Why Manual Therapy?

A personal goal for 2023 is to write a monthly pro-manual therapy blog series called "Why Manual Therapy?". My purpose is to challenge my capacity to generate knowledge on a topic by bringing together ideas, thoughts, and resources on manual therapy.

The series intends to push to the edge of this topic, “why manual therapy” by making a case for the necessity of manual therapy with our patients in a simple 1000 words or less blog, once a month, for a year. The readings will be to the point and thought-provoking to support using hands-on care in daily clinical practice.

My Three Hopes:

-We all finish this series knowing more than when we started to help our patients get better faster.

-To bring in some guest blogs along the way.

-That you enjoy the short readings over the coming months and follow along with the entire series.

 

Chapter 1: Sensory Input Drives Brain Plasticity

The 2013 article by Schabrun et al. titled "An Update on Brain Plasticity for Physical Therapists" is an easy-to-read reminder about the importance of targeting and integrating the adaptive capacities of afferent/sensory inputs to drive neuroplastic changes in the human body.

(The article can be downloaded HERE)

(If you were unable to download email me at mctajarrodbrian@gmail.com for a copy)

I had the privilege of hearing the author lecture several years ago and one of her direct messages stuck with me; "sensory drives brain plasticity".

The article's conclusion quotes, "The plastic capabilities of the human brain have significant relevance to musculoskeletal physical therapy. Afferent input generated by ‘peripheral’ conditions and in the form of exercise, manual therapy, or electrical stimulation is a powerful driver of plastic change. It is essential that physical therapists consider the effects of current therapies on the brain and contribute to the development of new plasticity-based therapies capable of enhanced performance, reduced pain, and improved recovery of function. Considering and integrating plasticity concepts into clinical practice, research and education will ensure physical therapists stay abreast of this rapidly advancing field."

This is a very appealing reason for me to use manual therapy. It may be my most foundational reason! Remembering the human nervous system is extraordinarily capable of neuroplastic change sometimes gets lost in the shuffle of a busy day in the clinic. However, her message of  "sensory drives brain plasticity” frequently resurfaces and reminds me to use my hands to drive sensory input as part of a multi-modal patient care approach.

Viewing the nervous system’s adaptive capabilities through the lens of “sensory input driving plasticity changes” is a big reason why I am passionate about manual therapy.

Until next time,

Jarrod Brian

 

1. Schabrun, Siobhan & Ridding, Michael & Chipchase, Lucy. (2013). An update on brain plasticity for physical therapists. Physiotherapy Practice and Research. 34. 1-8. 10.3233/PPR-2012-0009.

An Evidence Supported Alternative Manual Therapy Intervention for Individuals with Signs of Knee Meniscus Involvement

Do you use the Mulligan Concept Squeeze Technique?

The 'Knee Squeeze' is considered a "soft tissue Mobilization With Movement™!”

As noted in the 2022 Reep et al. systematic review, the MWM ‘Squeeze’ technique, tibial IR, and/or tibial ER demonstrated the ability to reduce pain, improve function, and improve patient-perceived disability following treatment of a clinically diagnosed meniscal pathology.

How to Apply:

Step 1: Test a functional movement that provokes symptoms, ie, squat, or active or passive ROM resulting in pain and or restricted motion; perhaps a positive Thessaly and/or McMurray test.

Step 2:  Perform the manual Squeeze Technique to assess for responders.  (See Video)

-Place the reinforced side of the thumb at a possibly swollen and tender spot at the tibiofemoral joint line, pressing directly into the joint with the overlapped thumb

- Sustain that pressure through the entire ROM with overpressure at end-of-range if asymptomatic (except for palpation tenderness) until the patient returns to previously neutral knee posture.

-If knee extension is restricted, release the pressure into the joint as the joint space closes

-Re-apply as the patient moves back into flexion.)

Step 3:  Re-test and reassess the previously positive test and note the change.

Step 4:  Consider an appropriate amount of reps depending on the patient's presentation using your clinical reasoning. The repetition range may vary from 6 on the first day to 3 x 10 on the following visits if effective.

