Every two years Mulligan Concept instructors from around the world gather to join forces and grow the Concept. Last month we met in Orlando. It was the first time since Covid that the group was able to get together and it was a wonderful experience! There was a lot of fellowship and good food. It was great to be around so many intelligent multinational therapists who all share a passion for skilled manual therapy.

My favorite day of the meeting was Teacher's Day. This is a whole day devoted to helping teachers become better teachers. It went way beyond Mulligan techniques, although there were plenty of those.

Various international teachers led small break-out sessions designed to engage clinical reasoning, communication skills,and our approach to manual therapy.

It was refreshing to focus on these topics and engage in the process to become a better teacher from a variety of great manual therapy teachers with strong manual therapy backgrounds. However, there was one major thing missing from my interaction with all these international manual therapy experts; Manual Therapy DOGMA! That’s right. There was absolutely none of it! It is a far cry from what many manual therapy critics say is wrong with manual therapy.

 

Manual Therapy Critics

One of the modern knocks on manual therapy is that it is too dogmatic. I believe this perception comes from the historical rigidity associated with some manual therapy approaches. The dogma of being told to palpate a muscle tone that maybe was not there. The dogma of being told they HAVE TO perform techniques in a specific way for a specific amount of time because of unprovable theoretical models of what manual therapy could do to different tissues. They were made to feel inferior by manual therapy gurus who told them that they were not "good enough" to perform well. This all led many to view manual therapy as a narrow, short-sighted intervention that looked too much like clinical magic tricks providing only short-term pain relief.

I have no doubt this was their experience and that is unfortunate. However, the bitterness toward manual therapy does not need to linger.

The Pendulum is Gone

It is often said the metaphorical treatment pendulum swings away from one intervention and moves toward another. Very often it is said to move toward a new, better, and more efficacious intervention.

Many say the pendulum has swung away from manual therapy toward a pain science or exercise approach. No doubt for a while this may have been true. However, the old hands-on / hand-off debate is no longer an issue. The pendulum is gone!

The pragmatic use of manual therapy when indicated is, and will always be, one pain modulatory approach to help a patient move toward recovery. Modern manual therapy always strives to be multimodal and its effects are likely related to using it on the right person at the right time rather than a perfect technique application.

Simply put a therapist who uses manual therapy when it is not indicated engages in a user error. It is not necessarily the manual therapy approach that is wrong, it is the manual therapy application applied when it was not indicated.

Using manual therapy is one approach, and when indicated, should always strive to be multimodal. 

If a dogmatic manual therapy approach has ever turned you off to using manual therapy, I encourage you to give the Mulligan Concept / Mobilization with Movement a look. It is different. It's arguably the most evidence-informed symptom modification approach around with over 300 published studies. Be flexible in your thinking, use your hands when indicated, and combine it with functional meaningful movement.

The Pendulum is gone, SNAG on!

Thanks for reading,

Jarrod

Recently British singer-songwriter Ed Sheeran sang and played his guitar on the witness stand in defense of a $100 million copyright infringement lawsuit filed against his hit song “Thinking Out Loud”. The estate of Marvin Gaye alleged Sheeran's’ chart topper copied a four-chord sequence from Gaye’s classic song “Let’s Get It On”.

The copyright litigation was all about chord sequence. Could different songs have the same chord sequence and still be unique pieces of music?

As Sheeran sang and played his guitar for the jury he showed the four-chord sequence on trial was a common chord progression in hundreds of popular songs across time and musical genres. Sheeran won! He discussed the outcome and played the series of songs that helped him win in a Howard Stern interview (HERE)

Musical chords are the building blocks of a song. When chords and lyrics perfectly join forces, they create a chord signature that just sounds good. It’s that unmistakable feeling, emotion, or rhythm you feel when your favorite song is played.  You reach over, turn it up, and smile!

What does Ed Sheeran's chord signature have to do with manual therapy?

Similarly, clinical treatments grounded in clinical reasoning are the building blocks of a successful patient outcome. When patient care is delivered it creates a treatment signature. 

A 2022 study by Lutz et.al compared treatment signatures of 1,240 physical therapists (PTs) comparing differences between high-performing PTs and low-performing PTs in the treatment of lower back pain. (HERE)

Can select clinical treatment combinations, like chord combinations that produce hit songs, form a treatment signature that shows superior outcomes for lower back pain (LBP)?  Indeed it can!

