Are You Priming Your Patients for Pain? A guest blog by Martin Bonnevie-Svendsen

So yet again I am really excited to give you another guest blog on 'The Sports Physio'. But this time not only have I managed to convince a non Brit to write for me, but also a non physio!
Martin Bonnevie-Svendsen is a Chiropractor from Norway who is also studying medicine at the University of Oslo. Martin has published work in neck pain, dizziness and manual therapy and has a passion for making research visually appealing. He has produced some amazing YouTube videos including this one here which is one of my all time favorite clips that I like to use for motivating people to move more. As all the best therapists seem to be, Martin is also active on Twitter so go follow him here!

Martin has done a fantastic blog for us on the extremely important, but often overlooked topic of words and language used by therapists and the negative effects and impacts they can have! And if you thought I was controversial in some of my blogs, check out Martins link to therapists and Nazi's at the end!!! Take it away Martin…

Lt Aldo Raine

Are You Priming Your Patients for Pain?

Can you complete the following test? Create a grammatically correct four-letter sentence from the following words:

”he it hides finds instantly”

This is called a Scrambled Sentence Test. It is exactly what psychology students at New York University were instructed to perform in a milestone piece of research from 1996 (1).

The students were given a test that included either set of words:

Aggressively, bold, rude, bother, disturb, intrude, annoyingly, interrupt, audaciously, brazen, impolitely, infringe, obnoxious, aggravating and bluntly.


Respect, honour, considerate, appreciate, patiently, cordially, yield, polite, cautiously, courteous, graciously, sensitively, discreetly, behaved and unobtrusively.

Do you notice the subtle difference?

The language test was a decoy.

Upon finishing the test, students of both groups walked down the hall to meet the administrator. Only to find him busy helping another participant. This was when a hidden timer was started. It would run until the newly arrived student interrupted the ongoing conversation.

The subjects who received the first set of letters interrupted the administrator in almost half the time spent by the second group (326 vs 558 seconds).

The reason becomes clear when considering the different sets of words in the Scrambled Sentence Test. One contains words associated with rude behavior and the other with politeness.

The study demonstrated that environmental stimulus, in the shape of language, has the capacity to prime social behavior. The words changed the way the students behaved. With the students being blissfully unaware of what was going on.

So what has this got to do with pain?

Stabbed in the back

Back pain is widely recognised as a biopsychosocial phenomenon (2). Yet, the contribution of the “bio” to the matter is poorly understood.

We know that with an anatomical derangement one would expect it to cause pain, yet often it does not (3). And while local neuromuscular changes like impaired muscle recruitment, altered balance strategies and increased joint positioning errors can accompany pain, attributing causation to such changes is proving difficult (4-6).

The uncertainty clouding the role of ”local dysfunction” in pain appears difficult to stomach for many. The reason is as easy to understand as it is flawed.

“If exercise makes you better, your problem must have been weak muscles.” “If joint manipulation helps, then restricted joint movement is to blame.” “If soft tissue work gets the job done, surely the pain origins from tight muscles.”

The human brain is notorious in wanting to establish association between observed events. It is also terribly bad at it (7). As a result of our reluctance to deal with cognitive dissonance, we patch our patients up with one hand and stab them in the back with the other.

It is about time we let clinical effort be led by certain knowledge first.

Stepping out of the shadow of doubt

The psychosocial components of back pain are now so clear-cut that the modern clinician has no choice but to adapt his or her practice accordingly.

We know that fear-avoidance predicts worse outcomes (8). We know that weak sense of self-control and poor confidence in performing activities are even stronger predictors of future disability (9).

We all agree we want our patients moving.

We all agree we want them not to worry.

We all agree we want them to stay optimistic.

We all agree we want them to take charge of their own health and wellbeing.

Then, why do we keep priming them otherwise (10)?

Language primes movement

Let us return to the 1996 study on priming and behavior.

Worried, Florida, old, lonely, grey, selfishly, careful, sentimental, wise, stubborn, courteous, bingo, withdraw, forgetful, retired and wrinkle.

Can you see which theme these words are related to? They all represent the stereotype of ”being old”.

This was the second part of the experiment. The authors primed a new group of subjects with words fitting the elderly stereotype and a control group with neutral words. They then observed what happened when the participants walked down the hall after finishing the test.

The elderly-primed walked slower. Bargh and colleagues then replicated the experiment. Again the elderly-primed participants walked slower than the control group. The study clearly demonstrated that priming by environmental exposure changes the way we move.

