Mark R. Bookhout MS, PT, CFMM
Hi y’all, welcome back to another conversation. This time with Mark Bookhout! I wanted to try out a different format for this conversation, and Mark was kind enough to oblige with it. Below you will find a written out question and answer format between myself and Mark. So, I’d love to hear your feedback on what you think about it. Please comment below!
Me: So what was life like for you growing up? With your family?
Mark: I grew up in upstate New York near the Catskill mountains in a small town of about 5,500 people. There was one major employer where my dad worked as a machinist. My mom worked as a secretary for an insurance company. As the eldest son with three younger brothers I was always inclined to try to take care of everyone.
Me: What do you think made you “inclined to try to take care of everyone” other than the fact that you were the oldest brother?
Also, were there any particular things that you feel were impressed upon you by your parents when growing up that you still carry with you or have passed on to others?
Mark: My dad worked second shift from 3:30 pm to midnight so he wasn’t home at night except on the weekends and my mom seemed overwhelmed by having four sons to manage which is why I think I stepped in.
My mom was a perfectionist and fortunately or unfortunately, I too developed that trait. Both of my parents worked hard and instilled in me that working hard was the best way to “get ahead” in life.
Me: What/who influenced you to become a physical therapist?
Mark: I decided to become a P.T. after visiting my uncle in the hospital while he was receiving P.T. to learn to walk again after a bad farming accident. He was told by his physicians that he would never walk normally again. His P.T. felt otherwise and my uncle regained full mobility and was able to walk without a limp after his therapy. He encouraged me to become a P.T.
Me: Were there any other professions/careers that you were considering along with PT? While your uncle was encouraging you to become a PT, do you remember any specifics about what he said, or why he thought you in particular should become a PT?
Mark: I also had considered being an elementary education teacher, but that was short lived.
My uncle felt that his physical therapist was more responsible for his recovery than his physicians were. I had also watched a TV show that I believe was called Dr. Ben Casey, and in the show he had a patient that he couldn’t connect with, who wouldn’t get out of bed and walk. There was a Physical Therapist in the show who was able to relate to the patient and eventually the patient responded and walked again. I thought after watching that show that being a physical therapist would be a rewarding profession. I believe I watched that show around the same time as I was visiting with my uncle at his P.T. session.
Me: What/who influenced you to get into manual therapy?
Mark: After graduating from the Mayo Clinic in 1977 I worked in an acute care hospital for about 6 months and was very disillusioned about our profession so I took a job in a nursing home. I then started a small business contracting P.T. services for several nursing homes. I had virtually no manual therapy training except for learning massage at that point in my career. I then was invited to attend an after hours presentation on manual therapy for the spine and watched a videotape of James Gould examining and treating a spinal patient. I was blown away that someone could palpate the spine and determine if it moved properly or not. I had never seen that before and I knew immediately that is what I wanted to do. I was told by the presenter that a new program under the tuteledge of Stanley Paris, PhD, P.T. was just starting in Atlanta, GA. I applied and was accepted to Stanley’s Master’s Degree Program in Orthopaedic Manual Therapy which I attended from May of 1981 to September of 1982.
Me: How did you decide to go to the Mayo Clinic for PT education?
Mark: I went to the Mayo Clinic for PT school because it was the only school that accepted me. Initially I was an alternate, so I didn’t know if I would be going to P.T. school or not until I received an acceptance letter about 5 days before I graduated from my undergraduate program with a B.S. degree in Biology.
Me: What disillusioned you so much about working in the acute care hospital? Do you look back on that time of your life (the six months in acute care) as a positive thing or a negative thing… with the realization that if you didn’t instead work in the nursing home you may have not been exposed to the manual therapy the way you were… and maybe your career could have been different? And the follow up to that would be… why?
Mark: My initial job in an acute care hospital was so frustrating because I was told to provide services that I didn’t think were effective or they seemed barbaric, ie treating a shoulder patient by strapping them to a shoulder wheel mounted on the wall and spinning the wheel while the patient shrieked in pain, or doing “gait training” with a CVA patient by holding the patient up with a walking belt while the PTA physically advanced the patient’s leg and locked the knee into hyperextension. I had even considered doing something else as I was so disillusioned by my first job.
