The problem with nocebic language

Nocebic language? What? Is Tim making words up now?
Ok- let’s back up a little bit and start with an old saying.
Sticks and Stones may break my bones but words shall never hurt me.

This is perhaps not the most truthful of statements, as pretty much anyone can attest. Ok, so words can hurt you emotionally- but they can’t hurt you physically… can they?

Nocebo is the opposite of placebo. A harm inducing practice. Nocebic language is pretty much an encouragement to harm. Why would any health professional say something that might harm you? It might seem strange to think, but this does happen. They might not do so intentionally, but there are situations when harm can occur through the language people (specifically in medical practice) use.

As an example, the amount of people who come through my door with painful shoulders who have “rotator cuff tears” is fairly high. They might be climbers, rugby players, housewives, whatever, it doesn’t matter. What they have been told is “you have a Rotator cuff tear”.
The internal monologue might go a little like this:
“A Tear? In my rotator cuff? That sounds pretty serious. No wonder it hurts. I’ll probably need surgery. I’d better not do anything that might make it worse…. Rest. Repair. Etc.”

But hang on. Once someone has the word “tear” associated with a rotator cuff (whatever that might be in their mind’s eye), they have the image of a torn piece of paper. Hanging on by a thread. This has a significant effect on how they see and use their shoulder and arm- not just in the present, but in the future as well.

I’m not going to pass judgement on whether or not someone actually has a tear or not- at least- not in this blog.
In an email conversation with a shoulder specialist physio about this topic, this gem was received:

“I think the bottom line is unless the patient has fallen over or had significant trauma followed by immediate loss of range of movement /function and onset of pain, a tear is not relevant until someone fails treatment and arguably rarely then!
Sprain or strain is a much better descriptor from a patient perspective- this issue is stopping them being imaged unnecessarily and being told about a tear that just reflects age related change. When you look at the prevalence of tears it is far more likely to have one that never causes you problems than one that needs surgery”.

Now that is fairly unambiguous. How about labelling?

“It is not clinically necessary to have the label or call it a tear ( as anyone over 50 is highly likely to have one that is irrelevant anyway) and ideally we need to stop using this label … apart perhaps from those traumatic tears ( when surgery is being considered) and those that perhaps have a degenerative tear that then have trauma- significant overstretch /trip etc- however the issue is amongst GP’s and many consultants the belief in structure still pervades. Our challenge is to undo the negatives and help patients find a positive reframing to set them up for success.

Even in trauma- only about 40 % actually have surgery and for the non traumatic – physio is generally as successful but takes longer than an acute shoulder pain”.

Well crikey. Look at that. Someone else that thinks that the term is not necessarily a good idea. Having seen a number of people who relate certain words to pretty negative consequences, and make themselves worse, I’d really like to see a step away from overly nocebic terms. Either that, or fully explain the meaning and the potential outcomes of what has happened.
If those who have “tears” are also told that 90% of people have a tear anyway, it’s more common not to have one than to have one. This may well help reduce the problem.

It seems to be the same with the dreaded term “osteoarthritis”.
“Say, dyou think I’ve got arthritis in my knees?” is a fairly common question.
To which my fairly standard answer tends to be along the lines of:
Um. You’re over 40, so – uh, yes. But then, so does pretty much everyone. Arthritis is a standard thing to happen as we get older. It doesn’t correlate to pain, it is simply a thing that happens, like white hair or wrinkles. You don’t hear people say they’re in pain because they have white hair, do you?

Is this answer honest? Yes.
Does this answer help? To a point, maybe – but also mentioning that although there are age-related changes going on, it DOESN’T mean that there is pain because of them.

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