This interview is a first: my first interview with a Physical Therapy Assistant. Michael Mullin is one of my favorite follows on twitter because he makes me view the human movement system through a variety of lenses. We dive into his unique and varied perspectives in this interview.
While concepts from a PT Continuing Education called PRI are mentioned, I want it to be clear that this interview is not meant to promote nor support PRI.
One last thing: Check out Michael’s blog for larger conversations on topics touched on in the interview.
Let’s start at the beginning…the beginning of your day. Do you have a morning routine? What do you usually have for breakfast?
I am an early-riser as I find myself to be very productive early in the day–like, really early. I typically get up, have some coffee (coffee is always, not typically) and check messages from various sources (i.e. e-mails, Facebook, Twitter). I look forward to when my wife gets up, I like to make breakfast for my daughter and often send a text to my son at college. Breakfast? Usually eggs with some quinoa, potato or rice, maybe some leftover roasted vegetables as I’m a bit of a veggie-holic, followed with some oatmeal with nuts and seeds. I have a lot of food allergies (celiac disease and therefore very strict gluten-free for 15 years, no dairy, very low sugar/yeast/additives, etc.) so I actually eat quite healthy. With all my dietary considerations, it certainly helps that my wife is a dietitian.
You’ve come across a variety of concepts to assist in understanding and applying various approaches & treatments in the clinic. What are some of your favorite?
First and foremost, understanding the role that the respiratory system has on our body. Having the ability to take the involuntary act of respiration (gas exchange) and be able to voluntarily modify it through ventilation training (air exchange) is one of the more powerful tools we have in the management of our organism. I have been amazed at how establishing volitional control of this can positively–and significantly–affect performance, recovery, muscle tone, joint position, resting heart and respiratory rate, physical and psychological stress, as well as many of our other internal systems. It is our environment which is often the big driver of the amount and degree with which we lose the ability to effectively manage this, so being able to take ownership of this mostly involuntary action is huge.
From an intervention perspective, without a doubt Postural Restoration® has changed the way that I look at human structure and function. It is the lens I look through when working with patients and clients. It is the direction I go to when providing activities, exercises, cueing, as well as providing other avenues of our system to tap into to aid in progress. That does not necessarily mean that it is the only “treatment approach” or training I do, but I bias my intervention strategies around this methodology. I feel strongly that our inherent asymmetrical structure and function, the inherent polyarticular chains that the Institute describes, their work and educational programs on how the different systems are integrated and how this influences the way that we move and position ourselves during the day, provides an invaluable roadmap for people to work with. It is a complicated science, but by the same token, the body is quite complicated as well.
I incorporate the work of other great approaches as well, such as “corrective exercise” interventions (Gray Cook and Lee Burton’s Functional Movement System activities and FMS/SFMA principles), some the principles and reflex mapping of Janda, Lewit and Kolar from Prague School of Rehabilitation and Dynamic Neuromuscular Stabilization (DNS), and definitely good ‘ole fashion strength training! I feel that a large portion of our population, including our young athletes, are generally weak and as such, have a difficult time negotiating gravity and its affects on our system. Our society has changed dramatically over the past few decades and we have not developed well along with it.
I am also a big advocate of manual interventions and use a lot of hands-on work with patients and clients as well. It could be called the Hruska (PRI)-Jones (strain-counterstrain)-Roth (Positional Release Therapy)-Mulligan (MWM’s, NAG’s, SNAG’s)-Johnson (IPA)-Myers (Anatomy Trains)-Weiselfish/Gimmatteo (IMT)-Rolf (Structural Integration)-Chaitow-Trager-Feldenkrais-Leahy (ART) approach. I use components of manual interventions to supplement a treatment session for most conditions with varying degrees and amounts. It is also very helpful in being able to quickly mobilize an area if a client is having difficulty feeling something or they are having an issue getting into a position during a training session. I find it most effective after I have been able to achieve a zone of apposition of the diaphragm, as achieving this ZOA alone cleans up all sorts of tone and positional faults of joints and tissue.
