Pain: Sticks and Stones

“Sticks and Stones May Break My Bones, but Words Will?...”

The next time you get under a heavy barbell, give yourself the following cues:

  1. Don’t round your back, or your discs will explode.
  2. Keep your knees from going over your toes, otherwise your kneecaps will slingshot forward and take out someone’s eye
  3. If you feel anything sketchy, just push through it.

How confident did you feel just now? Are you ready to smash a new PR? Words are neurological events and what we hear is transformed by the brain into emotional, conceptual, and potentially even danger signals (3). Words are very powerful tools, and have the ability to bring healing or cause harm depending on what words are used, and how they are delivered.

As a coach, using the “right” words in the gym or on the field can activate both the pain-busting opioid networks (7). and the feel-good dopamine-driven reward systems in the brain, producing motivation, effort, and empowerment. Using the “wrong” words can exacerbate pain, create negative self talk, and ruin performance (1).

Your programming and coaching has an impact on the physical health of your athlete, but your language also elicits processes in the brain that produce a placebo or nocebo (2); these are the positive or negative reactions to the words we hear. Though the two concepts are similar, their outcomes are polar opposites. The aim of this article is to clarify these topics and make you a more conscious coach, by illuminating the substantial effects our word choices have on our athletes.

Words Can Be Thought Viruses

The nocebo effect occurs when an athlete experiences adverse side effects as a result of a specific training stimuli, because they already expect these negative side effects may occur (2). The nocebo effect can be elicited when athletes are told there is a possibility that something bad will happen, and our suggestions can condition athletes to think or behave in a way based on how they interpret our words and non-verbal actions. If an athlete observes someone in pain after pulling a heavy deadlift, he/she is more likely to describe a similar amount of pain when experiencing  the same training stimulus; this reaction is coming from their expectation of feeling similar discomfort, especially if we follow that situation with words like “His back just blew up.”

Be careful with the seeds you choose to plant in your athlete’s mind;they can become a virus more damaging than any disease. The feedback that “you are about to rip through all your knee ligaments” might not be the best  word choice when describing a poor landing from a vertical or broad jump. Many studies have linked nocebo language to the development of chronic pain (1,2,5,6).

Your efforts to correct faulty mechanics have just reinforced negative connotations, and added fear to jumping and landing; as Dr. Adriaan Louw puts it, The fear of pain is likely worse than the pain itself.” The fear of pain even makes athletes more sore for longer after a workout (10). You want to punish your athletes? Just tell them how bad the next workout is going to hurt.

The negative beliefs and thoughts of the athlete will alter their physiology due to a hormonal cascade created by their negative response (10). Cortisol, for example, is one of these hormones released when in pain or when there is a threat of danger or harm to the body. Long term levels heighten the body’s senses, leading to chronic stress, fear, and persistent pain (13).

If you use some forms of nocebo language in your training environment, you may be causing the athlete to have negative expectations about the efficacy of your program. As coaches, building rapport with our athletes and establishing buy-in are critical for success. As such, we should prepare our athletes to be uncomfortable, but using language where pain is associated with the movement or exercise will cause the athlete to dramatize the situation (9,12).

For example, if you explain to an athlete that they should be feeling a “burning” or “pulling” sensation during a movement like a See Saw Walk, they will be more likely to perceive that exercise as painful, and may begin to associate that painful feeling with any form of hip hinging movement (Deadlift, RDL, KBS, etc.); forming this relationship between pain and hip hinging could spell disaster by inducing a fear of this movement pattern and producing a false belief that this feeling is a sign of damage. This will cause the athlete to believe their body is weak and brittle.

Telling an athlete they will bulge a disc is not a prudent way to correct movement, as this can create anxiety and now any “sensation” in the low back with hip hinging will be perceived as danger. After all, pain does not correlate to injury, but the perception of threat to the body.

In order to prevent fear avoidance behavior and persistent pain states, we must empower performance through placebo language.

Words That Empower

Negative feedback is the easiest to give as a coach; it grabs people’s attention and highlights a potentially dangerous situation. But as we just covered, it can actually do more harm than good. So, how can we use constructive language to elicit the response we want? For example, telling an athlete that back squatting in the UAP will make them stronger and more resistant to injury will produce a positive side effect due to their expectations (8). 

Research has shown that the positive expectations of the movement, rather than the effectiveness of the training style, are what caused the performance to improve; in other words,you need to sell it! Using language that promotes a placebo effect is beneficial in helping athletes work through injury, pain, and promote athleticism (4,9,11).

 

Nocebo Language Placebo Language
“You are wearing a hole in your knee squatting like that” “Squatting toes forward will improve your performance AND keep your knee joint lubricated.”
“Your shoulder is sloppy.” “We can improve shoulder function by working on your scapular stabilizers.”
“Your core is weak and spine is unstable.” “Improving the tensile strength of your trunk will help you produce more power through your hips.”
“That pain you feel must mean your body is damaged.” “Your body is extremely durable and capable of healing itself.”

 

How many of you have heard (or had) a typical conversation like this::

Athlete: Why do I hurt? What is wrong with me? Why can’t I move right?

