[ viewpoint ]

MICHAEL STEWART, MCSP, SRP, MSc, BSc (Hons), PG Cert (Clin Ed)1 • STEPHEN LOFTUS, PhD2

Sticks and Stones:

The Impact of Language in
Musculoskeletal Rehabilitation
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J Orthop Sports Phys Ther 2018;48(7):519-522. doi:10.2519/jospt.2018.0610

“Words are, of course, the most powerful drug used by mankind.” to be acknowledged and understood,
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

and deliberately used as part of therapy.

Rudyard Kipling13 Misunderstanding or ignoring psycho-
logical factors carries the risk that they

T
may have a negative effect on therapy. A
hroughout the often complex and challenging process of major problem is that our therapy, and
musculoskeletal rehabilitation, the words that we use can have professional education, still emphasizes
a significant impact on the clinical outcome. Words contain biomedical issues, with a focus on patho-
both the ability to heal and harm. Gaining an improved anatomical language. Biomedical issues
account for more than 99% of all under-
understanding of the frequently hidden influence that language can
Journal of Orthopaedic & Sports Physical Therapy®

graduate health care training.4

have on musculoskeletal rehabilitation is of paramount importance. Despite an increasing awareness of the
This Viewpoint article highlights the powerful consequences of the importance of psychological factors, and
words that we use in clinical practice and can lead to positive or negative behavior of the potent influence that language has
discusses the practical considerations for change. The worry and uncertainty of liv- on individual pain perceptions, muscu-
adapting the current language of muscu- ing with a chronic musculoskeletal condi- loskeletal practice can be a minefield of
loskeletal rehabilitation. tion frequently lead to a perpetual search threatening words and ambiguous infor-
One foundation of effective musculo- for answers. This can be a real problem mation. Without a meaningful reconcep-
skeletal rehabilitation lies in our ability in a world of online information and mis- tualization of pain as a highly complex,
to communicate and guide people toward information. We are only ever one click subjective human experience that is felt in
recovery. As clinicians, we play a pivotal away from either confirming our darkest the tissues but interpreted by the mind as
role in the lives of people in vulnerable, fears or igniting a previously unconsid- a response to perceived threat,17 clinicians
distressing situations. The words we ered concern. will likely remain unaware of the poten-
choose can either contain the capacity to Mounting research evidence indi- tial harm that their words may cause.15
heal or have the potential to cause dev- cates that psychological factors are more In musculoskeletal rehabilitation, we
astating and lasting harm.2 Like drugs, effective predictors of pain and disabil- should remain eternally vigilant about
words have an ability to change the way ity levels than are pathoanatomical fac- how our words may be interpreted. Hu-
another person thinks and feels. Words tors.6,12,14 It is therefore ironic that, by man beings consist of muscles, bones, and
are capable of corrupting or enhancing continuing to focus on the latter, clini- tissues, but the words we use in therapy
thoughts. Words can generate good or cians may well unwittingly exacerbate can have a profound influence on how
bad emotions and prompt actions that the former. Psychological factors need people make sense of their bodies and
University of Brighton, Eastbourne, United Kingdom. 2William Beaumont School of Medicine, Oakland University, Rochester, MI. The authors certify that they have no affiliations
1

with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to
Michael Stewart, University of Brighton, 49 Darley Road, Eastbourne BN20 7UR United Kingdom. E-mail: mike@knowpain.co.uk t Copyright ©2018 Journal of Orthopaedic &
Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 48 | number 7 | july 2018 | 519


