Confluence

Two lives colliding at the altar of care
A communion of collaboration
Weaving a tapestry of meaning
Converging into a new story
Woven in possibility
Inviting change
A confluence
Two stories
Transforming
Two-One

J.Millard

 

 

We are ultimately in the people business serving rehab, not in the rehab business serving people. We are in the people business! We serve people. People who are unique individuals with unique challenges. There will never be a recipe for treatment. No two people are the same, and no two problems are ever the same. The clinical “problem” may be found in a textbook, ie. Mechanical hip pain, but the patient’s context never will be in a textbook.

“If Content is king then Context is queen. Conversation is the kingdom, and the Currency is Human Connection.” Jim Millard

We believe that we tell stories but often our stories tell us. This goes for our patients but also for us as clinicians. Stories matter. Stories are both our sanctuaries and our prisons. John Launer, one of the key figures in Narrative Medicine, states that a consultation is really a conversation and our quest is to find and to create meaning. In clinical care two stories come together as one. That new story is built in the kingdom of communication and comes to life in the currency of connection.

Connection

Our clients and patients desire empathy and effective communication. At this intersection lies connection. Connection is the bridge to a strong therapeutic alliance. Connection and communicating may often be used synonymously. The truth is that we all communicate, however, it doesn’t mean that we are successfully connecting. As practicing clinicians, we need to communicate and connect with 100% of the patients we encounter, 100% of the time. We lead patients every day. We rely on sound communication skill to inspire and to positively influence others. Most of us assume that we do this well already. Communication is defined by what has been understood, not by what we have conveyed. Communication skills are rarely reflected on, practiced, or specifically trained in our clinical healthcare professions. Connection multiplies communication. Through connection we can find the path to meaning.

The work of Dr. Maxi Miciak shows that effective clinicians initiate connection with their patients. They create a sense of team on a deeper emotional level beyond just an interaction. Miciak also identified four conditions necessary to create a therapeutic relationship; being present, receptive, genuine, and committed. All speak to connection. Connection is the gate to effective communication.

What is a Clinician?

Everything intersects at the story we co-create. All of the evidence, our skill, our compassionate care and meaning intersect at the story. Confluence. Confluence precedes influence. Confluence is the heart of Being a clinician! A clinician, not a technician.

Being a clinician as opposed to a technician exists at the confluence of evidence, clinical skill, care, and communication. The confluence of art and science. The confluence of two experiences. The confluence of me and we. The confluence of two stories merging into one as I shared in the poem that I wrote above. We as clinicians are guided by evidence, our training, and the compassionate empathic communication of care. However, all of this is only as effective as how we create meaning for and with the patient. I believe that The Mulligan Concept beautifully demonstrates this confluence.

In The Mulligan Concept, we focus on the patient’s unique movement/function impairment. The context drives the treatment not the content per se. The patient’s unique impairment and how it affects their function becomes the treatment in itself.  The patient helps define meaning. Treatment is guided by communication lived together as a team. We truly form a therapeutic alliance in every sense of patient/relationship-centered care. We both perform the treatment together as a new story fueled by the foundation of connection.

Creating Meaning

John Launer calls finding and creating meaning, hermeneutics. The term hermeneutics is derived from the Greek word hermeneuo which means ‘translate’ or ‘interpret’. This originally pertained to the interpretation of classical texts. Launer and associates use the term hermeneutics to signify an approach that seeks to help clinician and patient find and create meaning in a context-specific manner. The perspectives and experiences of both are brought together during a therapeutic encounter to generate a new understanding. Far from just storytelling. It is creating a shared understanding that becomes a new story. Agreed-upon truths and solutions are established by the process of dialogue itself. A confluence.

Treatment encounters are always a meeting of interpretation and translation. Our patients ultimately define if communication actually took place. Launer refers to “listening in order to speak” and “speaking in order to listen.” In the former, we only scan the words that patients are saying, looking for opportunities to jump in, to give advice and to rescue them. In the latter, we do the opposite: speaking only in order to give them more opportunities to explain their own views and how they make sense of their world. We collaborate on a shared understanding at the intersection of empathy, connection, and trust. To the clinician this understanding is a much closer approximation of the patient’s contextual reality. To the patient it is the deeper understanding of what matters to them with regards to their situation and what they need to do. It is far beyond the understanding of what is the matter with them. It’s about what matters to them! It is a conversation versus a consultation. Without this level of communication, adherence cannot be assured, with it, adherence is enhanced. Confluence leads to influence.

