An Interview with Brian Mulligan The Founder of NAGS's / SNAG's: Mulligan Concept Mobilisations with Movement A full transcription of an interview held in July 2015 between Chris Murphy (Director of PhysioUK) and Brian Mulligan (Founder of the Mulligan Concept) 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) Brian Mulligan: But that was really quite wonderful, and we've vindicated what we do for dizziness. The woman that had three papers published on us, the standard of her research was so high she's got a PhD, and we were totally successful in treating dizziness of cervical origin. We've got proof that there's a positional fault with ankles, and this is very significant because most ankles are recurrent. And that's disgusting. If you just have a ligament it should heal securely and it should never reoccur. And the reason being of course you get a positional fault in the ankle joint itself, and we've got proof that this occurs. They've done MRI scans, so we've ticked that one off. And two articles have just been published on what we can achieve with shoulders. And again vindicating what we do, and these are controlled trials. We've got the same for headaches. So we're really on a roll. So to say that there's no evidence actually is a load of rubbish. 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: So why isn't everyone already doing this then? Why something like that is it that people aren't successful? Brian Mulligan: Well you still need handling skills. And handling skills are no longer the forte of physiotherapists. I'm very disappointed that at the WCPT conference in Singapore about four months ago they summarised, they had all these people speaking on shoulder problems, and the conclusion was there's no place for manual therapy in the treatment of shoulders. And we just had two articles published proving with clinical trials there is. So it almost leaves me in despair, and the people who will take over from physiotherapists as far as manual therapy goes, will be osteopaths, chiropractors, and other people, because they still use their hands. Chris Murphy: That leads nicely to one of the other questions, how do you see the future of physiotherapy? Brian Mulligan: Well I feel we've become exercise therapists. And you know, in New Zealand you can get a degree in physical education, and physiotherapists just seem to mercilessly treat everybody with exercise. And we've come up with an option which I can explain to you later, that when we use our mobilisations with movement you can find out if they're indicated in one or two minutes. And if they're indicated use them, if they're not, do what you like. Exercise, I don't care what you do. But when we've got an option that's pain free and gives you an instant result, and only takes two or three seconds, it should be in the armaments of all physiotherapists to know of them and just in their assessments see if they're of value. And if it only takes two minutes, it's not time consuming, and when it works people call it miraculous. Chris Murphy: I'm guessing from what you've described there, just if someone's doing an exercise to lay your hands on them and with a small adjustment you could just be complementing the exercise. If people are saying well you've got to use exercise, fine you can be doing that, and integrating what you're saying with that anyway. Brian Mulligan: Yes, that's exactly right. I'm not rubbishing exercise. You've got to strengthen, you've got to do all sorts of things. But just as an example of ankles. Now this is why physiotherapists should be concerned. Chris Murphy: With regards to yourself as a character, how do researchers who, you just mentioned about that shoulder conference, how do they treat you, how do they react to you? Brian Mulligan: Well I have no problems with them because I only meet them if they turn up when I'm teaching. And I shouldn't say lecturing, because when I'm lecturing I'm treating people. Now, when they see the outcomes there's no argument. They see that it's of value. Last year I had to go to Korea, and I was invited by doctors. And these doctors when they invited me said that they would be, took our practice and some physiotherapists at the same time, they wanted extra people. And you know, on day one I
claimed that what I was teaching would work in over seventy five percent of patients when they were indicated, and there was a doctor there who was a pain specialist. And the poor guy had the most dreadful shoulder for two months. He couldn't abduct without severe pain and he had lost full elevation, and so his mates said can you help him? He's had drugs, injections, everything. Took three minutes and he was pain free. The next day was pain free and I had to go back to Korea and do some more teaching, three months later, and he reached me and said remember me? And he's had no pain since. Now the impact on those people was massive. I hate telling them what I can do, I like to show them. And if you teach on that basis, or lecture on that basis that you're showing people, that's fine. But the big problem, and I'm going to run soon as you know, master classes. I had some excitement because last year I was in India, and a girl from Australia came and presented a paper at this conference, and I was there with a chairman of my organisation, we were lecturing, teaching and running the exams. And she was with us all the time, she was just watching what we do. And she had passed our