The Force is strong in you

desember 21, 2017
Posted in forskning
desember 21, 2017 jevnehelse

“Fear is the path to the dark side. Fear leads to anger. Anger leads to hate. Hate leads to suffering.”
– Yoda

Clinicians possess enormous power. The power to bend the minds of others. The power to plant an idea, nurturing it and watching it spring to life and manipulating the behaviour of its host.

As a clinician, you have the power of words. Like the young Luke Skywalker you have a choice.

Will you use your power for good or evil?

The Berlin Wall of health care

“Information asymmetry” is an overlooked problem in health care. Kenneth Arrow, a Noble Prize winner in Economics, described the phenomenon as the severe disadvantages that people face when they know less about a commodity than the seller does.

This holds true in many aspects of life. From banking to housing, from couches to cars. Yet, one of the most frightening displays of competency difference is seen in health care.

The gap between the knowledge of the clinician and most patients´ proficiency to understand health information is so vast, that patients face gruelling odds [1]. An alarming minority of patients is actually able to receive, analyse and interpret information critical for their own health and well-being. In other words, patients are by all accounts totally and unequivocally at the mercy of the clinician in front of them.

This raises some serious dilemmas. Clinicians can recommend care of little or no value because:

  • It is financially rewarding
  • It is easy and it keeps patients satisfied
  • Professional indolence has caused auto-pilot habits
  • They genuinely (but incorrectly) believe in the actual service they are providing

For decades health literacy has allowed clinicians to assume a God-like status. Even in cases where evidence is scarce or completely missing, clinicians can quietly build a bubble of self-glorification without protest or scrutiny.

The uninformed public

The extent of misconceptions regarding musculoskeletal pain is well documented [2-7]. In turn, this emphasizes the important role clinicians have in providing accurate health information. Our language and explanations must respect the knowledge on health literacy and should be adapted accordingly [8].

Unfortunately, current research paints a bleak picture of clinicians’ execution of care:

  • Practice is frequently (and increasingly) discordant with clinical guidelines [9]
  • Many clinicians use wrongful and nocebic explanatory models for pain [10]
  • The first line of clinicians tend to deliver inferior care [11-13]
  • Clinicians’ biases matter more for management than evidence [14-17]
  • Marginal imaging abnormalities are used for explaining pain [18-20]

Nocebo dictionary

While an ocean of unanswered questions remains in MSK management, there is still a lot we can do with the cards we have been dealt.

But we cannot even hope to battle misconceptions among the general public if we do not rummage into our own professional beliefs and biases. While many clinicians spend years of their life to practice their manual techniques and palpation skills, surprisingly few will ever do a course in patient communication. On the contrary, most clinicians consider their communication to be top-dollar.

Unfortunately, what you say to patients and what they actually hear might be worlds apart. So here is a first glimpse of our patent-pending (just kidding) “Nocebo dictionary” (you might want to rethink using these phrases in the clinic):

“It´s just wear and tear.”
“That exercise will explode your disc.»
“You have the back of a 70 year old.”
“You’re degenerated.”
“It´s bone on bone.”

This sort of communication, where patients’ minds are polluted with the idea that our body is a fragile piece of pinewood, is associated with worse outcomes. And the above mentioned nocebo-classics paired with…

“You should be careful from now on.”
“You should avoid bending or lifting.”

And voila. A recipe for a disability disaster.

How to avoid the Dark Side of Communication

In making sure your power are used for good, here are some key points you might want to consider:

  1. Build resilience – not restrictions. The capacity of the human body is extraordinary and your communication with patients should reflect this. Use powerful and positive communication to build confidence, not insecurities. Do not trivialize their pain perception or worries, but avoid language suggesting they need protection. Explain pain in light of current neuroscience, without overcomplicating things. Use language that emphasizes their resources and what they CAN and deliberately tone down what they CANNOT.
  1. Focus on function – not structure. For decades clinicians have pointed to marginal asymmetries to explain pain. This view is outdated and evidence clearly illustrates how this does more harm than good. Focus more on patients´ abilities and resources and stress this in your communication. Do not let them leave thinking they have short legs or locked pelvises. Use communication to get them to MOVE. Pain upon movement is rarely a sign of true damage and more often a sign of sensitization in the majority of MSK presentations.
  1. Use goal-setting to trigger motivation. In keeping with a focus on your patients´ strengths and resources, work together with your patients to set high, but realistic goals. Let your thorough history guide you in this work and you will be surprised how varied patient goals are. Some just want to be able to sit on the floor again to play with their kids. Some want to get back to walking in the woods with their spouse. Some will simply want half an hour a day where they do not worry about their pain. Display empathy and understanding towards their individual goals and more importantly give them tangible strategies to accomplish them.
  1. Remember health literacy – use metaphors. We know that metaphors work better than plain language when educating patients on health concepts. Explain how many imaging findings are normal parts of aging, like wrinkles on the face or grey hair. Elaborate on how the acute back pain can be considered an “ankle sprain of the back”. Make sure you use metaphors that amplifies your positive message and that further fuels a belief that movement is safe and effective for relieving pain.
  1. Use visual aids. Following point 4) ensure you use easy-to-understand visual aids to help your explanations to patients. Again, strive to communicate a positive message, where you do not overemphasize structural damage. In stead, conceptualize their condition around the need for movement and future possibilities.
  1. Test your patients. Ask them to explain back to you what you have told them. This is a great opportunity to untangle potential misunderstandings that have emerged during your consultation. A great example is The Kieran O´Sullivan (@kieranosull) test, where the patient is asked to imagine the clinician being a family member or loved one and explaining back to the clinician the main points of the consultation.



