With a cross-sectional survey, this study explored chiropractic patients’ perceptions of three constructs commonly reported in clinical practice: discomfort, pain and stiffness. Lexical and qualitative analyses revealed that patients perceived discomfort, pain and stiffness as somewhat different constructs, although overlap was identified. Specifically, discomfort and stiffness were described as impacting patients’ activities, however, they remained functional; whereas pain was described as stopping/limiting activities. Patients described feeling displeased and annoyed when experiencing discomfort and stiffness, but hurt and in danger of harm when experiencing pain. Discomfort and stiffness were described as less intense than pain, with shorter/intermittent duration; however, all constructs could be experienced constantly. This study contributes to better understanding what patients actually mean when using these concepts in the clinical encounter.
The techniques employed in this study demonstrate that it is practical to conduct a lexical analysis of patient free-text entries, and to characterize the lexicons used by patients to describe different clinical constructs. In the small corpora derived in this study, patients appeared to use ‘general’ rather than ‘technical’ language to describe their experiences, and used lexicons which were largely specific to the different constructs under investigation. Thus, while our own corpora were too small to justify statistical comparisons, the trends that we saw toward lexical closure suggest that with samples from hundreds, not thousands or millions, of patients, we would have corpora which were convincingly representative of the broader language. Therefore, lexical analysis of adequately sized corpora appears practical, and the results could assist in facilitating patient-clinician communications, including history-taking and formulation of diagnoses.
Although lexical and qualitative analyses were conducted independently to avoid cross-contamination, results from the lexical analysis provided quantitative support to themes developed from the qualitative analysis. Specifically, while the qualitative analysis provided a more in-depth description of patients’ experience related to discomfort, pain and stiffness, lexical analysis provided quantitative support, emphasizing the Intensity, Character and Impact themes with the words patients chose to use to respond to our survey.
There is limited evidence regarding the concept and perceptions of discomfort, especially in musculoskeletal conditions, which limits our ability to compare our results with the literature. This lack of research related to discomfort is likely due to the investigative focus on pain. In fact, our results show that patients usually remain functional when experiencing discomfort. Given that most rehabilitative research is focused on bringing the patient to a functional state, relief of discomfort might not be perceived as an important outcome in rehabilitation. However, a high level of musculoskeletal discomfort has been reported to be a predictor of future musculoskeletal pain in workers , highlighting the importance of discomfort as a clinical outcome that should get more attention. Additionally, moving away from a problem-based and towards a quality improvement mindset, improving processes and interventions to enhance all possible clinical outcomes (including discomfort) may contribute to enhancing quality of care and patient satisfaction.
Interestingly, self-report questionnaires commonly used in clinical investigations, such as the McGill Pain Questionnaire and Musculoskeletal Health Questionnaire, do not clearly differentiate between discomfort, pain and stiffness. Our results indicate that patients make specific distinctions between these constructs, which might not be captured by these questionnaires. This highlights a limitation of currently available questionnaires and revisions could potentially be implemented to better align questionnaires with patients’ nuanced understandings of these constructs, enhancing clinical assessment and interpretation of patients’ responses.
Our results suggested that patients perceived that pain was an indicator of potential injury or harm; however, some patients also described pain as the feeling of being hurt, which can be interpreted in a non-physical context. It is well known that pain is multifactorial and that it cannot be solely inferred from the state of bodily tissues [25,26,27,28]. Indeed, both the revised definition of pain from the International Association for the Study of Pain and other recent evidence suggest that although pain is often associated with physical harm, pain is also influenced by cognitive, emotional, psychological and social factors [10, 25, 26]. Consequently, pain is a highly personal experience making it very challenging to conceptualize and measure . The literature also defines discomfort and pain more generally, often including physical, psychological and emotional aspects [1, 10]. Noticeably, the responses in this study focused on the physical aspect of these two concepts and are consistent with previous studies investigating patients’ perceptions of pain, reporting that they often talk about pain as a sign of a “physical” issue or bodily dysfunction [29,30,31]. Our results contribute to better understanding how patients perceive pain, specifically, and provide additional knowledge on how they differentiate pain from other unpleasant experiences, such as discomfort and stiffness.
Results from this study indicate that participating patients perceived the concept of stiffness to be closely related to reduced or restricted movement, mobility and range of motion. This is in accordance with previous findings reporting that stiffness was described as a perceived resistance to movement and a lack of movement velocity [12, 32]. Stanton et al.  suggested that the conscious perception of stiffness may represent a multisensory perceptual inference and is not derived exclusively from joint relevant sensory information. Indeed, previous studies showed that subjective or self-reported stiffness did not correlate with objective measures of stiffness [12, 15]. This indicates that, while a unique concept related to movement restriction, perceived stiffness is likely multifactorial, which may explain the overlap it presented with pain and discomfort concepts.
Lexical closure, the linguistic equivalent of a power analysis, revealed that the corpora of free-text entries used in this exploratory study were much too small to permit meaningful statistical comparisons among the 3 constructs. Our study used a convenience sample, where clinicians’ selection bias is possible. Therefore, our results are specific to our sample and might not represent the perceptions of the general patient population. Our qualitative data contained enough information to develop thematic categories and fulfill our exploratory study aim . However, this is preliminary work focused on patients, and our findings suggest that future studies should be undertaken, including exploring clinicians’ perceptions to complement that of patients. Specifically, qualitative interviews allow for more in-depth responses which in turn, allow for a more detailed analysis that may help us better understand the meanings of these constructs, their specific characteristics (e.g., intensity, duration, etc.), how they feel, as well as other constructs, such as suffering, soreness and ache. These could also inform the development and refinement of existing patient-reported outcome measures and questionnaires that measure discomfort, pain and stiffness for clinical and research purposes. In total, 53 unique responses, consisting of short phrases of few words to full paragraphs of 100 + words in length, were analyzed. We cannot be certain of data adequacy, which limits the extrapolation of our results beyond study participants. Most participants reported experiencing more than one construct at the time they responded to the survey. Although this might portray real-world clinical patient presentation, experiencing more than one construct simultaneously might have contributed to the overlap in qualitative themes observed in our study. Additionally, most patients were seeking chiropractic care for a chronic condition. This can potentially influence their perception of how discomfort, pain and stiffness are different and future studies should explore if patients with acute conditions have a unique perception of these concepts in comparison to chronic patients. Finally, distinct pathophysiological mechanisms of pain (neuropathic, nociceptive or nociplastic) are thought to influence pain profiles in terms of pain quality, spatial characteristics, and pain symptoms. Therefore, pain mechanisms may have also influenced the pain perception in our study.