Conclusion

Creative writing and poetry have played a big part of my own self-reflection process. The writing and study of stories and poetry build empathy and narrative competence to not only get to know ourselves but to meet others where they truly are. Poetry has assisted me in navigating the uncertainty of being a clinician as it embraces the mystery of just being alive. We can never trade mystery for mastery. I shared this journey as a poetic odyssey in my book, Cuoreosity: The heArt of Being. Please reach out to me if you are interested in where coaching and therapy connect to help to create a more fulfilling practice or how poetry/creative writing can transform the resilience of ‘being” a physiotherapist.

jim@mulligancanada.com

@jim_millard Instagram

Substack https://substack.com/@jamiemillard1

www.cuoreosity.com

Thank You,

Jim Millard

Manual therapy has been an essential part of healthcare for centuries, offering a hands-on approach to treating musculoskeletal conditions, reducing pain, and restoring optimal function. Among the various manual therapy techniques, the Mulligan Concept stands out as a quick, safe, and effective method, when indicated, and is currently used by manual therapists worldwide. It is distinctly different from some traditional forms of passive manual therapy that have been shown to be unreliable.

Understanding the Mulligan Concept

Developed by New Zealand physiotherapist Brian R. Mulligan, the Mulligan Concept is a manual therapy approach that includes mobilization with movement (MWM) and sustained natural apophyseal glides (SNAGs). Unlike many traditional manual therapy techniques, the Mulligan Concept involves active patient participation that is central to the treatment process. It aims to decrease or eliminate pain, increase functional mobility, and improve maladaptive movement patterns.

Potential Benefits of Including the Mulligan Concept in a Multi-Modal Treatment Plan

Modern views of manual therapy suggest that a multi-modal approach is key to success knowing that different individuals respond uniquely to various treatment interventions. Integrating a multi-modal approach that includes manual therapy, therapeutic exercise, patient education, and other techniques or modalities can provide a comprehensive and tailored treatment plan.

The Mulligan Concept fully embraces a multi-modal approach in the following ways:

• Immediate Pain Relief: Mulligan Concept manual therapy techniques such as MWMs can often provide immediate pain relief, even – when indicated - in chronic conditions. Often by applying minimal external forces, the therapist may change a painful movement into one without pain. This allows patients to experience reduced discomfort providing a pathway to uninhibited therapeutic exercise.
• Improved Functional Range of Motion: Restricted mobility is a common issue in musculoskeletal conditions presenting in the clinic. The Mulligan Concept's MWM approach promotes functional improvement by sustaining external forces similar to those applied in joint or soft tissue mobilization throughout the full ROM, with over-pressure applied at the end of the range, if pain-free.
• Enhanced Patient Participation: Reduction of fear-avoidance behaviors due to pain relief can lead to greater compliance and adherence to the treatment plan.
• Customization: The Mulligan Concept allows manual therapists to tailor treatment to each patient's specific needs and goals by directly addressing the client-specific impairment measure (CSIM). This personalized approach enhances patient outcomes and satisfaction with the treatment process.

The Science Behind Manual Therapy

Critics often question the efficacy of manual therapy due to the lack of concrete scientific evidence. This lack was present in the mid-1980s during the development of the concept. However, in the last 40-odd years numerous high-quality studies have confirmed the positive effects of the manual therapy techniques of the Mulligan Concept. Research published in peer-reviewed journals has consistently shown increases in range of motion, reduction of pain (and other symptoms), and improved functional outcomes in patients with various musculoskeletal conditions.

Interestingly, Mobilization with Movement is consistent with modern neuroscience theory. In their 2016 article in Physiotherapy Theory and Practice, Combining Manual Therapy with Pain Neuroscience Education in the Treatment of Chronic LBP: a narrative review of the literature. Puentedura and Flynn note: A narrative review of pain education suggests more benefit when manual therapy is coupled with exercise/activity.

While evidence-informed practice forms the foundation of modern medicine, it is crucial to balance it with patient beliefs and individual experiences. David Sackett, a pioneer in evidence-based medicine, emphasized integrating clinical experience with the best available external clinical evidence.

A Common Question Asked about the Mulligan Concept!

Must I accept Mulligan’s original hypothesis of positional faults to practice this form of manual therapy? 

No! In line with a significant volume of modern research, MWM examination procedures and treatment techniques do not:

• Require palpation of the relative position of bony landmarks or relative movement of bones
• Rely on findings of pain provocation tests
• Require belief in any biomechanical theory, including the "positional fault" hypothesis
• Depend on establishing a diagnosis, a classification, or identification of a specific pathology or a “pain generator”
  (Verbiage credit to Mark Oliver)

Mulligan Concept References

The 2022 edition of the reference list on www.bmulligan.com, the concept’s International website, currently contains 388 references pertaining to the Mulligan Concept. This number continues to grow year by year as more and more research about the concept is performed and published.