how they interpret what they are experi-
encing. A term such as degenerative discs
may sound mild and straightforward to
a clinician but catastrophic to a patient.
In this sense, words are like toothpaste;
once out of the tube, they are impossible
to put back in. As clinicians, we need a
keen sensitivity to how our patients are
responding to the words we use. We need
to talk about pathoanatomical features
and the realities of therapy in a way that
patients can understand, without being
alienated. This is complicated by the fact
that different patients will have different
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levels of understanding and will interpret
what we say in different ways.
Bullington et al5 state that, “To encoun-
ter another human is to encounter another
world.” With this in mind, there cannot be
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
one simple recipe or formula for how we
might use language within clinical prac-
tice. Not all medicalized language is harm-
ful to all individuals.1 We must, of course,
continue to ask crucial clinical questions,
such as, “Have you noticed any problems
with your bladder or bowels?” while also
recognizing the potential impact that this
question may have for anyone who’s wor-
Journal of Orthopaedic & Sports Physical Therapy®
ried about potential problems with blad-
der or bowel function.
The following clinical vignette high-
lights some examples of the frequently
concealed threats that are present in the
language of present-day musculoskeletal
rehabilitation.
Ben is a talented, 15-year-old track
athlete. He presents with a 2-year history
of worsening low back pain, and has been
advised by a previous clinician to give up
running and start swimming instead. Ben
has also been told that, despite his age, his
magnetic resonance imaging scan shows
that he has “degenerative discs” in his
lumbar spine. He attended the clinic with
his grandfather, who is also his coach. His
grandfather has a long-standing history
of low back pain and has been diagnosed
with “failed back surgery syndrome.” In an
attempt to help Ben, his previous physical
therapist has advised him to read an on-
line educational booklet, which has been
designed for young athletes with low back
520 | july 2018 | volume 48 | number 7 | journal of orthopaedic & sports physical therapy
[ viewpoint ]
pain. The booklet contains the following
words: “Treatment is similar to treatment
of a disc herniation in the adult popula-
tion. Epidural injections can be used but
are not necessary in most cases. If symp-
toms do not improve with a comprehen-
sive rehabilitation program, then surgery
may be indicated. This is necessary only in
a small percentage of young athletes with
disc injury.”
Ben says that he feels broken and can-
not switch off the thought that he is go-
ing to need spinal surgery. Although Ben
may be distressed, he is not alone. As the
current international pain epidemic con-
tinues to escalate,9 it is time to consider
whether the words we use form part of
people’s solution or part of their journey
toward disabling vulnerability. For Ben
and millions of others like him to return
to lives that are rich and meaningful,
clinicians need to develop the communi-
cation skills to help reframe medical find-
ings so that they make sense to patients
and show the way forward.
In practical terms, the first step need-
ed to help Ben is for him to come to terms
with what is happening in a way that is
realistic without being fatalistic. It is the
clinician’s duty of care to help Ben recon-
ceptualize the information provided to
him, such that the so-called “degenera-
tion” may be regarded as a normal age-
related change, which may be enough to
change Ben’s perceptions while remain-
ing truthful. However, a lot of education
may be needed before Ben can accept
that the term degenerative discs does
not mean that his spine is crumbling and
requires urgent intervention. It may take
some time and carefully worded support
from a therapist for Ben to see his situa-
tion in these new terms. 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.10 We can help people
like Ben to change his view of his body,
and a new view can be therapeutic in it-
self, despite any deviation from normal
that may be present.
Like Ben, many people receive rou-
tine scans and radiographs, which are
considered the gold standard to deter-
mine the pathoanatomical source of
their symptoms. The language used with
patients in diagnosis and therapy is just
as important as, if not more than, the
findings of such scans. The words used
to report medical imaging to patients
like Ben may underpin and perpetuate
unhelpful, outdated societal beliefs that
the spine is fragile, vulnerable, and ir-
reparable.7 However, evidence shows
that 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.3 Therefore, by focusing our
language toward Ben’s hopes, and not his
hurts, we may begin to lay the founda-
tions for his recovery. A vivid example
of this is the account of Mattingly,16 who
describes a therapist taking a new patient
around a rehabilitation facility, showing
him where the various activities will take
place. The new patient is a young man
with a head injury. The therapist is care-
ful to use words that emphasize how the
therapy will lay down the foundations of
a new life that can have purpose and be
meaningful. Mattingly16 describes this
approach as “therapeutic emplotment.”
Without this therapeutic emplotment,
there is a serious risk that the patient
may not engage in the therapy because
the patient will see it as meaningless. In
this therapeutic situation, the words used
are crucial to the success of the therapy
because they encourage the patient to
adopt a positive attitude. There is a focus
on what someone can do (or will be able
to do with help) rather than on what they
cannot do.
For patients like Ben, the word “de-
generative” can be truly alarming. The
language of musculoskeletal rehabili-
tation is filled with opportunities for
patients’ misinterpretations of medical
terminology. When communication is
not clear, our interpretations are colored
 by our psychological state. Ben has pre-
