Louis Gifford Aches and Pains
CNS Press Falmouth UK
ISBN 978 0 9533423 5 8
A Review: Paul J Watson PhD FCSP, Emeritus Professor of Pain Management and Rehabilitation, University of Leicester, UK. November 2014.
Most people reading this review will be familiar with the work of Louis Gifford who died in February 2014. Over many years Louis delivered a number of courses and these form the basis of these three volumes. I must declare that Louis was a friend who I admired greatly as a clinician, author and teacher so this review may lack some objectivity; however, both the author and the potential reader deserve a fair review so I will try my best.
This final publication from Louis Gifford is presented in a boxed set of three volumes: Aches and Pains, The Nerve Root, and Graded Exposure and Case Histories. This is a difficult series of books to review because they defy a traditional classification. They are part autobiography, part literature review with a focus on teaching through the use of the author’s own professional experience with clinical examples. Throughout the books the reader is impressed with the sense of wonder Louis had in the phenomenon of pain, how this presented itself clinically and how the patient’s presentation and response to treatment could be interpreted and understood through an in-depth appraisal of the research literature. The books are written in the author’s own witty and idiosyncratic style which I find easy to read, rather like chatting to an old friend, but those who want a dry and studious book may find the style frustrating but I encourage them to persevere; it will be worth it. The tone is frequently opinionated and outspoken about the short comings of the professions and approaches used in the management of pain especially chronic pain, although there are occasional apologies for this there is no doubting the author’s irritation at the lack of critical thinking which attends the management of many painful conditions.
A traditional review would criticise the series for not using the most up to date references throughout the book to illustrate the many fundamental points made. This would be erroneous and misses the point of much of the book which is a reflection of the journey Louis took to come to his understanding of pain through his learning and clinical practice. Instead he encourages the reader to “read what I’ve read”. This does not make his conclusions and his interpretation any less valid, most of the references cited are seminal in our understanding of the current theories of pain. In taking this approach he invites us to see if we too would reach the same conclusions with this information and states early on in the book that the work represents his understanding of the literature and he ask us to “feel free to challenge it and offer an alternative explanation”. In doing so it is a call to use this as a basis for understanding and a stimulus to better our own knowledge and understanding rather than to accept something as the given dogma.
Personally I found the first two books the most satisfying maybe because I, like Louis have a deep and unending fascination with the neurophysiology of pain in all its guises. This is not, mercifully for the casual reader, a complex discourse full of detailed descriptions of neurotransmitters, brain areas and detailed neurophysiology, it is described with a lightness of touch which few authors can achieve. This is peppered with case histories to illustrate points which clinicians will find very close to home and will recognise in many of their own patients. It lets the reader understand that pain is a dynamic, ever changing process which evolves into a complex phenomenon and, I hope, will stop people seeing acute injury pain and chronic pain as two completely separate entities. Louis has tried to bring together the neurophysiology, psychology, behavioural and immune responses together with the social environment within which the pain is interpreted and shows how these alter the presentation in clinic and how a better understanding can make us more effective clinicians.
It is in this section that Louis expounds further on his Mature Organism Model of chronic pain which was a seminal advance in the understanding of pain for many physiotherapists. With the passage of time since the original model was published more information has come to light which helps to support the model and to develop it further. In conversations with Louis he always considered this a work in progress which was unlikely to ever be complete.
The third volume is increasingly clinical and gives much space to case histories to explain and illustrate clinical applications which come from the author’s vast experience. This is likely to be the section many physiotherapists will enjoy reading – how we can put much of the learning into clinical practice. It includes Louis “shopping basket approach” to patient management which puts rehabilitation at the forefront of the whole of patient management and presents a model of clinical reasoning which demands a broad mix of skills without declaring one is a ………. insert your guru/dogma of choice in here….. therapist, the focus instead is on the patient, their presenting problems, their social circumstances, psychological needs and the ultimate rehabilitation aim; from this stand point one chooses what is appropriate for the individual.
Some will argue that there is a lack of reference to some of the more recent developments in the management such as more focused use of screening, the recent developments in the use of values driven rehabilitation approaches and mindfulness in chronic pain programmes but to me these are to be forgiven.
Minor niggles are an occasional repetition of information from one section to another and a lack of indexing making it hard to find information quickly. I am not sure the poetry and song lyrics contribute to the chapters but these are examples of the idiosyncrasies of the author, I am sure in a lecture he would make them seem perfectly in place. There are incomplete sections which were not completed before Louis became unable to continue, the sections are completed by his wife Philippa suggesting what Louis would have written; this adds a poignancy to the books.
I found these books eminently readable and I have read all 450,000 words with ease and found greater clarity in them than in many other textbooks on the subject. Even though the books are aimed primarily at physiotherapists I would recommend these to all clinicians from all professions. For students and people new to the study of chronic pain it gives a context for the current views of pain and synthesises a vast area which one could not hope to cover as quickly as one will by reading this series. The books are a testament to the intelligence, wit and charm of the author and represent a fitting final tribute to an excellent teacher and communicator.