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The Clinician's Narrative - Why Words Matter


Author's note: I wrote this around 2019 about an article that was integral to my own future research on beliefs surrounding pain. I hope others find it as useful as I did.



Key Points:

  1. This is a cross-sectional qualitative analysis study that assessed patterns of thinking (“discourses”) patients stated caused their recurrent low back pain and the origin of their narrative (healthcare provider, internet, family, friends, or other).

  2. Of the 130 participants, 116 (89%) stated their narrative came from a healthcare provider.

  3. The predominant discourse given was ‘body as machine” and was found in almost all responses.


Introduction

A primary outcome measurement clinicians are tasked with tracking and influencing is the patient’s subjective report of pain. Persistent or chronic pain has become a major global health issue. In the United States alone, it has been estimated between the healthcare costs attributable to pain and the annual costs of pain associated with lower work productivity totals $560-635 billion [Gaskin 2012]. Globally, low back pain is the leading cause of years lived with disability (YLLD) according to the Global Burden of Disease 2016.

Historically, persistent pain has been viewed through a biomedical lens, which takes a reductionist approach to the problem. This approach assumes the presence of biomechanical / structural “abnormalities” as correlates to patient symptoms. When treatment is anchored to this biomedical approach, therapeutic modalities are -- seemingly logically -- selected based on the ability to correct these perceived abnormalities [Durnez 2017]. Unfortunately, this approach has fallen drastically short when it comes to improving outcomes for patients with pain.

  The recent paradigm shift towards a multi-factorial approach to pain treatment has involved the application  of the biopsychosocoial (BPS) model, which postulates that pain perception can be influenced by biological, psychological, and sociological factors [Gatchel 2007]. Mounting research evidence is demonstrating the influence of clinician language on patient perceptions and understanding of pain, and thus outcomes [Nickel 2017, [Barsky 2017]. In order to effectively change patient beliefs and thus behavior, we require a basic understanding of the person’s thoughts on the matter and the origins of these beliefs.


Purpose

The primary purpose of the article reviewed was to analyze the discourse of patients dealing with recurrent or persistent low back pain. Discourse, in this sense, equated to the participants’ understanding, beliefs, and written communication of their low back pain. A secondary focus of the article was to assess the origin of participants’ discourse(s).


Methods

This article is a cross-sectional study analyzing qualitative data collected from an online survey of 130 participants. The majority of participants were females from Australia who reported daily pain (see table 1). The survey assessed participants understanding of their persistent low back pain via 2 open-ended question:

  1.  What is your understanding of why your low back pain is persisting or recurring?

  2. Where does this understanding come from?

    1. Health care provider

    2. Internet

    3. Family

    4. Friends

    5. Other (able to type answer)

A multidisciplinary (physiotherapy, psychology, medical, and social work) six-member team was utilized to assess and categorize the responses of the participants.


Findings

Origin of beliefs

 

The majority of participants (n = 116, 89%) identified healthcare professionals as the source of their beliefs regarding persistent and recurrent low back pain. Additionally, participants identified the internet as the second source of their understanding about low back pain (n = 31, 24%). 


Discourses Identified


The authors identified four discourses from the answers to question 1:

  1. Body as machine (structuralist) = "Like a machine, the body is considered to be able to break and can sometimes be repaired. LBP persists because something is physically defective."

  2. Low Back Pain as permanent/immutable (structuralist) = "Related to the first discourse, LBP is conceptualized as a static or fixed entity that once 'broken', it cannot be 'fixed'. LBP is not dynamic or fluid but unchangeable and permanent."

  3. Low Back Pain is complex (multifactorial) = "This is a counter discourse to the first two. Multiple factors can contribute to the persistence of LBP - not only biomechanical or anatomical but also possibly psychosocial or cultural factors. There is no simple explanation for ongoing LBP."

  4. Low Back Pain is very negative (catastrophizing) = "LBP is conceptualized as abnormal, catastrophic, or very negative experience. LBP should be avoided and/or has a large effect on life."


The first discourse, “Body as machine,” was present in almost all participant responses. These participants viewed their body as having something mechanically wrong leading to their persistent/recurrent low back pain.

 

Here are two participant responses:

 

Participant 3:

Degeneration of the integrity of my tendons and ligaments from faulty collagen due to Ehlers-Danlos Syndrome causing instability in my spine (and other joints) resulting in herniation of spinal discs *currently 3 cervical, 1 thoracic and 2 lumbar) and degenerative disc diseases at L5/S1. Also sacroiliac joint dysfunction, hip dysplasia and instability has a correlating impact to my back issues.

Participant 59:

My motor control has suffered due to chronic low back pain initially caused by an injury and then perpetuated by degeneration in the joints. Even though there is no acute injury any more (arthritis is still there), my motor patterns are inefficient and I recruit larger muscles to stabilise my back due to pain inhibition. This means sometimes I do movements that are actually more forceful that needed and increase joint loading at the degenerating level, which is what causes a flare up.

The authors found many participant responses included biomedical lexicon such as joint/muscle/nerve injury and disease, postural issues, and inflammatory conditions. Some examples included: “fusion surgery leading to sacroiliac joint problems”, “my L4 and L5 are rubbing together”, “spinal damage caused by arthritis”, and “spondylolisthesis L5S1 with pars defect”.

In conjunction with the "body as machine" narrative, many participant responses supported the second discourse that "low back pain is permanent/immutable". Participants who cited a structuralist issue as the origin of their low back pain also believed the issue to be permanent. Participant responses included: “Damage done earlier in life”, and “Injury from high school..." The word degeneration was also frequently cited by participants to demonstrate an ongoing damaging process: “Now, it has become a matter of degeneration to the structure due to age and injury”. “arthritic changes in the bones” “severe multi-level stenosis” “My understanding is that because of my scoliosis I may always have lower back pain – and this could increase as I get older.”