Application Examples:

• Hudson R, Richmond A, Sanchez B, et al. An Alternative Approach to the Treatment of Meniscal Pathologies: A Case Series Analysis of the Mulligan Concept "Squeeze" Technique. International Journal of Sports Physical Therapy. 2016;11(4):564-574.

Special Note from this Case Series:

"Of importance to the athletic population, each of the participants continued to engage in sport activity as tolerated unless otherwise required during the treatment period. The outcomes reported in this case series exceed those reported when using traditional conservative therapy and the return to play timelines for meniscal tears treated with partial meniscectomies.”

• Hudson R, Richmond A, Sanchez B, et al. Innovative treatment of clinically diagnosed meniscal tears: a randomized sham-controlled trial of the Mulligan concept ‘squeeze’ technique. The Journal of manual & manipulative therapy. 2018;1-10. http://dx.doi.org/10.1080/10669817.2018.1456614

 

Give it a try!

Don Reordan PT, MS, OCS, CMP, MCTA, CIDN

Continuing education is critical to providing the best care to our patients

Live weekend courses are a great way to learn new skills and stay abreast of the latest information. Residencies and fellowships are optimal to solidify long-term learning and behavioral change as a clinician, but with families and other priorities, this is not always an option. How often have you taken a weekend course, and wished there was a follow-up where you could get your questions answered, have dialogue, problem-solving sessions, and hands-on practice with that expert in the field who taught the course?

The Mulligan Concept™ curriculum is designed to fill this gap for busy clinicians. Start with learning Mobilization with Movement™ for the Upper Quadrant or Lower Quadrant – either is just as good. Once you have taken both of these courses, follow up with the Advanced course where there is plenty of time for problem-solving, practice, and clinical reasoning.

Is anything not working for you? The Advanced course is designed to help you through these struggles. To really solidify your knowledge, continue on to become a Certified Mulligan Practitioner (CMP).

My Experience

I had taken the UQ and LQ classes and loved using the Mulligan Concept in the clinic. However my experience with the advanced course and deciding to take the CMP in mid-2000’s was career changing! To study for the test I partnered with a friend, Pat Scott (shout out!) who lived in my area. We studied regularly and went through our UQ and LQ manuals and Brian Mulligan's textbook. I realized that I had only put about half the content into clinical practice! The remaining half had been forgotten over time. With the review and practice for the CMP, I realized how valuable the other half of the material would be in the clinic. Pat and I quizzed each other and practiced scenarios until we both felt confident we had mastered the material. Then on the Advanced course, we refined those skills and learned a lot of variations that helped with different patient types. Before the Certified Mulligan Practitioner exam, there was a 2-hour review with 2 MCTA instructors as well! The process of becoming a CMP is designed to help you master the Mobilization With Movement™ skills and clinical reasoning you need to effectively treat patients with the Mulligan Concept™.

Certified Mulligan Practitioners are also recognized as the Mobilization With Movement™ experts on our website and used as referrals in their respective areas. Take your practice to the next level!

Take a look at the curriculum below. Upper and Lower Quadrant can be taken in any order.

Requirements: 

*UPPER QUADRANT. MOBILISATIONS WITH MOVEMENT, “NAGS”, “SNAGS” AND MORE:
*LOWER QUADRANT. MOBILISATIONS WITH MOVEMENT, “NAGS”, “SNAGS” AND MORE:
*ADVANCED / FOLLOW UP. MOBILISATIONS WITH MOVEMENT, “NAGS”, “SNAGS” AND MORE:

Those eligible to apply for the CMP exam include: Physical Therapists, ATCs, Medical Doctors, Osteopaths, and Chiropractors (Note: RMT, OT, PTA, and COTA are not eligible). To be admitted to the CMP examination process, applicants must have completed all of the following courses provided by accredited MCTA teachers.

(In some regions, other courses may be offered such as an Introductory Course and other specific courses; while recommended these are not the primary courses required to be completed for the CMP process.)

It is manageable to work your way through the series with a 3-weekend commitment! This will change your practice!

Looking Back, Moving Forward

In 1999 when I took my first Mulligan course, it changed the way I treated patients and my career forever. I can’t thank Brian Mulligan enough for that! Taking the Mulligan Concept courses through the Mulligan Concept™ Teacher Association, you have the same opportunity! What are you waiting for?

