To clarify from the off, I loathe the suggestion that ‘the pendulum has swung too far’ when it comes to professional and societal understandings of pain, function and more broadly, human health. BUT, I am certainly concerned about the tactics being used by some ‘thought leaders’ and their followers as they try to move beyond the ‘hurt equals harm’, tissue-centricity that remains commonplace. This concern is related to their apparent willingness to implement whatever strategies they like to achieve this goal; at times this includes the overlooking of both logic and evidence.
To simplify a little, I’ll focus specifically on what I see as a self-induced phobia of talking about human anatomy. An example to set the scene:
A 30 year old laborer was assessed by a therapist following an injury at work. He was in a tight corner lifting breeze-blocks that would normally require assistance but instead, he tried to wiggle it out of the space alone. He did so with a flexed and rotated spine then felt sudden back and leg pain which he had not experienced before. A few weeks have passed with little resolution, he is now off work and, as is the nature of modern society, every friend, family member and shopkeeper’s dog have given their take on diagnosis and proposed solution. Fortunately (ish) he has seen his GP who has prescribed some medication and advised him to avoid bed-rest. His social consensus diagnosis of ‘slipped-disc-trapped-nerve’ is neither supported nor refuted by his doctor but fortunately (ish) he was encouraged to see a local Physiotherapist.
4 weeks later, subjective assessment by said Physio reveals significant concerns regarding work, sport, general ADL function and what the future might hold for him. All of which are completely legitimate and sensible concerns when efforts are made to view the problem through the patient’s eyes, especially in light of his current education regarding pain, injury and bioplasticity. Objective assessment reveals certain directional and positional preferences, tenderness in the lower lumbar spine and buttock, a positive straight leg raise but fortunately, no sign of significant neurological compromise such as myotomal weakness, reflex changes or overt sensation loss.
Now it is far beyond the scope of this blog and far beyond the reach of my current patience to discuss exactly how this patient should be treated and managed. Instead I will draw a line in the sand here and say that in my opinion, any failure to explain the likelihood of this man having had a disc injury that is affecting a nerve root is nothing short of dishonest.
How we go about doing this is where the conversation gets interesting of course, but any purposeful avoidance of the words that the patient brought to the conversation, is linguistic gymnastics that are very likely to make you (as well as the team, company and profession that you represent) look like idiots.
We now treat discussions with patients regarding anatomy, tissue physiology and structural injury with kid gloves. While our good intentions make us sensitive to the contemporary understanding of pain, and keep us from labeling disruption of structure as the only causal factor in pain experience, I argue that we are beginning to do society and our profession a gross disservice.
And so to my naming of this blog and the suggestion that many in the MSK industry are succumbing to what I call ‘The Voldermort Effect’.
Odd as the comparison may sound at first, failure to discuss structural injury, at least initially, in the terms that the individual has come to understand it, is doing the same disservice that members of the magic community did by refusing to mention Voldemort’s name in JK Rowling’s Harry Potter books. By refusing to label him, they prevent an open and honest discussion from taking place about possible solutions. And that is where mainstream Physio reformers find themselves today with regards to morphological and patho-physiological lexicon. The idea that we must avoid words that are well established in society due to fear of mortally wounding patients is rank hypocrisy that patients are very likely to see through.
How does this sound?:
“Your body is strong and robust with a wonderful capacity to adapt to the stresses and strains placed upon it. It will adapt regardless of your age and given the right stimuli, it is amazing what biomechanical and morphological quirks it can accommodate.
But your mind will latch irrationally onto words, regardless of the context in which they are discussed. Because unlike your body, your mind is invariably fragile and so we mustn’t take any chances.”
This ‘new-age dualism’ is bound to push patients back towards the pseudo-truth-tellers who, through ignorance and/or laziness and/or profiteering, will continue to attribute cause of pain to specific tissues.
‘He who shall not be named’ came back with a vengeance and the denial of his existence facilitated his reincarnation. Similarly, the failure to discuss anatomical structures in a patient’s own familiar terms is bound to give fuel to our nemeses and thwart the progress that we all dream of.
