Phrases like "Your back is so tight!" or "You're so full of knots" create nocebo effects, make the nervous system feel less safe and increase muscle tension,pain and guarding.
*Nocebo is when a negative expectation or belief about a medical procedure, injury, diagnosis lead to real symptoms,fear of movement and amplified pain.
Because our nervous systems are primitive, we are functionally Neanderthals. This means (among other things)that we are highly social and our brains love a powerful story to explain uncertainty.
You are the expert in the room, when name an injury or a condition, your patient listens and they place a lot of weight on your words. Your words can change the way they feel about their body for better, or for worse.
When we use words like “dysfunction”or even something specific and technically correct, like “disc herniation” to talk about our patient’s body, they will attach meaning to it. And this meaning will impact the way they receive the treatment you are providing and the way they think about their movement, strength, mobility and overall trust in their body.
They will believe the story their brain is making from your words and their understanding and context and make this a fact.
Once we are comfortable with our knowledge, it’s hard to imagine that anyone else doesn’t know what we know. So we use terms casually and make assumptions that our patients understand the context and meaning. You may be using a technically correct medical term to describe an injury they have, they hear something scary because they don’t have the same depth of knowledge.
Pain is complex. Way more so than most of us understand. (If this is your first intro to some of this, I cover this in Day One of Nervous System Safety! There are lots of great Pain Science courses out there to deepen your understanding too.) Just because someone has some mild degeneration in their lumbar spine discs, doesn’t mean that is what’s causing their back pain. In fact at age 40, 68% of pain free people have disc degeneration. We are all walking around with tissue damage we know nothing about!
The presence of bone or soft tissue changes or even injury don’t necessarily mean that is what is causing the pain!Especially when those findings are normal for their age.
I had a patient with localized pain around her SI joint. She had some imaging done and it showed she had normal age-related disc degeneration. She was either told, or she understood that her pain was a disc herniation. But nothing about her back pain was consistent with a disc issue. She was scared that if she went to the gym her disc would “explode out of her back.” So she was avoiding movement, the thing that is the most evidence-based relief for back pain that exists.
Reframe your language to highlight healing:"As soon as an injury occurs, your body starts healing, and how you think about your shoulder is going to influence how you use it. What I see and feel is tissue that is actively healing, and it already feels healthier to me.”
We can absolutely be honest with our patients about their injuries, and we shouldn’t down-play anything that is potentially serious. (Please get help from trusted clinician when you need it!) The key is emphasizing when movement is safe and encouraging as much pain free movement as possible!
Injury is one thing, we may need to have a conversation about what to avoid, or what an injury actually is, and that may require some “negative” words. But there is never a good reason to tell someone their back is the tightest you’ve ever seen, or their hip is the least mobile you’ve seen all month. This motivates no one toward better health and it can cause harm in the way they think about their body.
I had a friend who was told by a practitioner that her low back muscle were “essentially dead and they didn’t activate at all.”I don’t even know where to start with this. All it did was dramatically increase her anxiety about her (relatively mild) back pain and make her feel like she was at risk of damage at all times. Meanwhile, all I had to do to show her her back muscles worked was have her place one hand on her lower back and move the other arm in circles at shoulder height. This simple exercise proved to her that her back muscles worked just fine. I get mad just thinking about it!
This is what I say: “It’s way more important what it feels like to you! Sometimes I can feel what you are describing but I can’t always, muscle tension is actually pretty subjective.This tissue feels very similar to the tissue around it and on the other side of the body to me. That doesn’t mean what you are experiencing isn’t real, it just means that I can’t feel any evidence of injury or damage here.”
If I feel they need validation that their experience of that area is real I might say: “I can feel a bit of tension inhere, but this joint is moving well, there’s no heat or swelling, and the tissue isn’t grainy or scarred.”
Now what if the tissue really does feel “bad?” Well it depends how bad! If I’m worried that they are injured and won’t recover in a normal amount of time, I will refer them to someone who can properly diagnose. (Massage therapists don’t diagnose in my jurisdiction) If it just feels dense and hypertonic, I might say: “This tissue does feel tight tome, but muscle tension isn’t necessarily a bad thing, my whole body feels like this. (happens to be the truth!) If it’s not causing you pain during movement and exercise, you don’t need to be worried about it.” And then if we work together and do some nervous system safety work and their tissue feels better to them I’ll make sure they know that massage doesn’t “fix” anything and that this tissue is healthy enough to respond well to some brief work, therefore it’s healthy tissue!
If you want more guidance and skill in this area, my small group, online mentorship starts in November. We will cover this in detail!
You can find out more and sign up here: Mentorship