I’ve been blessed with what I feel is an innate sense of touch with the body, (certainly the same can’t be said for my luck with machines), for as long as I can remember. I am one of six children and growing up we all had to take turns giving my mother a back rub each night. To this day she mentions how I always seemed to know where to work and how much better she would feel afterwards–and who can argue with the word of your mother :). While I fully recognize that manual interventions are neither truly reproducible or measurable, I also feel that when I read articles or opinions debating the effects of the application of some of these methods, I have a hard time holding merit in their conclusions with something that helps almost every person I use some of these techniques on. While I am not suggesting any type of “guru” component, the careful application of hands-on interventions provides–and human touch also helps with–creating a sense of connection, involvement, empathy and other very powerful responses with my patients and clients.
This is one of my favorite posts on your blog. What are filters do you use when reading research with the intent of clinical application.
I am cautious with direct application of studies that are performed on cadavers that provide information related to movement, as things change once it is applied to an organism that is trying to manage gravity, gas and pressure. It is good information to understand the arthro- and osteokinematics of how things move, in a vacuum, but once the chaos of our environment is added, things change.
Conclusions that try to create prescriptive (versus diagnostic or prognostic) clinical prediction rules as the way to do something I have some difficulty with, as there are too many variables that cannot possibly be accounted for in a living, breathing system. It can’t possibly allow for behavioral influences, nutritional components, patterned bias’ and the like. I mean, maybe they were hung over or had a fight with their spouse, either prior to their involvement in the study or as a patient sitting in front of you on the treatment table. If a classification-based system were to become the standard, then we will have created practitioners who will not be able to use their ability to modify, adjust or adapt well to changes in a person’s presentation. Clinical thinking is much different than critical judgement.
Thinking from my Postural Restoration®-based brain, I have some difficulty looking at articles that don’t specify right and left arm or leg, and I am not referring to “dominant” arm or leg. I firmly believe and have found that our underlying polyarticular chained patterns have a tendency to make us use the two sides of our body differently, so I read critically things which do not glean this information out. I read them, apply as I feel indicated, but with a discerning eye.
I do believe very strongly in the model that evidence-based practice and practice-based evidence share a place with each in their applications to the clinical world. As soon as evidence is doing more than just guiding treatment, but is what is necessary in order to be able to render care, that is when I feel we are going to get into trouble. It is unfortunate that there are those of the mindset that unless it can be validated through research it should not be employed–and I am speaking of health professionals as well as those who dictate payment. As long as intervention strategies have the least possibility of producing some kind of iatrogenic response, on that particular person at that particular time, then no one should be able to tell a professional they are not allowed to employ that strategy.
You work with a variety of interesting populations including dancers and skiers. Let’s say I’m interesting in working with these populations. How do I make it happen? How did you end up working with them?
First would be to educate yourself on some of the things that are essential to know about that activity. When I went to work at The Stone Clinic in San Francisco in the mid- to late nineties, the surgeon I worked for was a physician for the U.S. Ski Team as well as a number of dance companies, including San Francisco Ballet. I had zero experience with dancers and didn’t learn to ski until college, so essentially, through baptism by fire, I had to do a lot of self-education on activities I was not as familiar with–in particular what it took to work with athletes at that level. I spent time going to dance classes to observe, read trade journals and had discussions with teachers/instructors/coaches, spent more time at the ski mountains observing as well as spending time with experts who were willing to allow me to tag along. I was responsible for coordinating dry land training camps for the U.S. Ski Team and World Pro Ski Tour so I had to figure out training protocols. I was responsible for doing pointe screens for Marin Ballet so had to understand what it took to be able to do that. I feel very fortunate to have been able to have had these opportunities and have been doing similar programs since coming to Maine as well.
Second would be, as I alluded to above, it is pretty much volunteer work on your own time. You have to be willing to put yourself out there and put in the time to become an expert at it. Programs have less and less money for ancillary services so many dance schools or companies would love to have someone willing to help them out or organizations who might be willing to have someone come in to do an inservice or training program. There can also be a tremendous amount of carry-over as well to other things which have similar movements or mechanics (i.e. ice skating with dancing).
