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  • Somethings been bugging me

    I've spent the greater part of the last three years deconstructing my own world views on manual therapy. Being a product of the Canadian Orthopeadic "system", I grew up believing that one could feel tiny restrictions and correct them with a high level of specificity.

    I now know that is the biggest myth perpetuated on our poor profession. Made me question every thing about "manual therapy". A recent research paper by Piva el al:

    Piva SR, Fitzgerald GK, Irrgang JJ, Fritz JM, Wisniewski S, McGinty GT, Childs JD, Domenech MA, Jones S, Delitto A. Associates of physical function and pain in patients with patellofemoral pain syndrome. Arch Phys Med Rehabil 2009;90:285-95.

    Made me question even further anything "manual therapy"...as in shoving or jabbing at the mesoderm.

    And truthfully, I never felt I had great sucess with PIVM and PAIVM's and looking at muscle imbalances etc. In fact....I think I made people worse( long term by perpetuating false myths about pain etc).

    Yet....I cannot deny the amazing results I get more often than not using Mulligan techniques. I mean truly outstanding results just as he describes in his text bookk and courses.

    What is going on here? A question for all ectodermal thinkers most specifically?

  • #2
    So... why do YOU think you got "amazing results" with Mulligan techniques, proud, when other kinds of MT apparently weren't so hot?

    Hint: look at the interfaces:
    1. Between you and your patient
    2. Between you and your "training" ( i.e. treatment concepts) as a OMPT
    3. Between you and your own perceptions of your real role as human primate social groomer.
    Diane
    www.dermoneuromodulation.com
    SensibleSolutionsPhysiotherapy
    HumanAntiGravitySuit blog
    Neurotonics PT Teamblog
    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
    Canadian Physiotherapy Association Pain Science Division Facebook page
    @PainPhysiosCan
    WCPT PhysiotherapyPainNetwork on Facebook
    @WCPTPTPN
    Neuroscience and Pain Science for Manual PTs Facebook page

    @dfjpt
    SomaSimple on Facebook
    @somasimple

    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

    Comment


    • #3
      Originally posted by Diane View Post
      So... why do YOU think you got "amazing results" with Mulligan techniques, proud, when other kinds of MT apparently weren't so hot?

      Hint: look at the interfaces:
      1. Between you and your patient
      2. Between you and your "training" ( i.e. treatment concepts) as a OMPT
      3. Between you and your own perceptions of your real role as human primate social groomer.
      I don't know Diane...that's why I posted the question. Mulligan techniques are not specific at all and just aim to restore mobility. Also....Mulligan is quite clear his techniques should be painfree.

      I'm not sure I'm following the hints.

      1. Why would the interface be different between Mulligan manual therapy and the other kind?

      2. I've let go of any notion that my high cost was worth a darn thing. I'm fine with that. In fact....I am coming to the point where I question how much I actually NEED to touch a patient. Which is why I find Mulligan stuff so challenging.

      3. Are you suggesting that I remain subconsiously convinced that the mesoderm is the PRIMARY culprit?

      I'm not sure I understand where your hints are taking me. But I want to know.

      Comment


      • #4
        1. Why would the interface be different between Mulligan manual therapy and the other kind?
        Proud, if I may:the Mulligan method requires mobilisation with movement, which requires hands-on AND patient motion, rather than just coercive externally applied forces on a passive patient in more "regular" MT. Makes a big difference in the patient experience, your own involvement (you are not the "operator" but a participant of the motion), and on the actual forces applied in the techniques.
        We don't see things as they are, we see things as WE are - Anais Nin

        I suppose it's easier to believe something than it is to understand it.
        Cmdr. Chris Hadfield on rise of poor / pseudo science

        Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

        We don't need a body to feel a body. Ronald Melzack

        Comment


        • #5
          Before I jump back onto the thread, maybe other people would like to have a crack at suggesting solutions to the riddle you have uncovered.
          Diane
          www.dermoneuromodulation.com
          SensibleSolutionsPhysiotherapy
          HumanAntiGravitySuit blog
          Neurotonics PT Teamblog
          Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
          Canadian Physiotherapy Association Pain Science Division Facebook page
          @PainPhysiosCan
          WCPT PhysiotherapyPainNetwork on Facebook
          @WCPTPTPN
          Neuroscience and Pain Science for Manual PTs Facebook page

          @dfjpt
          SomaSimple on Facebook
          @somasimple

          "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

          “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

          “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

          "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

          "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

          Comment


          • #6
            Bas, I like that explanation. But I cannot convince myself that simply having the patient "involved" while I do the mobilization is the answer.

