Inspirations and passions: My journey
After completing my physiotherapy training I always knew I wanted to specialise in the treatment of musculoskeletal pain. My father was a big influence, – a physiotherapist, a natural communicator, a manual therapist who’d learned his trade from osteopaths and bone setters in the late 40’s and 1950’s and who knew just what to do when for the best results. He was an impressive operator, almost theatrical, and my observations of him in work mode as a youngster left me in awe. His patients loved him. I came to realise that he was way ahead of his time – not only for his exceptional hands and ‘people’ skills but also for his diagnostic brilliance combined with his instinctive ability to instil physical confidence in his patients.
My father’s influence led me to getting immersed in manual therapy. I was lucky to be tutored by Robbie Blake and Asoka Jaywardena as an undergraduate in Sheffield and later to get work with Paul Chadwick in Liverpool and then with Peter Wells at St Stephens Hospital in West London. Both Paul and Peter had been to Adelaide and done the ‘Maitland’ manipulation graduate diploma course there. That was my goal too and within four years of qualifying, my wife Philippa and I moved to Adelaide in Australia to study on the Manipulative Therapy Graduate Diploma. This was 1985. Being taught by Geoff Maitland was a dream come true and I learnt a great deal on the course and afterwards working in Geoff’s practice for a couple of years. One of the greatest things I learnt from being with Geoff Maitland was his incredible ability to listen and communicate with the patient. I was also lucky to be taught by Patt Trott, Ruth Grant and Mary Magarey, all well known and highly regarded Physiotherapists and manual therapy teachers.
However, manual therapy wasn’t all I thought it was, my growing scepticism and desire for rational explanations was quietly growing. I wasn’t seeing the results I expected especially with the large population of chronic whiplash and RSI patients who frequented Geoff’s practice. Due to the very nature of manual therapy their problems were effectively reduced to some spinal joint ‘comparable sign’, their range of movement to pain was observed, a very specific mobilisation technique was performed and the range was reassessed. The range to pain invariably improved and the technique repeated a few times through the session… and then the process was repeated, often 3 times a week, week in and week out and month in month out…. I cannot ever recall any exercise of any relevance being given to the patient, the treatment was entirely passive, there was no patient responsibility in the whole process and the brunt of all therapist-patient interaction was in communicating the symptom behaviour during the range of movement assessment. To me, the symptoms were very cleverly ‘played with’, but the patient never moved on. The majority of patients in Geoff’s practice had very thick files.
Remember, this was over 25 years ago, and to provide a little fairness and balance, we didn’t know then what we know now. Reflecting, I now realise that I’d stumbled on a significant truth that would hugely influence my future, and this was that chronic pain, or maybe even all pain, lacked an adequate explanation. The tissue and biomechanically centred explanations, the ‘comparable signs’ and the biomedical model that we were taught, just didn’t explain the broken lives and madly complicated body charts I continually witnessed!
Thanks to the course and to Geoff, what I was learning and getting much better at was skilled physical examination of musculoskeletal tissues and the ability to think, reason and communicate at the level of knowledge we had back then.
In the early 1980’s in the UK and on the course in Adelaide in 1985, we were all learning the latest ‘neural provocation’ tests pioneered by Bob Elvey for the upper limb, and the slump test pioneered by Geoff Maitland. What today therapists call the ‘upper limb tension test’, back then we called the ‘Brachial Plexus Tension test of Elvey’, and many of the Adelaide post graduate manip students studied normal responses of these tests for their research projects. I’m mentioning this because it was probably the start of a wider, bigger and better integration of science into manual therapy. Dave Butler in particular stands out – and as most now know, made a massive contribution by researching and integrating nerve biology, physiology, mechanics and many ‘new’ neural tests and treatment techniques in the later 1980’s and early 1990’s. Dave, along with Mark Jones, whose work on clinical reasoning is well known, were both classmates of mine on the 1985 course. During the few years that followed the course there was a heightened atmosphere of ‘new direction’ with the Adverse Mechanical ‘Tension’ (AMT) of the nervous system analysis of chronic arm symptoms in RSI and whiplash patients. Dave was responsible for a plethora of new AMT tests (since called ANT or ‘neurodynamic tests) and later went on to publish his first book, ‘Mobilisation of the Nervous system’. Here at last was a scientific and rationally based attempt to try and make better sense of those complex patients and put movement, function and dysfunction of the nervous system into the declarative knowledge of physiotherapy.
