Foot Mobilisation Techniques (FMT)

Courses for mobilisation for Podiatrists to use have been available before the more recent advent of yourself, Ted, and Paul C (who like you is in the UK this year).

Unfortunately, for some of us at least, it has been necessary to have to look outside of the Podiatry profession to get the skill base. I learnt my mobilisation techniques through the Society of Sports Therapists, which itself is an organisation founded by a physiotherapist, Prof Graham Smith. I then learnt osteopathic manipulation, based around J M Hiss's approach via a Podiatric surgeon in Ireland. This latter technique was limited to the foot and ankle where as the mobilisations extended as far as and included limited mobilisation techniques of the hip.

An organisation called SOBSART (for training courses) in the UK is very much geared towards Pod foot and ankle rehab which, I understand, may use the various techniques described above.

What would perhaps be useful is for the role of some of the more basic techniques to be a part of Pod training, even allowing for the full training diary they already have at Uni. This may be naieve on my part of course. However, much as I value the role of Mobs they are but a part of the treatment armamentorium - just possibly more valuable than we have perhaps fully considered hitherto.

Ian

 

It's great that such courses exist Ian. I was in practice for 12 years before I heard of mobilisation for the foot. Now I often hear the comment 'I wish I was taught this at uni'.

I know I'm not the only facilitator of FMT and I think it's great for interested pods to experience a range of tuition. I recently reviewed Paul's course and picked up a couple of extra pearls of wisdom. We can never learn less!

Do you have any concerns Ian, about the issues that Tom has raised?

Ted.

 

From the University of Plymouth Module Record "POD201: developing clinical reasoning in practice 2 Indicative syllabus content: Manual therapy: massage, mobilization, manipulation, myofascial therapy, stretching and strengthening exercises".

This may have changed since my time, but I certainly included this within the sylllabus.

 

Hi Ted

Initially I have no concerns with regard to Toms coments.

I'd also agree that exposure to varied tuition techniques can have a more postive than negative affect. It will be interesting to see Paul's techniques this weekend here in Sussex.

I think Tom' comments are pertinent and a good reminder to check with our Prof bodies that we are insured for the techniques we use. However, mobilisations by their very gentle nature should rarely (with good pt assessment) lead us into problems.

Of manipulation or mobilisation I have given far more practise to the mobs because they lie very much within the pts control and by their very technique and practice can prevent us moving too much into the pain barrier and physiological action outside a pts control.

It was good to see Simons post and any comment I make on training is limited as I did not come the Hospital route.

Just relieved that the module title was not POD101
Ian

 

I know you are only joking but as a point of clarity, the module coding employed reflects the level of study so POD101, POD 201 and POD301 would be 1st, 2nd and 3rd year undergraduate modules respectively. The 01 bit is really just a catalogue number it doesn't necessarily follow that POD101 would be the first module studied on a programme.

P.S. what's a "master bone setter"?

 

Here you go. http://en.wikipedia.org/wiki/Bonesetter

 

.

Sounds great!

I'm not following the reasoning for such alarming comments.

I await Tom's reply...

 

I am attending the Foot Mobs course that Ian has kindly arranged this weekend. I too was trained in mobilisation techniques by The Society of Sports Therapists (in fact I was a Sports Therapist for 10 years before undergoing my Podiatry degree and used these techniques on all areas of the body). Anyhoo - I contacted the Society of Chiropodists and Podiatrists for their view on insurance cover for the course and this was their response:

"Further to our recent telephone conversation, I checked the Society records with regard to previous communications on foot mobilisation and so am able to advise you that foot mobilisation is considered part of the practice of a Podiatrist and so it is acceptable for you to attend a foot mobilisation course.

In addition, I felt obliged to let you know the following:

• In 2005, the Society sought the advice of the insurers and colleagues within the profession with specific regard to foot mobilisation. As a result of the discussions, an article was printed in the December 2005 journal titled Professional Indemnity Insurance. A copy of the article is enclosed for your information.
• It is to be noted that it is the responsibility of each delegate to use their own professional judgement as to their competence to carry out mobilisation techniques at the end of a foot mobilisation course.
• As your particular query referred to the matter of insurance cover for using foot mobilisation in the treatment of a podiatry complaint I can advise that there will continue to be a link between recorded CPD and third party indemnity insurance. As such, any member who is subject to a professional indemnity claim will need to demonstrate that they have kept themselves up to date in all areas of their practice. If the member cannot demonstrate this, they may be required to pay the £1,000 excess (normally paid on their behalf by the Society) for a successful claim against them."

