Have you been/are you currently a patient frustrated with your rehabilitation process, feeling low on the hope meter, or feeling like you’ve reached a dead end? Are you a physical therapist (or any healthcare provider) who is perplexed about a patient’s delayed or seemingly plateaued rehab progress? If you can check either one or both of these boxes, read on! The physical healing process involves far more than physiological repair. What I believe to be even more powerful and influential in the healing process is psychological and emotional status, which is often shaped by the words that we take in and the words that we put out, both towards other people and also ourselves.
As a Doctor of Physical Therapy, I frequently catch up on the latest research to see how I can improve my clinical skills and reasoning so that I can provide my patients with the best care possible. As I perused the one of the latest editions of the Journal of Orthopedic and Sports Physical Therapy, I came across an article that I believe all healthcare providers should read. First and foremost, authors Michael Stewart, MCSP, SRP, MSc, Bsc and Stephen Loftus, PhD encouraged the fundamental idea that patients are not defined solely by their injury. Rather, each patient is a human being with a unique collection of psychological and physical attributes that all play a part in the body’s pain and healing response. From the perspective of a current patient and practicing physical therapist, I believe that the message conveyed in this article is pivotal for optimizing patient care and improving patient outlook when it comes to the injury rehabilitation process.
In their article titled “Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation,” Stewart and Loftus begin with a quote from Rudyard Kipling, saying, “Words are, of course, the most powerful drug used by mankind.” As if that single statement wasn’t enough to draw the reader in, they expand even further to say:
“Human beings consist of muscles, bones, and tissues, but the words we use in therapy can have a profound influence on how people make sense of their bodies and how they interpret what they are experiencing.”
I am so grateful that this concept has finally made it into publication! Words matter to every human each one of us interacts with, but they are especially crucial to those enduring pain. From a movement expert and injury prevention perspective, research indicates that a more negative and depressed mindset effectively delays the physical healing process. Even further, athletes attempting to return to sport after recovering from an injury are more likely to sustain re-injury if their recovery process is marked by any extent of depression.*
*Depression does not have to be clinically diagnosed in this context.
As humans, we are wired to selectively choose and invest in community, experiences, conversation, and thoughts that reinforce our perspectives. If I am looking to experience joy, I will surround myself with people and opportunities that allow me to experience joy. On the other hand, if I am enduring pain and/or struggle, I will likely surround myself with other people and experiences that validate and reinforce my pain and/or struggle. Stewart and Loftus build upon this idea, saying, “When we are physically and emotionally low, we also seek information that supports our vulnerabilities.” Long story short, we crave a sense of belonging. We want to surround ourselves with people and spaces that validate our experiences. As a result, we can become tunnel-visioned in the way we process information we take in from our surroundings.
From a patient standpoint, recognizing that we, as humans, are wired in such a way can bring awareness to the opportunity of restructuring our perspectives when we are suffering and in pain. It is so easy to become overwhelmed by our pain, especially when it is chronic and nature and the light at the end of the tunnel appears to be very far off in the distance or perhaps even non-existent. However, when we consistently acknowledge that our pain is here to stay forever (ie. “I’ll have this pain for the rest of my life”), we are actually reinforcing its existence, allowing it to keep a nice cozy home in our brains and nervous system when the body may have stopped waving red flags a long time ago.
Personally speaking, I have lived out this concept in its truest form. I am guilty as charged, having unconsciously welcomed pain to live rent-free in my brain for an unnecessary length of time. Most patients who recovered from a knee surgery, especially and ACL reconstruction, can acknowledge the oh-so-frustrating existence of anterior knee pain. It is one of those aching discomforts that is constantly reminding you of its presence–sitting for long periods of time (long car rides, air travel, etc), climbing up and especially down stairs (or hills for that matter), during and after running (or any impact activity), or maybe even walking for a little longer than usual. Gah! So frustrating. What’s even more frustrating is recognizing that every time i acknowledge it’s existence, I give its studio apartment in my brain a brand new renovation–for free.
Don’t get me wrong, anterior knee pain and pain in general can be totally real, especially in the acute phase. Recognizing and staying ahead of pain during this period is crucial for symptom management and recovery. However, when we continue to coddle our pain long after the acute phase has passed, we invite our brain to fall victim to the chronic pain cycle. When we allow our pain to dictate our lifestyle choices, we unconsciously give it the power to own us. By choosing to take the proactive pain-reliever, by choosing to avoid participation in recreational activities that once gave us joy without fear, by choosing to take the elevator rather than the stairs, by choosing to stay at home rather than go for a walk with our friends, we unconsciously choose to fall victim again and again to the power of the chronic pain cycle. This not only interferes with our physical recovery process (as pain in inhibits appropriate muscle activation and strengthening), but it also commandeers many other facets of our lives that keep our psychological and emotional health tanks full. So how do we press the hard-reset button and pull a U-ie on what appeared to be a one-way street? The empowering piece in all of this is that we have a choice. We have the ability to face the trickery of our brains directly in the eye, saying, “Hello my dear pain, we’ve had a nice run. I see what you’ve done here. But I think it’s time we move in different directions.”
