Manual Therapy Forum

Timothy W. Flynn, PT, PhD, OCS, FAAOMPT



“The noiseless, painless, restoration of maximum function.”

– Tim Flynn quoting Paul Kimberly, DO, FAAO for his definition of ‘manipulation’



Passion for the patients that we are able to work with… curiosity… humbleness… an open mind… and a commitment to always improve your skill set.

– Tim Flynn



The thoracic spine and ribcage… at the end of the day, breathing and dialing down the sympathetic nervous system is a game changer for the vast majority of patients.  So, if your thoracic spine and ribcage is not mobile, you cannot breathe.

– Tim Flynn



Today, we have the fortune to speak with Tim Flynn.  Tim is a well known figure in manual therapy, research, and education.  He is a former military man as well.  While Tim has received extensive training in traditional forms of manual therapy, and is open about how his overall manual therapy approach has evolved with reseearch findings over the years.  Recently, Tim has been an amazing advocate for our profession to be the front line of musculoskeletal care, especially as the opioid epidemic has become fully exposed for what it has done to patients.  Tim shares his wisdom with years of experience in multiple areas of physical therapy and manual therapy.  I hope you enjoy this time with Tim!



Pain does not equal damage.

– Tim Flynn



Never underestimate the power of the medical system to make you worse.

– Tim Flynn



Yes, we get together at conferences such as AAOMPT, CSM, etc.  We get together and that should nourish us, but if we’re only talking amongst each other we’ve literally failed to do what we’re called to do.  We should spend 95% of our time talking outside our profession and 5% of time within.  And of that 5% maybe arguing about 0.5% and the other 4.5% of that collaberating on how we’re gonna make this dysfunctional thing we call a heatlhcare system better for society.

– Tim Flynn



Listen in here:



Or tune in down here:


Listen to Stitcher



Links of interest:

Michigan State University – College of Osteopathic Medicine

Colorado In Motion

Evidence In Motion

American Academy of Orthopaedic Manual Physical Therapists

South College

Baylor University

Pain Neuroscience Education

Tim Flynn (twitter)

Pain Reframed Podcast




Regaining Flexion/IR of the Hip



Ever have a patient with problems going into a deep squat (or even normal squat for that matter)?  What about someone having hip impingement?  Or just groin pain when sitting to prolonged periods of time?  The list could go on and on.  Usually, a lot of these patients improve well with regular mobilizations of functional mobilizations on and around the hip.  However, I’ve noticed that sometimes, there are other patients that don’t respond as well.  They tend to be the same patients with limited internal rotation while in a flexed hip position.  After playing around with it and thinking about the mechanics, I’ve started using this mobilization in the clinic and it seems to work really well.  Take a look and tell me what you think…







Do NOT manipulate these people!


If you have any interest in manipulation (i.e. high-velocity low amplitude thrust), you’ve likely learned a variety of techniques and which patients may benefit from this technique.  Most quality courses will also at least give some mention to contraindications or precautions to performing manipulation on patients.  Having posted a few videos on this blog about different manipulation techniques, I’ve realized that this is a topic that should also be discussed and not left as an assumption that those viewing our videos are aware of these things.  So, the following are some information I’ve learned from others over the years… most recently from my training with the North American Institute of Orthopaedic Manual Therapy (NAIOMT).


Generic contraindications:

  1.  Hypermobility syndromes/collagen deficits (i.e. Marfan’s, Ehler’s-Danlos, Hypermobility spectrum disorder, etc.).  The concern with these patients are how mobile their articular structures are and the possible strain that could be place on neural/vascular structures that pass from one segment to another.  With such extreme amounts of movement possible, these tissues risk being injured.
  2.  Induced collagen problems (i.e. long-term steroid use).  The concern here is the collagen tissues are severely weakened by issues such as long-term steroid use.  In such a case, articular structures could be weakened enough where a manipulation could cause injury (i.e. capsular injury, ligament sprain, fracture, etc.)
  3.  Osteoporosis (for any reason, but some may include:  immobilization for long periods, young females with known eating disorder, heavy drinkers/smokers, long-term aspirin users).  One of the biggest concerns here is a possible fracture.  Forget about causing a fracture with your manipulation, you don’t want to miss a patient that is presenting with a fracture.  It’s one thing to cause a fracture, but quite another to displace a fracture and cause neural or vascular injury.
  4.  Bleeding/clotting disorders and/or patients on anti-coagulants.  The concern here is obviously causing a bleed in a vascular structure that is around the area you are manipulating.
  5.  Patient does not consent to it.  This may seem obvious, but in reality there are many many clinicians out there that do not obtain proper consent for an intervention like manipulation.  Explaining to the patient what you would like to do, the reasons why, giving a “mini-thrust” to let them know what you are talking about, asking permission to do that, and still giving them an out as you are setting up are all necessary BEFORE performing a manipulation.  Even if the patient gives their consent, if their body language or facial expression is saying otherwise, beware!
  6.  The ‘unlucky’ patient that has had everything go wrong with them.  Maybe I’m alone on this one, but has anyone else had the occasional patient that has seen umpteen medical providers and find their way to you somehow?  They’ve been dealing with multiple aches/pains/symptoms since they got injured years before.  Everything seems to flare them up and most treatments that may help are ususally just temporary.  They probably mention how previous clinicians made them feel worse… but, they’re totally fine with whatever you want to do.  Beware of these patients because you don’t want your head to be the next one mounted on their wall.
  7.  Gut feelings.  Maybe everything is a green light for this patient in front of you, that manipulation is indicated and there is nothing contraindicating that intervention.  However, something deep inside you is saying “I’m not so sure this is a good idea!”  It could be that you aren’t having the best day yourself, so don’t chance it.  It could be something else that your sub-conscious noted when observing or conversing with the patient.  Either way, if the hairs on the back of your neck are standing up and you don’t know why… better to wait for another day.


