Yet again I find myself writing another blog on manual therapy. Yet again I find myself having to explain my views on it after some people got their ‘knickers in a twist’ about my views, opinions, and comments on a recent interview the legendary physio Brian Mulligan gave to the CSP here, the full transcript is available here.
Now, these Mulligan disciples were very quick to make some straw men arguments and jump to conclusions, accusing me of ‘throwing out the baby with the bathwater’ because I said I found this interview full of outdated reasoning, logical fallacies, and improbable claims. They say from this I must think that all of Mulligan’s work in physiotherapy is useless.
This is bull shit, and I have never said or suggested this. This is a straw man to make it easier to attack me rather than listen to my critique of Mulligans interview.
Character
I will admit I am enormously frustrated and disappointed with Brian after reading this interview. Mulligan is a legend within physio, known for his charismatic ways, colourful language, and straight-talking, and I like colourful language and straight-talking in the all too boring, dull, and grey world of physio.
Mulligan is also a legend due to his infamous textbook published in the 1980’s being illustrated with a female model in skimpy underwear (sometimes without the underwear) who, if the stories are to be believed, was a lady of the night he hired for $50 and the assistant’s hands in the photos were the ladies pimp.
But this interview has changed my opinion of someone I once admired and believed to be an influential leader in our profession. Someone who I thought was a good critical thinker, but more importantly who I believed was keeping current with the changes and advances we have made in our understanding of the effects of manual therapy.
I was taught many of Mulligans techniques as a student, and out of all the manual therapy bullshit I was taught, Mulligan’s MWMs, or ‘Mobilisations with Movements’ appealed to me greatly. They made sense. The premise was simple, try to facilitate a person’s painful movement with the application of external forces directed to the joint/tissues… as it moves. It was simple, straightforward and not surrounded with too many stupid explanations.
Of course, as a student I was taught to believe I was actually affecting the joint and tissues mechanically, changing the position of the joint, or its direction of movement, and it was this that made pain reduce or disappear.
This belief of re-positioning I now know, although not fully dis-proven is extremely unlikely. Rather our understanding of the effects of manual therapy is that its more about the host of other non-mechanical effects via the neural system, both peripheral and central that reduces pain, even with MWMs.
Baby and the bathwater?
Although our understanding as to the mechanism of effect has changed with MWMs, this doesn’t mean we have to totally abandon these techniques. Instead, we simply need to change our understanding and explanations of how they work.
Many assume that as I am a vocal and strong critic about manual therapy that I don’t touch my patients at all. They are wrong. I touch many of my patients, I just don’t call it formal manual therapy these days.
Personally, I think we should change all our descriptions for ALL manual therapy techniques, such as mobilisations, manipulations, massage, MWM’s myofascial release, etc and they should NOT be called manual therapy, rather just symptom modification techniques.
We know that ALL manual therapy is highly individual in its effect. We know that ALL manual therapy effects vary in size, duration and frequency, regardless of the technique, regardless of the of application, regardless of the experience of the therapist.
I am acutely aware of theses individual responses and variable effects of manual therapy, and I am under no illusions that many factors affect them. I know that there isn’t any superiority of one method over another. And I think physios should not be constrained by one set way or method, rather they should use various techniques and explore what may help a patient using a very basic set of principles…
These are…
- It must be comfortable, for both you and the patient
- It must reduce pain significantly for it to be classed as successful
- If it hasn’t helped within a few attempts, stop and do something else
Despite Mulligan boasting in this interview about how he gets immediate instant effects on everybody, I don’t believe him. He may believe his own hype and use the live demo’s on stage as a way to ‘prove’ it, but this is nothing more than cheap showmanship best left for faith healers, magicians or snake oil merchants.
So these are my musings on the Mulligan interview and my disappointment in it. Let’s hope the happy clappers have now unbunched their panties a little, although I doubt it.
I will finish by saying have never met Brian Mulligan and I am unlikely to now after this I guess which is a shame. However, I will occasionally continue to use some of ‘his’ techniques, just with ‘new’ explanations, so again there are no babies being thrown out here!