I have to say I enjoyed the fresh look at nerves as a ‘moving’ tissue, but I continued to puzzle over and I was never entirely convinced that adverse nerve mechanics and abnormal nerve movement was enough to account for the chronic pain symptom pictures I was witnessing. My experience with these new techniques for RSI and Whiplash, while exciting to start with, still seemed to amount to ‘playing with the symptom responses’. It was still passive manual therapy but applied to a ‘new’ tissue.
Philippa and I headed back to the UK in early 1988 where we both took over the family practice in Cornwall. I remained in contact with Dave who by the early 1990’s was travelling far and wide teaching AMT courses and bringing an exciting new era to physiotherapy. I occasionally assisted him on his courses when he was in Europe and the UK and it was during one of these in Holland that I started reading a chapter by Patrick Wall in a book called: Pain mechanisms and management, and edited by Clifford Woolf and Chris Wells. The chapter title was ‘Neuropathic pain and injured nerve: central mechanisms’ (Wall 1991). It changed my professional life because it explained how the central nervous system could plastically change if it was given enough of an incoming ‘afferent barrage’ from an injured nerve or from inflammed and damaged tissues. These plastic changes could result in impulse barrages being self generated from within the CNS, could result in massive spreads of inappropriate sensitivity and a massive enlargement of receptive fields. This was a far better explanation for chronic Whiplash and RSI related pain! Pain and spread of pain not coming from the tissues, but being generated maladaptively from within the CNS! Wow! The pain meant nothing, it was useless, and this revelation meant that I suddenly lost my clinical fear of it. This was what I was going to tell my patients! No need to fear the pain, you’re not broken, your pain processing system has gone mad! You’re safe to move and get your life back…!
These passive treatments that I’d rather denigrated as mere ‘playing with pain’ – I realised now were merely ‘playing with processing’!
In 1993 I went back to Adelaide to ‘top-up’ my Graduate Diploma and turn it into a Masters of Applied Science. It was roughly 6 months of doing a few ‘modules’ and writing a couple of dissertations. Free of any distractions and close to the best medical library in the Southern Hemisphere at the University of South Australia, I immersed myself in the pain literature, firstly of all the peripheral and central mechanisms and then later when I returned home, seeing the biological similarities, in the biology of memory…I actually wrote to and later met with Pat Wall to discuss my ideas an observations. The main one was that at the reductionist biological level of the synapse and circuitry, central mechanisms in pain biology were virtually identical to those described in the memory biology literature. The two disciplines, though miles apart, were actually seeing and saying the same things.
Over a couple of beers and many roll up cigarettes in Pat’s little flat in Grays End Road, London, we both agreed that the central mechanisms of pain and the biology of memory were broadly, if not precisely similar, something he hadn’t really thought about! He also agreed with me that many of our chronic pain patients, like Repetivie Strain Injury, chronic Whiplash related pain and chronic low back pain could well have similar pain mechanisms to those of phantom limb pain sufferers. Indeed, it was Joel Katz and Ronald Melzack’s 1990 paper: Pain ‘memories’ in phantom limbs: review and clinical observations‘ paper that led me to take a closer look at memory biology.
Phantom limb pain without the amputation is a good way of looking at chronic pain. Pat strongly agreed and with glee in his face and a sceptical little twinkle in his eye, he ‘wished me well’ in my task to try and change the attitudes of my professional colleagues to these sorts of pain problems. I knew, that his words had a humourous pinch of irony about them, – for he’d been stuggling to get his own medical profession to ‘get’ what he was on about since the publication of his and Ron Melzack’s paper Pain Mechanisms: A new theory, in 1965. That was the Gate Control thoery of course and what his medical colleagues were comfortably and cynically welded to was a Cartesian view of ongoing pain states: – that if nothing could be found to account for the degree of pain in the patients tissues and their examinations, then the patient was likely to be amplifying or fabricating the symptoms, which were thus of ‘psychological origin’, were for some form of gain and the patient was often considered to be a malingerer. Wall and Melzack’s Gate Control Theory integrated the CNS and the thinking and emotional brain into processing tissue damaging messages showing that they could be modulated. It seems simple to follow but practically and clinically it wasn’t and still isn’t as far as I can see.
