A link to an interview with Brian Mulligan was posted yesterday over at the Chartered Society of Physiotherapy website:
Physiotherapy pioneer shoots from the hip on joint repositioning
Interviewed by physiotherapist and founder of PhysioUK, Chris Murphy, Mr Mulligan outlined his approach of the Mulligan concept and its importance as a means of combating musculoskeletal (MSK) pain and dysfunction.
He pointed out that when joint surfaces were out of place their movements were often disrupted and painful. Repositioning can remove this pain and restore normal movement at once.
He also expressed frustration about his perception that many physios concentrate exclusively on using exercise therapy for MSK problems.
A full transcript of the interview is available on the PhsioUK website. Here are some exceprts from the interview transcript:
Chris Murphy: Evidence-based medicine. What are your thoughts towards those that say we shouldn’t be doing manual therapy when no robust evidence base exists?
Brian Mulligan: We’ve got robust evidence, so that’s okay. The first article on a manual physiotherapy procedure to get into the British Medical Journal, was on tennis elbow where they compared our mobilisations with movement treatment with steroid injections. And it made the medical journal because at the end of one year when all the patients were reassessed, those that had injections had had a reoccurrence, and not one patient that had our procedures had a reoccurrence. And on those grounds it made the BMJ. (Bisset, L (2006) Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. British Medical Journal. doi:10.1136/bmj.38961.584653.AE)
The full Bisset et al (2006) paper is available open access here. It’s worth a read in light of the statement above, particularly this section “Physiotherapy performed significantly better than wait and see at six weeks for all outcome measures… However, by 52 weeks no difference existed on any primary outcome measure, as most participants had either much improved or completely recovered (wait and see 56/62; physiotherapy 59/63)… Recurrences after injection [47/65 (72%)] were significantly greater than recurrences after physiotherapy (5/66) or wait and see (6/67), which were not significantly different from each other”
Chris Murphy: So with that, just a couple of points that you said there. Over time, obviously with regards to the ankles you talked about the positional fault there. Over time have your thoughts changed about how the techniques you’ve developed work?
Brian Mulligan: Well yes, of course I have. I reposition the joint, and the moment you reposition it, people who’ve got painful with planter flexion and inversion following an ankle sprain, it’s gone. But what we’re achieving with ankles, we’ve got no equal. It’ll all come out in time, and it’s got to because ankle reoccurrences are disgusting. You can damage any other ligament in the body, when it heals it never goes again. And yet the ankle keeps going. And no-one… one surgeon said oh that’s rubbish, I’ve seen that’s the ligament. So he was an idiot.
Chris Murphy: And how else do you respond to those that say what you do is a placebo?
Reading the interview transcript, reading Brian Mulligan speaking in those ‘beautiful absolutes’ I couldn’t help but be reminded of a beat poet.
*The tile of this post was borrowed from Howl, written by Allen Ginsberg.
Just by looking at the way Mulligan talks here, there’s no way he will wake up to what’s going on in his lifetime. He’s just way too invested in the false. I don’t mind him being absolute, but absolutely wrong bothers me. This is Physio as it was back in the 1980’s.
In a strange sort of paradox, it’s his absolute faith that engenders trust, thence pain resolution. But he obviously is completely ignorant of the expectancy effect and its power. All that needs to happen is that he transfer that absolute trust into expectancy itself. But that’s a huge gulf to cross. Instead he will teach his students that joints need to be manipulated into a pain-free state.
This phrase really struck me as interesting:
“The patient says that’s not right, that’s not right, and the fact that the patient’s fine-tuning the therapist means it’s not a placebo.”
There’s just no way I can make sense of this statement unless I reverse it – “… the fact that the patient’s fine tuning the therapist means that it *is* placebo” – with expectancy effects, a sense of control, beliefs, (DIMs and SIMs of course) all playing a roll….
Yeh it’s just a mess, the whole thing, and there’s nothing at all that can be done about it. He’s falling for the old “it works so well it can’t be placebo” routine.
