I have for some years now, been reading articles by the legendary physiotherapists Louis Gifford. Some of these quotes are from articles and some from scientific papers. Louis Gifford is one of the lesser known pain experts, but in my opinion he deserves a lot more attention, for the great legacy he leaves behind after his death. His pioneering teaching about pain science and pain management has influenced a generation of physiotherapists and continues to do so.
Louis Gifford was a clinician for over 30 years, and a lecturer and writer about pain and physiotherapy. From the early 1990’s through to 2007 he spent a great deal of time lecturing about pain biology, pain management and treatment. In the late 1990’s and early 2000’s there was a massive pain science revolution in physiotherapy, that Louis was very much involved in.
His book series on pain science called Aches and Pains, are highly recommend, and so are all his articles, and scientific papers. He was also the editor of the “Topical Issues in Pain” (1-5) series, that marked a milestone for the understanding of pain and physiotherapy.
Without further ado, here are 50 quotes from legendary physiotherapists Louis Gifford:
“Pain is multidimensional, and so should management be, that is what we are grappling with and it is not at all easy at present, but it will be before long. Important changes take time to integrate and get right. Things are changing for the better and the physiotherapy profession in this country stands to gain a great deal of respect for the way in which it is taking on this material. Patients and society should also benefit, and as Gordon Waddell (1998) powerfully points out, if medicine can create a low back pain disability epidemic, then it can also reverse it.” Louis Gifford
“If your therapist only does a ‘treatment’ to you and misses out the ‘get it moving/rehab/ graded recovery/functional recovery process – then its my opinion that your therapist is a complete waste of time” Louis Gifford
“Integrating psychological and social issues into practice is not an easy matter for professions that are linked historically to tissue/injury/pathology-based explanations and treatments for all pains. Overcoming a natural antipathy to integrate ‘other’ issues, concepts and explanations is a major step towards effective practice change.” Louis Gifford
“Most of us tend to think of pain as an unpleasant, distressing sensation that originates in traumatized tissues and courses its way along neural pathways to the brain and consciousness. Thus, the amount of pain perceived fits with the amount of damage done and the pain happily recedes in direct relation to the pace of healing.
The problem is that our clinics and departments are full of patients who have ongoing pain with no clear trauma or disease process, or who have suffered trauma but the pain continues on long after a reasonable healing period.” Louis Gifford
“A significant problem for physiotherapy is that it is by nature a physical therapy, and that while the inclusion of psychological and sociological factors are acknowledged in training, many see them as being outside the remit of our profession or of relevance only in some complex chronic pain states. Because increasing research into low back pain demonstrates that outcome is determined by psychosocial factors as much or more than by physical factors, this omission can no longer be justified” Louis Gifford
“It is also about our relationships with our patients, and their’s with their pain and their families. With changes in practice there is a necessary extension of traditional thinking into new territories and new skills to be taken on. We need to encourage those who are involved in the early treatment and management of pain to take on new information and new assessment and treatment approaches; the burden of responsibility for chronic pain prevention is with them.” Louis Gifford
“The biopsychosocial model proposed by Waddell (1987) draws attention to the impact of the patient’s response to their situation, and the impact of their work and social environment, as well as the impact of any tissue abnormality, the pain, and relevant biomedical factors on their progression through the problem and eventual outcome. Psychosocial factors are now acknowledged to predict low back pain outcome far better than do the available physical and biomedical findings” Louis Gifford
“Shifting therapist and patient thinking, from a largely unidimensional biomedical model based approach, to incorporating a multifaceted and multidimensional model, is the great philosophical and practical challenge confronting clinicians.” Louis Gifford
“Pain is distressing and high levels of distress do not help recovery, are likely to maintain tissue unhealthy behaviors, and may ultimately play a part in maintaining a low or weak physiological profile that inhibits reasonable recovery and normal coping mechanisms. The science of psychoneuroimmunology testifies to the importance of psychological well-being to recovery and fitness of the immune system, for example” Louis Gifford
“Physiotherapists must confront the problem of ‘if you look you will find’ when assessing tissues in on-going pain states. This means that clinicians will always find something wrong in the tissues, but it may not be relevant to the patient’s problem and focusing on it may divorce the patient from the full extent of the problem.” Louis Gifford
“Without doubt, ongoing unrelenting pain that escapes an adequate explanation and diagnosis and whose legitimacy is challenged is distressing, disabling and the cause of much suffering. The mature literature on chronic pain states, powerfully avoids using psychological status as a tool to use in order to blame the patient for their condition. However, psychological status and health beliefs strongly contribute to the level of physical disability” Louis Gifford
