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Language and the pain experience

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56 Physiotherapy Research International
Physiother. Res. Int. 14(1): 56–65 (2009)
Published online 13 November 2008 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/pri.424

Language and the pain experience

DIANNE WILSON School of Health Sciences, University of South Australia, Adelaide,
South Australia
MARIE WILLIAMS School of Health Sciences, University of South Australia
DAVID BUTLER Neuro Orthopaedic Institute, Adelaide, South Australia. School of Health
Sciences, University of South Australia

ABSTRACT Background and Purpose. People in persistent pain have been reported to
pay increased attention to specific words or descriptors of pain. The amount of attention
paid to pain or cues for pain (such as pain descriptors), has been shown to be a major
factor in the modulation of persistent pain. This relationship suggests the possibility that
language may have a role both in understanding and managing the persistent pain experi-
ence. The aim of this paper is to describe current models of neuromatrices for pain and
language, consider the role of attention in persistent pain states and highlight discrepan-
cies, in previous studies based on the McGill Pain Questionnaire (MPQ), of the role of
attention on pain descriptors. The existence of a pain neuromatrix originally proposed by
Melzack (1990) has been supported by emerging technologies. Similar technologies have
recently allowed identification of multiple areas of involvement for the processing of audi-
tory input and the construction of language. As with the construction of pain, this neuro-
matrix for speech and language may intersect with neural systems for broader cognitive
functions such as attention, memory and emotion. Method. A systematic search was
undertaken to identify experimental or review studies, which specifically investigated the
role of attention on pain descriptors (as cues for pain) in persistent pain patients. A total
of 99 articles were retrieved from six databases, with 66 articles meeting the inclusion
criteria. After duplicated articles were eliminated, the remaining 41 articles were reviewed
in order to support a link between persistent pain, pain descriptors and attention. Results. This
review revealed a diverse range of specific pain descriptors, the majority of which were
derived from the MPQ. Increased attention to pain descriptors was consistently reported
to be associated with emotional state as well as being a significant factor in maintaining
persistent pain. However, attempts to investigate the attentional bias of specific pain
descriptors highlighted discrepancies between the studies. As well as the diversity of pain
descriptors used in studies, they were inconsistently categorized into domains of pain. A
lack of consistent bias towards certain pain descriptors was observed, and may be explained
simply by the fact that the words provided are not those which subjects themselves would
use. Conclusion. These findings suggest that the multidimensional and individual nature
of the persistent pain experience may not be adequately explained by pain questionnaires
such as the MPQ. Personalized pain descriptors may communicate the pain experience

Physiother. Res. Int. 14: 56–65 (2009)