Specific contraindications:

  1.  Suspicion of fracture within kinetic chain you may manipulate.  Obviously if you knew there was a fracture in or around where you want to manipulate… you wouldn’t do it!  BUT, maybe they haven’t been properly imaged or diagnosed with a fracture.  Now your clinical skills must come in to play to recognize signs/symptoms that could indicate a fracture.  Better to play it safe and not displace something already fractured and cause even more problems.
  2.  Instability that can be effected by your manipulation.  Clinical instabilities are abnormal translatory movements that occur in a motion segment beyond it’s “normal” boundries.  Being able to identify these problems can be vital, and your one chance to not only avoid further injury to a problematic spinal segment… but, be the one person that can identify the actual issue and provide appropriate interventions.  As my palpation skills have grown over the years, I’ve noticed how problematic these problems can be.  Consequently, my interventions have changed to accomodate these findings.



Well, there you have it.  This list is certainly not all-encompassing.  That being said, I’d love to hear what you think are certain things we should all keep in mind that would indicate NOT manipulating certain patients.  While manipulation can be a marvelous intervention that requires a lot of skill to perform well, perhaps more skill is required to understand who NOT to manipulate.








Ray Klepper PT, DPT


Previously, Ray and myself sat down and talked about new trends within the nutrition realm regarding a growing movement of limiting carbohydrate and increasing fat intake.  This has been labeled as “Low Carbohydrate – High Fat” lifestyle.  More strict forms of this is also known as “Keto” which is short for ketogenic, meaning that limiting carbohydrate intake reduces the body’s ability to utilize glucose for energy.  Therefore, ketone bodies are produced and utilized for energy.  However, this lifestyle is not without controversy.  Many individuals and organizations are fighting hard to preserve a traditional macro- balance, primarily of carbohydrates with limited amounts of fat.  The pendulum doesn’t stop there though.  As further extremes are growing more popular.  Those are a “carnivore” lifestyle in which a person eats nothing but meat and fat, and veganism in which a person eats no animal products in any fashion.  These topics and more are discussed between Ray and myself in this conversation.

If you’d like to review previous conversations we’ve had, you can find them here… and here.


For the current conversation, listen in here:


Or tune in down here:


Listen to Stitcher



Links of interest:

New Atkins for a New You:  The Ultimate Diet for Shedding Weight and Feeling Great by Eric C. Westman and Stephen D. Phinney


Carnivore Training Systems

N Equals Many

Meat Heals:  Revitalizing health and performance through carnivory

Shawn Baker, MD (instagram)

Shawn Baker, MD (twitter)


The China Study:  The Most Comprehensive Study of Nutrition Ever Conducted And the Startling Implications for Diet, Weight Loss, And Long-term Health

Denise Minger

Dr. Michael Eades


MTHFR and Dr. Ben Lynch


Weston A. Price Foundation


Chris Masterjohn, PhD


Rhonda Patrick, PhD

Dominic D’Agostino, PhD


Dave Feldman

Gary Taubes

Gary Fettke

Nina Teicholz

Professor Tim Noakes


Diet Doctor



Research mentioned:

Campbell,  C. The China Study: Startling Implications for Diet, Weight Loss, and Long-Term Health; Review by Masterjohn, C. (2005) Retrieved January 14th, 2010

Casavalle, P., Lifshitz, F., Romano, L., Macerna, M., Gonzalez, C., Bordoni, N., Boyer, P., Rodriguez, P., Friedman,M. Gingivits and Insulin Resistance in Obese Children. 10.2337/dc16-0708

Fest, A.,  D’Agostino, R.  Jr. George H., Mykkanen, L., Tracy, Russell., &. Haffner, S. (2000) Chronic Subclinical Inflammation as Part of the Insulin Resistance Syndrome: The Insulin Resistance Atherosclerosis Study.   102: 42-47

Fung, J. Intensive Dietary Management; End Organ Damage; (2015) Retrieved on June 30th, 2016

Seung-Hwan, L., Zabolotny, J., Hu, H., Hyon, L., &Young-Bum, Kim. (2016) Insulin in the nervous system and the mind: Functions in metabolism, memory, and mood Molecular Metabolism. Aug; 5(8) 589-601; 2016 Jun 29. Retrieved December 15th, 2017.

Teng, K., Chang, L., Vethakkan, S., Nesaretnam K., &Sancers, T. (2017) Effects of Exchanging Carbohydrate  or Monounsaturated Fat with Saturated Fat on Inflammatory and Thrombogenic responses in Subjects  with Abdominal Obesity: A randomized Controlled Trial Clinical Nutrition 36. 1250-1258




Happy Easter!

Happy Easter to all!