Pain and the genius of the late great Louis Gifford

“Hard times create strong men. Strong men create good times. Good times create weak men. And, weak men create hard times.”

G. Michael Hopf

Before Louis passed away on February 9th, 2014 - he was still frantically writing and thinking through how health practitioners can help their clients and patients through pain.

In particular Louis wanted to assist musculoskeletal therapists help manage pain related to this system, given he was a trained physiotherapist. But his work led to so much more than just recognition that all the things that make up the musculoskeletal system - muscles, ligaments, bones, fascia, joint capsules, tendons, synovium, periosteum etc.

It runs deeper and the human nervous system, through its peripheral and central component parts, is a key constituent of his theories and work that have held steady for well over 25 years. The next few paragraphs attempt to paint a very brief picture of his work.

Traditional and contemporary concepts of the pain experience

When we injure a tissue, be it through repeated exposure and overuse or acute trauma, we can localise the area of pain felt to that part of the body and that particular structure. Either that "once of" impact or "constant barrage" of structural assault can agitate the local and small surrounding tissues. We get inflammation in the area, it creates sensitivity through something called a nociceptor, near or within that tissue, and it reports this to higher centres to signal that there's tissue damage. Particular parts of the brain like the insular cortex, the anterior cingulate cortex read into these nociceptive signals and then give people the subjective pain experience, leading in real time to the idea: 'Ouch, yes it hurts there where the tissue has been damaged.'

This still happens, but why does pain persist in some people (and not in others) when that tissue has since healed and is no longer showing any evidence of structural damage? Enter the biopsychosocial framework with pain and the magic of the human nervous system.

Pain is a human experience, not just a mechanistic one...

So if the structures mentioned above heal, repair, recover and the like then why do we still experience pain following tissue healing? There's not enough time to dive into all this and the work of Louis, but there's a memory biology involved in the hippocampus, there's other parts of the brain that this pattern is mapped onto like the pre-frontal cortex, the primary and association somatosensory cortices, the thalamus, the periaqueductal gray mater and it goes on and on.

On a very practical level, this basically means that all of these central processing aspects of the brain work in tandem to either increase or decrease the 'noise' experienced through pain and the perception of pain. These signals can tie in strongly to the emotional centres of the brain (the amygdala) and also play a role in how we feel about it too. For example, if the emotions are predominantly positive, we don't tend to experience pain as much as when they're mostly negative.

Think of the registering of pain as a knob on a music amplifier that controls for volume. The brain can turn the volume up - increasing the pain experience, or it can turn the volume down - decreasing the pain experience.

The brain can be tricked, for better or worse...

Fancy terms like allodynia (an otherwise non-noxious thing that touches the body in a sensitive area causes pain when the thing is not harmful) explain an oversensitivity of the nervous system. As does a nocebo effect and one of the most sinister forms of trickery, is the phenomenon of phantom limb pain impacting amputees.

People can come into the clinic and further perpetuate these things themselves with other jargon-based terms like hypervigilance, kinesiophobia and pain catastrophising. These are all areas a clinician can work in with a patient to assist them through their situation.

On the other hand, there's the classic placebo effect and this can work very favourably in pain management. A peaceful clinical setting with relaxing music, a smiling receptionist ensuring you won't be waiting long and a practitioner with unconditional positive regard for their patient during discussions all combine to favourably increase the person's presenting condition - and this can transcend pain and even improve functional outcomes.

In 2002, a trial for patients with an osteoarthritic knee showed placebo surgery to be as effective as two types of orthopaedic knee surgery. Don't underestimate the power of the mind above and beyond pain.

We are just scratching the surface here

Louis Gifford amongst others before him, came to a very important realisation in musculoskeletal pain management. That is, the tissues involved are important, but the person that owns those tissues is far more important, so our biggest take home here is this:

The body is strong and robust. It is adaptable in a way that you have power to shape and people can build resilience through their choices in how they manage the pains they experience.

Look after the person, not their condition - don't fall victim to the idea that a person's condition defines who they are and go chasing for provisional or working diagnoses all the time. These should be handed out with caution and when there is an underlying sinister cause of the person's presenting complaint.

The body of evidence that continues to grow around the incredible complexity that is pain neuroscience, only continues to support the theories and ideas Louis has been discussing for around forty years - make the most of them in practice to help people.