Guidance, empathic communication and teaching is the main role of a physiotherapist – A blog inspired by Louis Gifford.

This is a guest blog produced by Ian Stevens and was delivered to The British Pain Society presentation on Compassion in Modern Healthcare. Great thanks to Ian for contacting me and sharing this with me.

Louis Gifford was a unique individual whom I am profoundly grateful to have known. Professionally Louis opened up my mind to new ways of thinking about interacting with those with persisting pain problems. Personally, and on many levels, Louis also helped me keep my faith in the human condition as he was consistently generous, kind and enthusiastic in all his communication with me over the years I knew him. Louis, like many of the influential people who have given talks at these meetings, was charismatic, driven and a real iconoclast. He achieved much in his life and died in 2014 of prostate cancer. He spoke with the gentle distinctive burr of a Cornishman and followed in the footsteps of his physiotherapy parents Louis was well known in the emerging physiotherapy pain interest world, but he will be probably unknown to most medical practitioners outside the Falmouth region of Cornwall where he lived and practiced. Despite this his influential and critically wellreceived books have been sold throughout the world. Louis’ idea of compassion involved action and interaction with those he listened and communicated with as patients and the many clinicians he taught when delivering his ground- breaking courses.

Most doctors and physiotherapists are educated in a structurally dominated
pathological model. This is appropriate in some circumstances, particularly where acute injury or end stage pathology is concerned. My education was firmly within this structural model of the body and initially I tended to see all problems through this lens. However, very early on in my career I quickly came to realise the limitations of this model, especially when presented with the typical outpatient caseload of on-going pain or unsuccessful post-operative management. As is often the case in
physiotherapy practice there is a desire to assist patients with the ‘tools’ at your disposal: physical assessments, tissue ‘treatment techniques’, exercise, ergonomic ‘adjustments’ and the like.

When I met Louis and spent a week with him on a teaching programme I realised that I had become fairly stuck and frustrated in my practice. That week of being exposed to information from pain science, stress biology, motivational psychology and seeing how some patients could be transformed by knowledge, education and extended consultation was a revelation. I’m going to talk about Louis’ influence on my career through his immersion in pain biology, his interactions with pain pioneers like Pat Wall, his interest in memory and his interaction with Steven Rose.

A case history

At the micro level of pain management we are all dealing with suffering and often profound frustration. The following case history is that of a patient who had an RTA in 1977. A scan two years later suggested that he needed surgery but had to wait a further two years for the operation. During this long period he explored lots of alternative therapies and was also treated by three or four different physiotherapists. The operation was a fusion of the L4 and 5 vertebrae. In his words:

“After six weeks of aerobic rehabilitation I hit a brick wall and my
symptoms returned, leaving me in a permanent state of chronic pain
for the next 11 years. I underwent lots of treatment and moved to
Spain (from Glasgow) for the better weather. I attended the pain clinic
in Glasgow where every possible drug and treatment was thrown at me from TENS machines to steroids, none of which helped and some made me worse. I was finally deemed suitable to go on the pain management programme, having initially refused by the psychologist, as she believed that my understanding and attitude towards my pain was incorrect. I felt that it was the other way round and that they were trying to make me fit into their rigid understanding of what would work rather than assessing my life to see what would be most effective. The psychologist refused point blank to believe me when I said that I wasn’t feeling any better from the tasks, which she prescribed, and my experience within the programme was similar. All of my passions in life involved music, art and film, and their pacing system required me to minimise practising in these fields to the extent that I was doing so little I was getting depressed. One of the negative aspects of this programme was that I was with a group all of whom were at least 20 years older with a drastically different life outlook. They were extremely negative, but right from the time of my accident I had always felt that it was up to me to take responsibility. I did get some positive things
from it, such as learning mindfulness meditation, and being believed by
the other health professionals. After leaving the programme I felt I was
only marginally better informed about chronic pain. Shortly afterwards
my wife and I had a daughter and I had to become her primary carer.
This took its toll on me and increased my pain.”