I am able to apply a significant amount of the work I do to most populations and specialties if I understand the essential tenets of those activities and am confident in my understanding of the biomechanics and integration of multiple systems. For example, if I am working with a ballet dancer who is in for “X” injury, and I watch them at barre or doing some of their movements, they likely have some underlying micro-pathology. “Micro-patho” is the phrase I use to describe things which have happened to the body over time, or from an event, which creates a laxity, or imbalance, or response, that would not necessarily require surgical or extreme intervention, but does need to be managed. I then apply activities and cues to address these in their particular situation. Having the PRI roadmap, for example, to recognize their likely bias’ helps as well. For example, most dancers like to turn clockwise onto their left leg so it would be easy to think that it is because it is their “dominant” leg, but it is actually due to their ability to use their dominant right leg while it is in close to their body to manipulate and balance them out, create more stability when turning, and also because of their turning bias to the right. With skiers, patterns dictate–and research has shown–that right footed turns (turns to the left while skiing) produce more force, have easier time to transition into and are smoother, even at the highest levels. Again, pattern driven. Being able to use interventions which help to correct this on the base level and then apply it at the activity level is tremendously empowering for these athletes.
Another key aspect is that when you can “talk the talk”, or speak on aspects of their activity in their language, then that is also a huge buy-in for them. When I speak about inclination and angulation and edging principles with skiers or 1st-5th positions in dance or ask them to do something like releve into passe or a rond de jombe, they realize that you “get it”. From there, you can even then ask them things about positions, movements or even what a coach or instructor is doing so you can get a better understanding of the activity, as they will be more than willing to provide that info at that stage. Everybody benefits.
We are biomechanics experts and with that we are able to impart a significant amount of change in how people are performing their activity or art. I am not going to necessarily coach someone on their sport, but the things I can teach them about how to apply what I feel is best for their bodies from a biomechanical perspective, this will have a significant positive impact on their performance as well.
Favorite PT and non-PT books?
PT books: Historically, I like, in no particular order:
- Assessment and Treatment of Muscle Imbalance: The Janda Approach (Page, Frank, Lardner)
- Great book looking at the impact muscle imbalance has on on structure, function and movement
- Positional Release Therapy: Assessment & Treatment of Musculoskeletal Dysfunction (D’Ambrogio, Roth)
- As far as I am concerned, the resource to have under your treatment table as after the manual techniques I use based on Postural Restoration®, this is one of the basis’ of my manual techniques.
- Movement: Functional Movement Systems: Screening, Assessment, Corrective Strategies (Cook)
- What Gray Cook has done and his views of movement and function are tremendous. He is also one of the better orators there is out there.
- Frankly, I spend a lot of time currently reading through my Postural Restoration course manuals. These are, in my opinion, one of the most comprehensive course manuals out there in describing anatomy, physiology, assessment and intervention techniques, etc.
- Anatomy Trains (Myers)
- Thomas Myers has done an incredible job of mapping out and identifying various fascial lines and the influences these have on us. I also believe that they are also influenced by other factors, but his descriptions and strategies for managing are quite good,
- Functional Training for Sports (Boyle)
- Mike Boyle has done groundbreaking work in the field of performance coaching and does an amazing job in this book on providing his methodology to the public. I am fortunate to call him a friend and have learned a great deal from his work.
- I also like PT-ish books which discuss the influences other things have on us such as:
Non-PT books I like a lot are:
I like books that follow a storyline, but also educate the reader on aspects of the topic they are discussing. In the books listed, one learns about the space race and the Apollo spaceflight project; scuba and deep sea wreck diving and finding a U-boat within a few miles from our eastern shore; piracy within the fishing industry and the longest nautical chase in history; natural running and influences of a culture on how we function; and meteorology, storms and the influences on our environment.
Given that you’ve been in the field for 25yrs or better, what fads and themes have you observed over the years? Any favorites? Any keepers?