“Patients in chronic pain states also suffer from an excessive pain ampli®cation response and spread of pain to physical movements/activities and testing procedures. The pain response often increases with repetitions of a movement or test (the windup phenomenon) and it often continues for many hours or days afterwards.” Louis Gifford
“Acute adaptive pain signals threat. Its major purpose, in parallel with the biologically linked emotional reactions like fear and anger, is to motivate and bring about an alteration in our behaviour in order to further our chances of recovery and survival” Louis Gifford
“The weakness of the tissue based model for diagnosing and treating on-going pain has been highlighted because there is powerful evidence that it does not help and that it may actually be making matters worse” Louis Gifford
“Recent revelations about the capacity of axons to become pathophysiologically sensitised and active self-generators of impulses, goes a long way to help explain the way in which pain behaves clinically. Injured or degenerate/regenerating axons within nerve trunks or nerve roots can become sites demonstrating enhanced sensitivity as well as sources of ongoing and self-sustaining barrages of impulses that have the potential to cause long lasting and high intensity pains” Louis Gifford
“It is not surprising that in our attempts to help our patients, legitimise their pain and find something for them, that we have plunged into greater and greater depths of skilled tissue testing and focused analyses of the behaviour of pain. A fundamental reasoning error may be made by labelling a tissue as faulty on the basis that passive manual testing can reproduce the patient’s pain. The reasoning error is to assume that a sensitive tissue evoking pain on mechanical testing is responsible for the pain rather than a reflection of the sensitised state of the nervous system.
The strength of the tissue basis of pain construct can be further reinforced by the application of apparently successful techniques and interven- tions to the ‘blameworthy’tissues. For example, successfully relieving pain by mobilising, manip- ulating or injecting the cervical zygapophyseal joints of a patient who complains of neck and arm pains can be seen as validating the targeted joint as being the source of the problem. This logical application of reasoning unfortunately omits a broad understanding of the effects of factors” Louis Gifford
“Physiotherapists are pulling ahead and some, are way ahead. These are those who base their day to day work practices around a multidimensional and biopsychosocial model of pain. Those who read, understand, feel at ease with and implement the kind of material found in the Topical Issues in Pain series! No arguments, no political manoeuvring, no in-fighting, but sound and well reasoned agreement around a very sound model secured by outstanding and continually growing scientific support – it’s powerful, it ﬁts, it works – but will it endure?” Louis Gifford
“Clinicians involved in the diagnosis and management of all benign pain states have two major problems. First, evidence of pathological changes in tissues underlying the painful area and in tissues which can refer pain to the area is often lacking. Secondly, there is a large body of evidence demonstrating tissue pathology in the absence of pain” Louis Gifford
“Unfortunately physiotherapists have rarely questioned this paradox and have persevered with highly skilled physical tissue analyses aimed at validating the tissues and peripheral nerve trunks and roots as definitive sources of ongoing pain in the great majority of patient presentations. This is hardly surprising, considering that the only alternative status for on-going pain states that medicine cannot fit within a tissue abnormality/disease based construct, is the unsavoury and unproductive ‘psychogenic pain’ label. So often the implied message for the patient is that if nothing can be found, nothing can be wrong and the patient is therefore to blame” Louis Gifford
“The powerful links between the neuroendocrine and sympathetic systems and the immune system are also well recognised. The important clinical implication is that if we can positively change the way people feel emotionally, by for instance changing their knowledge and beliefs about their problems or situations, we can beneficially change activity in the output systems” Louis Gifford
“Even though tissue damage and subsequent nociceptor activity can be seen as a dominant mechanism in acute pain it should be appreciated that psycho- social factors have a powerful role in determining and modifying the implicit physiological outputs and explicit behavioural patterns that are such an important part in recovery.
In the chronic pain situation, similar sampling- scrutinising-output analysis applies, it is just that the pathobiological pain mechanism focus shifts from the tissue and nociceptor mechanisms in the periphery to focus more on maladaptive and widespread reactivity and sensitivity of the whole sampling-scrutinising-output systems.” Louis Gifford
“Evolution of practice is unstoppable; there are always changes going on and there always will be. New material is often integrated inappropriately, and occasionally dangerously, and failures will always occur, especially in the untrained and unwise. Good therapy and management skills endure, like good inventions. Some changes are for the better, some are not, and many are fads that come and go.
