechanical pelvic neutral for all things “core” related. Many PTs stress to their patient that this is needed in order to keep your back from getting hurt again. Yes, a “neutral” pelvis (in this definition via Panjabi’s explanation of neutral) may look appropriate via force loading on the spine, but is it absolutely necessary for every movement to be in a neutral pelvis? We need to work away from stressing a biomechanical neutral position that causes the patient to over focus their attention (in most cases) and become fearful of working outside this neutral zone. We might want to think about the neutral pelvis being where the patient is most comfortable or threatened (this may be in a lordotic position or the reverse) and work to encourage the patient to push into novel pelvic positions without a heightened pain response.
2. This leads me to my second point--PTs reinforcing pain generation from a peripheral structure. If you understand Melzack’s pain neuromatrix, (Melzack, 1999, Moseley, 2003) you catch my drift on this. We need to start educating patients correctly on what the pain experience really is and how it works. Building off of the “hurt does not equal harm” will get you far, especially with the patients who are scared to move. We need to push for the use of metaphors (Gallaher, 2013) that connect with the patient so that they understand that most of the time, structurally things are fine; it is the brain’s protective response that we need to address to get them moving again!
3. PTs over emphasis on pelvic obliquities. I can talk about this for days, but we need to stop telling patients that their SI joints are “out” or “one side is up” or “your pelvis is off.” How does this make the patient feel? Just stop. Granted that some patients do get better by using treatments targeting these findings (although the evidence is clear that we are poor at reliably assessing for this and probably are not correcting anything), one needs to be careful about how you explain to the patient what you are doing. We need to be more general with our explanations and not feed into fear avoidant behavior. This goes beyond the SIJ as well.
These are just a few examples of common faults in our communication to a patient who is already in a fearful state of mind. We need to stop and think about words that will harm and words that can heal (Bedell, 2004) or empower a patient. I am sure many others can think of examples similar to the ones I have listed. I wonder what you would think if you listened to yourself talk…it’s time we self reflect on our language and make sure we are empowering our patients at every step in our care.
1. Ferriera PH, et al. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2012. Published online at doi: 10.2522/ptj.20120137.
2. Melzack R. Pain--an overview. Acta Anaesthesiol Scand. 1999 Oct;43(9):880-4.
3. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther. 2003 Aug;8(3):130-40.
4. Gallagher L, McAuley J, Moseley GL. A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain. Clin J Pain. 2013;29:20-25.
5. Bedell SE, Graboys TB, Bedell E, Lown B. Words that harm, words that heal. Arch Intern Med. 2004 Jul 12;164(13):1365-8