Pain? Physiotherapy and pain?..Try starting here? …..And, the ‘Toblerone-recovery graph’ story!

I’ve uploaded two chapters:  A relatively young one…. from the 5th Edition of the tome that is the ‘Textbook of Pain’…. click to view and download….

Gifford L S Thacker M and Jones M 2006 Physiotherapy and pain. In: McMahon S, Koltzenburg M.  Wall and Melzack’s Textbook of Pain, 5th Edn pp:603-617

and relatively dated one, but still quite relevant for the most part…..

Gifford L S 1997 Pain. In: Pitt-Brooke (ed) Rehabilitation of Movement:  Theoretical bases of clinical practice  Saunders, London 196-232

When I wrote the Textbook of Pain chapter I had in mind the likely readership!  Nerdy pain scientists and folk like me who really like reading heavy stuff and trying to understand pain..? In other words virtually no one!  I also had in mind the other authors who were mainly research scientists and also a few therapy research clinicians… who’d probably last seen a patient about 20 years ago, might they be interested!!  Unlikely.   Then I thought to myself, you know what I’d really like to write?  ‘Something I, or any physio colleagues, could photocopy and give to the local GP’s to read so they got a better idea of the state of the art and science of modern physiotherapy – rational, reasoned and well supported by good evidence…look how we practice, think and do!!!  Rather than how they mostly perceive us – as ‘modality’ applicators… doing a bit of ‘massage’, ‘joint wiggling’ ‘exercises’ (we can do that in 2 minutes anyway)..’ultrasound’, ‘acupuncture’  (there’s no evidence for it… hmm just a placebo…), ‘passive movement’… ‘walking practice’…. ‘stairs’…. You know what I mean?  It’s the old….. physio does a bit of rubbing and it’s all a placebo, waste of money, here’s a sheet of exercises, off you go…I wanted to put pain and physiotherapy in a good place and a respected and needed place, if I could..

That was the main thing in my mind then… and I hope you may find it useful to ply your GP’s with and follow-up with a tutorial on!!

The next thing I thought was that I wanted to write something so that budding physiotherapists, or any other practitioner for that matter, might read and see the ‘state of the art’ in physiotherapy for the treatment and management of pain.  I also thought it’d be good to try and persuade the most important people – physiotherapy tutors and the various ‘Schools of Physiotherapy’ round the country and even round the world – to see that maybe the pain part of their undergraduate curriculum needed a big shift, a revamp, and something a bit fresher than teaching modalities like TENS and some vague reference to pain-gate theory.

Well I know that’s all a bit arrogant of me, but that was the thinking and it was great that in writing the chapter I had help from my close friend – Dr Mick Thacker – one of the most pain knoweldgeable physiotherapists in the world.. (probably the most pain knowledgeable!!) and Mark Jones who many of you will have heard of in relation to his work on Clinical Reasoning.  Mark, has to be ‘the most clinical reasoning knowledgeable physiotherapist in the world’!! There you go.

The second chapter, the 1997 one, has a lot of basic nitty-gritty stuff that should fairly easily start anyone off on a ‘pain’ journey understanding. ( I’m quite OK if you hate it!! Don’t waste your time trolling me into a grave via Twitter though, I don’t go near that stuff, and I’m nearly dead anyway!).  My warning is that some of the clinical reasoning categories are old now and have since been updated… see the Textbook of Pain for the more or less current state of the art here…


Over the years I get the odd communication asking me about how some of the stuff I used to do came about… like the story of the Mature Organism Model…some of the ‘explanation’ stuff like the ‘annoying tune’ and Colonel Bogey!  Recently the ‘Toblerone’ graph stuff came up.  Here’s the story, it’s an extract from the forthcoming book…(to be editied possibly!)

The toblerone Recovery story

The following is an extract from my forthcoming book…. Help! It has not title yet… how about….this… Gifford’s Aches and Pains – Essays, thoughts, swearing and patients!

 The Toblerone recovery…(excerpt)…

There’s a story behind why we call it the ‘Toblerone’ recovery.  It goes back to the mid 1990’s when Dave Butler and I were giving a 5 day course in Zurzach in Switzerland.  I was up the front teaching the group my way of explaining recovery for nerve roots… similar to what I have just described.  I was saying something like this……(I’ve got graphs of how pain goes up, along then down during nerve root recovery on the board)

‘Do you guys ever get a new patient in and you do a bit of treatment and they do quite well, their range of back or neck movement improves and there’s a nice drop in the level of pain… the patient kind of looks at you and says… ‘Wow, that’s good, we’re getting somewhere….’  The patient then goes home and comes back 3 days later and can hardly walk into your treatment cubicle, they look like death and they’re moaning in pain…. ‘I don’t know what you did to me last time but I’ve never been in so much pain in my life, I haven’t slept since I last saw you and I’ve been back to the Drs … and he says that you shouldn’t do any more of that manipulation…he said he was going to write to you…..’ 

‘You feel absolutely shit now and you’re wishing you were an office worker drinking a cup of coffee and sending jokes on the internet. Jesus, what’s the guy’s friggin’ Dr going to think of me, my reputation with him has now gone totally tits up.’

I pause and then ask the group…

‘Anyone been there? Does it piss you off as much as it pisses me off?  Come on hands up….?’

90% of them eagerly put their hands up and there’s a babbling and nodding of heads….