I still have the letters Pat and I exchanged. He was a great supporter of our ‘pain movement’ in physiotherapy, featuring as key note lecturer with great enthusiasm at the first physiotherapy lead conference on pain in Adelaide in 1995 instigated and organised by Dave Butler. We had a particuarly pleasant evening with Pat, visting a local park with the specific intention of helping him spot a duck-billed-platypus for the first time, which in the late evening twilight we duly did. Pat also honoured us here in the UK with a keynote address for the first ‘Patrick Wall annual lecture’ at our Physiotherapy Congress in 1998. I seem to remember we gave him a bottle of whiskey to enjoy! Thereafter the ‘Patrick Wall lecture’ became a massive feature of Congress for quite a few years. Speakers included Johan Vlayen (fear avoidance), Steve Thompson(pain biologist and researcher); Steve Linton (Yellow flags), Paul Watson (psychosocial) and in 2002 Ronald Melzack (gate control and the neuromatrix)!
Back in Adelaide in 1993, towards the end of the masters programme, I did my first ‘aches and pains’ talk to a few friends and colleagues – ex students of the manip course from 1985 and some of the lecturers if I remember rightly. I think back then I was a bit too ‘born-again’ with my presentation and maybe left the audience with a feeling that my new fad might just be ‘hands-off and talk’. Anyway, arriving back in London after the masters and before disappearing down to Cornwall, I tried doing it again at Peter Wells’ new clinic in West London and from there the aches-and-pains lectures really started to roll! I was probably far too critical of manual therapy back then and may well have irked a good few of the well entrenched manipulators who attended. The phrase ‘Don’t throw out the baby with the bathwater’ still rings in my head. I agree, but back then I was desperate to give the profession a good shake-up.
My reading continued and as well as Patrick Wall,I also enjoyed much discussion with the memory biologist Steven Rose, whose book ‘The Making of Memory’ was hugely influential. Memory involved synaptic plasticity in representational neural networks and increasing efficiency of those synapses – in effect, the formation of a memory was the formation of new neural circuit – and so was pain. Interestingly, the use of memory biology terms like ‘Long Term Potentiation’ (LTP) and Depression (LTD) are common parlance in the pain literature of today.
For me chronic pain was like an ‘annoying tune’ playing in your head and this became very easy to explain to receptive patients. I used the awful ‘Colonel Bogey’ marching tune! It also dawned on me that once something was committed to memory it was very hard to get rid of, and that the same logic could be applied to ongoing chronic pain. Doing pain focused passive manual therapy techniques to chronic pain patients in 20 minute time slots was hardly enough to erase a pain memory! There was a need for a shift from pain treatment to pain acceptance, pain coping, pain management…. and gradual reactivation, despite the pain.
An exciting voyage of understanding and implementing had started, those chronic pain presentations were beginning to make sense and a massive shift in my treatment and management strategies was required and undertaken.
Over the next 2-3 years I obsessively revelled in the pain, neurobiology, memory, phantom-limb, placebo, manic-depression, psychoneuroimmune, evolutionary (I was a zoologist before becoming a physiotherapist!) and stress literature and started to integrate what I was learning into clinical practice. I started teaching the ‘Clinical Biology of Aches and Pains’ courses in a much more organised way, and so began my shift away from the purist manual therapy and passive treatment dominated approach to pain problems. I sensed freedom and was excited by what I was discovering. Complex pain presentations were looking less daunting and much more explainable! I was losing my dread and fear of those long term and often misbelieved sufferers. I was losing the notion that when pain was bad, ongoing and chronic – that it was best to be careful, the structure was somehow faulty. I felt confident that even though the pain was bad the tissues could easily start progressive and graded loading. This was backed up by a very thorough and well explained physical examination. So, despite chronic ongoing pain, the newly reassured patient could be fitter and far more functional if they wanted to come along!
