Mulling over Mulligan’s musings…

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 get their ‘knickers in a twist’ about my comments after a recent interview the legendary physio Brian Mulligan gave to the CSP here, the full transcript is available here.

Now the Mulligan acolades where very quick to make straw men and jump to conclusions, accusing me of ‘throwing out the baby with the bath water’, suggesting that because I said I found this interview full of outdated reasoning, logical fallacies and improbable claims, that I think all of Mulligan’s work is crap and therefore should be abandoned. This is bull shit. I never said or suggested such like. This is a straw man fallacy. This annoys me greatly.

Character

However, I will admit I am enormously frustrated and disappointed having read this interview of Brians. Mulligan is a legend, known for his charismatic ways and straight talking, and I like straight talking. The guy even has a whole section of therapy and therapists named after him.

Mulligan is a legend due to his infamous notoriety due to his well known text book being illustrated with a lady in skimpy underwear (sometimes even without the underwear) who, if stories are to believed, was a lady of the night he hired for $50.

mulligans-g-string_2

I have the utmost respect for Mulligan, I like charismatic characters in this profession of stuffy ego’s and serious dullards, and he is certainly is one of the most well known characters. But this interview has completely taken me aback, and I will confess has completely changed my opinion of someone who I greatly admired and believed to be an influential leader in our profession. Someone who I thought was ahead of his time in his thinking, but more importantly who I believed was 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 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. Simple, effective.

Of course as a student I was taught to believe I was actually affecting the joint/tissues mechanically, changing the position of the joint, or its direction of movement, and it was this I was told, 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 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, this doesn’t mean we have to abandon the technique. I haven’t, I have simply changed my understanding and explanations.

Many assume that as I am a vocal and strong critic about manual therapy that I don’t touch my patients, and that I don’t use manual therapy. They are wrong. I poke and prod my patients from time to time, I just don’t call it manual therapy. I call it all symptom modification. Manual therapy to me is simply a series of tests to see if I can change symptoms, for a short time, to allow them to do what I really want them to do… move more.

Sometimes it works, often it doesn’t.

I argue that we should change ALL of our descriptions for ALL manual therapy, mobilisations, manipulations, massage, myofasical release, pulling, poking, prodding etc etc it should NOT be called manual therapy, lets just call it symptom modification.

A new premise, needs a new name. A bit like a commercial rebrand.

We know that ALL manual therapy is highly individual in its effect. We know that ALL manual therapy effects vary’s in size, duration and frequency, regardless of the technique, regardless of the of application, regardless of the experience of the therapist.

We are simply using manual therapy, sorry symptom modification, to see what effect it has on this individual, at this moment, with this issue.

I am acutely aware of theses individual responses and variable effects daily, and I am under no illusions that many factors affect them, and that there really isn’t any technical skill in their application or superiority of one method over another. I recommend that we all play around with symptom modification, not constrained by a set way or method to use or apply them, rather have fun and explore what you can do using a 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
  • Don’t keep trying, if you haven’t found a way in within a few attempts, change tact and do something else

Despite Mulligan boasting 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 stage showmanship best left for faith healers, magicians or snake oil merchants. This explanation by Andreo Spina here on one of his own courses about these live demos fits my own views nicely, its nothing more than bullshit showmanship.

So there you go, these are my musings on the Mulligan interview and my disappointment in it. Lets hope the happy clappers have unwound their panties now, although I doubt it. I have never seen Mulligan teach or lecture, and after reading this interview I don’t think I want to! However, I will continue to use ‘his’ old techniques, just with ‘new’ explanations, there are no babies being thrown out here…

As always thanks for reading

Adam

 

24 thoughts on “Mulling over Mulligan’s musings…

  1. 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

  2. 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…

  3. 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,

  4. 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

  5. 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: yuimustow@hotmail.co.uk

  6. 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.

  7. 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.

  8. 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!

  9. 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

    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

  10. 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!

  11. 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!

  12. 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

  13. 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.

Please leave your comments here...

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s