            I mean...try this:

            A patient cannot forward flex the shoulder beyond 150 degrees without pain. You utilize a muligan mobilization such as outlined on page 107 of his book( for those that have his latest).

            Seems to work almost astonishingly well.

            Now do the same thing but this time glide the scapula in the opposite direction...see what happens. Either they get worse...or do not improve.

            That suggests something mesodermal( mechanical) is going on to me.

            BTW...I've done these little expirements before with PIVM/PAIVM's and a multidude of other manual therapy techniques and have found( to my amazement) that a patient often improves( or doesn't) regardless of the way I mobilized a joint. Convinced me pretty fast that all the manual therapy course( via the Canadian system) were quite bogus in their thinking.

            Seemingly not so with the Mulligan stuff. Pretty consistent results. Worse or no change when you do it wrong.....improvement when you do it right.

            Interesting( to me anyway).
            Last edited by proud; 16-02-2010, 06:03 PM.

            Comment


            • #7
              Originally posted by proud View Post
              That suggests something mesodermal( mechanical) is going on to me.
              So.... in your mind, mesodermal = mechanical?
              Why?
              Diane
              www.dermoneuromodulation.com
              SensibleSolutionsPhysiotherapy
              HumanAntiGravitySuit blog
              Neurotonics PT Teamblog
              Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
              Canadian Physiotherapy Association Pain Science Division Facebook page
              @PainPhysiosCan
              WCPT PhysiotherapyPainNetwork on Facebook
              @WCPTPTPN
              Neuroscience and Pain Science for Manual PTs Facebook page

              @dfjpt
              SomaSimple on Facebook
              @somasimple

              "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

              “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

              “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

              "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

              "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

              Comment


              • #8
                I like to tell patients that I am taking tension off the area that hurts by stabilizing it. Then I have them perform their range of motion exercises while I'm holding the area allowing the brain to see that the threat is no longer present.

                Comment


                • #9
                  Well, I do not see that it is either/or. If a neurophysiological issue occurs around the shoulder, it is very unlikely that there won't be a biomechanical "effect" of that issue. I have seen so many painful shoulders and I am willing to put money on the slight antero-position of the humeral head in the glenoid fossa (with associated medial rotation). Invariably.
                  I expect that this is likely part of the natural protective pattern about the joint (protraction).
                  Hence the effect of the motion in your example.

                  This does not mean that the biomechanics are in any way the causative factor, just that they occur and their non-threatening manual management can certainly have an additional positive effect on the outcome.
                  We don't see things as they are, we see things as WE are - Anais Nin

                  I suppose it's easier to believe something than it is to understand it.
                  Cmdr. Chris Hadfield on rise of poor / pseudo science

                  Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                  We don't need a body to feel a body. Ronald Melzack

                  Comment


                  • #10
                    Originally posted by Bas View Post
                    I have seen so many painful shoulders and I am willing to put money on the slight antero-position of the humeral head in the glenoid fossa (with associated medial rotation). Invariably.
                    I expect that this is likely part of the natural protective pattern about the joint (protraction).
                    Hence the effect of the motion in your example.
                    Right. But how does that explain that when I glide the humeral head ANTERIORLY in graded fashion( a la Maitland)....the patient demonstrates improved motion?

                    In other words....opposite to what you would think.

                    This does not seem to happen with the MWM stuff....

                    for me anyway.