As always thanks for reading
Adam
Hi Adam many thanks for your open/honest opinion. I really enjoy reading your blog/tweets. Some cracking info. Do you have any references for the effects of manual therapy on the PNS/CNS, and the fact that manual therapy is unlikely to actually effect joint mechanics? Thx as always n hoping to get on one of your courses soon. @jimmypeo17
Hi Jimmy
There is heaps of papers on the effects of MT on PNS/CNS.
However this is a good read on the proposed effects of MWMs specifically and as you will see there is no evidence either way http://www.iaopt.org/downloads/mwm_current_concepts_effect_vicenzino_07.pdf
Thanks for the comments
Cheers
Adam
Thx Adam. Just looking for something get me started.
Hi Jimmy //
This book have some chapters as well regarding possible effect of MWM’s…
Cheers
Jeppe
Does it matter what we call it? As long as we’re not bullshitting our patients and telling them we’re wiggling their joints around, realigning their tissues or clicking their bones into place. We still use the old text book techniques..Its clear that they have an affect on pain, although those effects are not what was first hypothesised, if it gets someone on board and facilitates movement who cares!?!
I think the terms we use continue the old myths to linger. If we now have completely new understanding of the effects then why not change the terms to reflect this, kind of like a commercial rebrand…
Reblogged this on Neil Wise Physio and commented:
A kit bag of fancy tricks or using the system of assessment & force progression which directs loading required. Hmmm choices….
Adam,
Great post mate. Thank you for sharing!
Performance Coach School of Strength Bega Phone: 0414957478 https://www.facebook.com/StrengthSchoolBega
Adam ,
I find myself in the same boat in terms of my approach to treating patients who are unable to move for what ever reason. In my clinic I treat mainly chronic spinal pain and , I think the greatest skill is attempting to sub categorise my patients as to why the can’t move or have pain. Are they scared? Are they stiff? Do they have irritated neural tissue? Do they move / or not move in a way that stresses tissue. Are they deconditioned? Are they trying to ” turn on their core” inappropriately? Treat the factor that has the biggest effect on their pain initially , explain things well to de-threaten the pain (some might call this CBT) and get them moving.
The beauty of Mulligan techniques are that they can work well to get a stiff patient moving by seemingly localising movement, a trick in the kit bag just like needling, STM, or “trigger point” release, and allows us to address the other factors that might also be causing pain. I tell my patients that the technique is helping their back / neck move in a more normal way . What am I actually doing? Facilitating normal movement? Inhibiting neural systems? Maybe just giving someone the confidence to bend over who hasn’t moved in 12 months? Who knows, but if it works in combination with a good explanation and allows the person to move with less pain in the short term, it is a technique that I ill continue to use. Whether or not there is an evidence base is not particularly useful as it often doesn’t apply to the patient in front of me.
I did a course with Mulligan about 5 years ago and although there was a lot of bravado and questionable explanations, he did state that he really didn’t know the mechanism for the techniques working, but that they worked. He said it was up to the next generation to work out how.
Am I a ” Mulligan’s practitioner” , well yes I have done the courses, but I am more than happy to use a completely different approach to get the job done. Using one sort of approach does not make sense in my book, because the cause of patients pain varies greatly and is often multi-factorial.
Great Blog Adam, keep them coming.
Cheers
John Kingston
Revive Motional Health
Tasmania,
Thanks for your comments John
Hi Adam,
Enjoy your blog and the fact that you speak your mind, warts and all so to speak. I was wondering if you know much about the Ridgeway method and if you do, could you give your thoughts about it.
Thanks again!
John
Hi John
I have not heard or come across the Ridgeway method, do you have any links?
Just keep pushing
Adam, you are funny. I’m glad you send me your blog below. It made me cry at first but with relief that am not on my own getting into trouble. The difference is I have decided to give up on them and leave them to decide what’s best for our great physiotherapy profession that we love.
Regards
Yui?……..?