It is the same in medicine as it is in physiotherapy. Fads are based on beliefs, anecdote and charismatic individuals. We have all been seduced. As followers we tend to believe that revered and published therapists are highly effective with all patients. Yet when we try to emulate them we often struggle and get frustrated. I do not know of any outcome studies with long-term follow-up using multiple measures that have included a ‘guru’ in the therapist population.” Louis Gifford
“I have always believed that every patient who goes to see their doctor wants to know the following:
- - Doctor, what’s wrong with me?
- - Doctor, how long is it going to take to get better?
- - Doctor, is there anything that I can do to help it get better?
- - Doctor, is there anything that you can do or give me to help it?
The order of importance to each individual may alter slightly, but for most, a reassuring answer to the first question is always somewhere near the top. Implicit here is a simple desire to know whether there is something seriously wrong. It is often the most important starting point for a successful treatment outcome.
Perhaps clinicians need to think about this more, because without a thorough understanding and without reassurance, the patient’s progress is likely to be hampered by feelings of uncertainty and insecurity.” Louis Gifford
“The therapist can then use the knowledge to provide the patient with a well-reasoned explanation. For example, where maladaptive central mechanisms are operating, the pain is likely to be mysterious and worrying, and often been given inadequate explanations from previous medical encounters. These patients are often grateful to receive a well-supported and rational explanation for their pain. An explanation that reconceptualizes the problem away from the notion of tissue weakness and harm is often the point from which patients start to be able to move on towards a productive recover}” pathway.” Louis Gifford
“Physiotherapy is attempting to move away from a largely inefficient unidimensional focus on pain relief pain response towards function and normal movement in parallel with appropriate pain relief modalities, medications, and pain management. Movement undertaken with fear and trepidation is likely to result in a great deal of tension or guarding as well as increased attention to pain. Conversely, appropriately guided goal-oriented movement, in which the patient feels in control, is approached in the context of no or little fear can provide a wonderful starting point and focus for recovery. This takes a great deal of skill and the integration of cognitive-behavioural principles.” Louis Gifford
“Integration takes time, mistakes are made and those critics who seem unwilling to learn, listen and change in the face of the growing body of sound findings are likely to be in a minority in the future.” Louis Gifford
“At last year’s CSP Annual Congress, Nick Kendall, one of the primary authors of the yellow flag assessment tool, indicated that those unwilling to change may well be forced to do so, and that peer pressure may be the key factor in seeing to it. This sounds like bullying, but like it or not, the pressures are on. Do not moan about them, get out and find out more — but be careful who you listen to before you make your judgements.” Louis Gifford
“The overwhelming message coming from respected researchers, clinicians and writers on the way forward with ‘pain’ is for patient empowerment via education and active rehabilitation of function rather than over-reliance on passive therapies” Louis Gifford
“The literature also recommends that this approach should be augmented with the recognition, assessment and adequate therapeutic focus on psychosocial factors that have been repeatedly shown to have great predictive value for chronicity and therapeutic outcome” Louis Gifford
“To identify patients who are at risk of developing chronic pain and associated disability problems, physiotherapists are being encouraged to actively screen for, identify, and then appropriately manage relevant psychosocial components” Louis Gifford
“I believe that physiotherapists in outpatient settings are working in one of the most difficult and most stressful areas in medicine – musculoskeletal pain and particularly chronic pain and disability. Day in and day out well-meaning physiotherapists do their utmost to try and help incredibly complex pain problems. Pain patients cause many physiotherapists to burn out — we often blame ourselves for the failure, and patient overload with severe time constraints is a big problem.” Louis Gifford
“Education about pain that includes the modification of commonly held ‘abnormal structure/ mechanics’ related beliefs about pain is seen as vital to successful rehabilitation and outcome. On-going pain states are best explained to patients in terms of an altered sensitivity state as a result of altered information processing throughout the system, and not solely a result of damaged and degenerating tissues. This helps patients accept the notion that hurt does not necessarily equate with harm – which leads on to the positive message that carefully graded increases in physical activity mean stronger and healthier tissues. This is reinforced when patients achieve improved physical function. By contrast, continued focus on a tissue as the pain source reinforces fear of movement and activity, the need to be constantly vigilant for pain and the desire for increasingly expensive passive therapeutic interventions that are yet to demonstrate convincing efficacy.” Louis Gifford