Copyright © 2008 John Wiley & Sons, Ltd DOI: 10.1002/pri

more appropriately, but may also contribute to an increased sensitivity of cortical pain
processing areas by capturing increased attention for that individual. The language used
as part of communication between therapists and people with persistent pain may provide
an, as yet, unexplored adjunct strategy in management. Copyright © 2008 John Wiley &
Sons, Ltd.
Key words: attention, language, persistent pain
INTRODUCTION
The language used by people to describe
their pain experience frequently provides
information concerning the site, duration
and intensity of the noxious sensation as
well as the subsequent behavioural and psy-
chological impact. The words used by people
to describe pain may reflect the underly-
ing mechanism resulting in tissue damage.
Where pain persists beyond the expected
tissue healing time, the words volunteered to
describe the pain experience may reflect the
multidimensional nature of persistent pain.
People in persistent pain have been reported
to pay increased attention to specific words
or pain descriptors. The amount of attention
paid to pain or cues for pain, has been shown
to be a major factor in the modulation of
persistent pain.
Communication is an integral component
of a patient encounter. The use of verbal pain
descriptors may impact positively or nega-
tively on an individual’s cognition or beliefs
about their pain experience. Could the
descriptors used in communication with
people in persistent pain (either by treating
clinicians or the patients themselves when
describing their pain) act as an input to
neural processes that construct and maintain
the pain experience?
The aim of this paper is to describe
current models of neuromatrices for pain
and language, consider the impact of atten-
tion in persistent pain states and highlight
Copyright © 2008 John Wiley & Sons, Ltd
Language and the pain experience 57
discrepancies in previous studies of the pain
descriptors. From a clinical perspective, the
attention afforded to pain and the language
used to describe it (pain descriptors), may
provide the pivotal link between the neuro-
matrices for pain and language. In order to
explore this concept, a review of the litera-
ture pertaining to pain descriptors and
their attention demanding properties, was
performed. This review revealed a diverse
range of specific pain descriptors that were
not consistently categorized into similar
domains of pain by the researchers. Further-
more, the unique nature of descriptors is not
adequately represented in frequently used
pain questionnaires such as the McGill Pain
Questionnaire (MPQ). In this regard, clini-
cians may not be adequately capturing indi-
vidual dimensions of the pain experience
when utilizing such questionnaires. Alterna-
tively, an excessive focus on unique descrip-
tors for an individual may act as a cue for
altered pain processing. This paper explores
the possibility that language may have a role
both in understanding and managing the
persistent pain experience.
EVIDENCE FOR NEUROMATRICES
FOR PAIN AND LANGUAGE
The pain neuromatrix
Melzack (1990) originally proposed the
concept of a neuromatrix to explain a
complex network of interrelated areas of the
Physiother. Res. Int. 14: 56–65 (2009)
DOI: 10.1002/pri
58 Wilson et al.
brain. The pain ‘neurosignature’ or ‘neuro-
tag’ is a characteristic pattern of nerve
impulses arising from different sites, unique
for that individual at that point in time. Pain
neuromatrix components are activated in a
parallel, rather than linear, fashion thus
allowing reciprocal links between somato-
sensory, motor, emotional, planning and
other components (Gracely et al., 2004;
Buffington et al., 2005). Therefore the neu-
rosignature will be influenced by genetic
factors, past experiences and memories as
well as sensory and contextual input.
Emerging neuroimaging technologies
have supported the neuromatrix theory. Pos-
itron emission tomography (PET) and func-
tional magnetic resonance imaging (fMRI)
have demonstrated activation of multiple
cortical and subcortical areas in a pain ex-
perience (Morrow and Casey, 2002; Jones
et al., 2003). Structures such as the primary
and secondary somatosensory cortices,
the anterior insula, cingulate, dorsolateral
prefrontal cortices, amygdala, thalamus
and hypothalamus are consistently ‘ignited’
during functional imaging studies of pain
provocation (Derbyshire, 1997; Bantik et al.,
2002; Youell et al., 2004). As well as record-
ing brain activity associated with different
types of nociceptive input (heat or mechani-
cal stimuli), these studies have also identi-
fied brain activity arising from anticipation
of pain (Porro et al., 2002).
With persistent stimulation or activation,
areas of the cortex such as the somatosen-
sory and motor cortices (homonculi) alter,
usually becoming enlarged, overlapping
other representations (Flor et al., 1997a).
Butler and Moseley (2003) proposed the
possibility of a cortical representation of a
‘virtual body’, which is influenced not just
by peripheral, motor and sensory inputs but
also by central inputs such as pain-related
memory, emotions, expectations and past
Copyright © 2008 John Wiley & Sons, Ltd
experiences. Within this virtual body, an
area representing a painful body part or
movement may be stimulated by afferent
input arising from the anatomical body part.
More importantly, in the absence of ascend-
ing input and as a result of the complex
interactions of the neuromatrix, the area
representing the painful body part within
the virtual body could be stimulated by
pain-related emotions, thoughts, memories
and contexts. The notion of the brain having
a memory of pain has previously been
explored by Flor et al. (1997a,b). These
researchers propose that pain memories can
be evoked in fearful situations, by certain
types of movement or certain words used to
describe pain. Could evocative language,
either heard audibly or thought, also stimu-
late or ignite areas of the neuromatrix and
influence the construction of pain within
the virtual body?
The language neuromatrix
Prior to the development of non-invasive
imaging techniques, cerebral localization of
speech and language was inferred from
impairments associated with brain lesions.
These structure-function relationships pro-
posed that the left posterior inferior frontal
gyrus (Broca’s area) was involved in speech
production and the left superior temporal
gyrus (STG) (Wernicke’s area) in audi-
tory verbal comprehension. Neuroimaging
studies (fMRI and PET) have identified mul-
tiple areas for processing of auditory input
and the construction of language. In a com-
prehensive review of neuroimaging studies
for speech, sound recognition and language
construction, Demonet et al. (2005) identi-
fied discrete and overlapping areas of cere-
bral activation for a variety of speech and
language tasks. For example: the processing
of language specific sounds (anterior part of
Physiother. Res. Int. 14: 56–65 (2009)
DOI: 10.1002/pri

