Three researchers from the University of Winchester – two of whom are physiotherapists by background – have co-written an article that sheds light on how patients perceive diagnostic labels for musculoskeletal (MSK) pain.

The trio are Stephen Martin, Matthew Smith and David A Wilson. First author Mr Martin and Dr Wilson are both senior lecturers in physiotherapy, while Dr Smith is a senior lecturer in sport and exercise psychology.

Their paper – which was co-written with three other physiotherapists (Joshua R Zadro and Giovanni E Ferreira from the University of Sydney and Mary O’ Keeffe from University College Dublin) – was made available in an open access version by the Journal of Physiotherapy last week (26 June).

Concerns about ‘overtreatment’

The team of clinicians and researchers focused on patient and public perceptions of diagnostic labels for MSK pain, and examined how these labels influence their beliefs, emotions and treatment preferences.

The authors note that the ‘overtreatment’ of patients is a growing problem in healthcare, and has, in part, led to an increased focus on how diagnostic labels might influence beliefs, behaviours and treatment preferences among people with MSK conditions.

‘Specific labels have recently come under scrutiny for several reasons. The ability to pinpoint a specific pain source is questionable due to low validity of clinical tests and multifaceted nature of MSK pain. They may have a negative impact on patients’ beliefs and behaviours, such as increased anxiety and fear avoidance,’ the authors note.

Labels may also increase a patient’s desire for further investigations and interventions, such as imaging and surgery, they suggest. Clinicians who are asked to diagnose MSK pain may opt to use non-specific labels as a result, though some have been reluctant to do so because they feel these can reduce patient satisfaction, lead to confusion and do not help to guide treatment.

‘Research into LBP supports these concerns, showing that non-specific labels can lead to patient confusion and frustration. Additionally, some research indicates that patients prefer a specific diagnosis that clearly explains and legitimises their pain. It remains unclear which types of diagnostic labels are most effective in positively influencing patient beliefs and improving outcomes,’ Mr Martin and his colleagues write.

‘To reduce potential harms, clinicians may need to explain that the specific label is required for administrative purposes, whilst providing a detailed explanation of the diagnosis using plain language that reassures the patient [Stephen Martin et al]

After trawling through various databases and other sources, they found that 18 studies that were worthy of analysis. Seventeen of them were conducted in Europe, North America, Australia and New Zealand, and one in Brazil.

Half of the studies investigated diagnostic labels in relation to low back pain (LBP), four investigated shoulder pain, while single studies investigated knee pain, arthritis, neck pain, hip pain and any MSK condition. The studies were published from 2007 to 2024, with a total of more than 6,000 participants.

For major themes emerged

The team says it conducted the first systematic review to synthesise qualitative research investigating patient perceptions of diagnostic labels for MSK pain. In their analysis, Mr Martin and his colleagues developed four major themes that summarised patients’ perceptions of diagnostic labels for MSK pain.

• patients strongly valued diagnoses to validate their pain and guide treatment

• poor diagnostic explanations and use of medical jargon led to patient frustration and confusion

• specific diagnostic labels were validating but promoted fear and a biomedical view of pain, whereas non-specific labels were associated with less fear but higher confusion

• non-specific labels led to more positive views towards prognosis and non-invasive management but led some patients to believe further investigations were needed

They note: ‘Our findings highlighted patient confusion and dissatisfaction with non-specific labels, which may explain this desire for further investigations. This dissatisfaction could create friction between therapists and patients if patients feel that their pain has not been thoroughly investigated.’

Caveats and conclusions

The authors acknowledge that their review had limitations. For example, most studies focused on investigating LBP. In addition, most were conducted in Western, high-income countries, limiting the generalisability of the findings to low and middle-income countries.

However, the research team concludes: ‘This review has several clinical implications and offers guidance for clinicians communicating diagnoses to patients with MSK pain.

‘First, it is clear that patients want a diagnosis; however, this is not always possible due to the multi-dimensional nature of MSK pain. To address diagnostic uncertainty and avoid patient dissatisfaction, clinicians may be tempted to provide a specific diagnostic label.

‘However, this review suggests that specific labels should generally be avoided. Whilst there are some circumstances where a specific label is warranted (eg, a fracture), in many circumstances specific labels are unnecessary and can cause patient harm. Instead, clinicians should use non-specific labels that are less likely to cause patient harm.’

Explanations should be ‘individually tailored’

They add: ‘To reduce potential harms, clinicians may need to explain that the specific label is required for administrative purposes, whilst providing a detailed explanation of the diagnosis using plain language that reassures the patient.

‘This will need to be individually tailored to the patient considering factors such as health literacy, pre-existing beliefs and previous healthcare experiences.

‘Using techniques such as the teach-back method can be helpful in confirming patient understanding. Finally, using consistent language across different healthcare professions will likely reduce patient worry and confusion when interacting with various professionals.’

Fact file

MSK pain, such as low back pain (LBP), neck pain and osteoarthritis, is the leading cause of disability worldwide

About 1.7 billion people are living with MSK pain globally, with this number expected to rise exponentially over the coming decades due to population growth and ageing.

The economic cost of MSK pain is substantial, amounting to as much as 2 per cent of gross domestic product in European countries.

Those living with MSK pain are at greater risk of additional comorbidities, such as cardiovascular disease and depression, impacting overall quality of life.

With the prevalence of MSK pain rising, there is an urgent need to improve clinical practices to reduce the burden of this public health problem.

To access the full version of the article – titled Non-specific diagnostic labels for musculoskeletal conditions foster positive views about prognosis and non-invasive management but require clear explanation: a systematic review – see: https://www.sciencedirect.com/science/article/pii/S1836955325000645