Most clinical training treats patient education as the part at the end of the visit. You assess, you treat, and then, if there is time, you explain. It gets a few minutes and very little practice.
That ordering is backwards. What you say to a patient about their body is one of the most durable things you do in a visit. The treatment effect of a manual technique fades in hours. A sentence like "your spine is degenerating" can last years. Explaining pain is not an add-on to clinical skill. It is one.
Words that outlast the visit
A qualitative study from New Zealand interviewed people with low back pain about what clinicians had told them, and found that these messages had an enduring effect on how people understood their backs, what they feared, and what they were willing to do.1 Participants could recall specific phrases from years earlier. Some had organized their lives around them.
The phrases were often well-intentioned. "Your core is weak." "You have the spine of a seventy-year-old." "Be careful bending." "That disc could go at any time." Each was meant to explain or protect. Each left the person more fearful and more fragile than before.
This is the uncomfortable part for new clinicians: the mechanism by which language causes harm is the same mechanism by which it helps. Patients take what we say seriously. That is a responsibility, not an inconvenience.
Why structural explanations backfire
The default way most of us learned to explain pain is structural. Find the damaged tissue, name it, and attribute the pain to it. It feels rigorous and it satisfies the patient's wish for a clear answer.
The problem is that for most persistent musculoskeletal pain, the structure does not explain the experience very well. Disc degeneration, bulges, and arthritic changes are common in people with no pain at all, and their presence rises steadily with age in pain-free populations.2 Telling someone their pain is caused by a finding that many pain-free people share is not accurate, and it hands them a problem that cannot be fixed by anything they do.
A structural label also tends to imply fragility. If the pain is "because of" a worn disc, then movement that provokes pain must be damaging the disc further. The person moves less, becomes more guarded, and the pain system becomes more sensitive. The explanation becomes part of the problem.
None of this means structure is irrelevant. Acute injuries have tissue damage. Some findings matter a great deal. The skill is knowing when a structural explanation is accurate and useful, and when it is a shortcut that will cost the patient later. We have written about this balance from the patient side in hurt versus harm.
What good pain education does
Over the past two decades, a body of work on explaining pain to patients has shown that teaching people how pain actually works, as a protective output of the nervous system influenced by tissue state but also by context, stress, sleep, beliefs, and past experience, can reduce pain, disability, and fear.3 A systematic review of this kind of education found consistent benefits for pain, function, and psychological measures in people with chronic musculoskeletal pain.4
Done well, pain education is not a lecture about neurons. It is a reframing that gives the person a way to understand their experience that is both accurate and hopeful. A few principles that make it work:
- Start with what they believe. Ask what they think is going on. You cannot replace a story you have not heard.
- Validate before you reframe. "Your pain is real and it makes sense that you've been worried" has to come before any explanation of sensitivity.
- Use their findings, not generic ones. "Your scan shows the same changes we see in most people your age who have no pain" lands differently than a general statement about imaging.
- Pair every explanation with an action. Understanding that pain does not equal damage is only useful if the next sentence is what to do with that understanding.
- Keep it short, and repeat it. One clear idea per visit, reinforced, beats a complete model delivered once.
Language to use and language to lose
Clinicians working on this have proposed that the words we choose in musculoskeletal care deserve the same deliberate attention as our exam techniques.5 Some practical swaps that come up repeatedly in our clinic:
"Degeneration" becomes "normal age-related change," because that is what it usually is. "Instability" becomes "this area needs more strength and control," which is true and gives the person something to do. "Wear and tear" becomes "your tissue has adapted to what you've asked of it, and we can change what we ask." "Be careful" becomes "start here, and build up." Rather than "your posture is bad," which no one has ever been helped by, try "let's find more positions you can be comfortable in."
The test for any phrase is simple: after hearing it, does the person feel more capable or less? Does it point toward movement or away from it? Does it leave them dependent on you or more independent?
This is also where mentorship matters. New clinicians usually have the knowledge to explain pain well. What they lack is practice saying it out loud to a frightened person in real time, and feedback on how it landed. In our clinic that is something we rehearse with students and associates deliberately, as part of how we approach assessment and care, because it shapes outcomes as much as anything we do with our hands. Our article on communicating with referring physicians looks at the same skill pointed in a different direction.
If you are early in practice, treat your explanations the way you treat your technique. Plan them. Practise them. Review them. The patient will carry your words a lot further than they carry your treatment.
References
- Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527-534.
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.
- Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16(9):807-813.
- Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-2056.
- Stewart M, Loftus S. Sticks and stones: the impact of language in musculoskeletal rehabilitation. J Orthop Sports Phys Ther. 2018;48(7):519-522.