I must point out that I have landed on this analogy through my interest in Liberal Democrat MP candidate; Maajid Nawaz who makes the same comparison to President Obama’s inability to name recent acts of global terrorism as ‘Islamic Extremist Terrorism’. I welcome you to draw the parallels between our causes, as always, I have my take, but most importantly it would be unfair of me to not mention his influence on my use of the term. So if you’re interested, this short clip explains his own use of the analogy very well: https://www.youtube.com/watch?v=6BQWqFyRpFQ
And yes, I’m suggesting we should talk about structures regardless of presentation and duration of symptoms if that’s what the patient wants to talk about. Because patients kind of matter in the whole ‘getting better’ process, right? The merry dance that some clinicians have found themselves doing to avoid certain words is very impressive, but the notion that a therapist would be admired for opening their explanation of assessment findings with ‘well, pain is emergent and we’ve come to understand that every person is influenced by biological, psychological and social factors’ makes me shudder and genuinely fear for the future sanity of my soon to be burnt-out colleagues.
I’ve long banged the ‘mind your language’ drum across all media, but I would suggest that I’ve been misunderstood if it has been thought that my mission is police language in an oppressive manner.
Mainly because words are just words.
Many are aware of the brilliant research of Ben Darlow and others regarding the impact that language can have on patients; and I am not for a second countering this work, since I have long promoted it. However I feel that a simple but intellectually dishonest interpretation of such work has infected the minds of many well-meaning reformers who seem to attribute power to words that they simply don’t have.
Words are just a series of letters. Letters are just a series of lines. It is our history, culture, language, consciousness, emotional maturity and many more factors that have led to some words having more meaning and connotations attributed to them than others. Forgive my over-simplification here but it is through this complex sociological process, coupled with complex individual biological and even metaphysical processes that some words can sometimes influence beliefs.
(This is what makes language so incredibly interesting, but I won’t assume that anyone is nearly as geeky as I am about the topic, so I’ll skip a chapter on linguistic theories… this time.)
But I can’t help but prioritise a plea for recognition of the widely respected concept that it is when words influence beliefs and when beliefs influence behavior that we should be most interested. Because these processes of influence can be demonstrably affected by our interactions, and therefore the impact that we have on any individual’s life.
I agree that clumsy use of jargon and structural reasoning has clearly demonstrated that we can have deleterious effects on these processes, but the answer is surely not to kick back so hard against it, as to stop using words altogether?!
How about we instead aim for honesty? Human pursuit of truth is an incredible thing so why not aim for delivery of our very best guess at that moment in time?
This approach means that using the term ‘crumbling’ to describe a spine remains off the table, because it’s dishonest. But using the terms ‘bulge’ or ‘fracture’ surely can’t have such deep-rooted negative connotations that they mustn’t be uttered in case they do irreparable damage, even when they are immediately placed in context?
Failure to talk about Voldermort did nothing to contribute to his existence and if anything, it fuelled the fear and mystery surrounding his power. We are seeing language being policed in all walks of life contributed to by ‘social justice’ movements and a new wave of Marxists suggesting oppression where it doesn’t exist. So instead of inventing our own brand of ‘political correctness’, could we instead reclaim the words, reframe them, attach reassurance to them, add humour to them, laugh at our historic mistakes and drive a process in which we are honest with our fellow human beings about what we think is going on at any given time?
In a recent in-service training session with the brilliant IPOPS band 6 team, we discussed the concept of individuals and groups being happy to promote or condone dishonesty if they perceive it to be in the ‘right direction’. This is a dirty tactic that we surely can’t succumb to at an N=1 level in clinic.
We all have our favorite topics attached to our specific agendas, especially on social media. The ease of the retweet to support our general narrative is something than no-one is immune from. But at a clinical level at least, a push for balanced honesty is surely the only way to stop the swinging pendulum of patient education becoming a wrecking ball.
In a nutshell: think hard, be critical, be reflective and then say what you want!*
*Including about this piece!