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How Brian Mulligan hijacked the direction of IFOMPT 2016

July 10, 2016 6:46 pm Published by


These opinions are my own, as a physiotherapist and a certified Mulligan practitioner. This perspecitve informs some, but not all of my practice, and this piece is intended to highlight a particular moment in the IFOMPT conference. Thanks for reading. Thomas Mitchell, Remedy Physio


The UK, a country in conflict with itself, and without strong political direction or leadership in the aftermath of the Brexit vote, seemed an appropriate backdrop for this fascinating conference. By the Wednesday morning of IFOMPT in Glasgow the tone of the conference was only clear in its state of ambiguity and discordant factions were clashing. The physiotherapy profession is uncertain of the best methods to approach musculoskeletal treatment in terms of assessment, evaluation and treatment approaches. The new leaders in the field have made a strong case for looking at patients from a biopsychosocial perspective and supporting their musculoskeletal disorders with a holistic understanding of their lives, delivered with empathy and attention, but there is little practical guidance on how to do this. Language, it was stressed, is powerful in either empowering and educating patients, or exacerbating their conditions and recovery through using the wrong terms. The brain and its relationship to the body and pain perception is complicated, and the issues of central and peripheral pain are hard to define and concepts of altering this neurophysiological state are in early stages of development. Manual therapy was contentious, both indicated by some, and vilified by others.


As a clinician in the audience, I continually returned to the question ‘so what does this mean, and how will this fit into my patient caseload?’. The answer was very difficult to fathom as the information coming through was at times contradictory. On one hand we were told of the damage of encouraging catastrophisation of patient’s symptoms through highlighting features on scans and stressing the extent of injury, the very next moment, we were being advised to give patients cauda equina warning cards with big red flags drawn on the top telling patients to worry if they developed symptoms often seen with cases of non-specific low back pain with associated radiculopathy. New studies revealed the lack of sensitivity of adverse neural tension testing where negative tests could indicate more serious injury, and we were reminded that the shoulder special tests were both non-specific and unreliable; a case to rename them not-so-special tests! By the start of the third day I felt as a clinician that I was not ‘biopsychosocial enough’, to the detriment of my patients, used assessment regimes that have little validity, that I was not conscious enough of haemodynamics and my patient’s limbs were at risk of amputation, that I was both contributing to catastrophisation of the patient in stating risk, and putting them in danger by not informing them of potential outcomes. In answer to my own question therefore, I jokingly argued that it doesn’t matter what message you take from the conference because I’ve got to get out of being a physio! The ambiguity, responsibility and risks are too high for too little reward.


So, amidst the uncertainty, the scientist talked to the scientist, the academic to the academic, the teacher talked to the teacher and the silent majority of the clinicians stared morosely at the stage. The question returned to me, ‘what does this mean, how will this fit into my patient caseload?’


It is hard to verbalise the effect the indefatigable Brian Mulligan had on the main auditorium that Wednesday morning. After two days of hard processing, quick-flicked datasets, suggestions of areas future study, inclinations of indications, ponderable risks, the vagueness of adverse behaviour, potential associations, beefed-up clinical responsibility, inadequacies, conceptual imagery, and risks again, up jumped the ‘prematurely rigomortic’ Kiwi. In an unbridled show of defiance, risk taking and showmanship the octogenarian manual innovator piqued the energy and literally stole the show. Here was someone who spoke to the masses, got excited about treating injury, pulled people from the audience and showed certainty in an uncertain world. The mood in the hall was uplifted, and the fractured crowd, in this single instance, rose as one to toast his life’s work.


The unity of the conference did not last long, in fact barely a few hours where, on the debate about manual therapy and its indication in the management of low back pain, one of the panellists exclaimed in desperation ‘how did we come to this point?’ after adversarial questioning. However, it was of little consequence as the dye had been cast, the unacceptable face (to some) of the enthusiastic manual clinician had been let out of the bag, and in side shows, back rooms and the corridors of the conference centre, he treated, charmed, enthused and ultimately won.


It is unlikely that IFOMPT will have a course of events such as this again. Brian gambled, played his hand, worked it strongly and deviated the axis from which the whole conference spun, and I doubt many others have his power. I hope the profession heeds the words of Lorimer Mosely, who called for professional unity rather than factionalism in approaching the problems of musculoskeletal care. For myself, the voice who spoke with the most clarity was Gwen Jull, and I urge people to look her up. I took from her that no one approach is sufficient for all patients, we need to treat our patients as individuals and be mindful of many different facets in getting beneficial treatment responses. We should not lose our manual skills as there is good evidence for them in certain areas and, although expert skill is perhaps overstated, good skill is sufficient to get results.


So, did I enjoy the conference? Absolutely, there are fantastic minds in our profession and I am optimistic about the future, our professional knowledge base, and was heartened by our ability to unsentimentally question all aspects of who we are, what we do and how we do it. I have confidence in the upcoming leaders in their fields. So, to answer my own question of ‘what does this mean, how will this fit into my patient caseload?’ I go back to Toby Hall in his analysis that clinical scenarios are complicated, and we have to be open to change, analytical and make informed decisions based on the evidence available. There is no one ‘best-fit’ treatment out there, and the joy of being a clinician is to try, fail, play and discover. Is it worth persisting with? I’m in!

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