existing knowledge leading to the con-
cern that, like his grandfather, he will
also require surgical intervention that
may eventually lead to “failed back sur-
gery syndrome.” This distorts how he in-
terprets the message he receives. As with
Ben’s narrative, Sillence et al21 found that
patients tended to value advice offered by
family and friends over other sources of
health information. However, conflicting
advice from multiple sources also led to
confusion and uncertainty.
Ben is selectively attending to infor-
Downloaded from www.jospt.org at on May 22, 2022. For personal use only. No other uses without permission.
mation that fits his worldview. The words
used reinforce Ben’s worries. For exam-
ple, Ben focused on the words “surgery
may be indicated” within the educational
booklet to the exclusion of all else. Ben’s
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
attentional bias naturally went in search
of information to support his beliefs. As
such, the words “surgery may be indi-
cated” were adapted to become the more
alarming certainty, “I will need surgery!”
Biro2 noted that single and at times
offhand statements can heavily influence
recovery expectations. This is important
when we consider that low recovery ex-
Journal of Orthopaedic & Sports Physical Therapy®
pectations are a strong predictor of poor
outcome.12 Within musculoskeletal reha-
bilitation, common words relating to the
probability of an outcome, such as “may,”
“possibly,” or “perhaps,” can be easily
dismissed and negatively determine our
emotional responses. Many patients with
musculoskeletal conditions are anxious
about their future and are naturally pre-
disposed to see the negative rather than
the positive. When we are physically and
emotionally low, we not only hurt more
easily, we also seek information that sup-
ports our vulnerabilities.11 Health profes-
sionals need a keen sensitivity to the ways
in which patients hear their words and
how those words may be misinterpreted.
So, if words like “degenerative” are
problematic, how else might health care
professionals describe pathoanatomical
findings? This is a major problem, as it is
clear that the commonly used “wear and
tear” metaphor may also lead to unhelp-
ful notions of “rusty” body parts.1,18 It can
journal of orthopaedic & sports physical therapy | volume 48 | number 7 | july 2018 | 521
be helpful to look at the underlying meta-
phors shaping how clinicians and patients
think through what is happening and
what is being said. A number of research-
ers have pointed out the different meta-
phors used by clinicians and patients and
how they are used.22 The common meta-
phor of the machine is often used to rep-
resent physical changes in terms such as
“wear and tear.” This may be unproblem-
atic for clinicians, but for many patients
a machine that has “wear and tear” needs
a technical fix, and things will only get
worse if this technical fix is not provided.
This may be why so many patients are so
desperate to find such a technical fix.
Changing the underlying metaphor
to one such as “life is a journey” can
help.20,23 The emphasis in therapy then
becomes on helping people manage their
conditions (such as chronic pain) and
move on with their lives, so that some-
thing like chronic pain can be managed
in the background of their lives without
dominating the foreground and distract-
ing them from their life goals and valued
activities.15 This highlights the need for
Typical Words to Avoid
TABLE
and Alternatives for Patients
Words to Avoid
Chronic degenerative changes
Negative test results
Instability
Wear and tear
Neurological
Don’t worry
Bone on bone
Tear
Damage
Paresthesia
Trapped nerve
Lordosis
Kyphosis
Bulge/herniation
Disease
Effusion
Chronic
Diagnostics
You are going to have to live with this
clinicians to have excellent relationship
skills to help patients manage how they
interpret what is happening to them in
a positive way. All this means that in
the clinical encounter, a clinician needs
to go beyond a 1-dimensional focus on
biomedical issues and adopt a more pan-
oramic view of how the biomedical issues
fit into the world of a patient. We need
to keep asking ourselves questions such
as, “What does it all mean to them?” and
“How can I help them find a positive out-
look in this situation?” This involves the
exploration of how language can impact
social, psychological, biological, and cul-
tural factors.19 The TABLE displays a list of
typical words to avoid in musculoskeletal
rehabilitation, and suggests a range of al-
ternative terms to use with patients.
In summary, all musculoskeletal con-
ditions must be viewed within a more
comprehensive framework that takes ac-
count 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.
The words we (and our patients) use are
Alternatives
Normal age changes
Everything appears normal
Needs more strength and control
Normal age changes
Nervous system
Everything will be okay
Narrowing/tightness
Pull
Reparable harm
Altered sensations
Tight, but can be stretched
The normal curve in your back
The normal curve in your back
Bump/swelling
Condition
Swelling
It may persist, but you can overcome it
X-ray or scan
You may need to make some adjustments

crucial to this more comprehensive view.
Eccleston and Crombez8 state, “Pain is an
ideal habitat for worry to flourish.” With-
out such a reconceptualization, clinicians
will likely remain unaware of the poten-
tial harm that their words may hold. As a
result, they may continue to unknowingly
fertilize pain’s vulnerable ground. t
ACKNOWLEDGMENTS: This Viewpoint article
has benefited from the input of Professor
Elena Semino, Head of the Department of
Linguistics and English Language, Lan-
caster University, United Kingdom. We
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[ viewpoint ]
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@ MORE INFORMATION
https://doi.org/10.1007/s11999-013-3100-x 13. K ipling R. Surgeons and the soul: a speech to the
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undergraduate pain curricula for healthcare February 15, 1923. WWW.JOSPT.ORG

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