Athletic Training and Sports Health Care

Pearls of Practice 

The Power of Words

Tim Reynolds, PT, DPT, OCS, CSCS

Abstract

It is every athlete's biggest fear. The buckling of a knee, the twisting of an ankle, or a pop within the shoulder can not only impact a player's physical health, but can also wreak havoc on their mental psyche. Questions such as, “Will I be able to play again?” or “Am I going to make it worse?” often race through their mind, creating an environment for worry, fear, and uncertainty to flourish. Although these questions are completely normal to ask, sometimes it is other people's word choices about their injury that can significantly impact their road to recovery.

For example, Sally Smith is a 15-year-old basketball player who goes to her sports medicine provider to have her knee evaluated. She points to her kneecap, says “it hurts to squat and go down stairs,” and undergoes a thorough assessment. All signs point toward patellofemoral pain syndrome, and the clinician starts off by saying, “Well, your knee cap isn't tracking right. You're getting pain because the back side of the patella is grinding on your femur, which is what is causing your pain.”

The potential issue with these statements within this hypothetical scenario is that they are known as “nocebos,” which, essentially, are various factors that can negatively impact a patient's outcomes.1 Elements as simple as a clinician's reputation, choice of clothing, and, most importantly, word choice, all can impact the course of treatment. For example, the phrases “isn't tracking right” and “grinding on your femur” may instill fear into the patient's mind, which as a result can reduce their willingness to exercise or participate in their sport. Other phrases commonly used by medical professionals and patients are listed in Table 1.

Examples of Nocebos Commonly Used in Health Care Settings

Examples of Nocebo Word Choices and Viable Alternatives…

It is every athlete's biggest fear. The buckling of a knee, the twisting of an ankle, or a pop within the shoulder can not only impact a player's physical health, but can also wreak havoc on their mental psyche. Questions such as, “Will I be able to play again?” or “Am I going to make it worse?” often race through their mind, creating an environment for worry, fear, and uncertainty to flourish. Although these questions are completely normal to ask, sometimes it is other people's word choices about their injury that can significantly impact their road to recovery.

For example, Sally Smith is a 15-year-old basketball player who goes to her sports medicine provider to have her knee evaluated. She points to her kneecap, says “it hurts to squat and go down stairs,” and undergoes a thorough assessment. All signs point toward patellofemoral pain syndrome, and the clinician starts off by saying, “Well, your knee cap isn't tracking right. You're getting pain because the back side of the patella is grinding on your femur, which is what is causing your pain.”

The potential issue with these statements within this hypothetical scenario is that they are known as “nocebos,” which, essentially, are various factors that can negatively impact a patient's outcomes.1 Elements as simple as a clinician's reputation, choice of clothing, and, most importantly, word choice, all can impact the course of treatment. For example, the phrases “isn't tracking right” and “grinding on your femur” may instill fear into the patient's mind, which as a result can reduce their willingness to exercise or participate in their sport. Other phrases commonly used by medical professionals and patients are listed in Table 1.

Examples of Nocebos Commonly Used in Health Care Settings

Table 1:

Examples of Nocebos Commonly Used in Health Care Settings

At times an individual's back pain may be influenced by lumbopelvic strength, or squatting may be contraindicated following certain surgical procedures. Practitioners must be mindful about the way in which these statements are made, because they are often perceived as the “end all be all” by patients, especially following an injury. Providing additional education such as tissue healing timeframes and injury prognosis may help assuage the athlete's concerns.

The use of nocebos may be detrimental to some of our patients, not only by instilling fear, but also from a physiological standpoint. Ritter et al2 noted that when patients with chronic low back pain read pain-related words, there was greater activation of the part of the brain that senses pain compared to when they read less threatening words. Swannell et al3 found that people perceived a heat laser stimulus as more painful after reading these similar painful words. Now imagine what we have the potential to do to the psychological state of our athletes if we are using words such as “grinding,” “pinching,” or “torn.” The words we use can unintentionally “add fuel to the fire” and augment an athlete's pain experience in ways that are often hard to appreciate or measure, but they are real and will impact patient outcomes. There are times when the severity of the pathological tissue injuries must be acknowledged, as is the case with an anterior cruciate ligament rupture. Medical professionals can still educate the athlete on this pathology in an empathetic manner, which may significantly reduce the stress and fear associated with the scenario.