“Patients with intense acute nerve root pains rarely find consistent positions of relief and if they do it is only for a brief period of time. A key feature is that the patient becomes physically restless with the pain and greatly appreciates an understanding of this problem. ‘The doctor told me to take paracetomol and lie down and rest for 10 days’. . . ‘The last physiotherapist insisted I sat up straight and kept my neck in perfect posture. I’m sorry I just can’t keep it up, at first its better for a short time then I have to move and get relief by bending my neck forward’ – are frequent comments from patients.” Louis Gifford
“Graded exposure tackles activities and physical tasks that are feared and/or avoided because of pain or the belief that they will cause further pain and damage. The process helps the patient to restore physical confidence via agreed graded progressions and pathways. For example, a patient with back pain who fears bending may agree with confidence to begin gentle pelvic rocking or flexing exercises lying and progress to bending while sitting before making attempts standing. As confidence and skills are improved, the later stages may include increased loading and more functional tasks, as well as performing the tasks faster.” Louis Gifford
“The clinical significance of this is that many tissues that produce pain when physically tested by manual techniques using physiological movements, static muscle tests or palpatory pressures may be relatively normal. Thus, the central consequences of tissue/ peripheral nerve injury may easily result in ‘false’ positive findings in examined peripheral muscles, nerves, joints, skin and any other soft tissues in areas segmentally related to the nerve, and in extreme/severe cases, tissues well beyond normal segmental limits.” Louis Gifford
“Pain science is now amassing experimental evidence to support the organic basis of chronic pain, regardless of whether signs of physical impairment are thought to fit or not fit with the `evident’ tissue injury. While the original lesions for a whiplash patient may be in the tissues of the neck, the legacy and the central focus of ongoing pain pathobiology in the literature, is on altered central nervous system excitability and altered central nervous system processing of normal inputs” Louis Gifford
“Thus, the mechanisms that produce the pain change and move with time – and for those that develop marked and severe chronic pain states the pain is said to be `maladaptive’ in nature. This means that it serves no productive purpose in protecting the tissues concerned, which have long since done their best to heal anyway. Its most powerful impact is on the life and happiness of the patient ± causing much distress, loss of physical confidence, loss of self-esteem, often powerful feelings of guilt and a sense of hopelessness and despair. Many chronic pain patients become clinically depressed, or demonstrate signs of clinical depression” Louis Gifford
“It should be clear from the above discussion that past injuries and past pain states predispose the individual to vulnerability to future problems. This needs to be looked at in two ways. Firstly, if previous injuries have occurred, tissue weaknesses are likely to remain and degeneration has the potential to be faster than normal ± the tissues themselves are therefore vulnerable. Secondly, long-term neural sensitivity changes or `memory’ throughout the whole nervous system, may remain after the recovery of an injury. As such this means that further injury may easily re-kindle past neural representations and past neural activity of pain and symptoms related to the same, or closely related, tissues.” Louis Gifford
“In other words, if the pain and posture are adaptive, what right do we have to get rid of them? have to get rid of them? If we do deem such a posture and pain to be adaptive, evolutionary reasoning would predict that too early a resolution of the pain, or too rapid a correction of the posture might not be a good thing, may prolong recovery and lead to more episodes later on. This is a very useful type of research question that is challenging to several physiotherapy method – and which needs answering. Clearly, whenever we examine a patient it is important to reason whether what we observe can be viewed as adaptive, maladaptive, or an imperfection/defect.” Louis Gifford
“The biomedical, or ‘disease’ model of pain is a single level construct which may be fine where a problem’s cause can be established and which has a remedy available for it. The biomedical model assumes that an individual’s complaints should result from a specific disease state represented by a focus of disordered biology, the diagnosis of which is confirmed by data from objective tests of physical damage and impairment.” Louis Gifford
“Intervention is directed specifically toward correcting the organic dysfunction or the pathology and if this doesn’t work the patient, rather than our inadequate understanding, is frequently blamed. Thus, the traditional medical approach adopts a simple dichotomous view: symptoms are either somatogenic (real and potentially fixable) or psychogenic (not real and hence of little or no interest). Although variations of this view still pervade, supporting evidence is lacking. If we really want to explain and understand pain, pain disability and pain response and prevent them from continuing to be major health care problems, we need to adopt a much more open minded multidimensional approach. We need new broader based models to help us understand chronic pain and incapacity and its development. This is what many in the vanguard of pain management and disability prevention are suggesting.” Louis Gifford