A month later he was bedbound with continuous muscle spasm, and once again he had hit a brick wall. It was at this stage he moved into the area where I work. He continues:

“His approach: discussing with me my life and pursuits, and treating me accordingly, was far more encouraging on anything I had had before. I focused on energy and fitness levels, exploring movements and exercise that would feed into my existing attitudes. It took daily commitment and dedication from me as all things do when dealing with chronic pain but it is the first time I have experienced progress as well as increased wellbeing. I was encouraged to do more of the things I loved rather than less, and felt less depressed.”

I am not saying that I helped this patient significantly, but the reason I was able to help him was probably due to my knowledge gained from managing some previous complex cases and the resonance and connection I felt with this particular person. As an aspiring musician myself and talking to a real musician I understood where he was coming from. Primarily, I was able to explain his pain in ways that he understood, and to engender by using active strategies to enable him to get a bit better. It was really only by understanding pain physiology and neuroplasticity at a micro level as well as the whole person, and ignoring most of my initial physically dominated
education that I was actually able to help him.

We can look for explanations of pain and suffering in many different areas and disciplines; philosophy ethics even global politics. At the local level – the ground and clinical level – I sometimes think that simpler approaches can ‘work’ and engender great change in people. When I reflect on places that allow me as a person to develop, it seems to me that these are quieter more serene environments. Patients, particularly those that are distressed, confused or fearful need environments that facilitate or promote change and reduce threat. However most of the pain clinics that I have worked in or have spent time in tend to do the opposite. I have often been asked to interact with patients in sterile environments where a silver tray for instrumental procedures and a stark couch are the items on view in the consultation room. This does not seem to be an appropriate environment for the promotion of relaxation and confidence.

We talk about the micro evidence in pain about neuroplasticity and maladaptive pain processes, but there is also positive neuroplasticity and things can improve as in the story I have just related. In retrospect, the postero-lateral fusion of this patient’s spine was unnecessary and his problems were possibly largely iatrogenic. He was disabled by the interventional structural approach to pain which led to an unintended
negative sequence of events.

I was powerfully influenced by the talk given by John Loeser, former president of IASP, at Launde Abbey in 2013. He described the influential and iconoclastic John Bonica. Bonica was a driven dynamic man who left an indelible mark on Loeser. Bonica worked twenty hours a day. He created the IASP by corralling people into a monastic retreat centre from which they couldn’t ‘escape’ . He started a movement through his own dynamic energy, his forceful attitude and persistent dogged determination. It wasn’t through randomised trials and science that the IASP was formed (although science was very much involved and Melzack and Wall were present at the inaugural meeting).

Physiotherapy, in my experience, is usually a secondary consideration in medicine; often viewed as something to placate patients when nothing else has worked. However many clinicians and patients fail to understand the role that movement has in life and health since, neurophysiologically, much more of the brain is developed to serve movement than to language.

‘Language is only a little thing sitting on top of this huge ocean of movement’, Oliver Sacks suggests. Movement is more than a little bit of exercise. The sensation of pain can be changed through perception and attending to movement and sensory experiences. This bodily attention coupled with cognitive evaluation or re-evaluation is perhaps one of the main roles that physiotherapy could offer in clinical encounters (particularly with the many patients with ongoing undiagnosed musculoskeletal pain). We hear a lot about limitation of time and resources in pain management but often failure of interaction is the biggest single problem.

In order to take a photograph, particularly one that may have some impact, it is sometimes necessary to shift your bodily perspective: at normal height you may miss what you want to feel and you may have to crawl on the ground to look at a different angle. Many writers have described this process better than I can. In this regard I have been influenced by the phenomenological nature writing of Nan Shepherd. Shepherd, a writer who spent her whole life around the Cairngorm mountains, beautifully captured the transformational aspect of the way her bodily processes influenced her thoughts and feelings. Sometimes analogy is appropriate where a shift in perspective is necessary when interacting with individual patients. There is often a necessity to shift one’s vantage point or perspective in order to reach across to another person. I believe this process of guidance, empathic communication and teaching is the main role of a physiotherapist.

Compassion and interaction….