  1. Koh, H.K. , Rudd, R.E.: The Arc of Health Literacy. JAMA, 2015.
  2. Franz, E.W., Bentley, J.N., Yee, P.P., Chang, K.W., Kendall-Thomas, J., et al.: Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine, 2015. 22(5): p. 496-502.
  3. Darlow, B., Perry, M., Stanley, J., Mathieson, F., Melloh, M., et al.: Cross-sectional survey of attitudes and beliefs about back pain in New Zealand. BMJ Open, 2014. 4(5): p. e004725.
  4. Rainville, J., Smeets, R.J., Bendix, T., Tveito, T.H., Poiraudeau, S., et al.: Fear-avoidance beliefs and pain avoidance in low back pain–translating research into clinical practice. Spine J, 2011. 11(9): p. 895-903.
  5. Darlow, B., Dean, S., Perry, M., Mathieson, F., Baxter, G.D., et al.: Easy to Harm, Hard to Heal: Patient Views About the Back. Spine (Phila Pa 1976), 2015. 40(11): p. 842-50.
  6. Jenkins, H.J., Hancock, M.J., Maher, C.G., French, S.D., Magnussen, J.S.: Understanding patient beliefs regarding the use of imaging in the management of low back pain. Eur J Pain, 2015.
  7. Hoffmann, T.C. , Del Mar, C.: Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review. JAMA Intern Med, 2014.
  8. Hoffmann, T.C., Montori, V.M., Del Mar, C.: The connection between evidence-based medicine and shared decision making. JAMA, 2014. 312(13): p. 1295-6.
  9. Mafi, J.N., McCarthy, E.P., Davis, R.B., Landon, B.E.: Worsening trends in the management and treatment of back pain. JAMA Intern Med, 2013. 173(17): p. 1573-81.
  10. Darlow, B., Dowell, A., Baxter, G.D., Mathieson, F., Perry, M., et al.: The enduring impact of what clinicians say to people with low back pain. Ann Fam Med, 2013. 11(6): p. 527-34.
  11. Darlow, B., Dean, S., Perry, M., Mathieson, F., Baxter, G.D., et al.: Acute low back pain management in general practice: uncertainty and conflicting certainties. Fam Pract, 2014. 31(6): p. 723-32.
  12. Buchbinder, R., Staples, M., Jolley, D.: Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine (Phila Pa 1976), 2009. 34(11): p. 1218-26; discussion 1227.
  13. Briggs, A.M., Slater, H., Smith, A.J., Parkin-Smith, G.F., Watkins, K., et al.: Low back pain-related beliefs and likely practice behaviours among final-year cross-discipline health students. Eur J Pain, 2013. 17(5): p. 766-75.
  14. Houben, R.M., Ostelo, R.W., Vlaeyen, J.W., Wolters, P.M., Peters, M., et al.: Health care providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. Eur J Pain, 2005. 9(2): p. 173-83.
  15. Nijs, J., Torres-Cueco, R., van Wilgen, C.P., Girbes, E.L., Struyf, F., et al.: Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician, 2014. 17(5): p. 447-57.
  16. Nijs, J., Roussel, N., Paul van Wilgen, C., Koke, A., Smeets, R.: Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther, 2013. 18(2): p. 96-102.
  17. Nijs, J., Paul van Wilgen, C., Van Oosterwijck, J., van Ittersum, M., Meeus, M.: How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: practice guidelines. Man Ther, 2011. 16(5): p. 413-8.
  18. Brinjikji, W., Luetmer, P.H., Comstock, B., Bresnahan, B.W., Chen, L.E., et al.: Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol, 2014.
  19. McCullough, B.J., Johnson, G.R., Martin, B.I., Jarvik, J.G.: Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology, 2012. 262(3): p. 941-6.
  20. Bossen, J.K., Hageman, M.G., King, J.D., Ring, D.C.: Does rewording MRI reports improve patient understanding and emotional response to a clinical report? Clin Orthop Relat Res, 2013. 471(11): p. 3637-44.