Coach: Your core is weak, your glutes won’t turn on, your hips are jacked, and you move like dog shit.

How helpful was this? What kind of message did you just convey? We all want good movement from our athletes, and it starts with how we communicate. Here is how to set the environment and prime them for success:

Zip It! 

  • Be an active listener and don’t interrupt your athletes when they are describing their situation.
  • Understand where they are on their athletic continuum. If you are working with a novice athlete, they will likely experience paralysis by analysis if you bombard them with every coaching cue in your toolkit.
  • When correcting an athlete, minimize your language to emphasize your points and prevent them from overthinking (aka cueing).

Use Metaphors

  • Rather than telling an athlete “don’t round your back” during a deadlift, use something like “think of your spine as strong column” and “your trunk muscles are like scaffolding”
  • Using negative language here can produce fear or avoidance behavior of a movement by suggesting they are weak or broken.

Be Humble

  • If your athlete asks you a question that you don’t know the answer to, don’t bullshit them and make something up.
  • Instead, Battle the Bullshit. Misleading information, especially about anatomy and biomechanics, can create thought viruses that impede performance and propagate pain (6).

Be Empathetic

  • As the coach, athletes look up to you for guidance.
  • If they are in pain, acknowledge it. Put yourself in their shoes look at the situation from their perspective. What else in their life might be contributing to their pain?
  • Establish a connection. Athletes are more likely to comply with your program if they trust you and feel that you truly understands the pain they are experiencing.

Ask Questions

  • Everyone likes to feel like they are in control.
  • Ask questions that lead them in the direction of producing answers and solutions (7).
  • Don’t just lecture at them; make them reflect on their own beliefs.

You Can Do It! 

  • When in pain or not moving well, athletes typically focus on things they “shouldn’t do.” You should answer this question, but flip it around and show them movements they can and should do.
  • If you freak out, they freak out. Stay calm and confident in front of your athlete.
  • Create confidence by showing them variations of movement patterns that keep them training and focused on their goals (7,8).

Master Your Movement: Words Carry Weight

Our effectiveness as a coach comes down to language: the language we use to teach, the language we use to advise our athletes, the language we use to illustrate concepts and the language we use to prescribe movement. One word can create memories and emotions, a phrase can make us cringe in pain or laugh, and a sentence can provide motivation or lead us into depression. Those same words that elicit a positive response in one athlete can have opposite effects on another, based on their environment, their beliefs, their culture, their fears, their relationships…their unique perception of pain.

It is crucial that we are mindful of our word choice and tone when communicating with our athletes; remember, our language can change the entire perception of a training session. As coaches, we are supposed to be the ones who are encouraging wellness and empowering the performance of our athletes on a biological, psychological, and social level. The Power Athlete Methodology lays the foundation, but your words can be the difference to your athlete kicking ass on game day, or warming the bench for the season

Sources:

  1. Barsky AJ. The Iatrogenic Potential of the Physician’s Words. JAMA. 2017;318(24):2425–2426.
  2. Blasini, M., Corsi, N., Klinger, R., & Colloca, L. (2017). Nocebo and pain. PAIN Reports, 2(2), e585.
  3. D. Butler and G.L. Moseley. Explain pain. NOI Group Publishing, Adelaide, 2003
  4. 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
  5. 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
  6. Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. 2016;46(3):131-4.
  7. Louw, A., Zimney, K., O’Hotto, C., & Hilton, S. (2016). The clinical application of teaching people about pain. Physiotherapy Theory and Practice, 32(5), 385–395.
  8. 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
  9. 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
  10. Parr, J. J., Borsa, P. A., Fillingim, R. B., Tillman, M. D., Manini, T. M., Gregory, C. M., & George, S. Z. (2012). Pain Related Fear and Catastrophizing Predict Pain Intensity and Disability Independently Using an Induced Muscle Injury Model. The Journal of Pain, 13(4), 370–378.
  11. Puentedura EJ, Louw A. A neuroscience approach to managing athletes with low back pain. Phys Ther Sport. 2012;13(3):123-33.
  12. Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis.Br J Sports Med 2017;51:1679-1687.
  13. Wertli MM, Rasmussen-Barr E, Weiser S et al. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine Journal, 2014; 14(5): 816-836

 

Matthew Zanis

Power Athlete Block One Coach at Power Athlete
PT, DPT, OCS, CSCS Former baseball catcher and an avid outdoorsman. Worked with Division 1 basketball, football, and track and field at the University of Pittsburgh, along with the Pittsburgh Pirates and Arizona Cardinals organizations. Received a Bachelors in Athletic Training from the University of Pittsburgh in 2011 and a Doctorate in Physical Therapy from Duke University in 2014. Is board certified in Orthopedics and a Fellow in Training through the American Academy of Orthopedic Manual Physical Therapists. Currently owns and operates his performance therapy practice in Phoenix, AZ and became a Power Athlete Block One Coach in September of 2017.

Dr. Zanis utilizes the Power Athlete Methodology to optimize performance, reduce injury risk, and rehab his clients and athletes through movement assessment, coaching, and individualized program design.

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