Do you kiss your mother with that mouth?

I recently had an editorial in the ISPI Newsletter (I am an instructor with International Spine and Pain Institute).  I wanted to reprint it here as well for readers.


I’m sure many of us used the phrase, “sticks and stones may break my bones, but words will never hurt me” as a child, heck maybe you still use it as an adult. This catchy phrase may be slightly inaccurate based on current pain neuroscience understanding and I propose we offer this more correct version in the future: “sticks and stones may break my bones and words will never harm me, but they can hurt me”. This is of course a play on the popular pain neuroscience metaphor of “hurt does not always mean harm”. We have a good understanding that harm (physical injury or illness producing nociception) is not the same as hurt (the brains output of pain). We actually have evidence showing that the words we use can change the hurt people experience.

In a recent study (Ott J, 2012) researchers found that words associated with pain increase the perception of pain during venous blood sampling. The authors came to the conclusion that words have an impact on the individual evaluation of external stimuli. This finding has been found in other research and fits into Melzack’s pain and the neuromatrix in the brain theory with cognitive related brain areas being inputs into the body-self neuromatrix that can produce outputs of pain perception.

Another interesting study (Beck JG, 2001) used a modified Stroop procedure to assess processing of threat
words in motor vehicle accident (MVA) survivors. The traditional Stroop color-word interference test looks
at reaction time while a participant is asked to name the color the word is printed in, but ignore the word itself. For example the word “red” might be printed in blue ink and your job is to say blue. You will see if
you do this you are inclined to say red and your response of blue is slowed, thus you experience interference.
You can check out Wikipedia for more on Stroop Effect, it’s kind of fun to do (well that is if you’re a nerdy nerve head like myself). So back to the study, they had three groups of MVA survivors one had no problems, the other had persistent pain and the third group had persistent pain and post-traumatic stress disorder (PTSD). The PTSD and pain group had slowed responses with both accident and pain words. While those with just pain had slowed response with just pain words not accident words and those individuals that had no symptoms saw no changes in their responses for either pain or accident words.
This study shows that there was some specificity to processing of words by an individual based on their condition.

So what can we, and should we, take away from such studies? The words we use can “hurt” our patients more than they already are. As health care providers we need to be aware of the choice of words that we use on a regular basis with our patients in pain. While using threat words such as herniation, rupture, tore, etc. with a person in no pain may not affect their neuromatrix to produce pain, but for those in pain it actually could.

Adriaan, along with Ina, David and Louie recently finished a paper that is waiting for submission (Louw, 2012) looking at the difference in the words we use with pain patients with pre-operative education. They looked at two different post-surgery pain education booklets. Booklet A had been shown to have no added benefit to outcomes or cost from previous research with surgical patients. Patients receiving Booklet B have
shown initial signs (from a case series and preliminary multi-center RCT data) to have improvement in function and decrease in pain catastrophization upon using pain neuroscience education approach (Yes, this is Adriaan’s PhD project and the same booklet you are aware of “Your Nerves are Having Back Surgery”).
They had a group of seventeen expert PT’s compare the use of provocative terms in each booklet. What was found that Booklet A had three times the use of provocative terms associated with fear, pain and anxiety compared to Booklet B that utilized the latest pain neuroscience education. The original study of Booklet A did not list the use of pain words as a possible reason why the study failed to show a difference in outcomes with or without the additional patient education. This study suggests that possibly the words we use during our patient education may make a difference in the outcomes we get.

So understanding this important piece of information, that words can hurt our patients, I get a little agitated with the choices some of my fellow health care providers choose to use when it comes to their words. Have you ever seen a patient that reports to you that the physician or some other health care provider stated that their back, shoulder or knee was the worst they had ever seen. Isn't it amazing how patient after patient we here this from, is each patient actually getting worse than the one before? After almost 20 years of practice it is amazing that patients somehow consistently seem to be progressively become the worst case month after month. A statement like this does not help a patient in pain in any way and only has downside as it is laden with fear and anxiety (two of the things we should be trying to reduce). While this kind of statement does give us, the health care provider, with lots of upside. Consider if they don’t get better it’s not our fault because it was the worst case ever; and if they do get better it only shows how good we must be to help the worst case ever. I think we can and should be able to do better for our patients.

As physical therapists we need to be aware and improve the therapist portion of our care just as much, if not more, then the physical portion of our interventions. One area of this can be done by paying attention to the words we use during our interaction with our patients. Avoid using threatening words in our explanations to patients in regards to diagnosis, etiology and prognosis from their current condition. These terms only provide the opportunity for the individual to perceive greater threat through the fear and anxiety interwoven into the meaning of them and enhancing the defender response (pain) from the patient.

Proper interaction and education can instill positive expectations and hope through the use of our language to our patients and not create negative connotations or threatening inputs to their body-self neuromatrix. The choice of the non-threatening language and words we use may be another avenue to provide input into the neuromatrix as an adjunct to our management and treatment of their painful condition.



References

1. Beck JG, F. J., Shipherd JC, Hamblem JL, Lackner JM. (2001). Specificity of Stroop Interference in Patients with Pain and PTSD. Journal of Abnormal Psychology, 110(4), 536-543. 
2. Ott J, A. S., Nouri K, Promberger R. (2012). An Everyday Phrase May Harm Your Patients: The influence of Negative Words on Pain During Venous Blood Sampling. Clin J Pain, 28, 324-328.
3. Louw A, Diener I, Butler D, Puentedura L. (2012). The Lanugage of Patient Education for Lumbar Radiclopathy. unsubmitted research.