‘Sticks and stones will break my bones but words will never hurt me.’ The evidence suggests that is complete b***s**t! Words affect pain.
When I’m talking about bad language in this context, I’m not talking about F-bombs.
I’m talking about words and phrases that can negatively influence our patients’ outcomes.
My aim in this article is to demonstrate that not only can poorly chosen terms reduce people’s expectations, words can directly affect pain.
This discussion is based on the presentation by the amazing Associate Professor Tasha Stanton at PainAdelaide 2021 (‘the best little pain meeting in the world’).
Words really do matter
We know that words are important.
When you meet someone that has been told NOT to do a particular activity, it can take quite a bit of convincing that it is safe to start doing that activity again.
There are a range of scenarios to explain why this can happen:
It might be an explicit recommendation from a health provider that was unfortunately misguided (aka plain wrong).
For example, advice like ‘Don’t squat, it’s bad for your knees!’…’Whatever you do, don’t bend over or you’ll blow a disc!’…’Don’t bend backwards’…’Don’t run, it’s bad for your joints!’
It could be that a health provider recommended to avoid an activity and it was only ever intended to be avoided for a limited time.
But that activity or movement was never reintroduced.
There are situations where temporarily resting from an activity is OK. It may be a reasonable step to prevent healing from being interrupted by forces that it isn’t ready to deal with.
BUT there should always be a plan to reintroduce those activities.
Or it might not be as explicit as either of these.
It might be a simple throwaway line from a health professional that plants a seed in the mind of the patient.
Just a simple turn of phrase that gives the impression that something is bad, wrong, fragile, vulnerable or simply stuffed. This is particularly the situation that we are talking about.
The effect of poorly chosen or clumsy language which can directly influence many factors…including pain.
But can words really make that much of a difference? Can words affect pain? Yes they certainly can. I’ll show you …
Everything influences everything – words included
As Tash said in her presentation, as physios we often think of choosing our words carefully if we are dealing with people in persistent pain, or with an anxious patient. It might be more conscious because we don’t want add to their distress or anxiety. It isn’t usually because we are concerned that our words might directly affect their pain though.
But the effect of words doesn’t just apply to the anxious or sensitive. This is just as important for every patient. Even the most robust and happy-go-lucky person.
This is the reason. Everything we see, hear, feel or think (ie experience) influences everything we experience.
We don’t have to be consciously aware of something for it to influence our experiences. These influential factors can include:
- Things we believe
- Things we ‘know’
- Things we experienced as a kid
- Things our mum, neighbour, taxi driver told us
- Things we have heard, tasted, smelt, touched in the past
- Things that have hurt in the past and previous injuries
and fleeting interactions with health professionals who make a fleeting reference to the cause of your pain, the state of your tissues or the prognosis.
If you aren’t following me so far, hang in there. Let’s use some illusions to explain what I mean…
The rotating mask illusion
Take the ‘rotating mask illusion’ – one of the coolest tricks since David Copperfield got engaged to Claudia Schiffer.
Even when you understand what is going on, it still works (though not for everyone – Kimberley didn’t get it, but she is well and truly extraordinary).
Why does the illusion work?
It works because we have a previously established expectation that noses protrude outwards, and that they don’t go inwards.
That expectation is stronger than the incoming visual information about the mask, so it influences what we see when the mask rotates. So much so that it your brain thinks it is more likely that the mask reverses direction rather than there being a concave nose!
This expectation from previous experience has been called a ‘prior’.
Every visual illusion exploits this idea of the prior. In an illusion, prior experiences are influencing what you see. And even when you know it’s an illusion it can still work!
What about the other senses? I’m glad you asked – here’s an auditory example.
Watch the clip and read the word on the left ‘green needle’ or read the word on the right ‘brainstorm’. You’ll only hear the word you are looking at.
Then watch the clip again and read them the other way around to confirm it works both ways.
It’s so cool. Why does it work? The sound that you hear is literally a ‘noisy’ signal ie not clear, and your ‘prior’, your belief or expectation about the word is strong enough to influence what you hear.
It even works if you close your eyes and just think about the words!
So what does this have to do with my pain?
Vision and hearing are are pretty trustworthy senses, aren’t they?
You don’t second guess what you see when you are driving, do you? After all, if you don’t trust your vision, you have no business driving a car.
The examples above show that if there is an expectation from previous experience (and there ALWAYS is), it will influence what you see or hear, regardless of how trustworthy the sense is.
It stands to reason that your ‘priors’ will influence your experience of pain too.
The messages from our tissues, our bodies, our thoughts can all be considered to be ‘noisy’ signals too, just like the noisy signal in the video above. In that example, your priors completely determine what you hear, whether it is ‘green needle’ or ‘brainstorm’. And that can be influenced
- in real time
- quite easily
- over and over and over
Similarly, the phrasing your health professional uses to describe your problem or your prognosis creates a really strong prior – whether you realise it or not.
Great theory, but where is the evidence that words affect pain?
As a clinician, your choice of language is important. And perhaps more important than we appreciate.
Yes, it can influence motivation. It can clearly influence what someone thinks they can achieve, that is, their prognosis. But it can also directly affect their pain.
The evidence supports this concept that words can affect pain. If you are keen, check out this study by Vuckovic et al from Cambridge in 2019.
You can read the entire article here, the title really explains what it is about!
How to use this information about how words affect pain
If you are a health professional, it is really important to consider the words that you use with patients.
Words can strongly influence beliefs, expectations and directly affect pain.
The most obvious culprits are those throwaway phrases like ‘bone on bone’, ‘degeneration’, ‘wear and tear’ and ‘slipped disc’. Each of them send messages of damage, vulnerability or fragility that create super strong priors.
Examine your own language for terms that you use that could be misconstrued or send a message that could affect pain or outcome. We can all do with a self-audit (or a peer audit!)
And if ever you question the relevance of beliefs or priors, ask yourself ‘green needle’ or ‘brainstorm’?
If you are looking for a group of physios that really get it and are always looking for ways to better help people with persistent pain, you have found them!
Click here to find out more about how we help people with persistent pain.
