My Course Review 1- The Mulligan Concept

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 Good

  • 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.

The Bad-

  • 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

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

My two cents on Kinesiology taping

Healers

Hope you had a great week and abolished some major pain and misery wherever you are. Keep up the good fight. Today I’d like to discuss one of my favorite tools I incorporate in my practice every day. Not only has it helped my patients immensely but it has taught me a valuable lesson which has changed the way I treat my patients (more on that later). If you have not guessed it by now my opinion is biased in favor of these colorful pieces of tape. Like most, I first saw it on TV watching sports sometime in the summer of 2010 and like most I was intrigued and confused by it at the same time. To convince myself it was more than just some athletes attempt at fashion I decided to go for my first workshop and have never looked backed ever since.
I learned taping from two different schools- K-active (European based) and Rock Tape (American). Rather than stating their differences I would say the two schools of taping have more similarities in principles then differences. Both taping techniques have no set protocol to tape like the original kinesiology tape which teaches taping from origin to insertion and vice versa. This meant the direction of my taping is based on my assessment and not dictated by some preset protocol (I have tried that too, not with the best results for me and my patients).

Taping for neck and shoulder pain.
Taping for neck and shoulder pain.

Reasons why I love kinesiology taping (rock tape) and incorporate it in my practice –

1. If manual therapy and soft tissue work is a big part of your treatment, taping helps in locking down any progress that you make with the patient who might not be very compliant with home exercise program. It’s like taking part of your therapy home with them.

2.The assessment that I learned from K-active and tweak taping @ rocktape is a quick assessment (does not take more than 1-2 minutes) that helps me differentiate between pain originating from soft tissue structures and muscle guarding (most of the times) compared to patho-anatomical and bio mechanical reasons like disc herniation, nerve compression, arthritis etc as seen and exaggerated by MRI’s and other diagnostic imaging (less common).

3. It’s a great tool to quickly reduce pain, increase ROM, control swelling and bolster movement. I love the fact that it does not restrict movement like rigid elastic taping.

4. The teaching principles of K-active and rocktape resonated well with me as they are based upon modern concepts of manual therapy and movement science and incorporate the work of gray cook, janda, sharmann, lewit, Tom Myers and likes. I love the fact that it teaches us to tape movements over individual muscles and function over structure.

5. It generates great interest among people when they watch someone sport a colorful tape. Rest assured people will ask you or your patients about it and kinesiology tape might help bring in more business for you ( at rocktape you could also design your own custom print on your tape- a brilliant marketing idea but a little pricy).

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I was clearly too excited for this course.

If the above reasons were not enough, one of the best things that came out of learning this technique was how it influenced the way I perform my manual therapy and soft tissue work. Gone are my days of deep tissue myofacial release and elbow kneeding to alter fascia ( hopefully, we now know we can’t alter fascia). Not only did these old techniques leave some of my patients with soreness and often times bruises and discoloration, it also took a toll on my hands (mind you I am a new professional and I’m in it for the long haul). It made me believe that if a simple tape on skin could alter pain perception and improve movement, I didn’t have to dig my hands into my patients skin. light pressure during soft tissue manual therapy works way better than deep pressure for me. If you haven’t incorporated this in your tool box yet, I highly recommend it. As always comments are welcome and if you like the content please feel free to share.

Pursue Excellence –

Abhijit Minhas PT

(BPT,MS,CMP,FMT)