Lutz et.al states “It is well-established that baseline disability level has the strongest influence on the change in patient-reported outcomes (PROs) from initial to final PRO. However, clinical performance and care delivery strategies of PTs have not been described or demonstrated to vary across patients of differing baseline disability”

The purpose of the study was to compare differences in care delivery, aka treatment signatures, of PTs classified as “outperforming”, “meeting expectations”, or “underperforming relative to the predicted change in the Modified Low Back Pain Disability Questionnaire (MDQ) across patients receiving care for LBP.

Highlights:

Patients were divided into quartiles of baseline disability via the MDQ and outcomes were compared to the type of billed units per visit (UPV). The study examined four types of billed UPV:

1. Active Exercise-based UPV
2. Manual Therapy UPV
3. Modality UPV
4. Skilled UPV (this group was created to describe the sum of a combination of active & manual therapy UPV)

A consistent pattern emerged in which “high-performing” PTs maintained a high level of Skilled, one-on-one interventions across their entire caseload.

“High-performing” PTs incorporated a treatment signature that included a consistent blend of Skilled, Active, and Manual therapy interventions distinct from lower-performing PTs.

“Low-performing” PTs significantly decreased the use of the same interventions as baseline disability increased.

My Take:

This study’s massive sample size unmistakably demonstrated the therapeutic power of including MT for LBP. However, the current profession-wide trend of exercise-only and “just load it” remains strong. This trend remains despite a multitude of studies supporting the superiority of multimodal care.

Further, while clinicians continue to weigh the place and importance of MT, there is a steady decline in manual therapy handling and clinical reasoning skills. There are many influences for this trend, however, studies like this suggest we must have and build solid manual therapy skills!

I encourage all clinicians to have confidence that there is good research supporting MT combined with other interventions. It does not have to be only exercise to be EBP.  Explore manual therapy courses to find one you like.  Dig deep into it and get certified. Not for the letters that come with it, but for the skill and confidence you will gain.

Conclusion:

It is common for hit songs from different times and genres to share similar or even identical chord sequences and yet not sound the same. Some chord signatures sound better together.  So too with MT!

Developing and practicing manual therapy handling skills gives you treatment options that create evidence-based treatment signatures. Joining MT interventions with exercise, activity modification principles, and education topics are “four-chords” that will help you create “platinum record” clinical hits.

Find your clinical tune, your rhythm, and your style. See how it plays.

Reach over, turn it up, and smile together with your patients!

Jarrod

Some clinicians have a strong opinion that manual therapy is not a useful intervention.  Some label manual therapy as a purely passive intervention succumbing to the priority of increasing patient activity level. Perhaps these perceptions are unfounded biases (which they are), and maybe these considerations are somewhat legitimate.

Nevertheless, current management strategies for numerous conditions are demonstrated to be ineffective for a high enough percentage of individuals that additional research and intervention strategies MUST be explored. For example, in some cases, upwards of 50% of individuals with tendinopathy report a suboptimal outcome.

The simplicity of a “just load it” approach from less than a decade ago has now been replaced with “it’s a difficult condition with unknown outcomes” over the past couple of years.

What is Manual Therapy?

But before I get too far into the discord and difference of opinions, we must first ask ourselves, what is manual therapy? 

• Is it thrust joint manipulation? 
• Is it oscillatory mobilization?
• Soft tissue work to muscles and connective tissues? 
• Is it Dry Needling? 
• Is it MWM’s? 

The current answer is that research has categorized all of these things as “manual therapy”.  This creates confusion, to begin with.  Rarely does any argument specifically state what manual therapy they are talking about.  And many controversies are still based on the bias of the presenter as both sides pro and con can be easily referenced.

So is manual therapy the technique?  Is it the clinician approach?  Or something else?

Perhaps I should take a different approach with this short blog?!?

3 Considerations for "Why Manual Therapy?"

Pain Modulation

The application of manual therapy to address pain is one of the most common uses by clinicians.  While contemporary evidence suggests a specific biomechanical approach to manual therapy is limited and unreliable, the use of manual therapy has been associated with improved range of motion and clinical outcomes.  Through improved mobility, an individual may be able to more appropriately load tissue, improve ROM, eliminate pain, and restore function with the applications of manual therapy. 