Mobilization with Movement: Validated – an example

As referenced in a previous post in this year’s blog, the APTA Clinical Practice Guideline (CPG) published in the December 2022 issue of the Journal of Orthopedic and Sports Physical Therapy (JOSPT) offers compelling evidence in favor of its efficacy. This CPG identifies Level I evidence and assigns a Grade B rating, indicating moderate evidence, for the use of manual therapy techniques and specifically the Mulligan Concept Mobilization with Movement in the treatment of lateral elbow tendinopathy.

Conclusion

So, back to the questions:

1. Can manual therapy be beneficial?
2. Should it be part of a comprehensive treatment plan?

There is definite evidence in favor of including manual therapy in a treatment plan, particularly the Mulligan Concept. By incorporating this efficient and effective technique into a multi-modal plan its numerous benefits can be harnessed to provide quality care and maximize patient outcomes.

So…manual therapy…

Should you use it? YES!  (…says the evidence base, and many therapists and patients.)

Could you use it? YES!  ( If you have been trained in manual therapy techniques such as the Mulligan Concept, and especially if you are a Certified Mulligan Practitioner (CMP)

Would you use it? OF COURSE!!

 

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

Michael Møller Nielsen
 B.PT. Post. grad cert. sports phys., Dip. MPT. CMP, MCTA. Msc.Med PainMgt.

Looking Back

My first meeting with The Mulligan Concept was in 2010 when Josef Andersen introduced me to the concept. My background in manual therapy was rooted in the "classic" manual therapy - Maitland, Mckenzie, and structural osteopathy. At first, I was a bit provoked by the claimed efficacy of the Mulligan Concept and techniques which were conflicting with the education and knowledge I had gained from education in the “traditional manual therapy” courses.

By nature, I’m curious and I tried to implement the Mobilization with Movement techniques in my treatment protocols. I was amazed at the efficacy of the techniques when I included them in my multimodal treatments!

The same year I passed the Certified Mulligan Practicioner (CMP) exam. A year after that I felt lucky that Brian Mulligan came to Denmark to give a workshop about "the art in manual therapy". Brian traveled with his wife Dawn and Mark Oliver who also held a lecture about his approach to the SIJ and TMJ.

On the last evening of these courses, a group of CMPs were invited to have dinner with the teachers. During the dinner, I was fortunate to sit at the table with Brian, Mark, Josef, and their spouses. It was at this time I experienced the warmth and cordiality of these wonderful teachers – just like a big family – which is something I highly valued.

Looking at the Present

Now 13 years later I passed the Mulligan Concept teacher accreditation exam in Orlando. I have become part of the Mulligan Concept Teacher Association (MCTA). The joy of passing the exam was naturally a fantastic sensation, but what made me even more happy was the warm welcome of all the teachers in the group. It was just like being adopted by a family.

I believe the energy in the group is something special that is hard to describe in words only. Perhaps it is best described by Brian Mulligans DNA – great humor and excellent professional skills – has merged into the values of the group. It was fantastic to experience my first professional meeting with other highly skilled and experienced teachers in the MCTA. I discovered there is room for disagreements without losing friendships. A sign of great leadership and integrity from all members of the MCTA. An organization that put its values on top of all the decisions is an organization that can withstand all challenges!

My personal values are loyalty, honesty, and credibility. I treasure people who are like-minded. I reached my goals through hard work, being humble and honest with myself, and life values. In my private life, I’m married to Lene, with whom I have two children, Thor who is 15 years and Freya who is 12 years.

Before I became a physiotherapist, I was a sergeant in the Danish army and a sub-elite soccer player. My leisure time is spent with my children where I’m a soccer coach for my daughter’s team. When I have the time, I love the feel of adrenaline when riding my Ducati motorcycle on racetracks in Europe.

Looking Forward

I love to learn and evolve as a therapist and believe in knowledge sharing for greater mutual output. Becoming a teacher in the MCTA and being a part of a group of extraordinary people is a big shoe to fill – especially comparing myself to my mentors through the years – Josef, Peter, and Mark.

The transition from focusing on my own career to focusing on teaching other colleagues and helping them to evolve in their professional life is a responsibility I will take very seriously. I will strive to become a welcoming and appreciated teacher. I think teaching makes you an even better therapist and entering the MCTA will not be an end station for me, rather it will be a new starting point from which I can educate, research, and practice.

Thanks for the warm and friendly reception in the group. It means a lot to me and I will with humility and diligence try to repay the fine reception.

Cheers

Michael Møller Nielsen, (Denmark)

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