What You Say to a Patient in Pain Changes Their Biology

A patient with low back pain was told by a surgeon to "get in a wheelchair and stay there — too much wrong, too hard basket."

Another was told: "At first it was due to a compression fracture on my T12, but now, almost two years post-fusion surgery, the pain continues."

A third described the confusion of being told by one clinician not to move until pain-free, and by another that graded movement was the answer.

These are not edge cases. These quotes come from research exploring the lived experiences of people with low back pain in the Australian healthcare system (Mouatt et al., in preparation).

What clinicians believe shapes what clinicians do

A study by Exercise Physiologist Mitchell Gibbs and colleagues set out to examine how clinicians' beliefs influenced their clinical decisions. Exercise physiologists and physiotherapists were given clinical case vignettes and asked how they would manage each patient. Clinicians with stronger biomedical beliefs made systematically different treatment decisions — decisions more likely to reinforce structural narratives, restrict movement, and signal fragility (Gibbs, Morrison, & Marshall, Spine, 2021, 46(2), 114–121).

What clinicians say to patients mirrors what clinicians believe about pain. And patients are listening.

Research by Darlow and colleagues has consistently shown that health professional advice is one of the strongest influences on patients' beliefs about their back. That influence persists over years. It shapes whether people return to work, resume physical activity, and seek repeated healthcare — or don't (Darlow et al., 2012; Darlow et al., 2017).

The safety paradox

There is a fundamental tension in clinical practice between trying to keep someone safe and inadvertently making them feel less safe in their own body.

Advice designed to protect — "rest it", "don't bend like that", "your disc is pressing on a nerve" — can generate its own downstream harm. Not through any failure of intent, but because the nervous system responds to perceived threat. A patient who believes their body is structurally vulnerable will engage with physical activity, daily tasks, and clinical interactions through a lens of threat.

This is not a soft clinical problem. There is neurobiology behind it. Allostatic load — the cumulative physiological cost of perceived stress and threat — has been linked to metabolic, cardiovascular, and musculoskeletal conditions (McEwen et al., 2017). The clinical interaction itself can contribute to or reduce that load.

What "not immune" looks like

It is tempting to frame this as a critique of biomedical care and an endorsement of a BPS approach. But the research is honest: a poorly delivered BPS approach carries its own risks.

"A lot of people would struggle to get their head around the idea... it's almost like what you're saying is, your pain is in your head — and they would misinterpret that to mean that your pain is not real." (Rizzo et al., under review, 2022)

Clinicians who communicate BPS principles poorly can leave patients feeling dismissed, blamed, or confused. The framework is only useful in the hands of someone who can translate it accurately.

The takeaway

Clinical communication is not a soft skill that sits alongside your clinical reasoning. It is clinical reasoning. What you say, how you say it, and what belief system it reflects will shape your patient's internal model of their own body — and that internal model will influence their recovery.

If you want to build the skills to communicate in ways that reduce threat, validate experience, and facilitate recovery, our Biopsychosocial Clinical Practice and Low Back Pain and BPS Practice courses are where that work gets done.

→ Explore the courses at tkex.org/courses