Iatrogenesis…What’d you say to me?!?

Iatrogenic illness is defined as a disease or impairment that is inadvertently caused by a doctor, medical treatment, or diagnostic procedure. You hear examples of this every day and almost certainly when watching television. Here’s a good example… You’re watching TV and see a commercial for a medication when it says you may experience change or loss of vision, ringing in ears or hearing loss, chest pain or irregular heartbeat, shortness of breath, oh and DEATH!… These are dangerous iatrogenic reactions to medicine, however the purpose of the drug is for something entirely different. Another example is gait abnormalities after a total hip or knee replacement. As physical therapists we don’t give drugs or perform surgery but we do talk a whole lot to our patients and we provide a lot of education. Can we iatrogenically increase impairment/disablement and create a negative pain experience with what we say? Can our words actually hurt?

Physical therapists, as well as other healthcare providers, can most certainly increase impairment and disability with words. How we speak with people, the words we use, and the education we provide can have unintended negative consequences. One thing I have noticed in PT and can honestly say have been guilty of is using outdated, sometimes bogus, guru-like, explanations to placate our patients or their doctor. For instance when someone says, “I threw my back out” or my favorite, “my disc has slipped”, what do you think they mean? Where’d you throw your back? Also, Your disc doesn’t slip, if it did you would be in a world of trouble and no amount of pushing and manipulating is going to “put it in”. The other gem I frequently hear, is after an MRI, the doctor may say something like you needed surgery yesterday, or even better, how are you still walking. We know these scans don’t necessarily correlate to pain and functional disability so inciting fear with lines like these do more harm than good.

Perpetuating false information makes the treatment cycle difficult because now you need to reprogram someone’s mind to understand factual, legitimate science. Partial knowledge or “fake news” leaves the patient skeptical, anxious, and creates provider dependency. Why? Well, you tell someone that a disc has slipped, and only you can pop it back in. Good luck getting them to help their own back. In my opinion this is a form of disability, so knowledgeable guidance and creating an internal locus of control is key.

Negative words and anxiety driven diagnoses or explanations only propagate a painful experience leading to further disablement. In a clinical commentary piece Bedell et al (2004) reports that medicine remains bogged down by technical jargon and metaphors that create fear. Negative words and expectations that create anxiety or fear will also create pain. This is a nocebo effect, which is the opposite of a placebo effect. A nocebo is providing an expectation of a negative outcome that can actually create or increase a real world negative outcome. Bendetti et al. (2007) reported that negative expectations might result in the amplification of pain. Using an fMRI on the brain it was shown that as the magnitude of expected pain increased, activation of pain-related regions (thalamus, insula, prefrontal cortex, and anterior cingular cortex) also increased. Conversely, expectation of decreased pain reduced activation of these areas. Interestingly, anxiety and fear also biochemically change the pain experience to create nocebo hyperalgesia.

Cholescystokinin (CCK) is a peptide hormone, or a preprohormone in the central nervous system that has been shown to play a crucial role in many complex physiological and psychological functions (Hebb et al. 2005) including pain. Why do you need to know this? The reason is because CCK turns anxiety into pain. Bendetti et. al (2007) explains that as verbal suggestions of a positive outcome (pain decrease) activates mu-opioid neurotransmission (feel good), while suggestions of a negative outcome (pain increase) activates CCK receptors. This is important because CCK will actually decrease or reverse natural opioid analgesia, which creates a pain cycle.

words hurt pain cycle

It’s clear to see how seemingly innocuous language can actually create more pain and impairment. As physical therapist’s we can iatrogenically make our patients worse by talking to them without thought. Remember, people come to your for help, if you don’t think many are hanging on every word you say, you’re sorely mistaken. The beauty of knowing this is that you can change it instantly. We have more time with patients than most so a good outcome can always start with your words.

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