I often think of people with religious beliefs. Their whole sense of being ‘good and safe’ is tied up with a certain belief set. If you try to usurp that with evidence, you are met with a very strong denial. If the evidence sinks in to some degree, you are met with anger. Beliefs are really pernicious things. In saying this, I include scientific beliefs, because scientific folk have the EXACT same tendency to get stuck on beliefs that make them feel safe. Beliefs appear to provide security, esteem, connection with like-minded others, and yet all they do is bind us to what is false. By ‘false’, I mean to say that beliefs are at best just “descriptions of reality”, not reality itself.
When I read stuff like this interview, I try to remind mysef to hold my own beliefs very lightly, and allow others to smash them to pieces (if they are capable of doing so! ).
Dear Brian is one of the last Gurus left from the 70s. Bless him and be grateful for those broad shoulders of his clan that we have stood on to get where we are today. His thinking will never change and why should it as it works for him and his patients. One could worry that he is in the way of progress but then the dinasours didn’t get in our way either…..time will solve the issue……
Total respect for his generation
I don’t know David, it took a very large asteroid and a global extinction event to get rid of the dinosaurs, not sure that we mammals would be as successful as we are today were it not for that interplanetary wanderer. And Brian is still teaching his stuff, to a new generation – as evidenced based practice to boot.
I’m with you on standing on the shoulders of giants and respect for generations past, but I do worry that we are ignoring Einstein’s advice to look for new ways of thinking to get out of the trouble that we have gotten ourselves into.
Who needs Asteroids when we have NOI ❗️I hear what you are saying Tim but we have to think positively and the universe will eventually deliver. My old karate Sensei always said, when I was confronted with what I perceived to be impossible ” Step by step” and you will get were you want to go……
Big hug DB
Nice article, Tim. I especially like the invocation of the absolutes of the Beat poets haha.
My understanding of the mechanism of effect for joint mobilisations (and manipulations) is that they create a barrage of afferent firing because of the density of afferents in and around joints which respond to cavitation or joint positional change. This input leads to a modulation of motor output- usually a subtle decrease in tone. It seems like a lot of sophisticated physio exercises operate via a related effect. Many modalities draw on complex afferent processing, as it functions in concert with a complex set of (usually motor) outputs for the given task – whether a Feldenkrais exercise, mirror box therapy, laterality recognition, or even the old-fashioned wobble-board.
Is it possible, then, that there’s still a role for manual therapy, because in my anecdotal experience, sometimes some manual therapy aimed at providing stimulus to the brain can be beneficial, as one aspect of trying to normalise brain outputs. And if that was true, it would not necessarily translate at all well into RCTs.
My question is: could manual therapy be useful but not for the reasons Mulligan thinks? And could this utility actually be extremely difficult to capture in RCTs (which is not to say we shouldn’t keep trying)?
“could manual therapy be useful but not for the reasons Mulligan thinks? ”
I reckon so, and some cleverer-than-me people have suggested some compelling arguments.
The danger I suppose is in people believing that the reason it worked is the reason given by the manual therapist – that their joint’s were ‘out of position’ or something like that. This belief encourages and reinforces notions of fragility and vulnerability, which we suggest are really powerful DIMs.
“And if that was true, it would not necessarily translate at all well into RCTs.” I don’t know. Why do you think manual therapy techniques might be any harder to pick up in RCT scenarios that any other interventions? Given the controlling of variables etc, wouldn’t an RCT be more sensitive to picking anything up?
The suggestion that manual therapy works via afferent barrage has never entirely convinced me – i just don’t think we know enough about what happens to that information – how it is coded, what is passed on, what is lost along the way etc etc, to make simple cause-effect hypotheses – that is – afferent barrage in – altered tone (output) out. Predictive coding theories and Bayesian models of brain functioning further muddy these waters – if all that is passed forward is prediction error, then might an afferent barrage be more or less of a barrage depending on prior experience??
I think that there will always be a place for manual/touching therapy – right patient, right time, right explanation and all that, but perhaps all the complicated explanations are not necessary, perhaps caring touch could just be framed as a powerful SIM?
Thanks for taking the time to raise some great thoughts and questions, awesome to have you here on the ‘jam
I think many of Brian’s techniques reposition joints powerfully in the brain. They are educational as well as you can demonstrate to someone how easy it is to change. You can put the techniques in a big treatment package with lots of other good stuff. I’d probably have a different story to Brians but that’s OK.
Interesting stuff. Tim, would you have any recommended intro reads on Bayesian models and/or predictive coding?