Clinically one of the big things I started to do was spend plenty of time with the chronic pain patients, not only listening, but also getting them to try and see their problem from a different perspective. I was getting patients to shift their thinking about their problem from one of:- ‘There’s something seriously wrong with me… nobody’s found the cause yet… when they do…they’ll be able to fix what’s wrong and I’ll be better…. To:- ‘There’s a flaw in my processing system…. the tissues have healed the best they can, they may not be brilliant but…. they’re safe to start loading…they can get fitter and stronger… and, the pain has remained on far too long and too strongly when it shouldn’t have’. A few patients changed massively, they lost their concern and fear and with my input and guidance started to unlearn all their maladaptive over-protective movement patterns. They got active, more physically confident and fitter. A great many found the pain became far less intrusive and less troublesome, in a few the pain went but in others there was no change at all. A great many simply got their lives back together. Some got fitter than they had ever been. I was starting to change a few lives and my confidence was growing. Pain mechanisms made it all make sense, yet in a passive therapy dominated world I felt very alone. In my Aches and Pains lectures I introduced the pain science and meshed it with the ways I was explaining things to patients. I tried to get my audience of professionals to shift their thinking – which for the most part proved to be harder than shifting it with my patients! I had Patrick Wall’s ‘Good luck Louis’ comment quitely ringing in my ears!
The key was to demonstrate using real patients. Information doesn’t change many people’s hardened beliefs, but witnessing change certainly can. I think it was around 1994 or 95 when Dave Butler and I decided to start teaching a 5 day course together using patients. The course was called ‘The Dynamic Nervous System’ and attracted a great many physiotherapists who were really expecting, at least in those early days, an ‘Advanced’ Butler AMT mobilisation course with Louis Gifford assisting. Well, what they got from me was pain mechanisms, the integration of pain into clinical reasoning and me out the front with a live chronic pain patient – getting deeply into all the dimensions of their problem, examining them and then spending a great deal of time explaining their pain problem with the aim to shift their thinking from ‘my problem means I’m damaged in some way I cannot move on…’, to ‘my body has healed but my pain processing system is at fault…’ And then starting to find ways of helping them to move and exercise that they’d never considered.
I saw the patients over 3 days of the course and spent a great deal of time with them. Many of the patients were incredibly open and some made massive changes and thankfully helped many of the entrenched manual therapists to grasp what I was on about. I still hear from course participants that the course and the patients I grappled with were clinical life-changers.
After the patient demos Dave grasped what I was up to and came on board. Those early courses in a way were a mismatch:- With me emphasising hands-off and start talking – or at least ‘top-down’ (get the head right/accepting) before ‘bottom-up’ (doing any form of physical exercise or treatment), but with Dave emphasising hands-on still, teaching the tension tests and all the neural mobilising sliders and tensioners that were all the rage then. Over the few years we taught the course Dave also immersed himself in the pain literature and the course became more balanced with the passive mobilising being placed much more comfortably and with less emphasis. His chapter: ‘The upper limb tension test revisited’ in Ruth Grant’s book:Physical therapy of the cervical and throacic spine; elegantly confirmed the shift in reasoning to one that embraced pain mechanisms.
Through four or so years in the latter 1990’s he and I were close, as well as regularly teaching the Dynamic Nervous System course together we both set out to write a book of the same name. Every time we met we’d bring a pile of books and articles with us and we exchanged much material between Cornwall and Adelaide, via fax before the internet and then rather more easily via the relatively crummy internet we had back then. Dave particularly immersed himself in the ethics, suffering, epidemiology, psychosocial, anthropological, cultural and clinical reasoning literature in relation to pain and was very good at it. It brough a much broader and powerful dimension to our teamwork and teaching presentations.
Together, we pondered the clinical reasoning hypothesis categories that Mark Jones had been teaching and pleaded for change and integration of what we had been learning. The original hypothesis cateogories that Mark introduced for manual therapy were:-
- What is the source of the symptoms and/or dysfunction?
- Are there any contributing factors?
- What are the precautions and contraindications to physical examination and treatment?
- What is the prognosis?
- What treatment shold be selected and what progression is likely?
