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me of ‘throwing out the baby with the bath water’, suggesting that because I said I found this interview full of outdated reasoning, logical fallacies and improbable claims, that I think all of Mulligan’s work is crap and therefore should be abandoned.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.
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.
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
- 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