exam, a certified Mulligan Practitioner exam, and when she got back to Australia she emailed me two weeks later, and she said: Brian, I was only succeeding or having a thirty or forty percent success rate using your techniques on patients. And you had virtually a hundred percent. Everyone you dealt with you eventually could help. And she said I came back and wondered why I didn't have the same result. And she realised she didn't have accurate handling skills, nor did she have the confidence to develop them. But it changed her whole attitude, and she just said to me her practice has changed. And I've another email to say her success rate would equal mine. And so that's why I'm now running these courses (www.physiouk.co.uk/brian), because people who know of my techniques and not getting successes, I'm going to tell them why and show them why and fine-tune them. But it's an enormous task, and this year I've travelled more Air Miles than I've done my entire life. I go everywhere from Poland to South America to America, I've been all over there, Australia, all around the Middle East. It's only because I'm running out of time, and people have got to have what we do available. Chris Murphy: Linking in with how do you see the future, what are the main changes that you've seen in physiotherapy? Brian Mulligan: Well, remember that when you qualify as a physiotherapist now, there's a tendency to specialise. But in the field of musculo-skeletal medicine they're falling behind. If all they've got to offer is some equipment and just exercises, well, that leads to some despair. And remember three of my teachers now, no four of them, are professors in Universities and I think seven of my teachers have PhDs. These people are pretty smart cookies. There's people like Toby Hall and there's Bill Vicenzino. I've got some incredible support from some very bright people, and I would love to go to WCPT and have an audience, and there must be people, if you've got a thousand people, with problems. And I'll treat their shoulders on stage. That would change their thinking. Chris Murphy: With that, I think the ability to stand up there and see patients in front of people, apart from yourself there's maybe Peter Sullivan, and there's not many, you know Diane Lee and LJ Lee, there aren't many people who say right, give me a patient now, stand up and I'll do some work with them. And that can be, I think that's a powerful testament to what is possible. That guy you said with that follow up after three months, that's interesting because people could easily turn around and they criticise and say oh it's you being charismatic, they'll have their pain back tomorrow.
Brian Mulligan: Yes, I know. I've got enough film footage of course to impact, but I still prefer to have an audience and treat, and you can't say that it's psychological. If someone has not had full elevation for twenty three years, and suddenly they've got it, it's pain free, and the next day they're waving their arm around and saying I've got no problem. This is all filmed, I've got evidence of that. You've got someone who hasn't bent a knee for eleven years and she ends up sitting on her heels. And we made an announcement that her knee had been numb and felt strange for eleven years, and the sensation had come back and it felt like the other one. Now that took probably three or four minutes. It's so potent when they're indicated. Chris Murphy: And I'm guessing it's quick to work out when they're not indicated. Brian Mulligan: It's the whole stupid point. Somebody came up to me in America and said well you're doing this without assessing people on stage. I said: a mobilisation with movement should be part of everyone's assessment. It only takes a few seconds, and you're just looking to see if you can reposition the bony surfaces and bring about a change. It only takes two or three minutes, and if it's successful then it becomes a treatment. And why would you stuff around? And the other thing is if you can get an instant result that's diagnostically significant, because what you're doing is virtually confirming the whole hypothesis. I could go on and on, but... Chris Murphy: What's interesting to hear from the passion in your voice is that sometimes characters like yourself, and in the 80s and the 90s there were very charismatic individuals and people would maybe less complimentarily label them oh gurus, it's about them and promoting their way. What seems to come across in the way that you explain it there is just this passion for the patient and this, for you know to empower physiotherapists and bring health and healing to people. Brian Mulligan: That's right. People should have available, I have a surgeon friend now in China, and he wants the whole of China to have access to what we do. Now, the problem is there are no physiotherapists in China. There are physiotherapists in places like Shanghai or Beijing, but they've been trained, most of them in UK. But the rest of the country we don't have physios. Now in New Zealand and I think the same in UK a lot of manual skills were developed by physios. It was quite popular and hands-on. Look what Cyriax did with his frictions. That's sort of been given up. But today when you go to some parts of the world and you teach them something manual, their handling skills are dreadful. I can see why they don't get an eighty percent success rate, because their handling skills are pathetic. And in New Zealand, everyone