10% don’t put their hands up because they know that they cure everyone and that no one gets worse in their smart-ass clinic. They’re liars/faith-healers I reckon.

I go on…

‘Right, show them this recovery graph and explain that recovery is always up and down…and that up and down is normal and not to worry… and it’s especially up and down when a nerve is involved in the pain scenario…. one minute the pain’s quite OK, the next it’s agony again, you get several hours feeling good then for no reason it comes back again… you get good days occasionally, then later on it goes awful ….. etc…

Since I’ve been doing my little graph thing with my patients I don’t get the nasty ‘it’s-your-fault-look-what-you-did-to-me’ type reaction… I get…

‘Louis, I felt really good after the session so I went home and did a bit of gentle gardening and even felt so good that we had sex.  You know that pain went flying up after but I thought about that graph you showed me and it didn’t bother me.  I used the TENS and took the tablets like you said and it soon settled down…..’

As I was drawing the wavy up and down graph on the board Dave Butler piped up from the back…..

‘Hey Louis, that’s the ‘Toblerone’ recovery!’

Being Switzerland , the home of Toblerone chocolate, and Dave being Dave – it got a great laugh.  Ever since then the term has stuck and we always tell patients about the Toblerone recovery when appropriate The key for me, and why I came up with it and used it so often, was that it took the pressure off me – it stopped the patient blaming me for a natural fluctuation in symptoms and it kept them chill with what was going on, – especially if I’d given them some kind of ‘flare-up’ plan should the increase get too much for them to cope with.

….That’s the story!

Thanks for coming here, and thanks for following… I’ve had some wonderful comments and emails from folks!  You’re all amazing…



8 thoughts on “Pain? Physiotherapy and pain?..Try starting here? …..And, the ‘Toblerone-recovery graph’ story!

    • Anoop…
      Right, I had to re-read it…(… That leg length mention was almost in there by reflex I feel…

      You ask about the relevance of leg-length… well it’s absolutely no big deal, and what could be done about it anyway?… Tell the patient/sportsman and make them worry about it unnecessarily?…… Tell him it’s because of an SI joint upslip or something… Sorry, not my scene – it creates fear of structure, notions of weakness in the very people who want to feel invincible….. and its… bull-s**t

      A great many patients come in and say that the chiropracter/osteo told them their leg length was out… so if they say this I always check it and 90% or more of the time its fine… So, patient lies flat, I ask them to wiggle the hips and back and get as straight as they possibly can … I bring their legs together at the ankles, both medial malleoli hit each other exactly, I get the patient to look and … they go ah it’s OK…
      and I usually say… ‘They must have fixed it….!! and laugh…(if appropriate)… or if it is slightly different… I say – If we took 50 people off the street with no problems at all we’d find a large number of them had differences like yours…. Leg length difference is normal and very common and is of no consequence…. Anyway I can lengthen or shorten whichever leg you want… watch…. I shift his hip slightly to one side… and hey presto… same length… or bring legs off to one side… or push one of the legs back…. all with the effect of slightly side flexing the back/pelvis and hence shortening/lengthening the leg. Hey, I can make your longer leg even longer… and your shorter leg even shorter… party trick…. show your kids… get them to watch your feet and tell them one leg’s going to grow shorter….and just subtley and very slowly pull your hip up from the pelvis/back little by little…. do it sitting with your legs on a chair….do a bit of chanting at the same time…. even turn the lights down a bit to create atmosphere…

      Chiros charge for this flim flam and faith healers make gullible worshippers think that a miracle has happened…

      Check out James Randi on faith healers..( ….. he shows how they do it… swing the legs to the side and pull the shoe off a little…. maybe even surruptitiously create a fearful trance like atmosphere… and while this is going on, push the leg so the knee bends a bit too….. they’re taking the piss and a load of money… Shocking in my opinion.

      Do Chiropracters really believe they’re lengthening/shortening the leg…. ?? Anyone want to be a whistleblower and afterwards go hide in an emabassy somewhere???
      Do I ever use a heel raise to correct it…! If it changes processing it may be worth it!! You try going round all day with a small heel cushion in your foot… Novel eh? Go for it… but don’t make the patient leg length obessed… they might just go see and orthopod…
      Any good??
      Louis… (scpetic/skeptic and non believer with life spirit).

  1. Hello,
    Just heard about your blog!! I have read your articles peakperformance online on treatment of chronic pain in athletes and a couple of book chapters. In there, you write about checking the patient for leg length discrepancy , assymmetry and hamstring length and ROM. My question is what does these measures tell us about the person’s pain or tissue condition? If a person has leg length inequality, what could it tell us?

    Thank you so much

  2. Louis-A whole new generation of Physios and GP’s (hopefully) about to be inspired by you & the irrepressable Mr Thacker (how is he by the way, has his brain expolded yet?) I even have a Consultant Orthopod waiting keenly to read all your offerings !!! but I have been training him for a number of years. Keep up the good work its great for me and the other lazy or perhaps I should say overstretched NHS Physios to be spoon fed the info it keeps us focussed in these stressful times. Thankyou Judex
    ps I hope I have done this right I’m ashamed to say I’m a bit new to this blogging lark !

    • Jude, great to hear from you after so long! I spoke to Mick recently and he’s good, same as ever!
      Good on you getting your Orthopod on board! The text book of pain chapter might help!
      Thanks for your support now and over the years too…
      Louis xxxx

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