"Cyriax is oldfashioned and not evidence based" is a quote we sometimes hear... Another question we regularly get is : "What is the best method : Cyriax, Mulligan, Maitland,...?" This deserves a clear answer.
Many therapists across the world certainly are familiar with “Cyriax”, many know something about it, but often not enough to appreciate the real value, few people display a kind of an "allergic reaction" on the name “Cyriax” and ask why this "oldfashioned stuff" still is taught, and fortunately many therapists across the world discovered the added value and it’s clinical importance in musculoskeletal medicine and apply this knowledge successfully in their daily clinical practice.
We strongly believe that many updated Cyriax principles are very compatible with actual scientific views in musculoskeletal medicine.
It is important to realize that “Cyriax” is not an “all-in-one” approach in which the same logic is used in the extremities and the spine.
The functional examination procedures used in the extremities are totally different than the ones for the spine ; the clinical reasoning algorhythm is also different, as well as the diagnostic categories. In the extremities we very often reach a quite specific diagnosis, whereas in the spine the diagnosis is quite often very aspecific. This also reflects in the treatment strategy.
We should focus on two different entities : the diagnostic system and the treatment system.
In the treatment system we do use certain DTM techniques, mobilisations, manipulations and injection or infiltration techniques.
We strongly believe we can make interesting symbiotic combinations with other techniques when it comes to certain procedures.
Do you really think we just do DTM in case of e.g. a tennis elbow ? Of course, we can combine this with some other elements, as described in some actual evidence on tendinopathy (cfr. the work of Jill Cook, Jeremy Lewis, Ebonie Rio, etc.). We also provide you the link to this information. DTM can represent an interesting added value, certainly also in case of ligamentous and muscle belly lesions. The combination of a specific treatment technique in the extremities with a non-specific approach often is an added value. We show you the way on how you can combine the best of both worlds.
The main importance of the modern orthopaedic medicine Cyriax approach is the diagnostic aspect : how can you reach a relevant diagnosis in an objective way, without any "artificial hypercomplication"? What is valid, what is nonsense? We provide the absolute basic knowledge and skills for therapists who are interested in objective clinical reasoning in musculoskeletal medicine.
"Show me the evidence !"
Of course, EBM plays an important role!
Unfortunately we came across several books and “scientific” articles in which the author is e.g. executing a treatment technique in a complete wrong way : wrong position of the patient, wrong position of the therapist, wrong localisation (!) (e.g. frictioning the acromion instead of the supraspinatus) and wrong technique…in that case it becomes difficult to draw solid conclusions.
Not all publications display a good quality...
This is a challenge we are confronted with : too many “self-proclaimed” (Cyriax)-teachers just seem to do something, without critical reflection.
Let’s focus on the more relevant research papers which we also discuss during our courses ! Everything is subject to evolution.
Actually, some hypotheses are confirmed by actual science, some others are refuted, some others are "black hole" hypotheses. We guide you in this discovery !
Part of our mission is to stimulate therapists to think, to act and to implement EBM in a critical way.
The British Medical Journal stated once that over 50% of the published studies in the musculoskeletal field have a very poor quality! Perhaps this is an important signal towards the scientific world to go for less overestimation and more selfevaluation ?
Let’s be honest…aren’t we all confronted with too many “classifications” and “therapy recommendations” which merely represent some “artificial hypercomplication” but often have a poor clinical or practical relevance ?
If you only read the conclusion of certain "scientific" articles, without critically evaluating the set up of the study etc., you won't discover the sense or nonsense and therefore automatically miss the mistakes.
We very often post some films on examination and treatment procedures on the ETGOM social media channels, which seem to be well appreciated by many people, but sometimes those posts trigger some reactions :
“Your films don’t have any value, because there are no scientific references in the film”
In fact we go even one step further : on purpose we don’t incorporate scientific references into our films and our course hand outs !
Why ? We want to offer practical, well illustrated, study tools for our participants, tools which they can use in daily practice. We believe there is no point in presenting a database of numerous conflicting references and tests, from which 50% seem to be rather irrelevant, in a hand out. There are other more suitable settings for that kind of information.
We prefer to focus on what really matters. It is logical that in a 20’ film you could find some topics which are open for discussion. During the “live” courses we are very happy to go deeper into the subject. Therefore it is always interesting to aim for the full picture (after all we provide about 18 hrs of film on our online learning platform and a 15 days "live" training program).
