“Up With The Good, Down With The Bad.” It’s a saying you hear multiple times per day, maybe even each hour in a rehab setting. It’s focus is typically in post-operative knee patients with a goal of helping the patient to remember to step up with their non-operative leg and step down with their operative leg. It’s catchy. It helps the patient remember. And it’s poisoning our patients.
While it is a fantastic way to help a patient remember how to perform stairs early after surgery, it also may have the potential to influence the way they think and behave long-term. We have growing evidence that what we say, and how we say it, influences both thought processes as well as actions. Recent publications, such as Stewart’s, “Sticks and Stones”3 and earlier Bedell’s, “Word that harm, words that heal”1 paint a picture of how what we say and how we say it can influence a patient’s beliefs and outcomes.
I would not advocate that we never say “up with the good, down with the bad”, but I would advocate that we have a plan to expand on that shortly after the patient has shown an understanding of safe stair negotiation. Zeni et al4 has discussed the ongoing asymmetry seen well after a joint replacement and David Butler discusses the concept of brain smudging eloquently in this You Tube Video. These brain changes have been demonstrated further in CRPS as cortical reorganization occurs and the brain literally changes as the pain and dysfunction continue.2
So how would I propose we change this? The first is to recognize the influence our words have. As we begin to recognize this, we make a playful (but clearly serious) game in the clinic of ending a patient’s ability to talk negatively about the body part. I am not advocating that they can’t talk about pain or dysfunction. They need to be able to explain this so we can help them work through their deficits. However, non-helpful terminology should end. Phrases such as, “Do you want me to do that exercise with my bad knee or my good knee?” need to be stopped! A correction for the patient would be to instruct them to discuss their knee as their “new knee”, “rehabbing knee”, “recovering knee”, or more humorously, “bionic knee”. We want language that is empowering. We have seen the benefit of using a more positive and progressive language in other areas, such as helping depression by using an internal locust of control.
Listen to your rehab team and the patients’ discussions this week. How many times do you hear a patient reference their “bad body part”. I would challenge you to make a change and help empower the patient to think differently about their injury. This can start with the language we use.
- Bedell SE, Graboys TB, Bedell E, Lown B. Words that harm, words that heal. Arch Intern Med. 2004;164(13):1365-8.
- Maihofner C, Handwerker HO, Neundorfer B, Birklein F. Patterns of cortical reorganization in complex pain syndrome. Neurology. 2003;61(12):1707-1715.
- Stewart M, Loftus S. Sticks and Stones: The impact of language in musculoskeletal rehabilitation. J Orthop Sports Phys Ther. 2018;48(7):519-522.
- Zeni J, Abujaber S, Flowers P, Pozzi F, Snyder-Mackler S. Biofeedback to promote movement symmetry after total knee arthroplasty: A feasibility study. J Orthop Sports Phys Ther. 2013;43(10):715-726.