The thoracic spine (T-Spine) is an interesting part of the body. In recent times it has taken the brunt of the modern sedentary lifestyle of being hunched over on a chair and working on a computer for hours in a day for many months and years. These modern sedentary lifestyle changes and new work/office setups have had implications on our musculoskeletal system. What is interesting is that the T-Spine itself presents only with a few symptoms like mid back myofascial pain, stiffness, loss of mobility etc. However, other joints in proximity of the T-Spine are affected adversely due to this. Here is a list of problems we often see in an physiotherapy office that our closely related to an excessively stiff kyphotic T-Spine.
Shoulder impingement- An excessively kyphotic mid back places the scapula in a downwardly rotated, anteriorly tipping and protracted position. This position of the scapula has shown to decrease the sub acromion space in the shoulder when performing overhead activities leading to a common problem we see often; shoulder impingement/pain. Try this little test, try elevating your arm up to the maximum flexion elevation with a straight Tspine and shoulders pulled down and back and then with an excessive hunched over position. Which one feels better and which is worse? See the video below and try it yourself.
Neck pain- A kyphotic hunched over posture tips the head (weighing about 10-12 lbs approx.) anteriorly and extends our line of sight downwards to the floor. For compensation, we tilt the head backward which increases Cervical lordosis and causes upper cervical spine to go into extension to have a regular straight field of vision. This causes increase tone/tension in the cervical extensors often compressing the greater occipital nerve and other important cervical structures causing symptoms like neck pain, headaches, radiating symptoms etc.
Low back pain- An excessive kyphotic T-Spine pushes the thorax anteriorly and causes compensatory increase in the lumbar lordosis due to increased tension in the lumbar extensors causing pain at the low back. This is the classic presentation of the ‘Lower Crossed Syndrome’.
Breathing- Along with the above compensation, the thorax lifts up due to inability of the abdominal muscles to provide inferior stabilization (lower ribs flaring) decreasing overall chest expansion and causing poor breathing quality and control.
Furthermore, if you follow the joint-by- joint model of training by Cook and Boyle, you can see that the thoracic spine is meant to be mobile but has a tendency to get stiff.
So, here our some strategies/exercises we can use to maintain general T-Spine mobility. The angles drawn in the video are not exactly accurate and are used for demonstration purpose only-
Bench/chair thoracic spine extension with stick-
T-Spine extension on foam roller
T-Spine windmill rotation
Four point T-Spine rotation
Threading the needle
Closing thoughts, the mid back is meant to provide mobility but tends to get stiff and excessively kyphotic given our contemporary lifestyles. This can open the floodgates to a myriad of musculo-skeletal problems. It is paramount to keep working on its mobility.
Part deux of this blog is not really a course review but my thought on taking the Certified Mulligan Practitioner exam. To begin, I’ll say this, you don’t need to be a Certified Mulligan Practitioner (CMP) to be a good therapist. I know many physios who are great clinicians but haven’t taken the CMP exam. The Certified Mulligan Practitioner exam is a test to check your competency in Mulligan concept principles and application of techniques passing which you get the title CMP. Like I mentioned in the last blog, the Mulligan concept does not cover a whole lot on assessment/diagnosis. So the testing skips that part too.
What to expect in the test-
I gave the test back in 2010 and back then the test had two components. I have heard that the format has not changed a whole lot but don’t quote me on this.
Written Component- consisted of 50 MCQ’s. The Multiple choice questions which seemed tricky and often felt like they had more than one correct answer (they did not) was the easier part of the exam in my opinion.
The practical component- I believe was demonstration of 10-15 techniques (approx). Successfully passing the exam requires the test taker to be competent in each and every technique of the book and one would be asked to demonstrate any random 10-15 techniques covering all bases. This included everything- NAG’S, SNAG’S, MWM’S, SMWAM, SMWLM, headache SNAG’S, belt techniques, BLR, taping techniques etc. The practical component was conducted by two Mulligan Concept Teachers Association (MCTA) members; in our case one local from India and one from Australia.
Passing requires around 80% scores (approx) and attention to detail is important making sure one applies all the 7 principles of the concept when performing the techniques.
Is it worth it?
I can see why this question would cross someone’s mind. After all, one doesn’t need the title to practice in the profession or even to apply these techniques. You could just do the workshop/seminar course and still apply the concepts in your clinical practice. However, in my opinion it is worth it. Going through the extra grind has its advantages. I’ll give you not one but…. two!!
Early on in my career as a new grad, I always used my CMP credentials to bag better than average job opportunities and a little higher than average salary that a new physio would expect. To the new graduates starting their career in physiotherapy I’d say this, physio school will teach you the basics and how not to harm a patient but some of the curriculum is not up to date with the latest in the field and taking certifications will improve your overall clinical skills. It will also make you a more desirable candidate in the job market. Good physiotherapy offices value continuing education certifications and titles. CMP is a good title to have.
On becoming a CMP, you become part of the network of Certified Mulligan Practitioners. The database for a full list of CMP’s across the world can be found on the Mulligan website here.. This directory can sometimes be a good source of referrals for new patients/clients. I have had other mulligan practitioners refer patients who were around my practice and I have also had patients use this directory to find me directly. It can be quite a useful tool.