Now consider a common conversation around low back pain:

[Patient]: So what is wrong with me and why am I in pain?

[Therapist]: Well, as you can see from your x-ray here, there is some degeneration in your spine. This is wear and tear and quite normal for your age. Furthermore, your examination reveals lumbar joint restrictions, gluteal trigger points and your back muscles are somewhat weak. This kind of back pain is completely harmless, and nothing we cannot fix with some therapy and exercise.

What kind of behavior do you think the highlighted words would prime your patient for? An otherwise helpful consultation can still convey the wrong message if you don't mind your language.

It's time to turn the table and use language for the benefit of our patients.

7 steps to successful patient empowerment

Back pain sufferers benefit from movement through graded exposure and exercise (11-12). This might be explained, at least partially, by the potential of movement in altering pain memories (13).

But how do you prime patients for movement?

Consider applying the following strategies in your patient communication:

  1. Cut to the bone.

Avoid polluting your language with fear-inducing phrases. Cut negatively loaded words to the bone.

  1. Minimizing your language.

When you do need to report on positive findings, use a minimizing language. Consider a phrase like common, age-related changes rather than degeneration or wear and tear. Use muscular control as opposed to instability.

  1. Use metaphors.

Metaphors are showing promising results in helping patients reconceptualize complex phenomenon (14). Reporting on degenerative changes on an x-ray could sound: ”These changes are like the wrinkles on my face, completely normal with aging and 100% inevitable.”

  1. Sidestep the allure of flawed biomechanics.

Patients with erroneous biomechanical understanding of pain do worse (15-17). Don't worsen this understanding by assigning causation to the trigger point or the joint restriction. If you lack the pain science knowledge to replace these explanations – giddy up (18-19).

  1. Be Socrates.

Engage your patients in Socratic dialogue and use questioning to make the patients reflect on his or her beliefs concerning pain (20). This might work better than overloading them with pain science lectures.

  1. Prime purposeful movement.

Think of the emotions and themes you would like prime your patient with. Use associated and positively loaded words throughout the consultation.

  1. Emphasize can-do.

Patients are often eager to know what they should not do. By all means answer the question, but always replace activities to be avoided with activities the can and should do. ”Granted, today might not be the best day for you to move your piano. Instead, engage in your normal everyday activities. Go for a walk, play with the kids and any other light physical activity that brings joy to your life.”

Stop drawing swastikas on patients

In the final scene of the Tarantino movie ”Inglourious Basterds” Lt. Aldo Raine wants to ensure the German Colonel Landa never forgets he is a Nazi. So he carves a swastika into the colonel's forehead:

I'm gonna give you a little somethin you can't take off.”

Don't let your language carve swastikas on your patients. It's time to stop priming patients for pain and start priming them for movement.



  1. Bargh JA, Chen M and Burrows L. Automaticity of social behaviour: Direct effects of trait construct and stereotype activation on action. Journal of Personality and Social Psychology, 1996; 71(2): 230-244
  1. Pincus T, Kent P, Bronfort G et al. Twenty-five years with the biopsychosocial model of low back pain – is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain. Spine (Phila Pa 1976), 2013; 38(24): 2118-2123
  1. Brinjikji W, Luetmer PH, Comstock B et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic pupulations. AJNR American Journal of Neuroradiology, 2014 (Epub ahead of print)
  1. Abboud J, Nougarou F, Pagé I et al. Trunk motor variability in patients with non-specific chronic low back pain. European Journal of Applied Physiology, 2014; 114(12): 2645-54
  1. Kiers H, van Dieën JH, Brumagne S and Vanhees L. Postural sway and integration of proprioceptive signals in subjects with LBP. Human Movement Science, 2015; 39:109-120
  1. Georgy EE. Lumbar repositioning accuracy as a measure of proprioception in patients with back dysfunction and healthy controls. Asian Spine Journal, 2011; 5(4): 201-207
  1. Chapman LJ. Illusory correlation in observational report. Journal of verbal learning and verbal behavior, 1967; 6(1): 151-155
  1. Wertli MM, Rasmussen-Barr E, Weiser S et al. The role of fear avoidance beliefs as a prognostic factor for outcoe in patients with nonspecific low back pain: a systematic review. Spine Journal, 2014; 14(5): 816-836
  1. Foster NE, Thomas E, Bishop A et al. Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care. Pain, 2010; 148(3):398-406
  1. Lin IB, O’Sullivan PB, Coffin JA et al. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open, 2013; 3:e002654
  1. Macedo LG, Smeets RJ, Maher CG et al. Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review. Physical Therapy, 2010; 90(6): 860-879
  1. Smith BE, Littlewood C and May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskeletal Disorders, 2014; 15(416)
  1. Nijs J, Lluch Girbés E, Lundberg M et al. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual Therapy, 2015; 20(1): 2016-220
  1. Gallagher L, McAuley J and Moseley GL. A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain. Clinical Journal of Pain, 2013; 29(1): 20-25
  1. Foster NE, Thomas E, Bishop A et al. Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care. Pain, 2010; 148: 398-406
  1. Vlaeyen JWS and Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 2000; 85: 317-332
  1. Young Casey C, Greenberg MA, Nicassio PM et al. Transition from acute to chronic pain and disability: a model including cognitive, affective, and trauma factors. Pain, 2008; 134: 69-79
  1. D. Butler and G.L. Moseley. Explain pain. NOI Group Publishing, Adelaide, 2003
  1. CJ Woolf. Central sensitization: implications for the diagnosis and treatment of pain. Pain, 2011; 152; S2-S15
  1. Kennerley H. Socratic method. Oxford Cognitive Therapy Centre Essential Guides, Oxford, England, 2007.