At least in the nursing home job I was free to treat the residents the way I felt best and was supported by the owner of the nursing homes and the medical staff.
Me: Other than palpating the spine to determine motion, what else do you remember about the video you watched of James Gould? Anything else that fascinated you and made you want to pursue manual therapy?
Mark: I do remember that after watching James Gould palpating the spine, our study group tried to practice what he demonstrated and it was a challenge to feel anything. Initially I could not, but I was intrigued by the concept.
Me: What was Stanley’s program like during the time you were there (this is a particularly interesting question for me regarding the history side, since he had a major impact on educating so many people)?
Mark: Stanley’s program was amazing as we had so many gifted instructors and the program was quite demanding. Some days we would be in class and/or lab for 8 hours or more if Stanley was in town, as back then he was often out teaching CE courses on the road.
Me: Consequently, who have been your biggest mentors and why? In what ways did they mentor you?
Mark: Stanley Paris, Bob Donatelli, Steve Kraus, Rich Nyberg, Allan Grodin, Walt Personius and George Davies were my instructors and mentors in the program. We were also fortunate enough to receive instruction from Dr. Barry Wyke and Olaf Evjenth.
Me: What do you think were some of the highlights during your time with all of these mentors? Was there anything you learned at that time that has really stuck with you over the years?
Mark: When I attended Stanley’s program there were only two other organizations known to me that were teaching manual therapy in a classroom setting: Kaiser Permanente Program in Hayward, Ca and Dick Erhard and Richard Bowling’s Masters program at the University of Pittsburg. So naturally I felt very priviledged to have been able to attend Stanley’s program in Atlanta as it only existed for 3 years before Stanley eventually moved the program to St. Augustine, FL
Stanley instilled in us the importance of being able to stand up to and communicate with physicians about what we do and to act and dress as professionals.
After finishing Stanley’s program I was encouraged by Steve Kraus and Rich Nyberg to attend the continuing education programs offered at the Osteopathic College at Michigan State University to learn more about Muscle Energy Techniques and Craniosacral Therapy. I subsequently attended every course they offered from 1984 to 1987 and was then asked to join the teaching faculty at MSU as an adjunct associate professor in June of 1987. My main mentors were Philip Greenman, D.O., Fred Mitchell, Jr. D.O., Barbara Briner, D.O. and especially Carl Steele, D.O., P.T. who befriended me and patiently answered all of my many questions.
Me: Do you recall any particular reason that Steve Kraus and Rich Nyberg encouraged you to learn more about MET and CST from MSU?
Mark: Steve and Rich encouraged me to go to MSU because that’s where most of the giants in Osteopathy were practicing and teaching. Phil Greenman and Fred Mitchell, Jr for MET, Ed Stiles for Functional/Indirect Technique, Robert Ward for Myofascial Release, Barbara Briner for Craniosacral. Paul Kimberly, D.O. John Bourdillon, MD and John Mennell, MD were also my instructors.
Me: What struck you about the MSU program that you wanted to take every course from ’84 to ’87? I would certainly imagine the greats that you mentioned would be reason enough, but just wondered if you could share any stories about learning from all of these guys!
Mark: I was only the second P.T. asked to join the teaching faculty at MSU and I was very humbled by being able to teach, ask questions and share my observations with this amazing faculty. I really appreciated that they valued my ideas, opinions and my teaching style and were open to new ideas.
Me: When you mentioned Carl Steele, DO, PT… what kind of questions did you have that he so patiently answered?
Mark: Carl Steele was a P.T. before becoming a D.O. so he understood my questions better than anyone, especially regarding motion palpation versus positional testing. Positional testing is all they originally taught in the MET courses and after taking Stanley’s classes all I knew was motion testing in 3 separate planes and not combined movements.
Me: Given how long you’ve been a therapist, what has excited you the most, either past or present, about going to work and treating patients?