 

There is no doubt that we want to be a safe as possible when delivering any therapeutic service. In my experience, it's quite difficult to cause harm even with manipulation. We are dealing with physiological structures that are designed to withstand multiples of body weight forces. If you can generate those kind of forces (such as the force required to sprain an ankle) you should be entering an olympic strength event.

There is risk of course, if you try to manipulate an acute sprain or recent injury. But then again, these injuries are classed as 'contra-indications' for FMT because they are classed as 'possible fracture until proven otherwise'. Professional assessment must always be exercised before any treatment option is implemented.


Ted

 

I have looked quickly through the responses and will try to respond in turn.

Quote TedJed
Breaches under Osteopaths Act 1993 have attracted fines of up to £27,000 plus costs.

I'm not following the reasoning for such alarming comments.

The actions to enforce the Act mentioned above relate in some cases to the practise of osteopathy. That would mean any one using an osteopathic based technique could be challenged in the criminal court in the UK and if the court deemed a therapist was implying he or she was an osteopath they would be fined within the range I mentioned. So there is no logical reasoning just simply the record of prosecutions.


How medical practitioners (who receive no practical undergraduate training in spinal manipulation in Australia) get exemption is a testament to their lobbying power I guess...

Good point. Who said the law was fair?

The Podiatrists' procedural terminology of the Australasian Podiatry Council lists services defined under the heading of 'Physical Therapy' which includes the national Item Code Quote:
F147 Manipulation / Mobilisation

Ted is that statement statutory law? If it is then you can legally manipulate, but in accordance with the CHIROPRACTIC AND OSTEOPATHY PRACTICE ACT 2005, you cannot practise manipulation, which seems confusing. Perhaps you could get me more information as to this situation.


Why podiatry practice would be subject to the Acts of Chiropractic or Osteopathy does not seem logical. I understand you are basing your deductions on one definition of manipulation but I find this a rather long bow to draw.

The above Act seems to be proscriptive and essentially states exemptions but not podiatry. Like many pieces of legislation implementation does not follow logic and such Acts have been used in the UK to criminalise any professional using osteopathic techniques. That is why I have an interest - the final word is that it is not podiatry practice but the sourcing of the technique that is the problem. I believe your source to be osteopathic from Dr Hiss.


Before I look further at the comments I would like to state the definitions, as I understand them for mobilisation and manipulation to help clarify matters.

• Mobilisation is under the patient's control and movement goes up to the end of the physiological range of motion.

• Manipulation ( by whatever method ) goes beyond the physiological range and into the paraphysiological range, but not beyond the anatomical barrier.

These definitions are stated unequivocably in the CHIROPRACTIC AND OSTEOPATHY PRACTICE ACT 2005.
So what I wanted was the exemption for podiatrists to practice manipulation. That would mean a Governor's Proclamation or a similarly worded Act in favour of podiatry and specifically allowing manipulation - an act of joint adjustment beyond the physiological limit.

Is there a Governors proclamation or is one not needed? Maybe the only way to get an answer is through legal advice, which should give specific guidelines and clarify the definitions.

Quote TedJed
I believe this stemmed from perceived dangers to the public associated with spinal manipulations. (There is as yet, no empirical evidence to suggest spinal manipulation is hazardous to the public.)

Both osteopathy and chiropractic owe their roots to the bonesetter profession. Orthopaedics also have their roots in bonesetting via Hugh Thomas. There has existed a powerfully lobby to gain protection of title and thus stamp on the market the brand. From that motive it appears the cascade to statutory regulation has flowed. The evidence for spinal manipulation being hazardous is clearly documented in the law reports. In the last century at least 32 deaths occurred as a result of spinal manipulation.

Quote TedJed
I wonder if the public benefits in any way from precluding podiatrists to practice physical therapies. Is this what you are proposing?

The public will certainly benefit and also the profession. However how you describe what you do and the source of your technique is of vital importance.


