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 snowflakes have 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to conclusions, accusing me of ‘throwing out the baby with the bathwater’ because I said I found this interview full of outdated reasoning, logical fallacies, and improbable claims, that they think I think all of Mulligan’s work in physiotherapy is crap. This is bull shit. I never said or suggested this. This is just a straw man that the buttercups like to use to make it easier to attack me rather than listen to my critique of Mulligans interview.
I will admit I am enormously frustrated and disappointed with Mulligan after having read this interview of his. Mulligan is a legend within physio, known for his charismatic ways, colourful language, and straight-talking, and I like colourful language and straight talking. The guy even has a whole section of therapy and therapists named after him.
Mulligan is also a legend due to his infamous text book published in the 1980’s being illustrated with a female model in skimpy underwear (sometimes even without the underwear) who, if stories are to believed, was a lady of the night he hired for $50 and the assistants hands in the photos was the ladies pimp.
Now I like charismatic characters in this profession of ours with is many stuffy and serious dullards, and he is certainly is one of the most well-known. But this interview has completely changed my opinion of someone I 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.
Not so it seems.
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 persons 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 much poncy language or 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 what made pain reduce or disappear. This belief of re-positioning I now know, although not fully dis-proven is extremely unlikely. Rather our understanding on 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 bath water?
But although our understanding as to the mechanism of effect has changed with these MWMs, this doesn’t mean we have to totally abandon these techniques, 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 manual therapy. Manual therapy does not cover all hands on things we do, simply placing your hands on a patient and interacting with them is NOT manual therapy.
Things such as a simple as a handshake, a reassuring hand guiding them through a movement, or even passive movements are not what I class as manual therapy.
Personally, I think we should change our descriptions for ALL manual therapy techniques, such as mobilisations, manipulations, massage, MWM’s myofasical release, etc they should NOT be called manual therapy, rather just symptom modification.
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… sorry symptom modification, and I am under no illusions that many factors affect them. I know that there isn’t any technical skill in the application or 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…
- It must be comfortable, for both you and the patient
- It must reduce pain significantly for it to be classed as successful
- Don’t keep trying, if you haven’t found a way in within a few attempts, 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 showmanship best left for faith healers, magicians or snake oil merchants.
So there you go, these are my musings on the Mulligan interview and my disappointment in it. Lets hope the happy clappers have unbunched their panties a little by now, although I doubt it. I will finish by saying have never met Brian Mulligan, nor seen him teach or lecture, and after reading this interview I don’t think I want to, which is a shame! However, I will continue to occasionally use ‘his’ old techniques, just with ‘new’ explanations, so again there are no babies being thrown out here…
As always thanks for reading