Pearls: How (and Why) to Use Participatory Language When Communicating with Patients About Osteoarthritis

Do you believe in a single objective reality? Or do you believe that multiple realities exist?

A single objective reality is the notion that the chair you are sitting on is made of real physical properties, and these real physical properties exist regardless of your ability to perceive them. Similarly, the osteoarthritis in someone’s knee exists as a real physical entity, regardless of their lived experience. This notion is referred to as realism or positivism: The idea that there is a real physical entity, and it is the scientist’s or clinician’s job to locate it.

However, most clinicians recognize that two people may have the same objective signs of disease but present with vastly different clinical symptoms. So, can health solely be understood as an objective reality that would exist without human involvement? Could it also be understood as a construction resulting from interactions between people and their social worlds?

The idea that multiple realities are constructed by individuals is called constructivism. When attempting to understand why two people with the same signs of disease present with different symptoms, if one uses methods designed to limit subjectivity through tightly controlled experimentation, the positivist scientist or clinician may become stuck. The constructivist tools necessary to unpack this do exist, but those tools are sitting on the margins of mainstream knowledge systems in orthopaedics [3].

One such tool is discourse analysis, which can be used to understand how realities are constructed through language. Discourses (ways of talking) influence what people think and do about their health [4]. The way practitioners talk can have a powerful influence on the beliefs and behaviours of people seeking care, including coping responses and treatment decision making [5]. How can physicians harness the power of discourse to improve patient outcomes in orthopaedics?

Discourse analysis in the field of osteoarthritis care suggests that by avoiding mechanical analogies (impairment discourse) and adopting participatory language that focuses on what people can do, rather than can’t do (participatory discourse), physicians may encourage active participation in healthy behaviors [1].

People who use the so-called “impairment discourse” refer to bodies as machines and typically draw on mechanical analogies when talking about “healthy” and “unhealthy” joints. Healthy knees are described as “well-oiled machine parts” that glide smoothly over each other. Unhealthy knees are likened to “un-oiled engines” or “worn out brake pads” in a car. Like with any other machine part, knee joints are perceived to have an inevitable “used-by-date” beyond which point they are “unsafe” to use until a mechanic can “repair” or “replace” the damaged or worn-out parts. Physicians who use analogies of the body as a machine may inadvertently perpetuate unhelpful beliefs about using the “damaged body” and increase reliance on others to fix the body.

People who use a participatory discourse describe “healthy” joints as those that enable the body to be active and “participate” (be involved) in valued life activities. As such, people can think of their bodies as “healthy” even with signs and symptoms of osteoarthritis. A participatory discourse shifts the focus away from what one can’t do because of osteoarthritis toward what one can do with osteoarthritis. Physicians who use a participatory discourse may support people seeking care to live active, engaged lives where possible, rather than only focusing on fixing the damaged body part.

Physicians may consider transitioning from an impairment to participatory discourse (Table 1). In support of transitioning from an impairment to a participatory discourse, the International Classification of Functioning, Disability and Health framework considers participation, rather than amelioration of disease, to be the ultimate health outcome [6]. In addition, messaging from physicians that joints do not have a “use-by-date,” that osteoarthritis does not always get worse with age, and that joints are safe to use despite changes on imaging is consistent with guideline recommendations [2]. However, to understand the effect of changing the way physicians talk on the beliefs and behaviors of people seeking care, future intervention studies are required. Discourse analysis can make a valuable contribution to the interventionists’ toolbox by building the evidence base for why talk matters and how we might change it.

Table 1.

Examples of how physicians may transition from an impairment to participatory discourse

Impairment discourse	Participatory discourse
“Your pain is due to damaged joint structures. To cure your pain, we need to fix these structures.”	“Because joint changes are common among pain-free people, other factors are also important in explaining joint pain. Many of these factors are influenced by things you have control over such as strength, body weight, sleep, and mood. Let's make a plan to help you address these.”
“The results of your imaging show that the cartilage lining your joint is worn out, so it is bone on bone. You should limit weightbearing and loaded exercise to protect the joint.”	“Graduated weightbearing exercise is safe for people with osteoarthritis. Exercise is important for the health of your joint.”
“Because of the osteoarthritis in your joint, it is inevitable that we will eventually need to pull out the old joint and replace it.”	“Building your confidence to move and becoming strong and active can improve your pain, and in many cases it can reduce the need for surgery.”