was taking Freddy Kaltenborn's courses years ago, and they took Geoff Maitland s courses, and by the time they start to become acquainted with what I'm doing they had good handling skills and you could get somewhere. But people today don't have good handling skills. Chris Murphy: That's interesting, I wouldn't have thought of it like that, in the sense of going back to my previous question about what people label gurus, is that the things that we did, we did touch people. In my training there were massage skills, passive movement and mobilisation, I suppose people labeled the tool per-se and said oh, this doesn't work or that doesn't work, but one of the skills that it gave us was the ability to touch. And that's the thing I certainly I remember from it and I've taken, I think my hands are pretty good. You words are a commonly heard criticism. So taking a sidestep with regards to that, and to
pitch a slightly different question regarding this idea of guruism, people say it's a bad thing and stifles individual thought, what's your response to that? Brian Mulligan: People came up to me in the Middle East and they didn't regard me as a guru. What really impressed them was my genuine desire to teach them, my enthusiasm made them think again outside the box. And see, you need handling skills. Now when I first developed mobilisations with movement, it began with me with the finger. And the only explanation for the success of what I suddenly got, it was a miracle to me, was that there was a positional fault. So then I wondered if there were positional faults in other parts of the body that would respond the way their finger did. In other words: no pain, instant result, and so I had the handling skill so that I can go to the knee, go to the ankle, go to the scaffoid and the rest and reposition it accurately, and get a result. So I had a background which made it easy for me. I would've thought that all I had to do, if people had handling skills, is to get up at a physio conference and say: look, there are often positional faults, and if you just take any joint and reposition the surfaces, see if you can achieve this with no pain. And if you do, see if they can move without pain, and they should be able to go through the body like I did and come up with what I did. But they just haven't got those skills to go ahead. Chris Murphy: The other word that I wrote down as you were talking there, which I guess would engender that kind of attitude to go and explore, is curiosity. Brian Mulligan: That's right, curiosity, yep. And I always quote Louis Pasteur: "In the field of discovery, chance only favors a prepared mind." And when I had that miracle with the finger I had given that girl tractions, biomechanical glides, I did everything that I was teaching, because I was teaching all those techniques, and they didn't work. And then I tried something that caused no pain, and it instantly moved. And when she came in two days later she was better, she didn't need any more treatment. Now that, I had a prepared mind because why didn't what I was teaching work, and why did that miracle occur? And I came up with an explanation, and I have just been around the States on pelvic pain with one of my teachers who has refined what I do. And his success rate would have been ninety percent with everyone he saw on stage. There was one woman that he filmed and she was a McKenzie therapist who had not flexed her spine for thirty one years. And when he repositioned her ilium she touched her toes, and she's completely free today after thirty one years. What about her adaptive shortening, what about all the other stuff you read in textbooks? Chris Murphy: It's kind of funny, your Louis Pasteur quote, a quote about Einstein came into my head and I thought actually you could just tweak it slightly. His original was: "The definition of insanity is doing the same thing over and over again and expecting a different result." And for you it's almost, the words are: "Sanity is doing the same thing over and over again and expecting the same result." Brian Mulligan: Well done, yes, yes. But there's an agenda now, can I just read something here? Chris Murphy: Yes sure. Brian Mulligan: I was doing something for another purpose. When I lecture now I say, where the hell was it, sorry... yes I say there is no other concept in the field of manual therapy that is applicable to the entire musculo-skeletal system, and that when indicated gives you an instant pain-free result. Now, people might
have techniques that might work for a knee or a finger. If' I'm talking about the entire musculo-skeletal system there is no other concept in the field of manual therapy that only takes two or three minutes to establish if it's indicated, and when I was in the Middle East I got people to time me when I had someone come out, and in many cases it was thirty seconds. The third thing is, a bonus, is that when indicated, it's diagnostically significant. Because if you've got pain down the arm and I shift C4 spinous process across, and all your arm symptoms disappear, that tells me that's coming from C4-5, and that's why you've got pain going down the arm to the wrist. Then, the third claim is that audiences who have attended my presentations around the world will confirm that my success rate would be over seventy five percent with patients who came on stage. Perhaps the age range of those I see is between twenty four and sixty five years, and that's