Date: Wed, 26 Aug 2015 20:33:23 +0000
To: [email protected]
Manual Therapy is no different than any other intervention per se, simply an input used to try to change an output from the nervous system. Sometimes it helps, sometimes it doesn’t. Unfortunately our profession doesn’t seem to have caught up to the updated explanations backed by best available evidence.
Well said Adam. I’ve felt this way for a few years now and have even lost faith to a degree. I really feel that you need to fully believe what you are doing is working and at times physiotherapy treatment can fall short. We are a young profession and changing the language and theory of Maitland, Mulligan, Cyriax etc.. When new theory comes along can only be a good thing.
A mate of mine met Mulligan once at a New Zealand Airport customs point. He had a bag literally full of cash that he was declaring to the customs guys, my friend was stood next to him, he said he’d been teaching in Dubai!
Great post.
I especially liked the “magician” part.
I especially liked it because before my physio career i myself was a magician.
Thus i have some insight for you in this matter.
I took the “mulligan concept course” as a young physio and fell in love with the concept. For a whole year i implemented the techniques on every patient, without the promised success rates, and most of the time with only immediate relief but no long term relief. I abandoned the technique especially after the following:
I saw mulligan in person some 10 or 11 years ago (or more?) in the Netherlands giving one of his “shows” performing his “magic”. Only when i saw him person i had a revelation: As a magician i immediately recognized specific traits he was using that were used by magicians while performing tricks. first his suggestive tone and dialect that are used by hypnotherapists, second by using ideomotor tricks and responses from subjects he demonstrated on them.
My revelation was that he is probably one of many persons who are totally unaware of their abilities and he uses them out of instinct and i call them “sucessfull fools”. A charlatan is someone who knows that what he is doing is wrong and still does it. “Successful fools” are ones who actually believe that what they are doing is right !!! I suddenly understood that he (Mulligan) truly utterly believes in himself. The traits he used suddenly explained me why the techniques he uses are so great on the short term. In hypnosis you are able to reach amazing results in seconds but without proper psychological augmentation (psychotherapy) it is only momentary. That is why magicians use these ideomotor response,NLP and suggestions in their show and sometimes as a covert part of a trick. Another realization that hit me is that those traits when possessed by therapists (aware or unaware) is what makes them into “great” “magical-therapists, witches, electrical hands” etc. The ideomotor response is only in its diapers in relation to the clinical world research and some of it is explored in placebo response research. Its important that therapists get to know the ideomotor response in relation to their logical flaws and deduction abilities. I teach that a lot to my colleagues here in israel.
Here in the link is a great example of a fool who utterly believes in himself
https://www.youtube.com/watch?v=rMtuWymUzz4
James randi (the amazing randi) is a magician that has a foundation set to track and identify Charlatans and explain trickery to the public.he is a great man and suggest you follow some of his insights.
the moral of my story can be summarized by what Obi-wan Kenobi asks in star wars: “Who is more foolish? the fool? or the fool who follows him?” (excuse the geek in me)
glad to finally meet someone who thinks like me in regards to mulligan.
i got dissed a lot here for my opinios.
keep up the good work
Hey Asaf
Thanks for your great comment. What you say is really interesting about the similarities between guru clinicians and stage performers
I too have noted this, and have mentioned it before in my blog on the ’10 worst types of therapists’
As you say some are charaltans and snake oil merchants, others truly believe their own hype and are deluded to anything else, living in a bubble of their own making.
Thanks again
Adam
This is such a relief to read so thank you for that, it makes so much sense to me, especially alongside Asaf’s comment. I often idolised a physio ‘guru’ who seemed to get such good results from manual therapy. It left me feeling inadequate (I’m sure I’m doing something similar.. Why don’t I see the results?) so cue booking on more courses to try and perfect techniques, which I now know was a waste and the ‘gurus’ teaching the courses were also convinced of their skill, never telling us about the pitfalls or not so successful case studies..why would they.. £££! But I believe they were convinced in their own skill rather than trying to completely deceive us..I distinctly remember a quote.. ‘patients come to see us and we tell them we will cure you.. It gives the patient hope and confidence’.. That coupled with the fact that patients paid £70 for an Ax might have had a strong influence on the outcome! My local guru was so convincing of the diagnosis and of having ‘sorted’ the patients ‘misalignment’ with certain techniques, I was convinced myself, so no wonder the patient walked out a million dollars…. They did see patients week in. Week out, for months.. On and off.. For years. Patients were addicted to them… And I realise now they were as addicted to the techniques as they were to the guru and the stage performance.