For manual therapy or any therapy geared towards a tissue based approach and a passive treatment approach to a pain problem, this was how it was. The answers to those questions were always described in terms of physical injury, tissue abnormality and movement and biomechanically altered function.
Pain mechanisms and a more ‘top-down’, self-management, multidimensional view of things required changes and additions and these were commited to the literature in our combined article: Gifford, L. S. and D. S. Butler (1997). “The integration of pain sciences into clinical practice.” Hand Therapy 10(2): 86-95.
The clinical reasoning hypothesis categories now became:
- Pathobiological mechanisms
- Contributing factors
Pathobiological mechanisms had the following sub-divisions:
- Tissue mechanisms (i.e. what’s going on in the tissues? Are they: healing, healed, scar tissue, inflammed, ?? etc)
- Pain mechanisms – (i.e. what pain mechanisms are operating or dominant: nociception? peripheral neurogenic? central? Affective emotional? Sympathetic? Motor (output).. even immune?)
The Dysfunction category was expanded and defined in terms of the clinical ‘expressions’ of the pathobiogical mechanisms. Hence:
- General physical dysfunctions – what would now be termed disabilities – for example inability to walk for more than 5 minutes, inability to type or write or do house work, lift objects and perform work tasks.
- Specific physical dysfunctions – what I now call ‘physical impairments’ – they’re the things that physical therapists find from their physical examinations – losses of range of movement, pain on certain movements and tests; weaknesses, neurolgical deficits… and also all the little physical minutiae that many physical therapists seem to get obsessed about – muscle imbalance, an accessory movement not being quite right, a fascial band restriction, a core stability abnormality and so forth.
- Psychological/mental dysfunctions. This was an early recognition and germination of the importance of psycho-social factors being important.
So, pain mechanisms, or pathobiological mechanisms, and a broadening of the ‘dysfunction’ category were integrated into clinical reasoning and it was an honour for my work to be acknowledged and to co-author with Mark Jones and Ian Edwards the article: Conceptual models for implementing biopsychosocial theory in clinical practice, published in the Journal, Manual Therapy in 2002 as well as in Mark Jones and Darren Rivetts’ book ‘Clinical Reasoning for Manual Therapists’.
The utility of my ‘Mature Organism Model’ (MOM) first published in Physiotherapy Journal in1998 seemed to be popular with educators and clinicians alike. The basics of it were roughed out while squashed up in the back of a the Heathrow to Billund (Near ‘Legoland’ in Denmark) plane while David was comfortably easing and stretching somewhere up front in business! We were on our way to teach a 5 day Dynamic Nervous System course. I tried it out on the course participants who then used it with great zeal and success with some of the course patients!
I still get communications that thank me for the MOM, many saying that it challenged and changed their clinical perspective for the better, which is really nice. The model was scented heavily with my zoological background and was really born out of frustration with my physiotherapy colleagues for not ‘getting-it’ …. I guess it was my own unique biological/evolutionary perspective on pain and pain related disability that embraced all the dimensions of pain. It was an honour to present the model, in my ‘Explaining Pain to Patients’ presentation at the International Association for the Study of Pain (IASP) world congress in Vienna in 1999.
So, time and again the Dynamic Nervous System course feedback indicated that it was the ‘live’ patients backing up the ideas from all the pain mechanisms, the stress lectures, the MOM and Dave’s ‘Pain, art and politics’ lecture that left a deep impression, hugely challenged beliefs and shifted the participants to see a much bigger picture. On some courses there were some quite emotional scenes because a lot of what we did occasionally penetrated some of the personal difficulties that course participants were having in their own lives.
By 1997-8 we were taking the course all over Europe but also to South Africa and once back to Adelaide! I remember a young and rather hippy looking Lorimer Moseley (tin whistle/flute and all!) in the Adelaide audience as well as a great number of the well established manual therapy heavies. As many of you will know Lorimer went on to do a great deal of impressive research on pain education and is a great, communicator, thinker and researcher, being highly regarded by the world’s pain research community.
