”It’s bone on bone at L4, mate”If you have your brain thinking in a neuromatrix and neuroplasticity mode you could probably see that a limp output that is making someone hobble around is not much different to a language output such as “it’s bone on bone in my back”. Both are made by the brain, both are repeated innumerably, and both exist in widely distributed brain neurosignatures with probable overlap. There is no doubt that a limp would be a therapeutic target for any reasonable therapist. Get your patient to see what is happening in a mirror, stretch this bit and strengthen that bit etc. etc. And you could expect that better gait could decrease pain through a combination of altered limp circuitry in the brain, and healthier and more appropriate use of the body structures. But an alteration of the language output may be as clinically potent in desensitising pain neurosignatures and it certainly has not been considered as deeply in rehabilitation.Nearly all readers would aim for full and best expression of motor outputs, but many patients are left with a limited linguistic expression of their injury and therapeutic journey. For example, left with language neurosignatures such as “I have a popped disc” or “it’s bone on bone in my neck/lower back”. I am sure you can think of many more. It’s like leaving someone with an uncorrected limp – any educationalist will tell you that what is uncorrected one semester will show itself magnified the next semester or year.
Metaphors in a diagnostic sense
Modern, high quality, clinical skills require assessment and delivery of neuroscience knowledge in both narrative and metaphorical forms, but it is metaphor in particular which dominates patients’ descriptive language and our education.
Metaphor has had limited study in the pain area, but a way to start viewing metaphors in a diagnostic sense is to listen to the patient’s stories and to try to categorise them.
On the NOIjam blog there are posts seeking information and feedback on various metaphor categories to help our research. We welcome your help. Here are some suggested categories adapted from Lackoff and Johnson’ classic work on metaphors (1980).
‘Pain in the arse’ to ‘it’s totally stuffed’
We all use simple equalising metaphors all the time (‘he is a pain in the arse’, ‘she has a heart of gold’, ‘it hurts like hell’) – these are common, useful, colourful, open ended ways to express yourself.
Many patients use invasive metaphors (‘like a knife in there’, ‘my head is in a vice’) and sometimes therapists give them to patients ‘it feels like something is out of place’, ‘your pelvis has slipped’. X-ray findings – ‘degeneration, compression’ etc. – also create a perception of invasion, which these days we are aware could have potentially unhealthy immunological ramifications with glial cells on alert for challenges to the representation of the part in the brain. These metaphors need softening, reframing, removing.
Ontological metaphors are when people try, often desperately, to verbalise and objectify abstract notions such as pain and emotions (‘I feel as though I am going to pieces’, ‘It’s so fragile’). Just like new movement is precious post injury, so is emerging language as patients try and objectify and grasp what is often not objectifiable – i.e. pain, especially chronic pain often has nothing to link it to as smell has coffee, touch has texture and hearing has The Bee Gees. Patients want to grab this thing ‘pain’ inside then take it by the scruff of the neck, give it a damn good shake and have a look at it. No wonder they cling to a mere mention of ‘disc bulge’ if it gives it some object. This emergence of language needs to be helped and guided.
Some metaphors are orientational as in ‘my back is out’, ‘it goes up to my head’, some are static (‘something is wedged in there’) or mobile as in ‘it moves from back and goes into my groin’. I have no ideas what it might mean – maybe it will show up as a diagnostic in some smart study, but the change in language to a more normal output would be ideal.
Yet other metaphors suggest a separation of body and mind or ownership, as the problem gets labelled ‘it’, or even ‘my back is killing me’ suggests a separation of ‘back and ‘me’. ‘I want to cut it off’ or ‘give me a new one’ are also suggestive of disembodiment and the need, where possible, to get that person to take back and love the body part again.
Yet others are prognostic. ‘It’s stuffed’. ‘It’s completely ruined’ are common, but it’s not all bad as another metaphor could be ‘there is light at the end of the tunnel’.
I think that analysis of metaphors, based on the clinical question of ‘why are they saying this at this particular time’ and then considering whether the language could be diagnostic or need change/reframing, or is it just the local vernacular? This discussion continues on NOIjam and we would love to get your input.
Lakoff, G, Johnson M. (1980) Metaphors We Live By, Chicago, University of Chicago Press.
We are collecting examples of patient metaphors. Please add any below.