Louis was a driven, interesting and independent thinker. I communicated with him for over 15 years and he has left an indelible memory in me. He spent much of his adult life researching into and communicating about pain. Looking at this picture I think you can see the kindness in his expression and the twinkle in his eye – he was an amusing bloke. Remarkably, he was able teach complex information to people schooled, drilled and brainwashed into thinking that the structure of the body holds all its secrets. As physiotherapists we have to think and to interact and we have been trained to use our hands. Most people are not averse to being touched if it is done in the right way. Scientifically the justification and relevance of touch in medicine may be understood by considering the work of Robert Sapolsky who is one of the world’s foremost stress biology researchers. Sapolsky’s primate research emphasises the powerful interaction that baboons derive from touching. The ones that most regularly have nits picked off their backs have the lowest cortisol profiles. Raised oxytocin levels associated with engagement and bonding are developed through touch, not just through words. Physiotherapy is a structure and movement profession. Sometimes, as Paul Dieppe revealed fixing the structure, such as replacing a joint, doesn’t solve the problem. Some people are made worse by the rehabilitation process itself when this involves forcing the body to do things when it is in a defensive state. Understanding at the micro level why some people report pain, including the understanding of the sensitisation of peripheral tissues really helps in clinical decision-making. Louis explained, though his research and that of Patrick Wall and others on adaptive and maladaptive plasticity in the nervous system, why some people can be helped by massage and manipulation but in others it causes an amplification of pain. If you are schooled in a physical, structural, mechanistic knowledge base you haven’t a clue why that should be happening.

Traditional thinking about movement is structural, but largely through Louis’ pioneering work we are moving out to encompass culture, physiology and wider issues. Emotional suffering is a large and often overlooked aspect of clinical practice. Reasoning philosophically about touch, interaction and bodily processes can help to transform emotion. This is a big under-researched idea in medicine. Louis made sense of many complex presentations. He made me aware of neuroscience and through this enabled me to think about the individual psychosocial factors an broaden the rehab process.

Being the change

I attended a course with Louis Gifford about 15 years ago. The clinic was full of chronic problems: patients who had had ‘failed’ surgery, nerve root blocks etc. I saw great transformations in about three or four days purely through education, explaining neurophysiology and how severe pain had become maladaptive. Some people were completely transformed through simple understanding and movement-based practice. My structural training led me to try and find all sorts of complex physical reasons for apparently structurally based pain. However it is unfortunately still the case that the majority of practice appears to be based on dualistic notions of pain rather than more complex models and fluid constructs such as Melzack’s neuromatrix theory. Understanding the trajectory of Louis’ career is an illuminating journey of challenging existing paradigms, developing new integrated teaching tools and the realisation thatchange is never easy, as in the case history. Like me, and many other young physiotherapists, Louis wanted to get competent at treating physical, musculoskeletal pain and as I did went on traditional orthopaedicbased courses like those that James Cyriax presented (Cyriax was a bone-setting doctor at St. Thomas’s in the post-war years [with his own very aggressive methods of manipulation] that developed very financially successful courses [as well as a very lucrative private practice], which still attract a lot of attention). An Australian physiotherapist called Geoff Maitland, who had attended Cyriax courses in London developed a system of assessment and treatment for physiotherapists in the 1980s that strongly influences physiotherapy musculoskeletal practise even today. Louis went off to Australia to do the ‘Maitland’ course and research but he read a very seminal paper by Patrick Wall written in 1991 about central changes involving sensitization in the spinal cord and brain after peripheral nerve injury, and a lot of strange cases of pain sensitivity suddenly started to make sense. Louis immersed himself in pain biology and memory research, and integrated these with Sapolsky’s stress biology. He tried to integrate all these into a model, to explain persistent distress and dysfunction. Among the literature he produced was a teaching tool called ‘The Mature Organism Model’ whereby tissue injury was ‘sampled’ not only at the periphery but at the spinal cord and multiple different regions in the brain. This processing is influenced not only by cellular processes but also by past experience and the culture a person lives in. Subsequent motor and sympathetic output, the movements that we see and the experiences people tell us about are all part of a complex interconnected ‘sampling’ and ‘processing’ system. Most people manage perfectly well after minor injury with little input from medicine. However, there are, as most clinicians realise small numbers of patients where this is not the case and the pain defence system may become ‘maladaptive’. As time moves on and pain outlives its ‘usefulness’ a person may become increasingly disabled and deconditioned. Treating this type of scenario requires physiological and social knowledge as well as ethical and cultural understanding.