the STG and the superior temporal sulcus in
both hemispheres), speech comprehension
(left STG), sound localization (posterior end
of the auditory cortex and inferior parietal
cortex in the right hemisphere) and speech
output (left basal temporal area, left anterior
insular cortex and opercular frontal cortex).
As speech and language provide a primary
means of communication between individ-
uals, their neurosignatures must also inter-
sect with neural systems for broader cognitive
functions such as attention, memory and
emotion.
The impact of attention on pain
The attention an individual pays to pain and
to the language used in describing pain may
provide the pivotal link between pain and
language neurosignatures. Attention can be
considered as a form of monitoring or vigi-
lance to internal or external sensory events
(Weissenborn et al., 2005). Attention is
currently thought to be served by two com-
plementary global and focal neural networks
(Filley, 2002). These networks radiate
through both cerebral hemispheres with a
major representation in the right frontal and
parietal lobes. (Filley, 2002; Weissenborn et
al., 2005). As individual words and phrases
are learnt as part of a language, the brain
develops a ‘neurophysiological library’ of
known words, sounds and contexts (seman-
tic memory). Cerebral structures involved in
the semantic memory include the posterior
part of the left STG, inferior temporal cortex,
the middle and posterior temporal cortex
and frontal association areas (Demonet
et al., 2005).
Attention to pain is described as an
increased focus on the sensations and cogni-
tions associated with the pain experience.
Behavioural studies have shown that atten-
tion to pain is associated with emotional
Copyright © 2008 John Wiley & Sons, Ltd
Language and the pain experience 59
states and is a significant factor in maintain-
ing persistent pain by creating a state of
hypervigilance towards the pain state
(Keough et al., 2001; Villemure and
Bushnell, 2002; Asmundson et al., 2005).
Apkarian et al. (2005), in a meta-analysis of
functional neuroimaging studies investi-
gating the central processing of pain, high-
lighted differences between experimental
subjects and patients with persistent pain. In
particular, cerebral areas related to cognitive
and emotional components of pain process-
ing were more frequently ignited in people
in persistent pain. As well, a number of
studies have shown that self-reported pain
intensity is less when subjects are less atten-
tive, by being distracted from the painful
situation (Petrovic et al., 2000; Tracey et al.,
2002).
REVIEW OF THE LITERATURE
INVESTIGATING THE ROLE
OF ATTENTION ON
PAIN-RELATED LANGUAGE
In order to investigate the role of attention
on pain-related language (as a cue for pain)
in persistent pain patients, a systematic
search was undertaken to identify experi-
mental or review studies of humans. A total
of 99 articles were retrieved from six data-
bases, with 66 retained after meeting the
inclusion criteria. Articles were excluded
if they were not written in the English
language or had been published within the
past 10 years. Further exclusions were made
if the topics reported findings from the same
research team with minor modifications, or
investigated a specific persistent condition
such as osteoarthritis rather than a persistent
pain state, or were primarily concerned with
psychological conditions such as depression
rather than a persistent pain state, or in-
vestigated children or adolescents. After
Physiother. Res. Int. 14: 56–65 (2009)
DOI: 10.1002/pri
60 Wilson et al.
TABLE 1: Database search results
Database Limits
Scopus Article and review
CINAHL (EBSCO host) Peer reviewed
PubMed Nil
Medline (OVID) Nil
Psychinfo (EBSCO host) Peer reviewed
Academic Search Elite Peer reviewed
(EBSCO host)
CINAHL = Cumulative Index to Nursing and Allied Health Literature; EBSCO = EBSCO host database;
OVID = Ovid Medline Database.
eliminating duplicated articles, the remaining
41 articles were reviewed in order to investi-
gate a link between persistent pain, pain-
related language and attention (Table 1).
The specific words or combinations of
words used to describe pain are commonly
referred to as ‘descriptors’. Melzack (1975)
proposed that pain descriptors could be
broadly categorized into three groups each
reflecting a specific pain domain. Sensory
descriptors include words which describe
the sensory quality of the pain (throbbing,
burning, gnawing, aching). Affective
descriptors describe the emotive qualities of
the pain (exhausting, suffocating, sickening,
punishing). Evaluative descriptors provide
an overall impression of the pain experience
(annoying, miserable, intense, unbearable).
These three categories are represented in the
MPQ (Melzack, 1975) that has been widely
used in both clinical and research settings
to measure and evaluate the characteristics
of pain.
Verbal descriptors of pain either as single
words or short phrases have been studied
with respect to their attentional bias in
people with and without persistent pain.
Attentional bias refers to the vigilance
that a person pays to a specific stimulus. In
the case of people with persistent pain, the
degree of vigilance reflects the degree of
threat or fear that a particular stimulus is
Copyright © 2008 John Wiley & Sons, Ltd
Fields Retrieved citations Retained citations
All 36 27
All 5 3
All 21 12
All 13 5
All 20 17
All 4 2
accorded. Where increased attention (hyper-
vigilance) is focused upon a stimulus, it is
likely that the stimulus initiates, maintains
or sensitizes pain neurosignatures. In healthy
asymptomatic subjects, attentional bias to
verbal descriptors of pain appears to be
associated with traits such as fear of pain
(Crombez et al., 1998; Keough et al., 2001;
Van Damme et al., 2004). Typical of these
laboratory studies is that of Keough et al.
(2001). Using a selective attention task modi-
fied from the visual dot probe task, pairs of
words were presented on a computer screen.
The word pairs represent a descriptor word
and a neutral word (e.g. pain-related word/
neutral word or social threat word/neutral
word). The researchers demonstrated that
there was increased attention to pain-related
words only in those individuals with high
fear of pain scores.
In people with persistent pain, studies
investigating the attention bias of descrip-
tors for pain present conflicting results. Flor
et al. (1997b) investigated the processing of
pain-related and body-related words using
electromyography and electroencephalogy
acquired data to measure cortical and sym-
pathetic activity in a group of 12 patients
with persistent pain and an age and gender
matched control group. Subjects with persis-
tent pain demonstrated earlier reactivity and
increased autonomic activity to pain-related
Physiother. Res. Int. 14: 56–65 (2009)
DOI: 10.1002/pri