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

Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis

Kiran Satpute, Sue Reid, Thomas Mitchell, Grant Mackay & Toby Hall (2021): Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis, Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2021.1955181 

Introduction:

The objective of this systematic review (SR) and meta-analysis was to determine if there were any additional benefits of using Mobilization with Movement (MWW) manual therapy for shoulder pain, flexion ROM, abduction ROM, and for disability when compared to other non-surgical forms of management; including other forms of manual therapy, electrotherapy, placebo, sham, or no treatment for shoulder musculoskeletal disorders in two sub-categories: frozen shoulder and shoulder pain with movement dysfunction.

Why was this study necessary?

Current guidelines for conservative management of shoulder conditions include exercise, patient education, manual therapy, activity modification, non-steroidal anti-inflammatory drugs, and cortisone injections. (1,2,3) The hierarchy in priority of these strategies suggests exercise as the first in line for management (4).

Multimodal care that includes combining exercise + manual therapy has been shown to be more effective than either one alone, although the application of manual therapy is often ambiguous due to the variety of techniques, dosages, duration of effect, technique progressions, and rationale for usage (4)

Often in SR of manual therapy, all varieties of manual techniques are synthesized, which may not allow for discrimination between techniques to help guide treatment. A goal in this study was to specifically evaluate the potential value of shoulder MWM for sub-categories of frozen shoulder and shoulder pain with movement dysfunction.

Methods:

To determine which studies to include in the SR and meta-analysis a thorough eligibility screening process searched six databases. The search results revealed 1,637 potential studies to include. Additional inclusion screening evaluated study quality, risk of bias, a narrative synthesis, and qualitative synthesis.

The summation of the screening process allowed for a total of 21 studies available for meta-analysis; 12 studies in the frozen shoulder sub-category and 9 studies in the pain with movement dysfunction sub-category.

What Did the SR and Meta-analysis Reveal?

The results indicated MWM for the shoulder as having important benefits for all variables in each clinical sub-category (pain, flexion ROM, abduction ROM, and disability), although caution was required due to high levels of heterogeneity and risk bias.

Conclusion:

MWM in isolation or in addition to exercise therapy and/or electrotherapy is superior in improving pain, ROM, and disability in patients with frozen shoulder and shoulder pain with movement dysfunction when compared with exercise therapy, electrotherapy alone, or other types of manual therapy.

My Take:

The study claims to be “the first systematic review with meta-analysis to evaluate the clinical effectiveness of MWM in isolation or in addition to other physiotherapeutic modalities”. While there is never a single study that is the gold standard for all clinical interventions, evidence that potentially guides my ability to make patient care in the clinic both effective and efficient makes me happy.

This type of evidence deepens my bias to regularly attempt MWM because the techniques are always pain-free. Within 2-3 minutes I will know if an individual is a “responder” or “non-responder” to MWM manual therapy. This is diagnostically significant for clinical reasoning; if helpful the treatment becomes multimodal with exercise and manual therapy, if not treatment may be more of an exercise-only focus.  I have little to lose, but much to miss if I do not assess MWM techniques.

This is one of the many reasons I am passionate about teaching and sharing MWM. It is fast, effective, and immediate.

Jarrod Brian, MCTA

 

[1]  Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis. 1998 Nov;57(11):649–655.

[2] NICE guidelines ‘Management of shoulder pain’ 2017. [accessed 2021 Mar 01]. Available from: https://cks. nice.org.uk/topics/shoulder-pain/management/initial- management/#initial-management .

[3] sitecore\lewis.ashman@rcseng.ac.uk. Subacromial Shoulder Pain - Commissioning Guide [Internet]. Royal College of Surgeons. [accessed 2021 Mar 01]. Available from: https://www.rcseng.ac.uk/library-and- publications/rcs-publications/docs/subacromial- shoulder-pain/

[4] Pieters L, Lewis J, Kuppens K, et al. An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain. J Orthop Sports Phys Ther. 2020 Mar;50(3):131–141.