Often times we can reverse the power of pain simply by the words we tell ourselves. Instead of saying something like, “I’m going to be stuck with this pain forever,” perhaps we can reframe our words, reminding ourselves that the current situation is only temporary and not our final destination. Instead of opting out of opportunities due to fear of exacerbating our pain, maybe we say yes to the opportunity and participate in it to our fullest potential until the body really sends us a true red flag. Who knows, we might end up surprising ourselves! When we get angry about the ongoing presence of pain and feel as though our bodies have betrayed us, perhaps we reframe our perspective, saying “Body, thank you so much for being a part of this journey with me. We’ve been through a lot, but we’re stronger than we think and there are certainly better days ahead.” The words we tell ourselves are so powerful, especially in the pain journey. Becoming aware of our pitfalls and acknowledging when it’s appropriate to reroute is undoubtedly the biggest step towards finally seeing that progress and hope that we didn’t think was there anymore. How can you speak to yourself differently?
From a healthcare provider’s standpoint, much of the same ideas apply. Have you ever reached a hard stopping point in your patient’s progress, retrospectively thinking to yourself, “Perhaps I could have done/said that differently?” Have you been caught with a patient when he/she is having an emotional moment, often wondering what you’re supposed to say or do to rectify the situation? Don’t be afraid to step up to the plate here–you’re in overwhelmingly great company!
I think we as physical therapists do a great job of relating to our patients the best way we know how, but when it comes to uncomfortable situations, we–like most other humans–prefer to run as fast as we can in the exact opposite direction instead of sitting with our patients through their discomfort. Granted, our patients’ emotional turmoil is not necessarily our burden to bear, but we can certainly help to alleviate their discomfort within clear boundaries.
As mentioned previously, patients enduring pain often seek validation and reinforcement that their symptoms are justified. Patients coping with chronic pain often demonstrate decreased self-confidence and a less positive outlook, which often exacerbate the chronic pain cycle. One way that we can assist these patients to experience increased chances of improved recovery is helping to reframe their perspectives. Stewart and Loftus suggest the following:
“An essential step on the road to rebuilding self-efficacy and resilience is to understand that people can often be distressed and disabled by their view of things. There is plenty of evidence to support the claim that if we change the way we view things, the things we view can change.”
As physical therapists who generally see patients 1-2 hours per week, we are likely to be healthcare practitioners that spend the most time building relationships with our patients. Our words are powerful, and we should choose them carefully. Stewart and Loftus continue to build on this idea by saying:
“As the current international pain epidemic continues to escalate, it is time to conserve whether the words we use form part of people’s solution or part of their journey toward disabling vulnerability.”
Because we have the privilege of spending so much time with our patients, we must realize how much of an influence we can have on recovery outcomes. Most times patients will come to us having already seen a doctor or a specialist and having already received a diagnosis following a series of diagnostic tests. Other times we may be the provider performing the primary screening. In any case, patients often seek concrete causes for their symptoms. In today’s world, diagnostic images are heavy with technical medical terms, which can be easily misconstrued in the absence of proper education. Moreover, it is also easy as highly educated health professionals to speak to patients in technical medical terms, which can present the opportunity for a communication barrier or unclear communication. Stewart and Loftus suggest that, “When communication is not clear, our interpretations are colored by our psychological state.” For people suffering from severe or chronic pain, these fancy medical terms have the potential to negatively impact recovery outcomes.
A personal example stems from medical terminology associated with surgical findings after my first ACL surgery. At this point, I was not educated as a physical therapist and was therefore more prone to becoming hung up on big words that seemed to be associated with life-changing consequences. If my memory serves me correctly, my surgical findings included something along the following lines: left knee complete ACL rupture with bone bruising and Grade II chondromalacia underneath the patella. One of my immediate reactions… Grade II chondro-what?!! What does this mean? Keep in mind, I was a collegiate soccer player who recently sustained what used to be a career-ending injury. I was already scared that I would never be able to player soccer again. And I was also in a lot of pain after having a huge knee surgery. My psychological and emotional health were not in their prime, and I was certainly looking for misery to keep me company. So, after perusing WebMD like most people do, I was convinced I had advanced arthritis underneath my kneecap that would eventually lead to a total knee replacement and reduced participation or perhaps even none at all in all of the physical activities that contribute to my identity. That’s it–life was over as I knew it. We can all see where this is going, can’t we?