Great blog!
Hi there,
I’m a newly graduated PT from Canada (French part, so excuse my English). I also was taught a lot of manual therapy (mostly Maitland’s, but also Cyrix, Butler’s and some other soft-tissue nonsense). Being skeptical and curious by nature, I came across MWM I found it appealing. Brian Mulligan, just like Maitland, Ida Rolf, and other schools of quackery (like ART or probably the funniest of all… Applied Kinesiology), were old school people with no relevant technology to prove the hypothesis supporting their “techniques”. They were simply wrond, but had no alternative views. As we now know, the biomechanical view of pain is outdated. When I talk about this to my newly grads colleague, they just don’t listen or believe in the data. They all enlisted in costly useless courses already.
Back on MWM, keep in mind that Bill Vicenzino, who is probably the biggest MWM researcher, has drifted away from the biomechanical and “positional fault” hypothesis and has embraced the neurophysiological effects of manual therapies. (Interesting presentation here : http://www.aaompt.org/education/conference11/handouts/vicenzino_moa-mt_slides.pdf )
But what I mostly love about MWM is the active movement part. As persistent and recurrent pain are vaguely maldaptative conditioned responses (classical conditioning type), using MWM to help a client move without pain as an anti-hebbian learning process to help them “forget” their pain seems to be a legitimate reason to use MWM. The problem is, most practitioners don’t do as nearly as enough repetitions to induce any kind of plasticity changes in the CNS. But then I read a ton of articles about motor control adaptations to pain and how to manage the changes with a lot of active exercises.
Cheers!
Hi Adam,
Great blog as always (seem to find myself trawling through them more and more as weeks progress), but out of curiosity you seem to be incredibly up to date with EBP and research being conducted/completed etc. and I’m always very keen to do this myself.
More of a Q about where you access them? Having now left university, the only time I can find quality, up to date studies is on websites where they want extortionate one off fees (sometimes upwards of £50) for papers or pricey subscriptions. Do you just bite the bullet and pay or are there good websites that don’t cost you a month’s salary to sign up for?
Thanks as always!
Hi Georgeyboy
The difficulties with access to evidence is an ongoing problem. I don’t have any solutions really apart from trying to find a friend or colleague that has Uni access or Athens account
Cheers for the comments
Adam
Hi Adam
It’s a great relief to come across a blog like this of yours. Even I was greatly enthralled & amazed by Brian Mulligan’s MWM until I practised them on my patients. The immediate short term relief was more compared to the long term treatment goal achievement. This was a main reason of conflict causing mismatch of my pre-assesment & post assesment of patient condition. Then I realised some magical touch in Mulligan treatment when he himself performed them. His voice modulation; asking the patient questions to which the probable anwer will be only that which Mulligan had already in his mind(kinda closed questions); & most important not letting the already altered faulty biomechanics undergo further change causing aggravation of symptoms. Therefore I completely agree with your term to call these as symptom modification rather than name it some economically profitable market selling brand name. Thanks for ur valuable inputs Adam.
Hey Adam,
Cheers for this. I have my mobilisations exam on the 6th March. I’m going to demand a model like Brians or I will consider my findings null and void plus call boolshiiid on the whole exam (unlike my ultrasound exam last year which was entirely valid…not!). It’s hard enough remembering anatomy, special tests, gait analysis and all the rest of the content they teach over 3-4 years but to be taught something as part of your degree who’s evidence seems, yet again, majorly flawed, totally disappoints me. Not disappointed with your ever entertaining posts though. Thank you.
Now, see if I can find “Ladies of the Night” in the Yellow pages………
Paul