Quote M Weber from S Spooner
P.S. what's a "master bone setter"?

I am a master bonesetter. In the UK bonesetters are listed and subject to full professional checks, are subject to peer review and qualifying courses are validated.
"Master" category was given to me because I developed a procedure to adjust facet joint fixation in the cervical spine without force or amplitude and also because I produced the UK's first risk assessment of spinal manipulation in 2007.
Any medical professional doing the validated bonesetter courses can progress from the foot and leg course to learn and qualify for the remainder of the body and can get full professional insurance for both mobilisation and manipulation. The insurance validation took over six months for the foot and leg course. In the end I got insurance cover for students to practise on each other under my supervision and then when the assessments, which are very detailed, are signed off, graduates can get their own insurance as well as join the bonesetting profession.
Incidentally the last master bonesetter was Herbert Atkinson, later Sir Herbert Atkinson Barker. He was knighted for his joint manipulations as a bonesetter, and his manipulations were even more advanced than those used by his contemporaries in the orthopaedic profession. He came from a long line of bonesetters, namely the Atkinson family. I haven't receive a knighthood yet, nor do I expect one.

Quote from Simon Spooner
From the University of Plymouth Module Record "POD201: developing clinical reasoning in practice 2 Indicative syllabus content: Manual therapy: massage, mobilization, manipulation, myofascial therapy, stretching and strengthening exercises".

That is a very interesting quote. That means Plymouth is the only faculty in the UK teaching manipulation. I would be interested if you find out the source of the techniques.

I would be happy to continue the discussion after I look further into matters.

My philosophy after being involved in the legal consequences of statutory regulation and taking legal advice is that sources of technique need to precede 1875. That is the best safeguard against prosecution in the UK.

Tom Brett DO BSc(Hons) LL.M
Clinical Manipulative Therapist, Master Bonesetter, Master of Laws and Podiatrist.

PS Just to throw something else into the debate. Insoles and joint adjustment of both mobilisation and manipulation have been used for over 2500 years. If anyone wants the reference or any other references, please email me at mail@brettscourses.com

 

If the 'sourcing' of a treatment is the key, how's this...

Corns and calluses were originally described by Hippocrates who recognised the need to physically reduce hard skin, followed by removal of the cause. He (source) invented skin scrapers for this purpose and these were the original scalpels.

Hippocrates was a physician (also known as medical practitioner, doctor of medicine, medical doctor.)

Using the legal rationale Tom has described; Hippocates was the 'source' of callus debridement, therefore it would follow that the only professionals who can debride callus must be physicians.:wacko:

I'm interested to know why has 'manipulation' been legislated and 'callus debridement' not been legislated? Is one more dangerous than the other? I'd bet that more than 32 deaths have occurred last century as a result of callus debridement preceding vascular complications. I personally know of 2 cases in lil' ol' Adelaide.

Is it something to do with the lobby and the 'branding' issue Tom raised?

Ted

 

At the time it was Maitland.

 

Simon Spooner

Thanks for the information Simon. G D Maitland was a physiotherapist. In his book Vertebral Manipulation 5th ed. he did not refer to any source such as osteopathy or chiropractic. Therefore to follow Maitland after learning his techniqes you are practising physiotherapy, which includes mobilisation and manipulation. On that basis providing you are registered as a physiotherapist you can legally practise physiotherapy. That I believe is how the names tie up with the practise and the law. In all jurisdictions the detail of the law needs examined and considered. There are lots of issues with the way matters are between the chiropractors, osteopaths and physiotherapists.

Tom Brett DO BSc(Hons) LL.M
Clinical Manipulative Therapist, Master Bonesetter, Master of Laws and Podiatrist.

 

Yeah, thanks for that, I am familiar with Maitland and his works.

What's your agenda, Tom?

 

The essential part of my response is not a reference to an age where the practise of medicine was allowed by patronage of the ruling body (eg Hippocrates and Galen). The essential part is that we live in an age where professions are established which lay claim to the use of technique. Osteopaths practise osteopathy, chiropractors practise chiropractic etc. Each group has the vested interest of at least preserving its status and if possible extending it. Statutory regulation provides the legal framework in most cases to do that. To demonstrate that you don't use a technique with statutory closure requires researching the techniques and using the provenance. Debridement is not the issue. The issue is using techniques sourced in the case of Dr Hiss's legacy from the osteopathic repertoire or possibly the chiropractic repertoire.