Key moments in life and careers are good to reflect on. What would have happened if I hadn’t met….such and such? Or, that person said something that made me think…? One key moment was after one of my early Aches and Pains courses here in Truro, Cornwall. Throughout the course three physio’s were sat at the front who afterwards came up to me with great enthusiasm – saying… …that it was good that someone respected in the manual therapy world was challenging the current dogma… and appealing for a bigger and broader perspective to be adopted…’ The three physio’s were Heather Muncey, Vicki Harding and Jan Williams and this must have been around 1994 or 95, certainly in the early days of my pain lecturing journey. All three of them worked in Pain Management units and were CBT trained – trained by psychologists to help patients using Cognitive Behavioural Therapy models and techniques. Heather in particular urged me to take CBT and psychology on board and Vicki invited me to the INPUT pain management centre at St Thomas’ Hospital in London.
I very soon took up the offer and spent a week joining in with a one week programme for a small group of chronic pain in-patients. These patients were what Drs commonly call ‘heart-sink’ patients – chronic ongoing pain, with huge problems, not just pain but with mental, family, home, work, life, their Drs, their management, their surgeons and so forth.
I quietly watched, listened and made copious notes as the group of patients were assessed, tutored, guided, activated and assisted to embrace a means of learning better coping, better thinking and reasoning, better fitness and functioning and better self-help, in this brilliantly multidimensional and inspiring environment. The changes in these tricky patients was remarkable given the short length of time they were there. But the days were intense, active and the patients had to get involved. There was no hands on, no passive treatment here, they were learning to stand on their own feet and cope and reason with far better skills than they had ever had before. These patients had had every treatment you could think of and here they were moving on to a much better place.
I was privileged to meet some amazing clinicians: – Suzanne Shorland (now, Brook); Kate Treves, Toby Newton-John, Charles Pither, Amanda Williams…
Thanks to the enthusiasm of Heather Muncey in particular, the UK based Physiotherapy Pain Association (PPA) was fertilised, quickly gestated and born to the world! That was 1994! It was a fantastic coming together of a section of very able and wise physio’s tucked rather quietly away under the guiding wings of wise and highly regarded pain psychologists and a few of us more general physiotherapists who were beginning to see that there had to be much more to pain than we’d been taught. On my rather lonely general or ‘manual therapy’ side of things were three therapists… From the early days, Mick Thacker, physiotherapist, pain scientist and world class sceptic who I came across at a symposium where he was giving a pain talk, blasting various passive treatment modalities! He and I have collaborated on many occasions over the years and I hugely value Mick’s knowledge, openness and honesty. He’s probably the most pain knowledgeable physiotherapist on the planet! Physiotherapy is lucky to have him! Secondly, from a bit later on, I’d also like to include a good friend and another writing collaborator of mine, who ‘converted’ – Steve Robson! ….Steve I know, thinks in a very similar vein to me. Thirdly, like Steve, there’s Ian Stevens from Dunblane in Scotland who has been so supportive and kept me well ‘fed’ with his research of the research, his constant stream of ideas and his massive interest in the broader cultural, philosophical and ethical dimensions of pain. We both have a great passion for the way humans are, the way they think and the way they react and interact… and we both have our moments of great frustration with the profession from time to time! Thanks Ian, and a great photographer too!
Physio’s from psychology and CBT programmes came in the form of Heather, Jan, Vicki, Sue Mickleburgh; Suzanne Brook (nee Shorland); Paul Watson, Liz Macleod; Lorraine Moores, George Peat; Steve Goldingay; Pete Gladwell; Jennifer Klaber Moffett; Gail Sowden; Penny Mortimer and many more. For me, it was the opening of a hatch to a massive amount of work and research done on pain that was so needed at the basic musculoskeletal level of physiotherapy. At last a multifactorial view of pain and how best to help and prevent the dire consequences of long term pain related disability.
So, from the late 1990’s on the integration of psychosocial factors into clinical practice forged ahead in the UK with the formation of the Physiotherapy Pain Association, the publication of its work in the Topical Issues in Pain series and later university run courses headed by physiotherapists which were awarding Masters in Pain science and pain management. In the UK in particular I feel, the integration of some of the principles of Cognitive Behavioural Therapy (CBT) into mainstream physiotherapy has become significant. The research and teaching commitments of many PPA members is also to be commended.