Manual Therapy in combination with education and exercise is also recommended for management of chronic low back pain. We also know that forms of manual therapy contribute to the restoration of tactile acuity through the stimulation of the somatosensory cortex. Systematic Reviews have reported in general terms, manual therapy is considered better than a placebo treatment or no treatment at all for LBP.

Patient Expectations

Evidence supports the positive influence of meeting a patient’s expectation to enhance treatment satisfaction. Patients often request manual therapy, or even demand it, from their healthcare professional. According to Hidaglo, 2016, the expectations of the patient may matter most. Expectations were formed by an individual’s social environment and previous experience.  A treatment technique is perceived as positive if its characteristics are aligned with the individual's understanding of pain and if care is delivered in an informative and reassuring manner. 

Instant Change to Patient Impairments are Possible

This is perhaps the most significant reason! I know of no other Concept that allows me to break down psychological barriers like MWM’s and the Mulligan Concept do.  If clinicians were more willing to change their mindset to fitting the treatment to the patient, rather than fitting the patient to the treatment, would this change their expectations for treatments?

How would this work? A comprehensive understanding of the patient’s neurophysiological, psychological, and sociological perspectives may assist in selecting the most appropriate technique.

Perhaps clinicians should be looking more for responders than appropriate diagnoses? After all, participants knowledge and awareness of back pain were shaped by prior experience with health care practitioners including physiotherapists and general practitioners according to a study by Plank.  This was reinforced by a preferred technique that was selected if a positive change in pain and function was felt.  This selection is likely much more significant to improvement rather than the specific technique performed.  This conclusion by Plank reinforces the Concepts of MWM’s in the application as an evaluation tool to determine if patients would be a responder to forces applied across different tissues to result in a symptom-free re-test of a comparable sign they present with. Patients tended to immediately reassess their pain after the treatment to observe and sense any form of change in movement or pain.  This happens immediately during MWM’s as the comparable sign is affected in real-time for most techniques.  The expectation from the clinician applying the technique needs to be open-minded.  Not pre-determined of A will only happen if B occurs.

Conclusion

Consider a different angle to the same question.  If clinicians are not expecting to get an immediate change in the presentation of their patients, why would we expect the patient to have different expectations? Are these expectations grounded in scientific fact?  Or rather artificial biases that we have created in our minds to substitute our failure to attempt to create these changes quickly?  I don’t think these are rhetorical questions.

For another example, clinicians have classically also been known to blame patients for not improving because of compliance with their HEP.  However, how do we know that the HEP is going to actually be helpful if nothing changes during a visit?  We don’t.  Plain and simple. Let’s stop fooling ourselves, and more importantly, let’s stop blaming our patients for our unwillingness to have better expectations for improvement.

Perhaps we should start keeping an open mind for all of our treatments.  As a profession, skilled therapy has an opportunity to stop assuming that all rehabilitation and recovery take time.  Start investigating what can change during your visit and expect more from your treatments.

For me, the PILL response (Pain-free, Instantaneous, & Long-Lasting) of the Mulligan Concept flows through all of my treatments. I’m more interested in finding responders than I am about how I apply any technique or concept to a patient. Let the patient’s brain guide you to achieving goals.

As a recent attending at one of my Upper Quadrant classes in Ohio eloquently stated.

“find things the body likes….and do those”.

Eric M. Dinkins, PT, MSPT, DPT, OCS, MCTA

In clinical practice, there are many ways to skin a cat. Why is that? Because there are many different types of cats with many different types of ailments! Our job as clinicians is to use solid clinical reasoning, good investigative questions, and tests to try and determine which levers to pull or inputs to provide to accelerate recovery.

It has never made sense to me that people argue whether we should be using manual therapy or exercise, a hands on or hands off approach etc. Doesn’t it depend on the individual patient we are working with? As clinicians, shouldn’t we strive to understand the human body as much as possible to maximize our methods of creating positive change? Over the years I have prioritized education with some patients and specific therapeutic exercise with others. General conditioning guidance is at times top priority while an extra moment of active listening and empathy may be the fastest opening for positive change in others. Manual therapy can facilitate quick changes in function and at times moves to the top of the list of possible levers to pull. Each individual patient needs a different input or combination of inputs to create their optimal healing environment, and it is our job as clinicians to solve this puzzle.