                    Comment


                    • #11
                      proud,

                      I honestly know very little about Mulligan so a PT demonstrated one of his techniques on me.
                      It was about 6 yrs ago, when I had a tendency to a stiff cervical spine (I'm fine now, thanks to SC) with limited rotation to the left. He asked me to turn to the left as far as I could, and he 'followed' with one hand on the eccentric side. After one repeat I had full range.

                      His explanation was 'stabilising' the opposite side. I think we know better now, but it worked, painlessly and easily.

                      Ectodermal? I think so. Can't think of any other reason why it worked.

                      Nari

                      Comment


                      • #12
                        Proud, I tried Mulligan mobilization with movement on my hypomobile ankle. As explained here, www.advanceweb.com/pt put in the search website "recurrent ankle sprains".
                        The article is titled "searching for support". The mobilization described only seemed to irritate my peroneal nerve. If I did the nerve glide and mobilization seperately though, there was no problem. Still I think nerve glides are superior.

                        On my hypermobile shoulder, again, mobilization only seems to irritate nerves. Nerve glides help after a hard training day on my shoulders and neck.

                        The ankle mobilizations I do seem to work better on my HS kids, versus the semi-pro soccer guys I take care of. These guys are older 25-45yo. There ankles seemed to be really locked up. They also took notice of my neurodynamic approach, and liked it.

                        I think you've just had a good run of luck and expertise with your mobilizations. From my perspective, nerve glides are far superior. Mobilization may have a role to play though.
                        Last edited by smith; 17-02-2010, 01:32 AM.

                        Comment


                        • #13
                          Proud, I am not thinking capsule, I am thinking "changing" of sensitive tissues. If the HH is in forward position, and the shoulder is in a limited "habitual pattern", moving the head forward in a safe manner will certainly alter the neuromuscular responses.

                          I am just guessing, since I do not "know" how you are with your patients; my guess is that there is respect, education, careful introduction and manual intervention. And if you rmanual intervention is very comfortable for you and your hands, and comfortable to the patient in that particular environment - how can it not work.
                          We don't see things as they are, we see things as WE are - Anais Nin

                          I suppose it's easier to believe something than it is to understand it.
                          Cmdr. Chris Hadfield on rise of poor / pseudo science

                          Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                          We don't need a body to feel a body. Ronald Melzack

                          Comment


                          • #14
                            MWM's are my first manual technique of choice for all my 'hands on' patients.

                            I think there's a lot of things going on that contribute to their success.

                            1. The direction of the glide is determined by the patients pain not some theoretical idea about what biomechanics are 'wrong' and which are 'right'

                            2. They are very 'convincing' from a patients perspective. With the correct glide applied to the joint the patient can suddenly perform a movt that was previously painful without pain. Perhaps with this the brain relaxes the 'danger' signals associated with this movt.

                            3. The patient's brain is getting lots of somatic afferent input- movt, therapists touch, joint and m/s receptors etc.

                            4. The pain reduction with the correct glide may be due to better biomechanical joint glide, or reduced strain on neurological tissues, or the threat reduction of the joint feeling more supported or all of the above.

                            As I understand it Mulligan attributes their success to neurological processes (although he's a little vague on specifics). Not sure whether he uses the phrase 'joint memory' still in his newer editions to explain how the effects 'hold' but I believe that he's well aware that joints don't have memories.

                            Comment


                            • #15
                              Jono and proud, how do you account for the fact that you have your hands or fingers or the little foamy thing on skin surface, not on joint?
                              Diane
                              www.dermoneuromodulation.com
                              SensibleSolutionsPhysiotherapy
                              HumanAntiGravitySuit blog
                              Neurotonics PT Teamblog
                              Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                              Canadian Physiotherapy Association Pain Science Division Facebook page
                              @PainPhysiosCan
                              WCPT PhysiotherapyPainNetwork on Facebook
                              @WCPTPTPN
                              Neuroscience and Pain Science for Manual PTs Facebook page

                              @dfjpt
                              SomaSimple on Facebook
                              @somasimple

                              "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                              “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                              “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                              "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                              "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                              Comment

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