Mark: What has excited me the most about our profession is that I continue to learn from my patients almost on a daily basis and every patient presents as a unique new challenge which I thoroughly enjoy. I also have been fortunate to be able to open a private practice that specializes in treating orthopaedic conditions with manual therapy, teach continuing education courses and write and publish articles on manual therapy and co-author a textbook on spinal manipulation.
Me: Are there any particular stories or patients that you have remembered throughout the years that have stuck with you the most? For example, learning a particular treatment approach/technique that really worked well on one particular patient that opened your eyes to more possibilities for patients in the future?
Mark: I have learned a ton from my patients. For example, supine pelvic clocks was a Feldenkrais awareness through movement lesson that I had been shown at a CE course, but wasn’t told how to use it in the clinical setting, Then I had a patient who deviated from the midline every time he bent forward and my hands-on treatment had made no difference. Simply by having the patient perform the pelvic clock and monitor his ASISs to maintain symmetry during the movement immediately corrected his deviation with forward bending. I later discovered how to use the pelvic clock to diagnose FRS and ERS dysfunctions in the lumbar spine and to this day it is still an amazingly accurate assessment tool that I use every day. Every low back patient I see is given pelvic clocks for self treatment.
Me: Can you tell us about how you made the decision to open a private practice? Also, would you mind mentioning anything that you might have done differently in the early years of your private practice?
Mark: When I went to Stanley’s program I fully intended to return to Minnesota and open a private practice so I could provide my newly acquired skills. My early years in private practice were amazing, actually, as Stanley had been approached by a group of spine surgeons in Minneapolis who wanted him to come to Minnesota and reopen his school there. Stanley wasn’t interested, but told them about me and my eventual business partner, who was also in Stanley’s program and intended to return to Minneapolis as well. They hired us initially until we were able, through their assistance, to contract with the Sister Kenny Institute to provide specialized spinal services to their patients. We were off and running after that. We had so many referrals that we had to start hiring and training people to assist us and our private practice was born inside a hospital setting. At our peak, this one group of physicians referred 220-240 new low back spinal patients to us every month. We were invited to attend weekly rounds with them to discuss different cases and they would ask for our input. What was truly amazing is that they encouraged our growth, referred a ton of patients to us and never sought to have us work for them.
Me: What continuing education courses have you taught over the years?
Mark: I have taught at least 14 different CE courses over the past 36 years, averaging about 15-20 courses a year. Stanley actually gave me my start, teaching E1 for him from 1981 until February of 1987. Then in April of 1987, I was approached by Dr. Philip Greenman, D.O. about teaching at MSU while I was attending my last CE course at MSU. I’ve been on the teaching faculty at MSU ever since, and in 1990 I developed an Exercise Course for MSU to compliment the MSU CE course series.
I’ve also taught courses on my own at various hospitals, clinics and private practices throughout the U.S. I recently retired from teaching for the Barral Institute due to my health issues, but taught 22 Neuromeningeal Manipulation courses (NM1,2,3) from 2011-2017.
Me: I’ve seen your name in or on at least a couple of text books (i.e. Bourdillon’s Spinal Manipulation and Clinical Reasoning for Manual Therapists), could you tell us a little of what those are about?
Mark: In 1990 I was asked by Dr. John Bourdillon to write a chapter on exercises for his 5th edition of his Spinal Manipulation book and I subsequently wrote two chapters. I had the great pleasure of meeting Dr. Bourdillon at MSU and taught with him for several years before he passed away. Then in 2000 Dr. Edward Isaacs and I wrote an updated 6th edition of the Spinal Manipulation book in Dr. Bourdillon’s honor. The book covered both direct manipulation techniques and muscle energy techniques. Unfortunately it is now out of print.
In 2001 I was asked by Darren Rivett to write a case presentation on treatment of a patient with low back and leg pain incorporating Muscle Energy techniques.
Me: Because I love to hear about history, could you give us some background information about who Dr. John Bourdillon was?
Mark: Dr. Bourdillon was an Orthopedic Surgeon who himself developed back pain and sought treatment for his back, eventually obtaining relief thru manipulation of his spine. He then became a student and passionate supporter and practioner of manipulation and attended the CE courses at MSU. He became a member of the teaching faculty up until his untimely death while attending a ME course at MSU in 1992. He was a gentleman who had a big heart and a great sense of humor and he was always open to learning new ideas/techniques.