It has been very interesting being part of what I feel is the time where there has been the most significant amount of change and growth in our various industries–from a rehabilitation perspective, medicine, as well as strength & conditioning. I think back on seeing my first ACL reconstruction patient in 1990 and how that person was one of the first the surgeon did where he did not cast them afterwards, this patient’s slow return back to activity, learning the more accelerated rehab methods and how the insurance paid for months and months of rehab, 2-3 times per week, for about 9 months if I remember correctly. Certainly things have changed since then on many levels
For me, one of the biggest has been position training and education. From the upright, stiff posture I learned in school and my early years, to knee position when bending under load and not allowing “knees to go past toes”, to what would be considered a “neutral” spine, there has been a lot of misinformation with the best of intentions. We are a living, breathing organism that is designed for movement which has had to conform to societal influences that is, frankly, breaking us down. We should not have to work as hard as we do trying to achieve some good postural position to sit, stand and walk–there just shouldn’t be the amount of muscle activity involved as many of us try to aspire to. Knees have to be able to go past the toes when loading to some degree, as long as the body is able to decelerate it from going more forward than the pelvis and ankles can support (I tell people that with feet flat on the ground, drive weight through your heels and push your knees forward and that is where they should be). And being “neutral” is not a single-plane strategy–it is positional and respiratory balance and a nonspecific area for the systems to reciprocally circulate around and alternate through in an attempt to negotiate gravity, pressure and movement.
“Good ergonomics” is another thing that has changed and is repeatedly being discussed and evaluated. Many times it is in an attempt to get people to be able to sit for longer periods of time, which is incredibly ironic, and frankly many times not done correctly, in my opinion. Vertical positioning with joints locked into a position which decreases the ability of our bodies to be able to move or breath merely feeds into our stressed out systems. I wrote this article for Eric Cressey last year (http://www.ericcressey.com/tag/michael-mullin) which describes the affects long term sitting, inactivity, stress and a sedentary life can have on you and some strategies which can be employed to better manage it.
The use of modalities has changed dramatically as well and interesting in how my schooling spent an entire semester on their use and applications and how I use few to none of them anymore. I haven’t used ultrasound in I don’t even know how long, e-stim on a rare occasion for pain as I think interferential/TENS can be beneficial for some at times, iontophoresis if indicated can be helpful in focal, more superficial inflammatory cases, but again far less than in the past. Even cryotherapy I use and recommend considerably less than in the past. Moist heat I think can be beneficial in the right situations, but that’s about it. I don’t use IASTM or creams for manual rx, not because they are wrong, but I just haven’t found them beneficial for me personally. I know some very good IASTM practitioners, I’m just not skilled with it.
Static stretching, as I learned it in school and early in my career, and even PNF stretching, has taken a big backseat in my treatments and training. I will have people “stretch” some areas at times, but I feel it is just as much as for an inhibitory effect as it is muscle lengthening. When I do stretch most anything, I have them hold the stretch for 3-4 full breaths vs. a set time. More common areas would be: calf musculature, hip flexors, posterior hip capsules (usually left), posterior mediastinums, pecs, and maybe hip external rotators (usually right and inferior focus). I do, however, do a lot of mobility work which is markedly different.
What was it like to work with the Miami Dolphins? How did you get that gig?
It was and is an incredible experience. Dave Puloka, who is the Assistant Strength & Conditioning coach for the team reached out to me, as he had received my contact info from Mike Boyle. Dave wanted me to go to lecture the S&C and medical staff on Postural Restoration® and applications to that population. (I think it’s important at this stage to clarify that I am not on faculty for the Postural Restoration Institute and as such do not teach their specific courses. I do, however, lecture regularly on their principles, teachings and applications to rehab and training and am in regular contact with the Institute on the programs I offer.) I have been down a couple of times and have also done some consulting on some of their players, both while I was done there as well as FaceTiming and working with the staff and players in that capacity. That is a great staff and seeing the inner workings of an organization like that has been incredibly rewarding.
You’ve taken a ton of Continuing Education courses. I’m sure you’ve found some better than others. What makes for a good Con-Ed course?