Brian Mulligan

The passing of our special friend has deeply upset Dawn and I. He was a really wonderful guy to be with and made a huge impact as a teacher.  Yes, he and his dear supportive wife Donna were part of our MCTA family.  We will all miss him and the impact his presence made when we were all together.
Thank you Brian Folk

Gaetano Milazzo

What a wonderful man with such a strong soul.

Yuval Adi David

Your smile will be with me forever

Geoff Foat

I have incredible memories of Brian, both working alongside him in my formative MCTA years and of course his legacy as secretary... Indelibly imprinted on our organization.

 

Claus Beyerlein 

Brian was a great man and a wonderful person

 

Dan G. Pilderwasser

Will always remember the good times when teaching together in Brasil and Argentina and the terrible hangovers after drinking those nasties non-alcoholic beers!

 

Palmiro

My brain will keep beautiful memories teaching the Mulligan course here in Brazil and Argentina.
A person remains joyful and devoted to spirituality.
His smile and happiness was contagious teaching or social

 

Hani AlAbbad

I got to know Brian F for a short time and found him to be an amazing person.

 

Claus Bessler

He was a great character and a fantastic person who will be missed deeply.

 

Kiyokazu Akasaka

Takashi and I visited his course several years ago near Seattle and we both were so impressed with his nice personality, friendship, and the way he teaches Mulligan Concepts. He has a lot of humor and witnesses and makes learning fun.

After over 30 years of PT practice and 20 years of teaching the Mulligan Concept, Brian Folk shares some clinical thoughts:

What are we trying to accomplish in the clinic? What is perfect health? What are our patient’s expectations?

After over 32 years in clinical practice I finally started to learn some keys to being that person that patients want to see. Here’s what I’ve learned:

Human beings are extremely complicated. If you happen to embrace any type of spiritual cosmology, then you might be willing to say that they have spiritual/emotional, mental and physical dysfunctions that ALL may need to be treated for optimal health. “Well I’m just a physical therapist, I don’t “do” mental or spiritual work”. Here’s the problem: spiritual, mental and physical dysfunctions are not seen in isolation. They permeate our being. They overlap and have roots in all three “worlds” and if you don’t at least recognize, acknowledge and refer out to qualified therapists when needed, then you may not be as ultimately successful with your patients.

1.    Patients don’t care if you are the most technically skilled clinician (they do care to a degree and you must have those skills, but it goes so much further than that).

2.    They just want someone to LISTEN to them completely. They want to be heard (read spiritual/emotional, mental and physical). Clinical research on patient satisfaction at Kaiser in previous years indicated that patients felt more listened to with one simple act: The clinician came into the room and SAT DOWN! I heard that previously, but didn’t FEEL it until it happen to me when I was in need. That one act jaded my feeling about the visit and that clinician.

3.    Patients don’t react to what you say, they react to your body language and if we are “in- a-hurry-boy” they will notice. if that’s your agenda, man, you better have wicked manual skills to compensate for that lack of CONNECTION. But it still won’t fully compensate.

4.    If we want to be successful with our patients, what did Brian Mulligan always stress? “

“Always treat with confidence”! Why????......... I had a doctor speaking to me about a very serious condition many years ago. He stopped me, got my attention, looked in my eyes and said: “I’m going to take really good care of you, don’t worry”. I have never forgotten that. It had a huge impact.

5.    What are we stimulating when we treat with confidence? Placebo effect? That’s potentially a 30% gain in improvements if you listen to the physical scientists!

6.    Is this “placebo effect” just an imperfect label for the phenomenon of the innate natural healing potential endowed deep in every single soul? Could it be significantly more if skillfully nurtured?

7.    What does treat with confidence mean: good listening, good handling skills, realistic optimism, affirming health with your patient in every way you can.

Looking at the hierarchy of needs as I see it in human beings: our desire to be heard, understood, and thereby, loved is paramount. It is the ultimate goal of all human hearts, no matter what their stated desires or pursuits. If you can do this with your patient, you will leave a positive impact in the world. That’s what I’m going to spend the rest of my days doing. The rest is fluff.

Brian R. Folk PT, MCTA, FAAOMPT

Certified MCTA Teacher