Hope this information helps. More course reviews to follow in some upcoming blogs. Lets keep the dialogue going. Until next time.
This is my first blog post review on a workshop/course so it only makes sense that I write about one of the most pivotal workshops early on in my career. Drum roll, ‘The Mulligan Concept’.
Before we begin, I would like to take you’ll on a little flash back in history back to 2009. I was in my 4th and final year and was about to graduate with my bachelors in physiotherapy degree. Needless to say, I was still trying to put all the pieces of the puzzle together (almost a decade later and I still am!) and quite frankly struggling at it. By now I was expected to be able to figure out what was going on with my patients. I could follow the SOAP procedure to get all the information like I was taught but was unable to put it all together. To make matters worse, the few things that I had truly mastered at the end of my 4 years was how to make near perfect loopy circles on the body while giving ultrasound and mastered not to electrocute patients on modalities (that’s right, a slight exaggeration). Modalities were the biggest arsenal in my ‘physio toolkit’ along with some very basic home exercises and frankly it did barely something if anything to my patients pain scores or any other outcomes. It didn’t matter if the machines now had digital panels instead of the knobs, they were all a let down. Maybe I relied on modalities too much (In fact now I know that really was the case). But what else was out there? I had not even started my internship and the future didn’t look so promising. I was looking for a way out. And then…
Enter the Mulligan Concept
This 8 day workshop was everything I need at that time (almost everything). It was a real game changer. Taught by a dynamic and engaging teacher who was also a great role model for a young physio student, the concepts looked pretty straightforward and gave me new hope. I began using the techniques right away and as many physios have reported alike, the results were just like how Brian Mulligan would describe it instantaneous and almost miraculous.
Before we proceed, full disclosure, I am a Certified Mulligan Practitioner and I am biased to this approach in physiotherapy. But I’m even more biased at presenting accurate information through my experience in this blog. So here is my take on what I liked and disliked in this concept-
The 7 general principles of the Mulligan concept apply to every technique on every joint in the body. Now there are many techniques (NAG’s,Reverse NAG’S, SNAGS, MWM’s, SMWAM’s, SMWLM’s, belt assisted MWM’s etc) and even more joints in the body. However, there are no exceptions to the rule.
When a particular glide is applied correctly and it works good to reduce pain with a certain movement, it works just great.
If you follow the general rules of the concept, chances of aggravating patients symptoms are slim. All movements must be pain free or should reduce pain with every repetetion.
The concept focuses on function and I’m a big fan of that. If squatting hurts, your glides will preferably be in squatting, if its walking that gives your patients some grief, the glide is applied in walking (a little difficult) and so on. I’m not a big fan of prolonged passive treatments on a bed if the chief complain is doing some activities. Weight bearing and movement is not just encouraged, its a principle.
Results are generally quick and instantenous.
Most of the techniques are joint biased. It does not address soft tissue work that might be needed on up-regulated, knotted muscles etc. (Brian Mulligan does mention that his techniques should be applied with other interventions). So this course will not address too much of your ‘manual therapy for soft tissue’ needs.
In my mind the biggest short coming in the concept is the lack of understanding of why it works so well when it does. It is based upon the older mal alignment, ‘positional fault’ leading to pain model of explanation which we now know is not the best model to explain something as complex as pain. We have better understanding of these concepts now. I’m not sure if the Mulligan Concept Teachers Association (MCTA) has now changed their explanation/narrative in light of the new pain science research coming out. There is still some ambiguity there.
Unlike some other concepts like the MDT, Maitland etc that focus on the assessment part as well as intervention the Mulligan Concept is more of a treatment system. It won’t do a whole lot in terms of adding to your diagnosis or assessment skills.
Some techniques are too specific and in my humble opinion too subjective from physio to physio. Here’s an example, some glides like the rotational MWM’s require the practitioner to isolate say the L/R transverse process of the C6 vertebral body. This gets even harder by the time we get to the lumbar spine as now we cannot use our digits but gotta use the ulnar border of the hand on specific spinal and transverse processes. Try this with a bunch of your physio friends and see if you can agree upon your palpation skills every time on every segment of the spine. I struggle with some of these palpatory methods that need us to be highly specific and have such subjectivity. Another example is the PA mobilization (sorry not Mulligan but I had to throw it in there). I have found movement based observatory method more quantifiable.
I am not the biggest fan of the Mulligan Taping techniques. Some of the taping techniques are supposed to ‘hold’ the joint in the correct position. I don’t think a tape on the skin can keep for example a shoulder in a postero-lateral position and keep it from falling back in a ‘mal-position’. There are other examples too and I can state a few but I wont. You get the point. There are better taping courses out there with better explanation of why we belief taping works. Also, baring a few conditions, I like tape that permits motion not restrict it.
There is no ugly.
To sum it all up I think the Mulligan Concept has some shortcomings but is all in all a great concept. It definetly changed the trajectory of my professional career and taught me a lot. I will endorse it to anyone who cares to hear my opinion. Its a good concept to be familiar with.
Now would you want to go the extra distance to get recoganised in the system as a Certified Mulligan Practitioner (CMP), go through the pains of going through a written and practical exams like I did? More on that in part two of the blog post series. Until then