Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
Dear All
My answer to this question is simple but in a few parts.
Firstly we are trained in mobilising the joints of the feet; indeed many a famous Osteopath in the past made their name helping patients return to ambulation by using our techniques on feet.
Secondly I have a very special interest in Foot Biomechanics as I have made a study of this and have been associated with Orthotic Laboratories.
Thirdly my daughter was a Podiatrist in the UK both in Private and NHS practice. She is now is an assistant in the USA. Fourthly and most appropriate I have been teaching Podiatrists for many years Mobilisation Techniques. I have a system that I developed which is producing excellent results.
My thesis is that Chiropodists/Podiatrists are the best people to deliver mobilisation techniques to the Feet. Indeed it is a wonder to me that no University includes it in their courses.
Anyway that is my rational for being here and it seems a great place to be.
Yours
Brian Joseph DO FHEA
I was lucky enough to hear an osteopath speak to us when I was training.....
In particular one comment of his really stuck in my mind. He said that when manipulation has taken place, the associated soft tissue structure is permanently changed; therefore manipulation should only be used after all other conventional approaches have been considered.
What's your take on this?
PS: David Wedemeyer may have some Chiropractic input on this too.
I was lucky enough to hear an osteopath speak to us when I was training.....
In particular one comment of his really stuck in my mind. He said that when manipulation has taken place, the associated soft tissue structure is permanently changed; therefore manipulation should only be used after all other conventional approaches have been considered.
What's your take on this?
PS: David Wedemeyer may have some Chiropractic input on this too.
Kind regards
Peter
Dear Peter
Thank you for your very interesting post.
My approach is to teach Chiropodists/Podiatrists to use my System of Mobilisation Techniques.
I spent a lot of thought and time in creating a system that is coherent for these professionals. Bear in mind that an Osteopath cannot be taught to wield a scapel at feet after a few hours of instruction!
I was guided by my experience in Teaching and by my intetractions with Teaching organisations.
Of course my most important principle is that I want the Profession to have access to something that to me seems such a logical therapeutic addition to their practice.
The techniques are taught with proper practical instruction and care.
I want my delegates to learn a skill that they will use and that they and their patients will benefit from.
Mobilisation as I teach and understand it is not Manipulation, it is not an Osteopathic or Chiropractic technique.
Sorry to go on but I am dedicated to my approach. My past delegates will bear witness to this.
Brian Joseph DO FHEA
I've always wondered about the question I raised though....... I'd be most grateful if you could tell me (and fellow Pods) the difference between mobilisation and manipulation?
Let's say a patient has a stiff Subtalar joint - many pods know that these can often be moved into action quite easily by moving the calc around gently.
So what happens on a physiological level that would define the difference between joint mobilisation and manipulation?
Brian welcome to PA. I would of course be very interested in an explanation of your technique and how it varies from traditional osteopathic manipulation. Are you familiar with Dr. Rue Tikker here in the U.S. (He ran Dr. John Hiss' clinics)? I am trying to find the time to visit him in Napa, CA and to learn from him.
Peter;
Quote:
In particular one comment of his really stuck in my mind. He said that when manipulation has taken place, the associated soft tissue structure is permanently changed; therefore manipulation should only be used after all other conventional approaches have been considered.
The difference between mobilization and manipulation I believe can be summed up succinctly with the following:
(1) Mobilization: Slow, low-velocity techniques, often oscillatory, to which the joint remains within its passive range of motion/movement and within the paraphysiological barrier of the joint.
(2) Manipulation (often referred to as an 'adjustment' by the chiropractic profession): Rapid, high velocity techniques that take the joint beyond the paraphysiological barrier of the joint.
The physical therapy profession has a grading system I-IV for these two and everything in between with what chiropractors typically perform termed a grade IV manipulation.
To address your question above I disagree with whoever made the comment entirely. There is always the potential to harm with any mobilizing or manipulative treatment, that is why there is training. Knowing the structure of the body, the normal range of motion, end feel, joint angles involved in treating with these modalities and the progression of knowledge in these field have aided in making delivery of these techniques very safe. Learning the appropriate degree of force in manipulation is a skill acquired through years of delivery, it is an art.
