Professor Patrick Wall’s Review

(Professor Patrick Wall was editor of The Text Book of Pain and with Ronald Melzack responsible for proposing the gate control theory of pain in 1965) Published in the February 1999 edition of Physiotherapy Journal.
Patrick Wall sadly died on August 8, 2001, aged 76.

It is not an exaggeration to say that this book marks a milestone not only for an understanding of pain but also for the maturation of physiotherapy. For centuries physiotherapy has been placed in a minor subservient role among the medical arts. This low status encouraged a passive intuitive acceptance of therapy in a barren desert of intellectual questioning. The present rapid evolution of attitude no longer permits untested acceptance. The authors of this book and the organisers of the Physiotherapy Pain Association are clearly pioneers leading their profession out ofthe desert. They have been reading and experiencing and questioning everything to the conditions, which are treated rather than restricting themselves to the classical physiotherapy texts, which are often dull, repetitive and trivial. In addition to an open-minded education, they point to the almost unique opportunity characteristic of physiotherapy, which remains the close prolonged interaction with patients. Social pressure has removed this from almost every other branch of the medical arts.

The practical pragmatic obsession of old-school physiotherapy assigned questioning and investigation to a separate and distant other class who in practise in fact ignored the problems. Research was assigned to some non-existent class of intellectuals and thought to be beyond the scope of physiotherapists. A striking example is that to be found on page 94 where 20 therapies for whiplash are listed. Of these two are thought to be useless, two useful and the other 16 have not been adequately investigated. This vagueness is a threat to patients and to physiotherapists and to an understanding of pain. Research can not be the responsibility of others. It does not require huge high tech resources. The results are not to be feared. The discovery that a therapy depends on a placebo response should be welcomed with relief because it liberates the therapist into a positive area to explore the economics and the precise nature of the placebo component of the therapy.

Work over the past thirty years has rejected the model of a pain mechanism as caused by a fixed rigid modality-dedicated mechanism. The process, which produces pain, is plastic and changes sequentially with time. That essential mobility of mechanism exists in damaged tissue, in the peripheral nerves and spinal cord. This movement of pathology from periphery to centre proceeds with the triggering of reactive processes in the brain. It presents the therapist with a migrating distributed target. For that reason, I was particularly impressed by the chapter by Gifford on the “Mature Organism Model” which places pain in an integrated context without any permission to accept the old dualistic split that pain must be either in the body or in the mind.

I look forward to this series and to the activities of the Physiotherapy Pain Association because they promise to revolutionise the morale, dignity and way of thinking of physiotherapists and thereby to affect everyone concerned with pain.

With best wishes

Patrick Wall

Australian Journal of Physiotherapy Review

Review By : Dr Patricia Roche, Queensland University, Australia Published in the Australian Journal of Physiotherapy 2000: 46(3)p 246

The majority of the fifteen contributors to this book are practising physiotherapists. The editor Louis Gifford and the Australian contributors Butler and Zusman are amongst those who are to be commended for their meaningful and easy-to read integration of recent, international research in pain, as a practical model for pain prevention and rehailitation. Their focus is on integration of non-tissue specific approaches at all stages of physical management. The result is a well-supported critique of overly tissue-focused management and the importance of integrating more of the systems of human response that are available in order to improve patient outcome in rehabilitation. The aim for the physiotherapist is to engage the thinking and responding person (our patients) into a comprehensive treatment model. The applied model will make profound sense to any therapist (and patient) confounded by lack of success following a variety of treatments. This book is not typical of physiotherapy texts. Poor outcomes for whiplash injury are well chosen examples of the impact of ‘fear-avoidance-beliefs’ on pain disabilities and behaviour. Clearly reasoned and knowledgeable answers are provided to important clinical questions e.g. “Why do serious pain problems arise from apparently curable tissue disorders?”; “Why do physiotherapy techniques frequently fail the patients who develop these problems” and “What psychology is good psychology for patient care”. The challenge, to actively incorporate more cognitive-behavioural methods of therapy into treatment, is followed by practical guidance on essential assessment and communication management to achieve these goals. The book addresses, and gives answers to real physiotherapy issues. It does so comprehensively, with strong scientific validity, excellent illustrations and a clear background of clinical experience. For these reasons the book makes a vital contribution to physiotherapy teaching, research and practice at a time when the profession should be seen to integrate science with appropriate models of health care.

As the first of the series written by members of the Physiotherapy Pain Association, I agree with Patrick Wall in deeming this book ‘a milestone’ in the ‘maturation of physiotherapy’. I am looking forward immensely to the next in the series.

Patricia Roche MCSP, BSc (Psych), M.Sc (Psych) PhD

Readers Comment

“The first yearbook was probably the most informative and easy to read physio book that I have read. I have encouraged all my Physio and Occupational Therapist colleagues to read it! Thanks.”
Francine Toye, Chartered Physiotherapist

“Got it? If not, why not? Topical Issues in Pain 1 is invaluable and an indispensable text for ALL practitioners and Doctors”
Alan Leigh, Chartered Physiotherapist

“A seriously good book”.
Judy Waters, JJ Editorial Services

“A much sought after book in our information resource centre”
Ralph Hammond, Chartered Society of Physiotherapy