Of course scientific reference material is imperative, therefore during the “live” courses we provide an extensive set of powerpoint slides containing numerous OM related references and specific comment. As pointed out before, we do stimulate our participants to think clinically and scientifically !
Interested in more references ? I strongly recommend to read following excellent books, which provide a nice update in the theoretical backgrounds and science : “A system of Orthopaedic Medicine” by Ombregt and “Orthopaedic Medicine, a practical approach” by Atkins et al.
"Are you still doing corticosteroid injections ?"
Yes, we still do, and in certain specific cases (e.g. shoulderarthritis stage III) a series of i.a. injections proves to be very efficient, without sideeffects. Occasionally it can be done in some types of acute tendintis (rather rare). We also support the use of hyaluronic acid in certain situations and more and more we evoluate in the direction of prolotherapy. In that perspective we recommend the excellent, recent, publication of Dr Giuseppe Ridulfo “Infiltrazioni articolari ed extraarticolari”
"Those spine manipulations are aspecific, that can’t be efficient !"
Yes, indeed, most of the manipulations used in the cervical and the lumbar spine are aspecific, because the diagnosis is aspecific, and, on top of that, they are also much safer in comparison to “specific” maneuvers. By the way, so called “specific” segmental manipulations are one of the biggest myths in manual therapy. Those are absolutely not as specific as we might think.
"Some of your scientific references are older than 5 years !"
So what ? If there are some good references e.g. related to e.g. the fysiological effects of DTM on soft tissue, followed by similar other good references on the same topic, do we have to throw away this knowledge, just because of the date of publication ? Do you need some extra recent references to prove that planet earth is not flat ? On the other hand, when there is sufficient conclusive proof to abandon certain theories or approaches then we also do so! Again, looking at the full picture without tunnel vision proves to be more inspiring.
"I don’t need all of this to make a diagnosis, I have my ultrasound examination !"
The US examination is going to show what the problem is! This is rather wishful thinking : in fact, many findings on US examination are asymptomatic, and then the question what is responsible for the patient’s complaints remains open. A good clinical examination (history, inspection, relevant functional examination) is imperative. US examination can indeed provide accessory information in certain cases. In case you don’t manage optimal palpation techniques, US guided injection techniques can fascilitate your therapeutic efficiency.
What is the best method ?
I don't believe in all-in-one methods! There is no such thing as "the best method". Different approaches each have their advantages and disadvantages and to treat a patient according to one logic only is not always beneficial.
I don't believe in applying exactly the same logic in the extremities as well as in the spine Those are two totally different entities with their own biomechanical and diagnostic characteristics. I believe in combining some strong and actual elements from different approaches, but therefore you need a detailed knowledge of those approaches.
What we offer in the ETGOM course is the absolute necessary stepstone towards objective clinical reasoning and diagnosis of soft tissue lesions of the locomotor system.
When it comes to treating e.g. tendinopathies the combination with actual new insights is recommendable ; in case of spinal problems a combination with some McKenzie logic is also interesting. for certain problems in the extremities, a link with some Mulligan techniques can also be inspiring. On the level of treatment there are no holy truths.
Now is the time to be honest with yourself !
At this moment, as a medical doctor or physiotherapist, can you make the clinical distinction, on the basis of objective elements from the history and the functional examination, between following pathologies :
Shoulder arthritis stage III versus an AC-joint sprain ?
A bigger lumbar derangement versus a symptomatic spinal canal stenosis ?
A ligamentous sprain of the calcaneofibular and calcaneocuboid ligament versus a peroneal tendinosis ?
An acute MCL lesion in the knee versus a chronic medial coronary ligament lesion ?
This is quite important, because the preferred treatment strategy of those pathologies is very different.
This is what modern orthopaedic medicine Cyriax is about !
Objective diagnosis and differential diagnosis. Before you perform any treatment technique, regardless which name you stick on the technique, a solid patient selection is extremely important.
Determining a useful patient selection is one of the keys to success in orthopaedic medicine.
So, why do we still teach Cyriax courses ? …
We believe that managing your basic orthopaedic skills brings you and your patients beyond your expectations. You understand problems and offer solutions for which your patient is grateful.
We provide medical doctors and physio’s the necessary basic knowledge and expertise to become more successful in musculoskeletal medicine. This is the stepstone which is also going to enable you to objectively implement a symbiotic and efficient treatment strategy.
Some people fly high in the sky above the clouds, where the sun is always shining,…but…flying without knowing how to run, makes the landing quite painful. We take care of a safe take off and landing.