Research Review By Dr. Jeff Muir©


Download MP3

Date Posted:

September 2022

Study Title:

Discomfort, pain and stiffness: what do these terms mean to patients? A cross‑sectional survey with lexical and qualitative analyses


Funabashi M, Wang S, Lee AD, Duarte FCK, Budgell B, Stilwell P & Hogg‑Johnson S

Author's Affiliations:

Canadian Memorial Chiropractic College, Toronto, Canada; Université du Québec À Trois-Rivières, Canada; McGill University, Montreal, Canada; University of Toronto, Canada; Ontario Tech University, Canada

Publication Information:

BMC Musculoskeletal Disorders 2022; 23: 283.

Background Information:

In patient care, pain is often the main clinical outcome of concern to both clinicians and patients, although other outcomes such as discomfort and stiffness also make important contributions to patient functionality. A clearer understanding of these specific outcomes may increase the precision of patient assessment and therefore treatment.

Discomfort, despite being a commonly cited experience, has not been well defined in the literature (1). A recent study defined it as “a negative physical and/or emotional state causing unpleasant feelings or sensations” (1). Discomfort can be, but is not consistently, differentiated from pain. Indeed, many studies measure pain and discomfort together (2-4) or assess them on the same continuum (5, 6). Despite classification, the main differentiator between the two concepts is generally the presence of tissue damage in pain (1).

Stiffness is similar to discomfort in that it is not traditionally separated from pain (7). Stiffness is challenging to conceptualize and has variously been described as both a subjective experience and a physical state (8), with the latter more easily defined as: resistance to a change in length (9). Stiffness has been quantified somewhat in studies utilizing structured questionnaires, although more work is also required to better understand this construct.

While clinicians may differentiate pain, discomfort, and stiffness, it is not known whether patients similarly differentiate among these concepts. A disconnect between a clinician and their patient in this regard could lead to misunderstanding and adversely affect both diagnosis and treatment. To address this, the authors explored patients’ perceptions of discomfort, pain, and stiffness to determine if and how they differentiate among the concepts.

Pertinent Results:

55 patients were offered the opportunity to complete the study survey, with 53 responding. Most had received chiropractic care for low back pain (55%), neck (47%) or shoulder complaints (42%). The most common locations reported were the low back and lower extremity, with discomfort and stiffness also reported in the neck.

Lexical Analysis:
While meaningful statistical analysis was not possible due to the low sample size, the most common combinations of words used to describe discomfort were: “can be ignored”, “less severe than” and “feeling of/that”. For pain, the most common were: “cannot be ignored” and “sharp shooting”. For stiffness: “limited range of motion” was most common.

Qualitative Analysis:
5 major themes were identified: impact, character, feeling, intensity and temporality.

Impact described how the sensation affected activities. Pain was generally identified as something that could not be ignored, while discomfort required only partial attention. Both discomfort and stiffness affected activities but allowed participants to remain functional, while pain stopped or limited activities.

Descriptions of character were as follows: pain (sharp, shooting), discomfort (dull, tingling) and stiffness (tight, restricted). Discomfort and pain overlapped in that both were described as having a throbbing/aching character. Discomfort was additionally described as a mild ache, while pain was aching, pinching, throbbing, or stabbing.

Feeling referred to the emotional experience associated with each construct. Discomfort was associated with a feeling of “not at ease” and was described as unpleasant and annoying (the latter two also describing stiffness). Pain was associated with a “hurt” feeling and a feeling of “being in danger of harm”.

Discomfort and stiffness were described as less intense than pain and as not being restrictive or that they were able to ignore it. Pain was described as more intense and less easily ignored.

All constructs were described as potentially constant, although discomfort was perceived as being of shorter duration. Stiffness was described as constant and intermittent.