This is particularly true of spinal manipulation. Let's face it; there is a large difference between the structure of the spine and a motion segment (vertebrae, disc, vertebrae) and the joints in the feet but each has passive soft-tissue elements that restrain and protect them. All mobilization and manipulation is safely maintained beyond the paraphysiologic space but within this barrier (trauma and injury are an entirely different story of course). The spine though has the added protection of a fibrocartilage disc, allowing greater separation of the joint spaces prior to delivery and even greater passive protection from breaching too far beyond the limits of the passive soft-tissue element barrier. I find foot mobilization infinitely more difficult personally, but very worthwhile and therapeutic.
Peter I would argue that these techniques are the conservative approach and conventional and much less thought of as alternative. At least here in the U.S. Perhaps it is the same in the U.K. and elsewhere?
I hope that was of value and that Ted Jed sees this and has some of his keen input to impart. I also want to share a link that I found quite by accident one day on the history of manipulative foot care in the U.S.:
__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright
David G. Wedemeyer, D.C., C.Ped.
The Following 3 Users Say Thank You to David Wedemeyer For This Useful Post:
Unfortunately I cannot comment on the above courses.
I think David's explanation is clear. I would add only two things at this point. Firstly, mobilisations are not only related to restoring more gross motion they are, importantly, about restoring or improving accessory motion within a joint. This is a type of motion that is outside of a pts ability to activate themselves.
Secondly, Mobilisations must be within a patients control where as manipulations tend to be described as being outside a patients control.
I can comment on the Society of Sports Therapy Courses for Peripheral Joint Mobilisation. This was a weekend course run by Prof Graham Smith (Physio) and went as far as mobilisation of the hip (Society insurance does not cover us that far up though). A very thorough course and I left confident and competent.
I have done the Hiss training approach to manipulation to the foot and ankle (More osteopathic in style). This was done one on one over a weekend. It was thorough and I left feeling competent. I also have a copy of Hiss's book which makes fascinating reading!
I recently did Paul C's course on foot and ankle mobilisation. I found that extremely beneficial. Left confident and competent
From what I have read (Pod Now) people who did Ted's course feel to have gained from it.
The Kaltenbourne assessments for the foot actually serve as mild mobilisations in themselves.
In terms of practice I usually pick from the peripheral mobs to Paul's mobs to Kaltenbourne. I rarely use the Hiss type but do on occasions.
Importantly it is worth adding to this skill base soft tissue mobilisation skills.
I have no doubt these courses will grow in the offering! I have been asked to provide some type of Mob courses for fellow colleagues and it is something I am considering. But it would tend to be a local thing.
Certainly give a go with any of the above including Sobsart. I cannot comment on Brett's course as I do not know it and have had no feed back from anyone who has done it.
I've attached some info that Sobsart sent me earlier in the year when I was considering doing their course myself - may give you a bit more insight into the content
As a general comment on joint mobilisation I do think that Pods are fortunate in that the foot is far more forgiving as a structure, when it comes to mobilisation, than other joints elsewhere in the body.
Additionally I have found when teaching others that Pods can be a bit intimidated when grasping a foot. That is, they are not used to playing around with its full extent of range and variety of motion. Quite how much it can be placed in a stretch or quite how much the ankle joint can be moved passively with no pain or uncomfortable feeling to the patient.
Equally I have found that people of varying ages, including people in their 80's, have tolerated mobilisations very well! Also enjoying a subsequent degree of motion in the foot and ankle that had become unwittingly restricted in the ageing process. Restoring of such motion is a delight to them.
I need to correct this in my post: "All mobilization and manipulation is safely maintained beyond the paraphysiologic space but within this barrier".
Mobilization is contained within the physiologic space (movement which a patient can control and effect themselves).
Manipulation is just beyond the physiologic space, into the paraphysiologic space and is beyond the control of the patient.
Both are contained within the integrity of the passive soft-tissue element barrier. Ian got me thinking, thank you. Also, thank you for your input Ian on mobs and the courses. I viewed Ted's technique demos and he appears quite competent. The techniques that I saw were very familiar to me and appeared to be manipulation of the variety that we learned, ie; an 'adjustive' thrust or manipulation, not mobilization. Correct me if I am wrong Ted and Ian.