In order to best serve our patients we need to:

1. Have a solid framework for information gathering and organizing to understand our patients and categorize them to the best of our ability.
2. Use that information to determine which inputs might resonate best with the individual in front of us and use every lever possible at our disposal to facilitate the fastest recovery.
3. Educate our patients on their role in this process and teach them the most effective methods available for self-care.

After listening to our patient’s story, we need to decide if they would benefit from physical examination and how extensive this examination should be.

• Does their problem sound musculoskeletal?
• Are there contraindications to examination and treatment?
• Is the patient highly irritable (symptoms come on easily, are quite painful, and remain long after the aggravating activity ceases?) or non-irritable?
• What is their most painful or limiting movement or function (Client Specific Impairment Measure (CSIM))?
• Do you consistently apply a solid structure like this to your Subjective examination?

Would you voluntarily choose to disregard any information you gathered? Of course not - using all known information is essential, and gathering solid subjective information with as few biases as possible is one very important tool in formulating the most efficient plan.

Having a test-retest framework of clinical reasoning is also essential for understanding which levers to pull with different patient types. What works for the goose many not work for the gander. Assessment – intervention – then re-assessment proves the value of your treatment. But what if we could use an assessment and treatment paradigm that gave us immediate, feedback regarding its effectiveness?

What if we could assess the value of a particular input in real time, during the performance of the specific functional movement that bothers the patient the most?

The Mulligan Concept™ and Mobilization With Movement™ (MWM) allows us to do just that!

We can understand whether an input is helpful within a couple of minutes! Using good communication skills while applying various clinician or patient directed forces, we can determine if a manual therapy input is appropriate, needs more or less force, and in which direction the force must be applied to facilitate the best response. This increases the precision of our forces, and our chance of success with manual therapy.

Using all the tools available is essential!

With Mobilization With Movement™, patients can see and feel improvements in their function immediately, which alters their perception of their own problem consciously and subconsciously. Patients become actively involved with their treatment both mentally and physically, in the clinic and outside the clinic. Using active, pain free Mobilization With Movement™, we tap into multiple body systems at once providing manual therapy, therapeutic exercise, and neuromuscular re-education simultaneously. If you could eliminate a patient’s pain with their specific chief complaint, would you choose not to use this skill? Of course not, using all the tools available is essential, and with real time feedback on whether MWM’s are helpful – why not pull this lever?

Empowering patients to improve their own condition is also our responsibility. Educating them on the nature of their problem and showing them ways to speed recovery outside the clinic must be part of our intervention. With the Mulligan Concept™ we have options to maintain the successful manual therapy inputs we have discovered in our patients’ everyday life. Application of tape and self-directed MWM allows our patients to repeatedly reproduce pain free movements between visits. Using familiar, active, pain free movements as a home program allows patients to experience more normal movement once again, desensitizing their system. If your patient could move in the exact way that previously bothered them without symptoms as part of their HEP wouldn’t you want to use that input as often as possible between visits?

Why would we not pull this lever?

Patients become motivated to participate in their home program very easily when they immediately experience its value. Our job as clinicians is to discover and provide what each individual patient needs to the best of our ability. Accurate data collection, solid clinical reasoning, and using as many effective inputs as possible is what our job demands. When we have a manual therapy system that demonstrates the value of an input in real time, why would we not pull this lever?

As Brian Mulligan likes to say:
“Could you do it?”
“Should you do it?”
“Would you do it?”

I think we should all answer Yes! Yes! Yes!

Mark Thomson PT, DPT, OCS, FAAOMPT, CMP, MCTA

As an older physical therapist, past academic educator, and manual therapist, I have wondered why the pendulum and interest in “hands-on treatment” seems to be waning.  My disappointment in the waning interest in manual therapy (MT) stems from a long professional experience with the positive patient reaction to therapeutic touch.

I suspect many new physical therapists (PTs) and students can attest to the experience of seeing a medical caregiver who never touched them, despite a physical complaint of pain, swelling, or functional limitation in movement -  the clinician did no physical examination.  As therapists, we have likely heard patients seeking our help state, “the doctor never even touched my back, neck, arm, etc.”