As healthcare providers, it is important to consider our patients’ education level before we disseminate fancy medical terminology. Using my own experience as an example, it is easy for a patient to latch onto these big words and catastrophize the situation to various extremes. More often than not, when patients are introduced to big words like “chondromalacia” or “degenerative changes”, they may be too overwhelmed to think about asking for clarification. Even more likely, patients might be afraid to speak up out of shame derived from self-generated expectations that these big words are supposed to be understood by the average individual without 7+ years of secondary education.
On a similar note, words like chondromalacia, arthritis, and degenerative changes are often perceived as conditions associated with chronic and progressive negative life changes. From a patient point of view, this often leads to thoughts like, “I’ll have this pain for the rest of my life,” or “I can only manage X symptom by taking this pill every day,” or “I have to stop participating in the fun things that I love so I don’t make X condition worse.” In some situations, pathology may be severe enough that lifestyle changes have to be considered. But in so many other situations, we jump to worst-case scenarios and make drastic life-changes that decrease our quality of life when they might not have been necessary in the first place.
So when it comes to physical injury and the rehab process, how can healthcare providers adapt their vocabulary to reinforce positive thinking and a growth mindset? Steward and Loftus provide us with a general roadmap, stating:
“The language used with patients in diagnosis and therapy is just as important as, if not more than, the findings of such scans… By rewording and broadening the context of medical language used with patients, clinicians may begin to liberate people from a life of unnecessary worry and disability… By focusing language toward [the patient’s] hopes, and not [the patient’s] hurts, we may begin to lay the foundations for recovery.”
By taking the extra minute to explain to patients what these fancy medical terms really mean and by also encouraging them to ask questions if they do not understand, healthcare providers can help to significantly reduce the amount of stress, anxiety, and fear-oriented behavior associated with diagnostic tests. In doing so, we can allow for opportunities for patients to digest new information with fewer questions and empower them to better manage their symptoms given improved understanding. By focusing primarily on pathology that is symptomatic and normalizing asymptomatic findings, we may be able to help patients feel less like they’re “broken” and more like they’re normally aging humans. Steward and Loftus suggest that we can do a better job of empowering our patients when, “There is a focus on what someone can do (or will be able to do with help) rather than on that they cannot do.” And we can certainly dwell less on fancy medical terms that cause confusion, mental/emotional overload, and fear-avoidance behaviors that often exacerbate the chronic pain cycle.
Speaking from personal experience and with additional support from research findings, patients identities are significantly more than the physical ailments with which they consult healthcare providers or a diagnosis provided from a healthcare provider. Patients are humans with varying life experiences, home situations, life stresses, temperaments, and mental states that all influence the way information is received and processed. In a world with continuous medical advancements and healthcare changes, there is great opportunity for gaps in understanding of medical terminology to persist, thus continuing to endorse the chronic pain crisis. However, patients and healthcare providers alike have the potential to approach medical situations differently by changing mindset, asking for or providing more education, and improving understanding of the body’s complex response to pain and suffering. Steward and Loftus affirm this concept by saying, “All musculoskeletal conditions must be viewed within a ore comprehensive framework that takes account of biomedical issues and includes how patients perceive their injuries, their disabilities, their pain, and how they make sense of what is happening to them.”
If you’re a patient, I encourage you to speak up when you don’t understand, ask the question you think you should already know the answer to (because chances are you’re not alone), take accountability for the ways that you can optimize your recovery and symptom management, and reframe your mindset to prevent your pain from becoming a part of your identity. You absolutely can do all of these things. You are strong and you are completely capable. But you are also a human. It won’t be a straight-line journey and there will be ups and downs. But keep pushing. Every step you take is one step closer to the other side.
If you’re a healthcare provider, I encourage you to reflect on and reconsider some of the ways you might approach your patients dealing with chronic pain or devastating injury. These patients each have their own story. Ask questions so you can better understand where they come from and what they need. Ask questions so that you know how you can best empower each patient to be a positive driving force in their own journey. That fancy medical terminology surely sounds sophisticated, and it is. But sometimes–most times–simplicity can be more effective. Sit with your patient just a little while longer to explain medical information, allowing time for questions and processing. Your patient will thank you later–big time! And chances are, their outcomes will likely be better too.
If this post resonates with you and you know of someone else who might benefit from reading it (whether you’re a patient or a healthcare provider), please pass it along! One of the best ways to make an impact is to empower the people around us. Wouldn’t it be amazing if we could create a widespread epidemic of patient education and empowerment and kick these unnecessarily ridiculous complex recovery processes to the curb?!
Interested in learning more about the chronic pain cycle? Stay tuned for a follow-up post with more details.
Stewart and Loftus. “Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation.” J Orthop Sports Phys Ther, 2018: 48 (7), p519-522.