words compared with the control group. The
authors proposed that these differences
reflected altered cortical processing possibly
due to pain memories and selective attention
to words associated to their pain experience.
Similarly, Dehghani et al. (2003) reported an
increased attentional bias towards sensory
pain words (i.e. words describing the type
of pain) compared with neutral, affective or
evaluative descriptors in a group of patients
with persistent pain.
Alternatively, Asmundson et al. (1997)
using a dot probe task, found no difference
in selective attention to pain-related informa-
tion between people with and without per-
sistent pain (n = 19 per group). In a more
recent study, Asmundson et al. (2005) inves-
tigated the attentional biases for pain descrip-
tors using the sensory and affective descriptor
categories of the MPQ. Using a parallel group
design, subjects with and without persistent
headache completed a dot probe task of
attentional assessment. A lack of significant
difference between the groups might have
resulted because the specific words used
failed to pose sufficient threat to the subjects
in order to capture increased attention.
PAIN-RELATED LANGUAGE AND
McGILL PAIN QUESTIONNAIRE
An explanation for discrepancies between
the studies may rest with one key issue that
does not appear to be adequately explored
within the previous studies investigating
pain descriptors. They have overlooked the
fact that as the pain experience constructed
by the pain neurosignature is highly indi-
vidual, words that might pose threat stimuli
to one individual may not elicit such a
response in another, thereby not capturing
increased attention.
On reviewing these studies investigat-
ing pain descriptors and their attention
Copyright © 2008 John Wiley & Sons, Ltd
Language and the pain experience 61
demanding properties, a diverse range not
only in the specific descriptors but also in
the categorization of descriptors into the
domains of pain is revealed. Table 2 presents
an example of specific descriptors included
within a number of recent studies with a
clear focus on persistent pain. While
Melzack’s (1975) pain domains (sensory,
affective and evaluative) are commonly used
to categorize descriptors, additional domains,
such as body-related, threat, social threat
and disability have been created in an attempt
to more appropriately describe properties of
specific words or terms (Flor et al., 1997;
Keough et al., 2001; Dehghani et al., 2003).
Additionally, specific descriptors may be
classified into more than one domain between
studies. For example, ‘fearful’ has been cat-
egorized as both a threat (Dehghani et al.,
2003) and affective word in the MPQ
(Melzack and Katz 2001) while ‘crushing’
may be a sensory (Melzack and Katz, 2001;
Keough et al., 2001) or threat descriptor
(Dehghani et al., 2003). A number of descrip-
tors, such as ‘lancinating’, are actually
incomprehensible to many subjects
(Graham et al., 1980; Deschamps et al.,
1988; Fernandez and Towery, 1996).
Many of the pain descriptors included
within the reviewed studies originate from
the MPQ (Melzack, 1975). The MPQ was
developed in an attempt to encompass the
dimensions of the pain experience and enable
them to be measured in a quantitative
manner. This instrument is in common use
both in clinical and research settings and the
psychometric properties (reliability, validity
and sensitivity) have been established in
populations both symptomatic and asymp-
tomatic for pain (Dworkin et al., 2005). The
pain descriptors included within this instru-
ment were originally collated from psy-
chological and medical literature and
subsequently classified by healthy Canadian
Physiother. Res. Int. 14: 56–65 (2009)
DOI: 10.1002/pri
 TABLE 2: Example of specific descriptors included in a selection of studies of chronic pain
62 Wilson et al.