As a PT, I have taken immense pride in trying to gain trust and connection with my patients.  I have learned through open and professional communication, eye contact, and body language, that when appropriate, touching can be quite powerful at creating a trusting and positive connection with a patient. As we enter a new era of advanced diagnostic imaging and important clinical lab testing, it is easy to see PTs drifting away from relying on hands-on physical examination as well as treatment.

Looking Back

Over a career of numerous continuing education classes and post-graduate coursework in MT, I have always remained humbled by other clinicians and educators who have what I would say are “better hands” or the ability to feel something that I may not have been able to “feel” at the time.  Long ago, I came to appreciate and pass along the words of a past mentor - “practice makes better” - not the usual cliché of “practice makes perfect”.  I think it is critical to educate students that MT is an art and a skill development that takes time and practice.  Students need to know the limitations in scientific evidence for MT, but neither should they ignore the vast amount of reported empirical evidence for MT.

As a past academic educator in manual examination and therapy, I have also found that there are varied attitudes and abilities in developing manual skills.  Today unfortunately there are many academically gifted students and educators who simply do NOT see enough evidence in MT to invest the energy and practice time to improve their ability to perceive tissue asymmetries, pathology, and patient response to touch.  There are also numerous students and therapists who let cognitive intellect get in the way of “feeling with their hands” or simply give up saying, “I can’t feel anything”.  We should not forget that although we may not feel something as described by an expert, a patient will know whether you touch them or not.  At a minimum, we can at least communicate and be able to feel whether a patient responds negatively to touch / palpation.  I do believe a large majority of patients want to communicate about their condition, whether it is pain, swelling, lack of sensation, or asymmetry by being touched and physically examined.

Looking at the Present

I will readily admit that manual therapy (MT) lacks a significant degree of scientific evidence.  MT has relatively low intertester reliability regarding palpation and the application of manual forces.  A placebo effect with MT has been reported in the literature.  On my continuing education courses, I have stated that we should accept and embrace the benefits of the placebo effect when using MT.  I personally do not feel the need to “throw the baby out with the bathwater”, when considering the lack of scientific evidence for MT.  One only needs to look at the literature to see that there is extensive empirical evidence for MT and a wealth of valuable case reports.   Those of us who examine and treat with our hands will attest to its value, despite the difficulty in being able to determine MT value by clinically measurable and objective physiologic effects.

Looking Forward

I feel it is critical to the profession of Physical Therapy that at least a portion of us is known to the public as professionals who do place their hands-on for examination and treatment.  We only need to look around and see that other professionals are willing to take up more “turf” by the laying on of hands.  It is an undeniable human trait that many of us need to be touched and seek professional help through human touch because it is also a means of communication.  I think many of us have heard the claim that a particular PT was “so good with their hands”, and other endless clichés such as “I don’t know how they felt my pain without saying anything to them”, “I could not move without pain until they guided me with their hands”, “I finally could relax after hands-on treatment”, and of course, “at least the PT was willing to touch my …..”.

Paraphrasing an old saying that has always meant a lot to me is: “Finding the evidence for MT may be likened to a blind person looking for a black cat in a dark room that may NOT even be there.”  As professionals, it is important to keep looking for the evidence and accept that the laying on of hands does have a placebo effect.   However, there is scientific evidence and an overwhelming body of empirical and clinical evidence that MT and the laying on of hands diminishes pain and improves movement.  I do hope that physical therapists continue to be known as professionals who do use their hands to examine and treat those individuals seeking help for pain and movement restrictions.

 

The brilliant pain scientist Louis Gifford said when a patient arrives to receive care they are interested in learning four things:

• “What is wrong with me?”
• “How long will it take to feel better?”
• “What can I (the patient) do?”
• "What can you (the therapist) do?”

A 2022 qualitative assessment by Subialka et al. supported this well-known saying. A fifth question was also identified, “what is the expected outcome?”¹  Additional commentary suggested that many participants attending physical therapy for musculoskeletal conditions struggled to identify “how PT played a role within their overall healthcare.”

This leads me to more questions:

• Is creating patient buy-in to physical therapy necessary?
• Is it possible that working to answer these five questions is the ideal way to create patient buy-in?
• And if so, what is the best starting point?