  1. Another great blog from The Sports Physio. It’s time all health care professionals develop a better understanding of how their poor choice of language can be detrimental to the client. I know you have touched on it in previous blogs but the worst example I see Is people being told they have certain anatomical structures ‘out’ and ‘slipped’ it puts the fear into clients, increases pain behaviour and creates a reliance on the treating professional to ‘put it back in’. A perfect example of how not to empower your patient. The psychology studies mentioned perfectly demonstrate the effect language can have on behaviour! So let’s take note and place more emphasis on the psychology aspect of pain in better detail!
    Thanks again for yet another simple, evidence based, relevant blog!

  2. My neurologist told me flat-out I had “severe thoracic disc desiccation and degeneration and several bulging cervical discs that weren’t going to get any better and to expect a lot of pain.” My pain is in the upper-to-mid back. I have a displaced sternum from an auto accident but I figured if that was causing pain, it would have been constant and going on for years. I’ve always been active (gardening, cycling, hiking). I wouldn’t even consider seeing a physician for back pain but this had gotten pretty bad, for months. After she said that, I felt pretty depressed and was afraid to do much of anything. I assumed some degenerative thing had gotten worse recently. I wallowed for about a week but then decided that as long as it wasn’t a heart attack (it felt like that a couple times), I could live with pain. After using heat regularly, adjustments” I did off the side of the bed, and some upper body exercises, the pain started getting better. But I think it was letting go of the fear that had the greatest impact.

    • Thank you for sharing your story and I am sorry that you had such fear inducing and unhelpful advice from a so called medical professional. I wish I could say yours is a rare case but unfortunately its not in my experience.
      Just today I had a patient who had seen a consultant and been told that her shoulder was ‘hanging on by a thread’ she was petrified and hadn’t moved her arm for the last two weeks and was in more pain and distress than before her consultation. It took me a whole hour of reassurance before we made some progress, and think it will be many weeks until the ‘damage’ that the consultant inflicted with just his words is undone.
      I am glad to hear you have realised the connection between the fear and your pain yourself and hope Martins blog helps many others like yourself.
      I wish you well.

  3. that was great! I’ve got so many patients with terrible black bears lurking in their minds from the junk we so easily say – just yesterday, I heard, in sombre terms -‘The doctor says it’s Idiopathic.’ !!!

  4. You and Martin saved me the trouble of writing about this blog! I’m inundated with patients who have the perception that they are broken and or damaged. Deconstructing and rebuilding what they have already learned necessary and difficult. I struggle in my area as many practitioners pay their bills with sales pitch that “you need to be fixed.” I do think that things work but not in the way that we think they do. However, it’s so hard to have a non-emotional conversation with these practitioners when the language used fosters poor self-perception and dependence on others (namely them.)

  5. Well done debkl Thats a great result. Maybe you could write the doctor a friendly letter, ask him to reconsider what he says to others in future. Explain why and what happened and what you did. It might make him count to 3 and reflect a bit before he speaks out next time. Medics are only human & there is only so much they can do. Maybe you are pivotal in his career. Perhaps he hasn’t come across many others who have got better on their own.

  6. Personally, I believe that priming your patients is THE most overlooked thing in this practice. You described it beautifully. This was too good not to share — will be emailing to our sister practices. And maybe even bring it up at our next meeting. Thank you for sharing.

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