“Waddell’s writing is pithy, smart, and makes intuitive sense. The messages are sound, evidence based, clear, and easy to follow. Like many others, he argues that the biomedical approach to back pain has not solved the problem and may even be adding to it via inappropriate intervention. He advocates passionately that we should all adopt a biopsychosocial framework. “ Louis Gifford
“The physiotherapy and medical professions involved in pain diagnosis and management are facing major challenges. These are exciting times that should reap the rewards of the mature and well controlled research that is now available. Our professional profile can only benefit if we start to show that we are acting on the knowledge and messages coming from this high quality work. In a very timely editorial to the journal ‘Pain’ Steven Linton (1998) persuasively argues the case for the instigation of early preventative programmes in the management of acute low back pain: …..“we found that a secondary prevention program in primary care, for first time sufferers, significantly reduced disability and reduced the risk of becoming chronic by 8-fold as compared to ‘treatment as usual’. “ Louis Gifford
“The sensation of acute pain is the conscious signal of a physical threat whose major purpose, in parallel with producing the biologically linked emotional reaction of fear and/or anger, is to motivate and bring about an alteration in our behaviour in order to further our chances of recovery and survival” Louis Gifford
“Most therapeutic approaches usually consider pain in a single sensory dimension i.e., the perception of where the pain is located, the quality and type of pain, its intensity and the way it behaves over time. However, pain has been considered in terms of three dimensions for quite along time i.e., the sensory dimension as described; the cognitive dimension, which recognises that pain alters our thoughts; and the affective dimension recognising that for every pain we have there is some kind of emotional reaction.” Louis Gifford
“The following two examples demonstrate how basic science developments have’ changed and directed thinking and practice in physiotherapy. First, knowledge that changes within the central nervous system can contribute to pain states. These central changes may amplify modest incoming nociceptor traffic, and can modulate sensory impulse traffic from normal tissues so that it leads to pain. Even more malignly, it may itself generate nociceptive impulse traffic. Clearly, these central changes have implications for treatment. Traditionally, a flaring pain response was linked to worsening of the tissues, whereas ‘ in fact it may simply reflect maladaptive central sensory processing.
A second research finding to have great impact for physiotherapy is that some of the central changes share a similar biology to synaptic events associated with memory, involving early short- and later long- term potentiation. One implication is that, once established, these central changes may become permanent, just as a long-term memory becomes fixed” Louis Gifford
“‘Biopsychosocial’ is one of the latest physiotherapy buzz words. Along with ‘EBM’(‘evidence based practice), it is being perceived as threatening to our established and much loved methods and practices. This is unfortunate, because change and challenges in practice are some of the things that makes physiotherapy so exciting. Therapists and therapies need to evolve in parallel with new knowledge and rapidly changing values and culture. The position held here is that integrating the biopsychosocial model into our practice will actually empower some of our practices and methods if we interpret it and use it in the right way.” Louis Gifford
“The source of a patient’s pain changes over time. This is fundamental to enhancing the general understanding and confidence about pain and its meaning. For the long term pain sufferer it is a great help to start to appreciate that hurt does not equate with harm, and that there is such a thing as maladaptive pain. The longer pain goes on the more widespread and diffuse become its sources – hence the problems with therapy approaches that over-focus on finding a specific ‘source’ of pain, this is fine for fixing a car but not for fixing complex human pain states. “ Louis Gifford
“When tissues are injured the nociceptive cells innervating that tissue begin to increase their sensitivity and start to fire more easily, some may even fire spontaneously. Increased sensitivity and spontaneous firing is a product of the availability of active ion channels and receptors and their relative numbers” Louis Gifford
“They may have a point, but the complexity of factors that play a role in precipitating chronic pain and chronic disability are such that some at risk patients require thoughtful and time consuming assessment and management in the early days of their problem. This is the key time. Linton’s (1998, 1999) work, has shown that identifying and addressing the known risk factors in early management of back pain can reduce chronic disability by 8 fold over ‘treatment as usual’. The interventions Linton (1998) used involved understanding and dealing with the anxieties and fears patients have about causing pain and causing structural damage with movement and activity, plus other psychosocial issues” Louis Gifford