 

A Symptom-Modification Approach

Creating patient buy-in is indeed a necessary part of physical therapy! While there is no singular best way, when indicated, my bias is to use manual therapy within a symptom modification approach as a beginning. Greg Lehman’s 2018 JOSPT Viewpoint was invaluable for shaping my thoughts and opinions on the topic of symptom modification.

The Viewpoint describes symptom modification as, “an approach that aims at reducing symptoms and improving function with a variety of clinical approaches. It is born out of the realization that identifying the structural source of the symptoms is generally not possible, and that reducing pain is often a desired outcome of patients and therapists. If symptoms are reduced early in the treatment plan of care, the patient may be able to get back to meaningful functional tasks quicker.”²

A symptom modification approach always starts as an assessment, and if successful,  helps share the treatment plan and prognosis. Modifying symptoms can happen with a hands-on or hands-off approach.

Hands-on options may include:

• Mobilization with Movement^TM (MWM)
• Shoulder Symptom Modification Procedure
• Manipulations
• Spinal tractions
• Other manual therapy techniques that provide immediate pain relief

Hands-off options may include:

• Modalities
• Specific exercises (ie. isometrics, eccentric, etc.)
• Cognitive functional therapy
• McKenzie exercise
• Activity modification principles

 

Manual Therapy as a Symptom Modifier

Sometimes a hands-off approach is necessary based on an individual patient presentation that features pain-dominate characteristics (ie. acute injuries, peripheral neurogenic, nociplastic features, etc). However for me, when indicated, hands-on symptom modification is a priority. Individuals whose symptoms can be modified quickly in-session and between sessions with manual therapy may help identify responders to manual therapy and may help make a more accurate prognosis about their recovery timeline.^3-4

Symptoms commonly targeted for modification may include limited/painful ROM, pain with functional activity, or pain with force production (ie gripping, etc). Implementing a thorough hands-on assessment using Mobilization with Movement^TM procedures during the Objective Exam is my go-to.  I want to assess if an instantaneous change is possible. A change that the patient can feel and notice within minutes.

There is something about a hands-on manual therapy examination approach that adds context and confidence to the assessment vs. a hands-off approach.  Another Viewpoint I found helpful in shaping my thoughts is titled “Manual Therapy: Always a Passive Treatment?”⁵

How many times have you heard a patient say, “the doctor did not even look at my painful joint, let alone touch it!!”

The instantaneous change in symptoms may be short-term or long-lasting, but showing someone their pain is malleable is powerful!

 

The Bottom Line: “Using Manual Therapy for Patient Buy-in”

Using manual therapy early can add hope to a situation and change a mindset about pain when a patient perceives their symptoms can modulate quickly without medicine, without surgery, and without imaging.

If we anchor manual therapy in the correct context as a symptom modifier, and not a fix or permanent solution, the changes made with manual therapy can lead to patient buy-in. Early buy-in can pave a way to the good stuff; to multi-modal approaches like self-care, aerobic/strength training, sleep, lifestyle change, and behavior change to help pain now and overall health long-term.

Using manual therapy to modify symptoms, when it is possible, is a necessity to get early buy-in! Manual therapy as a symptom modifier is a driving force for “Why Manual Therapy”. It may also be the origin of consistently answering the big questions patients want to know.

 

Thanks for reading!

Jarrod

References:

1. Subialka JA, Smith K, Signorino JA, Young JL, Rhon DI, Rentmeester C. What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment. Musculoskelet Sci Pract. 2022;59:102543. doi:10.1016/j.msksp.2022.102543

2. Lehman GJ. The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice. J Orthop Sports Phys Ther. 2018;48(6):430-435. doi:10.2519/jospt.2018.0608

3. Cook C, Petersen S, Donaldson M, Wilhelm M, Learman K. Does early change predict long-term (6 months) improvements in subjects who receive manual therapy for low back pain?. Physiother Theory Pract. 2017;33(9):716-724. doi:10.1080/09593985.2017.1345025

4.  Cook CE, Showalter C, Kabbaz V, O'Halloran B. Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain?. Man Ther. 2012;17(4):325-329. doi:10.1016/j.math.2012.02.020

5. Rhon DI, Deyle GD. Manual Therapy: Always a Passive Treatment?. J Orthop Sports Phys Ther. 2021;51(10):474-477. doi:10.2519/jospt.2021.10330