The book that David and I were writing, ‘The Dynamic Nervous System’ never got to print. In 1998 David pulled the plug on the project in a rather sudden, messy, unpleasant and confusing way and then totally whitewashed my contribution to his pain learning/explaining and development out of what I still view as a unique collaboration during those early pain revolution years. Sadly it’s left me with a permanent and rather unpleasant mistrust in certain features of the human character. As a Darwinian reasoner I guess I shouldn’t be surprised really. Anyway, many of the chapters I wrote are still in my computer and maybe I will post some of them up here at some point. They need a re-read before I do, that’s for sure.
Thanks in particular to the stimulation of the UK PPA and all those involved, my ‘individual’ (rather than team!) private practice patient management, thinking and methods continued to evolve and change. I explored numerous routes to try and move complex patients on, found comfort in simplifiying things but continued to be bothered by ongoing ‘guru’ based treatment fads and methods that were resistant to any sort of criticism. (How unscientific are they?) In the end I spent time pondering and analysing how I think and work clinically, I reviewed a good deal of Mark Jones’ clinical reasoning material and came up with the ‘Shopping Basket Approach’ ! My ‘approach’ was pretty simple so I thought I’d try it out on the courses and guage the reaction! I still think it’s one of the best things I’ve done, – and back when, it was a bit of a dig at the ‘Surname-approach’ methods that everyone likes to ‘follow’… The ‘McKenzie’ approach, the ‘Maitland’; the Kaltenborn’; the ‘Bobath’ and so forth. So the term ‘shopping basket’ substituted for the surname…and on the 7th day the term ‘guru’ was to be frowned upon and put in its place…. etc…
The Shopping Basket approach was/is really designed to drag a ‘one method’ or ‘one tissue’ focused therapists out of their dark safe, but restricted unidimensional burrows, to see the clinical situation from a much bigger perspective. (You won’t come out until you recognise you’re in one though!). It strongly insists on a shift away from the top-heavy over-focus on tissue ‘impairments’ that practitioners seem to worship, love and get overwhelmed by. In a sense the shopping basket approach is a healthy shift back to the central tenet of physiotherapy that I love: ‘Rehabilitation’! An untrendy but great word that sits proudly and calmly in a specially reserved seat in the conclave that convienes to make sense of the multidimensional nature of pain. You can’t DO rehabilitation to someone, they DO, you DO the guiding!
I included the Shopping Basket approach in my Nerve Root and Graded Exposure courses which began around 1999. The ‘Graded Exposure’ course title was an adaptation from the fear-avoidance literature to my day to day practice helping patients to get going with physical function and loading their tissues again.
I also kept going with explaining pain, continually spinning things around so that I could adapt to any given patient at any given moment. My ‘Vulnerable Organism’ model seemed particularly helpful at both the clinician and patient level of understanding pain problems.
For a good 10 years I thoroughly enjoyed editing, contributing to and publishing with Philippa the PPA News until Steve Robson took over as Editor in 2007. I had free reign in my editorials – probably getting into quite deep water criticising the McKenzie approach, but also receiving a great deal of support too. The whole debate will by published on this site and it’s still very relevant today.
In reflection, I’ve worked very hard trying to understand clinical pain states and make better sense of them, especially in those early days. Today as I finish editing this piece I had a lovely email from a physiotherapist who said he attended my Graded Exposure course back in 2007and that it had changed his clinical practice – for the better! May it long last, some of the messages will surely endure.
I hope I can enthuse those who go on to download, read and study the work on these pages. Pain is amazingly complex, it bites at our most basic life force and it’s understanding holds so many exciting possibilities for the future comfort and well-being of mankind.
Well, it’s been like this: I started out my physiotherapy life wanting to help patients with aches and pains. It wasn’t that simple so I tried to understand what there was to know about pain, that wasn’t simple either. I then spent a great deal of my career trying to make something complex a lot easier to follow – for me, then for my patients and finally for the clinicians I came in contact with. It’s been very interesting!
I’m now looking forward to getting the last bits of my pain book and voyage finished and getting it out there!
Lastly, special thanks to Ellen and Bernie Guth for being there throughout.
Louis Gifford FCSP,