I am no expert on podiatric mobs but if you read through the history of manipulative foot care that I provided a link to, you will see there was a lot of overlap and sharing of ideas in the early days. I like having a lot of tools in my bag as no two patients are alike. It can only help to be knowledgeable in each.
Regards
__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright
I have heard the technique Ted uses and have had Pauls techniques (when I was observed doing it by a physio) described as a mid range "manipulation" (Her MSc was in manipulation stuff). I'm sure Paul would disagree with that. Certainly when you observe the arms of the practitioner (serving as levers) it looks quite forceful. Yet to the recipient it is almost negligible as a sensation.
Comparing Paul's (and likely Ted's?) techniques there is a significant difference between the leverage (and possibly force - me no good at physics) applied in the their methods and the Hiss/ Osteopathic type.
I am certain the gentle movement of the individual joints of the foot to position them at an optimum for mobilisation is in itself a exceedingly gentle mobilisation, bit like Kaltenbourne. I suspect this serves well to begin reduction of stiffness so that when an increased leverage is applied there is negligible feel by the patient but usually an instantaneous improvement in joint function.
Taking the mystery out of it, I suspect the action of setting up of the joints to a pack position for the mob serves to the ligaments and capsules what a soft tissue mob to the spinal muscles does for a spinal mob or manip. (?)
The mobilisation techniques of the Talus and Fibula heads (Paul and Ted's) are so slow and gentle that I would think it impossible to describe them as manipulations.
Dear Ian
My system of Foot Mobilisation is tailored for Podiatrists.
It works and the delegates have found it useful.
It is centered on careful techniques that restore the end motion to the Joints and muscle work.
It is not an Osteopathic or Manipulative treatment, only Osteopaths can give Osteopathic treatment.
Yours
Brian
I agree that only an Osteopath can give Osteopathic treatment but mobilisation and manipulation is not the sole prerogative of osteopaths and so as a treatment modality may utilised by other disciplines
I don't think I was implying that an osteopathic treatment was being given by any podiatrist or myself. Certainly the Hiss techniques I learned were linked with him also being an osteopath and so I presume his techniques were osteopathic in style, i.e. likely principles and approach to treatment, albeit in the 1940's and may be dated(?).
TedJed has evolved some of his approach from chiropractic models and techniques, at least what I have read suggests this, and I'm sure Ted would not suggest he is being chiropractic in his work.
It would be great for us to hear more of how you practically apply your techniques and what makes them significantly different from others around that have been geared to foot work by many other disciplines.
Whatever technique is applied a foot is a foot with joints that can be mobilised and soft tissues worked. I'm up for learning more. What is your approach? (not asking for detailed actions of course)
You said: "My system of Foot Mobilisation is tailored for Podiatrists."
I guess I feel a mobilisation is a mobilisation whoever applies it. That it might be called Podiatric mobilisation (not saying you call it this btw) does not make it any more significant a mobilisation or specialised to that disciplin. I do tend to think that Podiatry often borrows its approaches from other disciplines and I'd be glad to hear your take on it and have another mob technique added to the armamentorium. As David said earlier the more tools in the box the better, at least for the patient.
This is a good thread clarifying some of the definitions around manual therapies.
David; I like the definitions you have used for mobilisation and manipulation. I work with very similar definitions:
Mobilisation - oscillatory techniques within the joint's passive range of motion/movement at a speed and force that the patient can overcome.
Manipulation - rapid technique at the joint's passive range limit at a speed and force that the patient cannot overcome.
Speed and force being the key distinctions between the two.
Ian, your perspective that mobilisation and manipulation are descriptors of manual techniques and are not techniques exclusive to any one profession is something I agree with. In Australia however, the Chiropractic & Osteopathy Practice Act 2005 states that only a 'registered person' can provide a 'restricted therapy' meaning 'physical therapy' consisting of or involving the manipulation or adjustment of the spinal column or joints of the human body involving a manoeuvre during which a joint is carried beyond its normal physiological range of motion.
It looks like the chiros and osteos now 'own' manipulative techniques...
Peter, your question of what happens at the physiological level is, I think, the basis of some of the philosophical differences that exist between practitioners of Foot Mobilisation Techniques (FMT).
IMHO, I think the following premises form a good philosophical foundation for practitioners using FMT.
