The Negative Language of Back Pain

“Patient complaints that originate in the musculoskeletal system usually have multiple causes responsible for the total picture.” -Drs. Travell and Simons
“The first treatment is to teach the patient to avoid what harms him.” -Karel Lewit, MD “He who treats the site of pain is lost.” -Karel Lewit, MD
After seventeen years of running a private rehabilitation clinic, I’ve seen my share of back pain in my patients. It is one of the most common ailments I see, but it is also one of the most misunderstood concepts for the patient, mainly because of the confusing, and often negative, language in the medical field. Patients with back pain – much like pain anywhere in the body- are confused about why it exists: “How did it happen?” “I woke up with this,” are common statements. When the healthcare provider informs them “your back is out,” or “you have stenosis,” and “you have degenerating disks,” the patient assumes the worst ( “I’m degenerating?”). While these physical items might very well exist, and yes, back pain can be related, chances are the patient’s pain has nothing (or very little) to do with them. Yet the patient is told an MRI is “bad” because a disk is herniated (recent studies show that patients with herniations have no pain related to them).1 The patient begins to believe he or she is doomed. After an MRI is ordered – and they are processed at an alarming and completely superfluous rate in the United States 2 – the patient is hit with an onslaught of impossible medical jargon. Does the patient need to spend time listening to the radiologist so she can have a better understanding of the issues? Yes, but the delivery of such information needs to be filtered and converted into a more positive and educational bits. Over the years, many MRI reports I’ve read showed a myriad of structural changes (spondylolysis, lumbar stenosis, protruding disks, et al), yet in my own clinical experience most of the patient’s pain was not a result of these physical findings. Yet the MRI places the patient into an anxious mindset for therapy because of these “physical” findings and their foreboding visuals of “it,” the one thing that is the cause of it all. I’ve seen it again and again, the patient in obvious jabbing pain, unable to sit comfortably, pushing the MRI report in front of me exclaiming, “It’s the stenosis.”
The first thing I try to do when a patient brings in an MRI report is help relieve some of the anxiety associated with a “bad” MRI. For any therapy to take place, the clinician must establish a positive mind-set for the patient from the initial evaluation. I do this in part by explaining, in layman’s terms, how soft tissue reacts to stresses of the skeletal system, and how structural changes to the spine often are not the issues causing the back pain. I try, ultimately, to get her mind off that one thing that she believes is the problem. For example, I’ve had many lumbar stenosis patients who do not have every symptom of pseudoclaudication, but have a thoracolumbar muscle region that is completely dysfunctional. Yet most physicians overlook this. (And others, too. At a recent physical therapy symposium I attended, I asked the physical therapist who taught a course on back pain if he ever considered the sacral ligaments and related soft tissue in his manipulations. “No,” he said, “They really are not important.” Huh?) I also explain to the patient that, while we cannot eliminate the stenosis or structural change, we can focus on releasing the thoracolumbar area to relieve the pain and postural dysfunction. (That’s why massage therapy is so effective for back pain. See the story on NPR.) I have improved pain and quality of movement in my patients on this very premise, and have reproduced this result over and over in patients who thought they were destined for surgery. So “bad” MRI’s are not necessarily a ticket to debilitation and poor quality of life, and the patient, once she understands this, is in a remarkable position to improve her dysfunction.
Some of the Poor Language of Back Pain
• Your back is not “out.” This is one of the most common phrases I hear both told to and from
patients, and it’s understandable why it is used by the patient. The patient may often feel something is “out” when the thorocolumer region is in spasm. If disks are misaligned, research shows they will resolve themselves over time, sometimes with a little self-help. 1
• You are not “degenerating.” Yes, our bones undergo arthritic changes as we age, which means we need more muscle stability to help protect them, but we are not literally disintegrating.
Patients are not damaged but have dysfunction!
• It did not happen over night. While it might seem as though the pain suddenly developed over night, usually this is not the case. Soft tissue dysfunction has a snowballing effect; it develops from a single event that gets worse over time. 3
• Does the patient really need an MRI? Getting a second opinion is always a good idea. I recently visited a podiatrist to get a mucoid cyst removed from my second toe. He insisted he must order an MRI, even though it is one of the most common cysts that occur on the hands and feet. (I refused and the cyst resolved itself.) Radiological films are always a good start, too.
Timothy Agnew
1. Cherkin D, Deyo R, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic
manipulation, and provision of an educational booklet for the treatment of patients with low back pain.
N Engl J Med 1998;339:1021-9.
2. Magnetic resonance imaging and low back paincare for medicare patients. Baras JD, Baker LC.
Health Aff (Millwood). 2009 Nov-Dec; 28 (6):w1133-40
3. Bogduk N, Twomney L. Clinical Anatomy of the Lumbar Spine. Churchill Livingstone