Put yourself in the position of a person, who graduates from a course based on osteopathy without the taught technique being sourced prior to the start date of osteopathy, who is taken to court for negligence. The judge says what did you do to the patient? I used an osteopathic technique. It isn't as quick as that but under cross examination that could well be an outcome. The next question from the bench is 'Are you an osteopath'? Get the cheque book out and proceed to get a criminal record. The twists and turns are numerous. I took legal advice for both my practise activities and teaching. I did hours of research, mostly in the British Library, using original text to get the provenance of the techniques I use and teach. I have also involved myself in the study of manual medicine and the law relating to manipulation in as many jurisdictions as I can. The latter because the law, as handed down in cases becomes case law and that sets precedent, which can be used in other jurisdictions.

Tom Brett DO BSc(Hons) LL.M
Clinical Manipulative Therapist, Master Bonesetter, Master of Laws and Podiatrist.
PS I cannot dowload F147 relating to manipulation / mobilisation

 

www.apodc.com.au/Podiatry in Australia/Service_Item.htm

 

I have many agendas. With regard to this thread - to gather information about the various legal jurisdictions and the influence they have over my vocation. The secondary agenda is to stay ahead of the influence of proscriptive legislation.

To see more about my interests please simply google in Tom Brett -
medical law, medical legal reporting (I am a journalist), provision of courses in mobilisation and manipulation within the legal current parameters, support for my graduates, changing the statutory law through detailed and articulate submissions to the relevant executive parliament, recovery from a serious road traffic accident, having a pint in the pub with my friends, giving my mercedes a bootful, camping and walking on Hadrian's wall, meeting my best friends, training in the martial art techiques taught to me by Bruce Lee's teacher, treating more patients with my vector change techniques and especially with my procedure for zero force, zero amplitude adjustment of the cervical area, climbing on thatched rooves with my thatcher patients just to say hello, being a great friend and fearsome enemy, sharing quality time in the the Royal Society of Medicine restaurant, spending hours with original texts to develop for example the Reciprocal Inhibition exercises ( email mail@brettscourses.com for your free copy) teach all qualified medical practitioners how to mobilise and manipulate - my courses cover six parts and cover the whole body - not just the foot and leg, etc etc

Simon! Your question can be answered by doing a search as detailed above. OK?
This particular thread is almost closed for me. I would appreciate copies of the particular legislative provisions, which are in place in Australia. Then I can move on. By the way what is your agenda Simon and I believe Ted (in bringing to question the sources and legality of the techniques you are using)?

 

I'm trying to work out whether you are in favour or opposed to podiatrists learning mobilisation and manipulation techniques? Thus, are you in favour of People like Ted putting on courses for podiatrists to learn these techniques?


My agenda: "info freako- there is no end to what I want to know". I googled you a couple of days ago and I still can't work it out.

 

Tom I am curious as to your source for these statistics? A large review was performed by Dr. Scott Haldeman (MD and DC) some time ago and the results are referenced in this study.

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=altrehab&part=A347

I am not saying that there are no risks for cervical manipulation but they are rare as pointed out by this study and the track record for it's safety is well documented when following appropriate screening protocols for the likelihood of an at-risk patient. Also many of the cases of vertebrobasilar stroke are attributed to professions other than chiropractic and osteopathy, where the training is obviously a core principle and more complete.

I was unaware that the number of deaths for our professions have ever been quoted at that level. Fortunately, manipulation of the foot and ankle carries a much lower risk of injury and morbidity. At least one would hope.

In my experience at least in the U.S. manipulations of the foot and ankle by a podiatrist incident to the podiatric care of a patient are within their scope and license irregardless of where the technique originated. Turf wars aside there is a lot of overlap in professions where the manual healing arts are concerned. An MD has an unlimited license and can effect any treatment they deem necessary and appropriate but the issue of what is common practice and reasonable when there are competing professions licensed to perform that particular treatment in that geographical area.

It really begs the question as to why so many limited license professionals seek to practice beyond their scope or what is taught in their training. Don't beat me up, just a thought....