1. Everything works best when it's in the right position.
If a joint is displaced (subluxed) from its optimum working position, the joint and its related structures (capsule, ligs, tendons etc) will be forced to compensate which may contribute to symptoms.
2. A joint which has been immobilised or altered from its optimum working position will result in pathological changes to the joint and its related structures (Woo, Videman, Akeson).
3. The implementation of FMT to improve a joint which is hypomobile due to connective tissue restrictions will be beneficial to that joint.
Release of connective tissue restrictions takes time and work, just ask anyone who has had their arm immobilised in plaster after a fracture. It usually takes at least 21 days of mobilising, stretching and strengthening to restore a normal level of function.
Brian, can you provide some detail of your Foot Mobilisation 'system'? Is it the assessment method, the analysis of findings, the actual FMT used, a combination of all or some of these?
Do you have any video of your techniques uploaded on YouTube to view? (My search for 'Brian Joseph Foot Mobilisation' came up with breast augmentation clips - is this also your expertise?)
Ian, I'm pleased to hear of your opinion that FMT would benefit more patients. Having just completed a 'sell out' course training podiatrists in FMT in Perth, Western Australia, I'm pleased to say that that the professional interest in this field is on the increase. Great news for the growing consumers who are seeking more treatment options for their health choices.
I'm looking forward to the day when manual therapies is part of undergraduate training of podiatrists.
Dear Ted
Thank you for your interest in my work. You are correct to say that those 3 premises you mention have a place in my System.
All teh best
Yours
Brian
I had a client recently who went to a osteopath to do with a foot problem.
I would like to know more about what an osteopath offers, maybe the way forward is to do the coarse.
Thanks very interesting reading!!!!!
In Australia however, the Chiropractic & Osteopathy Practice Act 2005 states that only a 'registered person' can provide a 'restricted therapy' meaning 'physical therapy' consisting of or involving the manipulation or adjustment of the spinal column or joints of the human body involving a manoeuvre during which a joint is carried beyond its normal physiological range of motion.
123 Restriction on spinal manipulation
(1) A person must not perform manipulation of the cervical spine unless the person—
(a) is registered in an appropriate health profession; or
(b) is a student who performs manipulation of the cervical spine in the course of activities undertaken as part of—
(i) an approved program of study in an appropriate health profession; or
(ii) clinical training in an appropriate health
profession; or
(c) is a person, or a member of a class of persons, prescribed under a regulation as being authorised to perform manipulation of the cervical spine.
Maximum penalty— $30,000.
(2) In this section—
appropriate health profession means any of the following health professions—
(a) chiropractic;
(b) osteopathy;
(c) medical;
(d) physiotherapy.
manipulation of the cervical spine means moving the joints of the cervical spine beyond a person’s usual physiological range of motion using a high velocity, low amplitude thrust.
__________________ Stephen Tucker Calvary Health Care
Anyone enlighten me as to the difference between an osteopath and a chiropractor?
Excellent question Mark. There are obvious differences in their training and license, as well as the two professions philosophy. As a general rule though an osteopath enjoys an unlimited license like an M.D. and in the U.S. most practice as M.D.'s do. Most are primary care, have hospital privileges, perform surgery etc. Chiropractor's are considered physician specialists but their license is limited in that they cannot prescribe medicine or perform surgery and very few have hospital privileges. Traditional osteopathy, which resembles chiropractic in its approach is more of a specialty than the rule in the U.S., I'm not certain what the level of utilization is outside North America but I have heard it quoted that less than 5% of practicing D.O.'s in the U.S. practice traditional osteopathy (holistic).
The main difference in technique is in my experience osteopath's utilize long-lever, low-amplitude mobilizations and chiropractors utilize short-lever, high-amplitude manipulation (commonly called an adjustment there is a distinct thrust into the joint space). There is a lot of overlap in the two techniques though and having witnessed both and practicing chiropractic I see a lot of similarities in the two today, with both profession apparently borrowing the others techniques. If you take a foot mobilization course you may come to the same conclusion.
I would therefore say the biggest differences are in training, license and philosophy.
__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright
Thanks, David. Seems to me that application of techniques vary in all professions - goodness knows how many variances of clinical practise occur in podiatry - and where these variances are such that it divides two professions dedicated to treatment of the same problems, then it serves no purpose other than weaken those professions in terms of medical establishment and hinders the respective practitioners scope of practise by uneccessarily limiting them to artificial and self-imposed guidelines. Chiropracty works for some patients better than osteopathic Rx and vice versa. Why not incorporate all the clinical skills under one profession and increase the armament of the clinician for the benefit of the patient?