Much less prevalent was discourse 3, which opposes narratives to discourses 1 and 2. The authors stated participants categorized into this discourse believed “factors other than biomechanics and disease processes can contribute to LBP’s recurrence or persistence.”

Examples of participant responses:

“…in part my dependence on medication”, “Pain patterns in brain as well as muscles that engage to 'protect' me when they don't need to.”

Participant 50:

“I have a severe burst dispersion fracture of L1 with up to 75% of the body of L1 crushed and dissolved. I have no neurological impairment and the fracture was stabilised without surgery. In 2013 I had a 20-year MRI and consulted a private pain specialist (also ortho surgeon) and he confirmed that the root cause is mechanical. My background pain was very high for approx 1 year (mid 2012-13) during a suicidal depression period. I have several month long bouts of depression every 3-5 years but the 2012 episode was worse than others. This fed the pain which fed the depression and I started hating my pain for the first time in 22 years. Although it can be tiring and exasperating at times, I had never hated the pain or wished it gone. Interestingly, during a few months of intense psychological treatment sessions, I had a week and a half long bad pain episode but it wasn't until the 4th day that I realised that my attitude to the pain and my ‘automatic responses’ to it had reverted back to my usual acceptance so I saw that as a step forward. The year highlighted again the direct correlation of mood to pain.”

The final discourse, “LBP is very negative”, was prevalent in many participant responses. Example of responses classified for discourse 4 include:

“Severe spinal stenosis and an awful scoliosis” “severe sciatica...pain never goes away”
“I have worn out, my L5/S1 to the point, it can’t take anything else.”
“My understanding is that because of my scoliosis I may always have lower back pain – and this could increase as I get older.”

Why does this article matter?

Based on this article, it appears that people's beliefs about their persistent low back pain primarily originated from healthcare providers and were anchored to a biomedical model. The most prevalent discourse was based on the idea our bodies are “machines”, capable of being broken and requiring fixing. This biomechanical approach predisposes the belief that if treatment is not sought to correct the perceived issue, then pain and damage will persist or worsen.

Studies such as this one demonstrate the importance of disseminating the most evidentially-supported information we currently have available as clinicians. Additionally, this study sheds light on how our narratives influence the beliefs of our patients and may perpetuate an external locus of control affecting pain management. Locus of control can be defined as a person’s viewpoint about the level of control they have over events in their lives. A person with an internal locus of control typically believes events in their life are related to their personal decisions, while an external locus of control attributes outside influences and factors other than the person as major contributors to life events.

A narrative rooted in biomechanical lexicon may instill the belief something is wrong with the patient which requires correcting. Although biology will remain a correlate, research continues to demonstrate psychological and sociological factors may play an equally important, if not greater, role in persistent pain. As clinicians, research like this will continue to challenge our beliefs about pathologies and biological issues necessitating care or perpetuating a therapeutic illusion [Thomas KB 1978].

Our narratives are long-lasting with patients and have the ability to influence behavior. Patients unnecessarily worried about or catastrophizing over a biomedical issue may develop kinesiophobia, which will perpetuate disability and seeking of treatment. However, our narratives can also positively influence behavior. The framing of low back pain can be altered to one of acceptance of a typically normal occurrence, as demonstrated by the mounting evidence of asymptomatic imaging findings of the spine [Romeo 2018, Brinjikji 2015].

  Patient interaction can be utilized to reassure and instill the belief the issue will likely improve while supporting patient self-care and building self-efficacy in their own ability to manage pain. The authors do caution they are not denying the potential biomedical correlates of low back pain. Rather, they intended to highlight such discourse is not applicable to everyone and may instill false beliefs, thereby perpetuating fear-avoidance behaviors. The authors admit that initial causes of low back pain may be related to biomedical issues. However, little evidence exists supporting such a belief for persistent or recurrent low back pain, and instead demonstrates a biopsychosocial and multi-factorial approach.

  In conclusion, this study furthers our understanding how people dealing with persistent and recurrent low back pain view the issue and where their beliefs originated. The study emphasizes our need to formulate our narratives around a biopsychosocial approach and cautions disseminating negative beliefs centered around a “body as machine” discourse.


UPDATE:

Since writing this article, my team and I have looked further into low back pain beliefs in Northern America (US and Canada). Here are two studies from those investigations, aligning with the article reviewed above:

References:

  1. Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. Individuals' explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC musculoskeletal disorders. 2017; 18(1):466.

  2. Gaskin DJ, Richard P. The economic costs of pain in the United States. The journal of pain : official journal of the American Pain Society. 2012; 13(8):715-24.

  3. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet (London, England). 2017; 390(10100):1211-1259.

  4. Durnez W, Van Damme S. Let it be? Pain control attempts critically amplify attention to somatosensory input. Psychological research. 2017; 81(1):309-320.

  5. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological bulletin. 2007; 133(4):581-624.

  6. Nickel B, Barratt A, Copp T, Moynihan R, McCaffery K. Words do matter: a systematic review on how different terminology for the same condition influences management preferences. BMJ open. 2017; 7(7):e014129.

  7. Barsky AJ. The Iatrogenic Potential of the Physician's Words. JAMA. 2017.

  8. Thomas KB. The consultation and the therapeutic illusion. British medical journal. 1978; 1(6123):1327-8.

  9. Romeo V, Covello M, Salvatore E, et al. High Prevalence of Spinal Magnetic Resonance Imaging Findings in Asymptomatic Young Adults (18-22 Yrs) Candidate to Air Force Flight. Spine. 2018;

  10. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology. 2015; 36(4):811-6.

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