Not only can our words increase our athletes' pain, but the fear induced by pathological language can increase stress, which can impact their overall recovery process. Marucha et al4 examined the effects of stress on wound healing. The researchers created punch biopsy wounds on the hard palate of students during two different scenarios: one at the beginning of summer vacation and the other 3 days before an examination. The researchers then tracked how long it took each of the wounds to heal, and compared results between the two scenarios. Findings indicated that the wounds made days before the examination took approximately 40% longer to heal.4 These were the same type of wound on the same person, and all that changed were the situational stressors. Think how stressed your athletes are if they are coping with an injury and can't compete, and you keep reinforcing how weak they are, that their muscles are underactivated, or how damaged their body is. The words we use may roll off the tip of our tongues, but those on the receiving end may have a hard time letting them go.

Table 2 provides common pathological word choices that can serve as nocebos for our athletes, and some alternative ways to present the information. Although this isn't a complete list, it provides a framework that may offer a more person-centered approach. Think about the words that you commonly use, and ask yourself how negative they are, or if they seem overtly threatening. Sometimes educating the athlete on the severity of an injury is necessary to ensure the appropriate rehabilitation measures are taken, but the delivery of these words must be tactful. Whoever said, “Sticks and stones may break my bones, but words will never hurt me” lied, and we have to think of the powerful impact our words can have on those around us.

Examples of Nocebo Word Choices and Viable Alternatives

Table 2:

Examples of Nocebo Word Choices and Viable Alternatives

References

  1. Testa M, Rossettini G. Enhance placebo, avoid nocebo: how contextual factors affect physiotherapy outcomes. Man Ther. 2016;24:65–74. doi:10.1016/j.math.2016.04.006 [CrossRef]
  2. Ritter A, Franz M, Puta C, Dietrich C, Miltner WH, Weiss T. Enhanced brain responses to pain-related words in chronic back pain patients and their modulation by current pain. Healthcare (Basel). 2016;4(3):54. doi:10.3390/health-care4030054 [CrossRef]
  3. Swannell ER, Brown CA, Jones AK, Brown RJ. Some words hurt more than others: semantic activation of pain concepts in memory and subsequent experiences of pain. J Pain. 2016;17(3):336–349. doi:10.1016/j.jpain.2015.11.004 [CrossRef]
  4. Marucha PT, Kiecolt-Glaser JK, Favagehi M. Mucosal wound healing is impaired by examination stress. Psychosom Med. 1998;60(3):362–365. doi:10.1097/00006842-199805000-00025 [CrossRef]

Examples of Nocebos Commonly Used in Health Care Settings

My pelvis is “unstable” and “out of alignment.” They said it is “bone-on-bone.” I was told to never lift over 10 pounds again. Bending that way will hurt your back. Squatting is bad for your knees. You have back pain because your core is weak.

Examples of Nocebo Word Choices and Viable Alternatives

NoceboAlternative
InstabilityMovement coordination
DegenerativeChronological changes
ChronicPersistent
PinchedIncreased pressure
WeaknessStrength changes
PainSymptoms
MisalignedStructural positioning
UnderactivatedMotor coordination
RupturedIntegrity changes
Authors

From Ithaca College, Ithaca, New York.

The author has no financial or proprietary interest in the materials presented herein.

Correspondence: Tim Reynolds, PT, DPT, OCS, CSCS, 953 Danby Road, Ithaca, NY 14850. Email: t.reynolds1026@gmail.com

10.3928/19425864-20201022-02

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