Case of the Month #33: Exploring Patient Stories, Language and Communication

We now present several relevant and interesting papers that help us navigate the difficulties with helping patients understand their complex symptoms and move forward with their persistent pain:

1. Christe G, Pizzolato V, Meyer M, Nzamba J, Pichonnaz C. Unhelpful beliefs and attitudes about low back pain in the general population: A cross-sectional survey. Musculoskelet Sci Pract. 2021 Apr;52:102342. 
   https://www.sciencedirect.com/science/article/pii/S2468781221000266?via%3Dihub

   This survey demonstrated the presence of high levels of unhelpful beliefs about low back pain (LBP) and found beliefs were comparable across a range of demographic variables, regardless of the presence or absence of LBP. While people generally believed that staying active is important with LBP, they also thought that the back needs protection and is easy to injure. The authors suggest that information about LBP should go beyond general messages such as staying active with LBP and should directly target the unhelpful beliefs found in this survey, together with promoting helpful behaviour and attitudes about LBP.  
    

2. Darlow B, Brown M, Thompson B, Hudson B, Grainger R, McKinlay E, Abbott JH. Living with osteoarthritis is a balancing act: an exploration of patients' beliefs about knee pain. BMC Rheumatol. 2018 Jun 12;2:15.
   https://bmcrheumatol.biomedcentral.com/articles/10.1186/s41927-018-0023-x

   This study aimed to explore patient’s with knee osteoarthritis (OA) beliefs about the disease, how these beliefs had formed and what specific impact these beliefs had on activity participation, health behaviour, and self-management. The authors report that those with knee OA are often cautious of physical activity due to fear of accelerating joint degradation and these beliefs conflict with research demonstrating that exercise improves cartilage volumes, is safe for people with OA, and improves pain and function. They conclude that participants’ biomechanical models of OA and expectations of inevitable decline were influenced by clinicians’ language and explanations. These beliefs reduced participant exploration of management options and underpinned a perceived need to balance competing values.
    

3. O’Keeffe, M., Michaleff, Z.A., Harris, I.A. et al. Public and patient perceptions of diagnostic labels for non-specific low back pain: a content analysis. Eur Spine J 31, 3627–3639 (2022).
   https://link.springer.com/article/10.1007/s00586-022-07365-x

   This paper summarises the authors’ work examining participants’ thoughts/feelings and expectations for treatment evoked by the diagnostic labels. They suggest that clinicians should consider avoiding the labels ‘disc bulge’, ‘degeneration’ and ‘arthritis’ and opt for labels that are associated with positive beliefs and less preference for surgery, when communicating with patients with LBP. 
    

4. Mankelow J, Ravindran D, Graham A, Suri S, Pate JW, Ryan CG, Martin D. An evaluation of a one-day pain science education event in a high school setting targeting pain related beliefs, knowledge, and behavioural intentions. Musculoskelet Sci Pract. 2023 Aug;66:102818. 
   https://www.sciencedirect.com/science/article/pii/S2468781223001030?via%3Dihub

   This paper describes a one-day pain science education event in a high school setting, delivered as part of a public health campaign. The authors concluded the event was associated with improved sixth form/high school student pain beliefs, knowledge, and behavioural intentions in the short-term. Qualitatively, students reported limited prior awareness of persistent pain. Post education, students felt they understood persistent pain better and the need for a holistic approach to treatment. 
    

5. Gilad J Regev, Roi Treister and Silviu Brill et al. Low Back Pain Patients’ Perceptions Regarding Their Own Radiology Reports: Pre-Intervention Survey. J Pain Res. 2023. Vol. 16:933-941.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10029370/

   The authors of this paper aimed to evaluate three domains related to patients with lower back pain: the patients’ perceptions, misconceptions and the experience of anxiety-related symptoms following direct access to their thoraco-lumbar spine radiology report. An additional aim was the assessment of possible associations with catastrophisation. They report that, although patients stated a strong desire to review their radiology report without the mediation of their treating physician, they tended to exaggerate the severity of the reported radiological findings that provoked unnecessary anxiety symptoms, especially in patients with a tendency for catastrophic thinking.
    

6. Munday I, Newton-John T, Kneebone I. 'Barbed wire wrapped around my feet': Metaphor use in chronic pain. Br J Health Psychol. 2020 Sep;25(3):814-830.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7496857/

   This paper looked at metaphor use in pain. As there is no objective test for pain, sufferers rely on language to communicate their pain experience. Pain description frequently takes the form of metaphor. The authors found participants utilised a wide variety of metaphors to describe their pain and the most common descriptions couched chronic pain in terms of physical damage. They conclude that better understanding of pain metaphors may have implications for improved health care communication and provide targets for clinical interventions.
    

7. Hovey RB, Khayat VC, Feig E. Listening to and letting pain speak: poetic reflections. Br J Pain. 2018 May;12(2):95-103.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5958513/

   This article provides an invitation to learn how we might articulate and listen to pain carefully and differently. The authors’ work helps us to understand the complexity of the lived pain experience; we need to understand the pathology pain while also being mindful of suffering.
    

8. Moseley GL, Butler DS. Fifteen Years of Explaining Pain: The Past, Present, and Future. J Pain. 2015 Sep;16(9):807-13.
   https://www.jpain.org/article/S1526-5900(15)00682-3/fulltext

   This paper by Moseley & Butler describes Explaining Pain not as a technique but a range of educational interventions. The authors’ work aims to change understanding of the biological processes that underpin pain and to emphasise the distinction between nociception and pain. They describe their work to emphasise pain is a protective mechanism, not an indicator of tissue damage and use education to increase pain-related biological knowledge and decrease catastrophising.