How do I work with this kind of information in practice? I no longer get out my skeleton; I sometimes use my whiteboard to explain about the senses. Sometimes, but admittedly not very often, one can quickly reduce threat. Following on from Louis’s seminal work and the dissemination of knowledge to physiotherapists at national conferences and weekend courses more awareness of pain biology and educational approaches began to grow in physiotherapy practice. The well known Australian educators David Butler and Lorimar Moseley developed the book Explain Pain which combined cartoon drawings with up to date science in order to teach these concepts to patients. Education and interaction, rather than intervention and structural treatments, have helped many people in ongoing pain. An example of how I use some of the information I have learned over the years in practice is in the following brief case history.

A lady came to see me the other day that has really arthritic knees. Her knees were particularly sensitive despite having a few unsuccessful steroid injections. I simply doubled up my consultation time on the next visit and went over her case in longer detail. Within a week the temperature in her knee had reduced. Her knee pain was bound up with her husband’s mental breakdown; he was a butcher who had lost his business, and she had had to take on two or three jobs. I explained that the load on her body and all the central effects were affecting the output of her nervous system, and that she needed to calm that down. She understood that, and used ice packs, and in order to reduce the load on her body stopped one of her jobs and used a crutch temporarily. She was able to reduce her medication.

Louis introduced me to Benedetti and his book The Patient’s Brain: the science behind the doctor-patient relationship. Hope and trust – even if you are deeply suspicious of science – have a neurophysiological basis. The physical distance between people can affect them either positively or negatively as the nervous system projects around the body (the ‘peripersonal space’). People may become more vigilant and the space around their body ‘shrinks’ (through body-mapping as personal space neurons in the CNS have been reported to adapt to changing circumstances).

Traditional tribal people for example feel linked to distant people – whether that is a metaphor or an actual physiological process is speculative. However in our atomized and often-disconnected culture, where connection with others may be cautious and defensive, touch and clinical encounters may in some situations help to counter this. Perhaps this is one reason why in the right context massage and other body therapies are sought in times of distress? However, one thing that is apparent in the
scientific literature is that the nervous system is potentially plastic and adaptable.

I have been helped clinically by the knowledge I have gained through expanding out of ‘structuralism’ into complex physiology, as well as the literature of philosophy and ethics. Benedetti’s work rationalizes and validates what we are trying to do. The room you are working in, the way you approach people and the way you interact have measurable effects. In our science-based world that’s a pretty concrete reason for understanding it, and also for me minimizes the need to work with pseudo-scientific

Louis Gifford was ahead of his time and faced opposition from traditional groups in my own profession, and throughout the mechanistic world of rehabilitation. However Louis persisted; his work and ideas spread and led, particularly in Australia, to dissemination and the research which proved his ideas. He was a great disseminator, he was a great teacher and he modelled effective therapy. Over the years I have become less of a physical therapist and more of a teacher and a ‘therapist’ through reading, reasoning but primarily through my interaction with Louis Gifford.

It was heartening to me to receive a copy of Louis work, which was posthumously edited and published by Phillipa Tindle, Louis wife and partner. This trilogy of 1319 words is a fitting tribute to Louis and I know of no other person from the medical or therapy world that could have completed such a comprehensive piece of work. It is unlike so many books relating to pain and rehabilitation, the books are readable, funny, anecdotal and useful! The books reveal the man who wrote them, sceptical, impressively well read, articulate, personable but most of all a flawed human like the rest of us who is able to see the funny side and admit his mistakes too.

The best paper I have read for many years is Iona Heath’s The art of doing
nothing. Heath characterises the art of doing nothing in medicine as “active, considered, and deliberate. It is an antidote to the pressure to DO and it takes many forms including listening, noticing, and thinking, waiting, witnessing and preventing harm: peach an art in its own right requiring judgment, wisdom and even a sense of beauty”.

It is not an exaggeration to suggest that Louis Gifford did an enormous amount practically and academically but the end result of the action in practice would appear quite simple. He taught me to try to understand more and to be creative in getting this information across to the individual but most importantly to try and keep a sense of humour and perspective along the way.

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