responsible for the high success. In other words, these are physiotherapists or chiropractors or doctors, and they're in that age group. But as far as I'm concerned, no one can compete with mobilisations with movement because they take two or three minutes. Chris Murphy: I'd be interested to hear the conversations that we'll have when you are in the UK in September regarding the speed of change and what s possible. Brian Mulligan: And it's quite interesting about subtle changes because the woman that I filmed had not got her arm up for twenty three years, I repositioned it quickly, and she said that feels better. So now I explain to the class what I'm going to do. And when I went to do it again she said no, that's painful. I tried again, that's painful. I tried again, and it was fine. In other words I had to fine-tune what I was doing. It took me three goes to get it right the second time, and once I got it right, everything came right and next day she's better and she's better today. Now, that's again, it's handling skill, confidence. And now in Australia I ran a course like we're doing in England, a master class, a woman came from Orange, and she was a physio. And Orange would be a three and a half hour drive from Sydney, you can't fly from there, there's no flight plans. And she turned up while I was teaching because she had upper chest pain and pain with certain movements of her neck and arm. I got onto her ribs and I repositioned them and she just said that's absolutely marvellous, she had no pain. So then I got two of my colleagues who had passed my exam to come and do what I did. And she said no, that's not right, that's not right, it took them four or five goes to do what I did. And she was able to tell them what to do because she had experienced it from me. It's an example of handling skills, and that woman I got an immediate call back from her two days later, and she hadn't been sleeping, and she'd had no pain at night at all since we treated her that day. Chris Murphy: What came through my head is that, always playing devil's advocate or hearing two sides of the story, some people could be enthused and empowered by that, and others could say, oh it's alright for Brian, he can do it. But what you've done there is you've shown that with refinement, anyone can do it. Brian Mulligan: That's right, anyone can do it. And you've got to have the confidence to just make those adjustments, that's the other thing. And that woman said to the class, she said Brian you treated me with confidence. Now that gives you a placebo effect if you like. If someone hasn't slept for three months and they sleep right away, it's a pretty good placebo effect. Chris Murphy: And how else do you respond to those that say what you do is a placebo?
Brian Mulligan: Well, I then show them what I'm doing and there's no question then when they see it. And the other thing I should codger: for instance, knees. I will show people coming up on stage, consecutive people. So these aren't isolated examples of you might have a success. You can have a room full of people I'm lecturing in America, and one two three people I show, and all three people left the stage pain free. And one had an eleven year problem, one had a two, and one had a four year problem. And that takes, there's no placebo effect with those people. There's just no way, no way. And I get other people out on stage when I've done something for them to do what I've just done. And they do do it, but it takes them awhile. 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. The patient knew what it felt like, and knew what it did. So you know, placebo effects, they can come up with that if they like, and... Chris Murphy: So just to draw us towards a close Brian, there was two final things. You alluded to the upcoming trip in September. For those that attend, how would you like them to be when they leave this one day master class? Brian Mulligan: Well first of all, satisfied, because they already know what I do. I have some refinements which they won't be aware of and that will enthuse them. But every master class that I've done so far, people have gone away with a new interest, if you like, in the concepts. It's just got them up and moving. You know you often sit back and, oh yes, it works in some people, and you just don't try any harder. You become complacent. Chris Murphy: And so just to draw us to a close then on certain things that you said throughout, if a young physio came up to you, a recently graduated physiotherapist, and they asked you what should I focus on to become a great physio, what would you answer? Brian Mulligan: Well first of all, make sure you've got the knowledge. You've got to know your anatomy, and you've got to have a knowledge of all the conditions you're ever likely to encounter, because without that knowledge you would be hopeless. And you've got to decide where in physiotherapy you want to go. Do you want to work in the field of neurology, do you want to deal with children, are you interested in maternity, you know you've got all these specialties in physiotherapy. But I just say to them, if you're interested in musculo-skeletal conditions, you should learn or undertake courses that give you handling skills, mobilisation and manipulation. Chris Murphy: Brian. It's been an absolute pleasure to talk, thank you so much. Brian Mulligan: We'll see you soon. Chris Murphy: Yes I really look forward to it. [End of Interview]