Thanks, David. Seems to me that application of techniques vary in all professions - goodness knows how many variances of clinical practise occur in podiatry - and where these variances are such that it divides two professions dedicated to treatment of the same problems, then it serves no purpose other than weaken those professions in terms of medical establishment and hinders the respective practitioners scope of practise by uneccessarily limiting them to artificial and self-imposed guidelines. Chiropracty works for some patients better than osteopathic Rx and vice versa. Why not incorporate all the clinical skills under one profession and increase the armament of the clinician for the benefit of the patient?
Best wishes
Mark Russell
Another really good question Mark. At times you cannot get two chiropractor's to agree on anything. There is a major divide in my profession, one camp is philosophically based on the 'subluxation' being the causative etiology of all human ills (the Straight's) and the other being more evidence based and therapeutically driven (the Mixers). It naturally follows that treatment and practice adheres along those lines, with Straight chiropractor's more often adopting a 'wellness' type practice removing subluxations while the Mixers tend to focus on problem based musculskeletal treatment. We even have two National organizations that represent each philosophical bent.
I must admit that I have some sympathy for the concept of the wellness approach but feel that until we can produce some level of credible evidence that subluxations of the spine cause somatic and visceral complaints that it is a philosophy that needs to be reevaluated. I see a natural progression for the type of integration that you have suggested but Straight chiropractors are typically vehemently opposed to such a notion. Likewise I doubt Osteopathy would willingly relinquish their practice scope to allow this and allopathy, who has tried to eliminate us since the very beginning would oppose it (at least the AMA).
__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright
I guess every profession has its factions, but the strongest professions are those who adopt compromise, reasoned understanding and tolerance (not to say respect) of each other's abilities and philosophy - against instransigence and internal division. A compromise is the art of dividing a cake in such a way that everyone believes he has the biggest piece. And to quote Barak Obama
Quote:
A good compromise, a good piece of legislation, is like a good sentence; or a good piece of music. Everybody can recognize it. They say, 'Huh. It works. It makes sense.'
I can only really comment on Ted's course; the others I'm aware of but not experienced personally.
I'm pretty careful what I invest my time and money into and I have been stung before, but I can honestly say that FMT has been a good investment thus far.
Do I use it clinically? - within the majority of my private clinical sessions and have done since the course in April.
Does it work? - so far it's been successful and I have some very satisfied patients.
Would i recommend it? - if it's something that you are interested in and can see a clinical use for then I would absolutely recommend it.
I have also done Ted's course and use the information gained on a daily basis with a lot of happy clients. I think mobilisation is VERY beneficial in a podiatry clinic.
A throughly enjoyable day - he makes learning fun. and has overed support and follow up since. I work in the public sector and am limited in my application of FMT techniques (mainly by funding) but I've had good feedback from patientsthat I have used it on -but I know I'll never use it on the scale that it could be used on. I like the fact that he shows before and after Xrays -amazing.
I also will comment though that he did manipulation on me -and my was it sore afterwards... Wish I lived near to another person who practised so I could go for a full course and get the full benifit.
I think FMT compliments my podiatry rather nicely I'm glad I did the course. I think though that it sholud be taught to us at an undergraduate level.
You said: "I think though that it sholud be taught to us at an undergraduate level."
I have often thought that and hold some sympathy with mobilisation as a concept with one or two very basic practical techniques being introduced at an undergraduate level (for example a posterior anterior draw can be useful in helping pts establish a return of range of motion). It is very simple to do. Certainly there may be a place for a lecture or two that includes practical demonstration.
However, there is so much that has to happen at an undergraduate level that I suspect it would be tight fitting it into any course.
Equally, mobilisations are a very tactile procedure and to gain some of the tactile skills involved can be time consuming. So again I think, from a practical perspective for the educator, it is time that an be an issue.
Why is an Osteopath in this website?
. Certainly when you observe the arms of the practitioner (serving as levers) it looks quite forceful. Yet to the recipient it is almost negligible as a sensation.
Linear Mode