Words Keough et al., Asmundson et al., Keogh et al., Dehghani et al., Flor et al., Melzack, Cleeland and
2003 2005 2001 2003 1997b 1975 (MPQ) Ryan 1994
(Brief Pain
Inventory)

Pain, social
threat, positive
Throbbing
Aching

Copyright © 2008 John Wiley & Sons, Ltd

Beating
Boring
Burning
Cramps
Crushing
Danger
Drilling
Flickering
Fearful
Frightful
Gnawing
Gripping
Harm
Intense
Penetrating
Piercing
Pinching
Pounding
Pulsating
Hurting

MPQ = McGill Pain Questionnaire.

DOI: 10.1002/pri
Physiother. Res. Int. 14: 56–65 (2009)

university students in order to describe
different aspects of the pain experience.
While the limitations of verbal descriptors
to express a multidimensional pain experi-
ence have been acknowledged and disagree-
ment about the categorization of the
descriptors exists, the majority of subse-
quent studies have based their choice of pain
descriptors within the MPQ (Melzack and
Katz, 1992; Fernandez and Towery, 1996).
Although the MPQ has been validated
for use with persistent pain patients (Dworkin
et al., 2005), the words included may not
comprehensively reflect the descriptors that
people in persistent pain would volunteer if
they were asked. One possibility for the
discrepancies reported in previous studies
investigating the attentional bias of verbal
descriptors in people with persistent pain is
simply that the words provided are not those
which subjects themselves would use. Hence
the threat value of the word and the attention
it demands is not meaningful for each patient
with a completely unique pain experience.
CLINICAL IMPLICATIONS
The complex nature of persistent pain and
the possibility that descriptors of pain may
act to initiate or sensitize a pain construc-
tion, raise the issue that language used in
communication with the persistent pain
patient may be contributing to the mainte-
nance of that state. Recent investigations
indicate that education is a powerful tool
in persistent pain management (Moseley,
2004a,b). Clinical interactions, including
specific educational approaches, rely
heavily on the communication skills of
the practitioner.
Consideration of three possible clinical
outcomes emerges from the notion that
language has the potential to modulate pain.
First, the language used by people to reflect
Copyright © 2008 John Wiley & Sons, Ltd
Language and the pain experience 63
(via thoughts or words) on their pain experi-
ence may have the potential to act as an
input to their individual pain construction.
Second, the language used by health profes-
sionals in communication with the persistent
pain patient, may have the potential to main-
tain or modify this pain construction. In
both of these instances it may be the degree
of attention afforded to the language that
has the defining influence. Third, as the lan-
guage used to describe the pain experience
is unique to the individual, the language
used may represent factors such as personal-
ity and mood which have had a sensitizing
effect on the construction of pain.
If communication can be enhanced by
the exclusion of certain pain descriptors that
might serve to sensitize the pain neuroma-
trix and replaced by alternative, less atten-
tion demanding descriptors, then further
research consideration of these descriptors
is appropriate.
CONCLUSION
In conclusion, the descriptors or language
selected by individuals to describe the pain
experience may not simply be a general
reflection of culture, education or personal-
ity. If the language used by or to an individ-
ual with pain is conceptualized as a form of
input to the neurosignature, the potential
exists for language to ignite memories,
thoughts and emotions and contribute to the
construction and maintenance of the pain
experience. Thus as well as being a method
of communicating the pain experience, it is
suggested that descriptors of pain may con-
tribute to an increased sensitivity of cortical
pain processing areas.
In turn, appropriate language specific for
an individual, may prove to be a useful
adjunct strategy in the management of the
persistent pain client. The clinician cannot
Physiother. Res. Int. 14: 56–65 (2009)
DOI: 10.1002/pri
64 Wilson et al.
overlook the power of communication in
their patient encounters.
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Address correspondence to: Dianne Wilson, School
of Health Sciences, University of South Australia,
North Terrace Adelaide, South Australia 5000.
E-mail: Dianne.wilson@unisa.edu.au.
(Submitted July 2008; accepted August 2008)
Physiother. Res. Int. 14: 56–65 (2009)
DOI: 10.1002/pri