Clinical Application & Conclusions:

These results suggest that although patients perceive discomfort, stiffness and pain separately, there is certainly overlap. Generally speaking, pain is perceived as being more severe overall, but of course this could vary in individual patients. Stiffness and discomfort were less intense than pain and impacted activities, but patients were able to maintain function. Pain, on the other hand, was reported to stop or limit activities more significantly. This study hopefully increases clinicians’ understanding of these concepts, which potentially allows for a more accurate interpretation and utilization of these experiences to improve clinician-patient communication.

Study Methods:

A cross-sectional online survey was provided to a convenience sample of adult patients receiving care at one of three clinics associated with the Canadian Memorial Chiropractic College (Toronto, Canada). The survey was developed specifically for this study and consisted of 3 sections. The first section gathered information on whether the patient was currently experiencing discomfort, pain, or stiffness (yes/no); location of the experience; and intensity of the experience (visual analog scale). The second section had participants describe discomfort/stiffness/pain in their own words. The third section collected demographic data.

Quantitative data was collected including counts and percentage of patients responding “yes”. Responses were analyzed with lexical and qualitative approaches. For the lexical analysis, the 3 corpora (aggregated entries describing each construct) were analyzed to quantify the frequency of word usage. Additionally, an analysis of N-grams identified the frequency of use of 2-, 3- and 4-word phrases. For the qualitative analysis, an inductive content analysis approach (10) was used to categorize patient perceptions. Independent analyses were conducted by multiple investigators, coding each open-ended response. Representative quotes identifying participants’ perceptions were then identified, based on consensus amongst the reviewers.

Study Strengths / Weaknesses:

  • This well-designed qualitative analysis allowed for investigation of broad themes regarding patient perceptions.
  • Linguistic analysis provided a unique and robust form of analysis not common in this area of the literature to this point.
  • This was an important study given the role of the 3 constructs in the diagnosis and treatment of many conditions in chiropractic practice.
  • Lexical closure (the equivalent of a power analysis in this sort of study) indicated that the data was insufficient to allow for meaningful statistical analysis.
  • The convenience sampling could be subject to selection bias.
  • Study focused on patients only. Future studies would benefit from inclusion of clinicians in the analysis.

Additional References:

  1. Ashkenazy S, DeKeyser GF. The Differentiation Between Pain and Discomfort: A Concept Analysis of Discomfort. Pain Manag Nurs 2019; 20: 556–62.
  2. Cooke M, Chaboyer W, Schluter P, Foster M, Harris D, Teakle R. The effect of music on discomfort experienced by intensive care unit patients during turning: A randomized cross-over study. Int J Nurs Pract 2010; 16: 125–31.
  3. Smith NB, Meuret AE. The role of painful events and pain perception in blood-injection-injury fears. J Behav Ther Exp Psychiatry 2012; 43: 1045–8.
  4. Shinde SK, Danov S, Chen CC, Clary J, Harper V, Bodfish JW, et al. Convergent validity evidence for the Pain and Discomfort Scale (PADS) for pain assessment among adults with intellectual disability. Clin J Pain 2014; 30: 536–43.
  5. Melzack R. The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1975; 1: 277–99.
  6. Melzack R. The short-form McGill pain questionnaire. Pain 1987; 30: 191–7.
  7. Hill JC, Kang S, Benedetto E, Myers H, Blackburn S, Smith S, et al. Development and initial cohort validation of the Arthritis Research UK Musculoskeletal Health Questionnaire (MSK-HQ) for use across musculoskeletal care pathways. BMJ Open 2016; 6: 1–10.
  8. Stanton TR, Moseley GL, Wong AYL, Kawchuk GN. Feeling stiffness in the back: A protective perceptual inference in chronic back pain. Sci Rep 2017; 7: 1–12.
  9. McMahon TA, Cheng GC. The mechanics of running: how does stiffness couple with speed? J Biomech 1990; 23(Suppl 1): 65–78.
  10. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15: 1277–88.

Contact Tech Support  Contact Dr. Shawn Thistle
RRS Education on Facebook Dr. Shawn Thistle on Twitter Dr. Shawn Thistle on LinkedIn Find RRS Education on Instagram RRS Education (Research Review Service)