Pathologizing: Our Words Matter

by Walt Fritz, PT on August 3, 2017

As a physical therapist trained in the early 1980’s, biomechanical explanations for pain and movement disorders were the norm. As I drifted into a myofascial release manual therapy in the early 1990’s, the biomechanical model was reinforced and made more narrow through the beliefs that pain and movement dysfunction stem from issues of fascial tightness/restriction. All had both evidence to support their views, as well as well-presented logical assumptions. Myofascial release suffered from testimonial-type of evidence which seemed very compelling to a casual scientific observer (me), who was unwilling to question the sources of presented information. Biomechanical views still are well represented throughout the manual therapies, as evident by the daily squabbles regarding such things as the importance, or lack of, with such issues as posture, weakness, and asymmetry when it comes to both pain as well as movement disorders. This post is not intended to address these issues, but to briefly discuss the language we use when conversing with our patients/clients.

Patients pay us to help them. This help is most often accompanied by the thorough evaluation, after which we proclaim our findings on both what is wrong with them and what should be done to rectify the situation. We may call this our assessment or diagnosis, depending on the scope of practice allowances and limitations of your profession. Patients expect it and we feel it necessary to give them what they want and deserve, but is it always in their best interest, especially when there is a lack of consensus on the validity of our assessment’s claims? Biomechanical factors and judgement, such as poor posture being the cause of pain, are popular and logical assumptions which many of our patients believe and you may believe it to be true as well, but is it always true?

While at the computer, I leave my Facebook notifications turned on, which is probably one reason I am so easily distracted. As I was writing this post a notification came in that I will sanitize and post here:

I’m new to this group, but curious as to many issues a (named surgical procedure) could help with. My biggest issues are forward head posture – my (type of) therapist once told me it was the worst she had ever seen – neck/shoulder/upper back tension that my chiropractor gave up on treating because he didn’t understand why he couldn’t fix it, jaw clenching, anxiety, etc). Anyway, does anyone have a recommendation for a practitioner in (certain city)?”

The writer of this post was speaking from genuine self-concern and must have found some solace in her therapist’s statement about the severity of her forward head, but what does she now do with that? If she is the worst case her health professional has ever seen, it would seem to me that makes it less likely that she can be helped. There is information easily available that casts doubt on the degree of forward head posture and neck pain, but that therapist has planted a seed in the patient’s brain that she is one of the worst out there, at least from her therapist’s perspective. Do we really need to say things like this?

Below are some studies that were recently posted to a thread on one of the many groups there, all speaking to the effect of the power of our words. If you’ve never given this much thought, please read through some of the abstracts and papers. Our words have power, and often the message conveyed negatively impacts outcomes.

Easy to Harm, Hard to Heal: Patient Views About the Back.

CONCLUSION: Negative assumptions about the back made by those with LBP may affect information processing during an episode of pain. This may result in attentional bias toward information indicating that the spine is vulnerable, an injury is serious, or the outcome will be poor. Approaching consultations with this understanding may assist clinicians to have a positive influence on beliefs.

The enduring impact of what clinicians say to people with low back pain. (Full text link)

CONCLUSIONS: Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.

Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain – a longitudinal study. (Full text link)

CONCLUSIONS: Psychological factors emerged from this study as relevant in the early phase of acute neck pain. Particularly persistent anxiety and depression at baseline might be risk factors for a transition to chronic pain that should be addressed in the early management of neck pain patients.

‘Talking a different language’: a qualitative study of chronic low back pain patients’ interpretation of the language used by student osteopaths. 

CONCLUSIONS: The language used by student osteopaths’ influences patient beliefs about LBP in a variety of ways. The current study furthers understanding of how language contributes to these beliefs, identifying ways through which communication can contribute to improved healthcare through enhancing patient engagement.

Words That Harm, Words That Heal. (Full text link)

Both positive and negative beliefs are important in patients with spine pain: findings from the oioc registry.

CONCLUSIONS: Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability however, in this study only positive beliefs were associated with treatment outcome.

Do you have any studies to share regarding this topic? I’d love to have a look!

Cheers,

Walt Fritz, PT

Foundations in Myofascial Release Seminars

{ 4 comments… read them below or add one }

Harry Albert Adler August 5, 2017 at 8:51 am

…THANKS FOR YOUR EFFORT TO KEEP US READERS INFORMED.

I do a lot of Myof. Release.
Symmetry (which we therapists use a lot) is an interesting concept, although too visual (if I may say), and I have been allowing myself to bring the presence of “reciprocity” which opens a wider range for addressing patients’ conditions (which bring disconfort or pain or disability) as it is a concept which addresses visuality and also kinesthaetic approach… also permits me to relate (not only) to right left observation also including up/down and or back /front and even inside /outside patinet’c body relationships…
I wonder if you can use and or develop and comment something out of this idea.
truly, harry

Reply

Walt Fritz, PT October 14, 2017 at 5:25 pm

Hi Harry,
I do not discard posture and symmetry as being irrelevant, I just see the human body as an inherently asymmetrical being. We can bring awareness to an area that we/they may feel is out of symmetry and movement/comfort improves. Such relationships are hard to ignore, though there are issues of the post hoc fallacy that cannot be ignored.

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Deane Juhan October 24, 2017 at 3:37 pm

It is not that biomechanics do not matter. It is that merely mechanically prodding the tissue into pre-conceived models of posture is not an effective way to improve poor biomechanics–which is ALWAYS due to the neurological patterning of chronic muscular tension the inhibits free movement. There is no such thing as a tight muscle–there is only a tight mind. Muscles are dumb. They can only respond to our habituated dysfunctions and our beliefs of what is possible in our own self-regulated capacities to change the patterns that are afflicting us. Freeing the mind of past conceptions of “how it is, and must be,” and opening the conscious feeling of “how could it be?” is the whole thing.

Reply

Walt Fritz, PT October 24, 2017 at 9:23 pm

Deane,
Tight mind being used metaphorically, correct? WE have been long taught overly simplistic models of pain, movement, posture, etc., all simplified to reflect views from the perspective of the teller, vs. being a more all encompassing narrative. But such all encompassing narratives are still being written and are far from complete. Biomechanics matter in many ways, though probably not in the all powerful ways that social media memes would wish us to believe.

Walt

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