Early in my career, anything I took was worthwhile and filled with information I didn’t really learn in school. I learned a significant amount and have been able to apply some really excellent things from various programs over the years. A good continuing education program, to me, is one where there is lecture and lab, as so much of what we do is activity based. Practitioners have to be able to feel things on their own in order to be able to effectively apply them to their patients from a manual perspective or effectively cue them from an activity standpoint.
Certainly programs which include some of the most up-to-date research and evidence is important in terms of being able to understand and apply what has been found to be most effective (and for me, staying within the parameters that I listed above with respect to reading research).
I also feel it is important that a quality course manual is provided. I like to go back and read through material as I can’t take in nearly as much as I would like during a one-day or weekend program. Having great references and resources to refer back to is also important to me.
Staying in the world of Physical Therapy, what important truth do very few people agree with you on?
Well that is an interesting question, CinemaAir, and I hope that there is nothing that very few agree with me on 🙂 I do think that the influence respiratory imbalance has on our system–both the system itself as well as our other systems–is the most under-appreciated thing in the medical and rehabilitation fields. It is my observation that the strength, conditioning and performance world has been much more open to start doing respiratory training as part of their programming strategies which only makes sense, but I do find it incredibly unfortunate that more rehab practitioners have not studied, tried to implement components of it–let alone embrace it as the incredibly powerful tool that it is.
Taking that one step further, the respiratory imbalance piece I would further specify is the ability to achieve a Zone of Apposition, on both sides of the thorax, probably is the number one thing I have found which helps my patients the most, regardless of their condition. Now unless someone has taken Postural Restoration® coursework, knowing what this is can’t be summed up just in an explanation or definition, and therefore whether others “agree” with me, I almost find irrelevant. It is something that has be felt and seen in order for it to be appreciated. But as a rehab practitioner, if I am doing most any activity, or if I have a patient who is getting stuck, once I achieve–or re-achieve, as some lose their understanding of its importance–a ZOA, then things just keep progressing.
Taking that one step further, I am amazed and confused by the sometimes almost visceral response some practitioners have towards Postural Restoration®. Research and a basic understanding of anatomy and physiology clearly demonstrates the asymmetrical structure we have and the influence it can have on function, and yet to not at least recognize that this might play a role in even some of our patient’s symptoms and problems I find unfortunate.
Time for my time-travel question: You’ve just traveled back in time and are sitting face-to-face with your 30 year old self. What advice would you give yourself?
Take pride in the work you do and do not be swayed by what you believe others may think of you. It is easy to get hung up with the societal pressures of acceptance, not wanting to stand out, or even compliance. Life is too short to not take full advantage of everything it has to offer. Work hard and have fun….
I work with a brilliant PTA. I’ve learned valuable lessons from her. As an ATC and PTA, what is that you would want any/all Physical Therapists to know or recognize?
First, I commend you on respecting and recognizing your co-worker’s skills and knowledge base. I think that one of the biggest things for me that I feel very strongly about is that it really isn’t about what your credentials are. The rehabilitation environment should be a supportive and interactive one where everyone learns from each other. Humility is one of the more challenging emotions we all struggle with and being able to take a step back and ask questions without an ego getting in the way is huge. There is no way we can all know everything so work alongside with who is in your clinic versus individually.
I also would want them to recognize that there are many bright minds out there that do some incredible work with none of the more recognized post-nominal lettering that some practitioners seem to think matters a lot. I have seen some amazing things and some really smart people who are performance coaches or massage therapists, for example, that I would send people to before some of the allied health professionals that I have seen over the years. It is about what is best for that particular person at that particular time in what they have going on that matters the most. If you are good at what you do, then you should never have to worry about what others are doing.
Thanks so much Cinema Air for the opportunity to do this interview with you. I learned a lot about myself and hope that some of the information will help others as well. Cheers….
Michael, thank you for this incredibly in-depth interview!
Connect with Michael Mullin via twitter: @mjmatc
And find me: @Cinema_Air