Me: As an aside… what did you like about this particular book that would make it worthwhile for someone to have in their library?
Mark: The 6th edition of Spinal Manipulation book has information in it that is not found anywhere else on problem solving for the lumbar spine and sacro-iliac joints. It is truly a classic, if I do say so myself.
Me: Has your treatment approach/paradigm evolved over time? If so, how?
Mark: My treatment approach continues to evolve as I wind down my career and I’m trying to incorporate all that I’ve learned over the past 35 years. I try to evaluate the whole patient and not focus on just the patient’s region of pain.
Me: Are there any particular strategies or thoughts that have been helpful in integrating such a vast amount of knowledge or variety of treatment approaches? Is there any particular thing that is more dominant in your evaluation of the whole patient?
Mark: I have found that using Listening as taught by Barral in combination with observation of gait and what I call postural loading through the pelvis, shoulders and head helps me define where the primary or most dominant issue is in the patient’s body at that time.
Me: Who or what are your biggest influences more recently, and why?
Mark: My biggest influence over the past 15+ years has been Jean-Pierre Barral, D.O., Alain Croibier, D.O. , Gail Wetzler, P.T. and the rest of the teaching faculty at the Barral Institute from whom I’ve learned the art of Visceral, Neural and Vascular manipulation.
Me: Are there any specifics from the Barral Institute’s curriculum that has influenced you the most during this time frame?
Mark: The Neuromeningeal courses have also been invaluable to me because of their specificity in addressing both the peripheral and central nervous system including the cranial nerves, as opposed to mobilizing a positive ULTT1 sign or slump sitting someone without regard as to where the primary fixation of the nerve may be.
Even more recently I have attended classes on Fascial Counterstrain developed by Brian Tuckey, P.T. and have been impressed by his original insights, skill and knowledge. If not already, I predict that he will be considered a pioneer and giant in our profession.
Me: What concerns do you have for the profession of PT or manual therapy in general?
Mark: My biggest concern for our profession and especially for manual therapy is the tendency for some educators to downplay the importance of specificity in treating patients and the focus on teaching only evidence-based techniques. I know many massage therapists who have better hand skills than many therapists.
Me: Do you have any ideas or thoughts regarding how clinicians can better improve their hand skills or sensitivity with their palpation?
Mark: Rich Nyberg wrote a really good article on palpation that I have often encouraged people to read. He talks about where the best receptors can be found in the hand and fingers depending upon what you are attempting to palpate. Ie. the difference between palpating with the palm versus the fingertips. I hate to say this but some people have a great sense of touch and others not so much. It truly is a gift, but needs much practice. Trying to visualize the anatomy under your palpating finger/hand is also a very helpful and powerful tool.
Me: What kind of things have you learned over the years that you wish you had known as a young clinician?
Mark: I wish I had learned the art of listening with the hands much earlier in my career. I’ve found it to be an invaluable tool in evaluating patients to determine their primary area of dysfunction and in identifying the tissue involved, i.e., visceral, neural, arterial, articular.
Me: Could you offer any advice on how to improve a clinicians skills regarding listening?
Mark: Practice, practice, practice it every day and on every patient and trust what you feel. I had a young girl, age 12, with severe low back pain whose mother had been told that it was psychological when her scans were negative. I tried listening to her abdomen and I was drawn to her R ureter consistently, but I didn’t trust my finding. With some reservation I did share this information with her mother. After going to the Mayo Clinic and having a complete work up with no answers they returned to see me and I found the same thing, R ureter. Finally an Ob/GYN physician took a chance and did an exploratory laparoscopy and found endometriosis on the R ureter, just where I said it was. She was prescribed a birth control pill and her back pain was gone. I’ve been a believer ever since.
Me: Any particular advice for young clinicians out there today?
Mark: My best advice to young clinicians is to continue to ask why a patient presents the way they do; to learn as much as they can from each patient and to attend continuing education courses. I encourage every young therapist to find a mentor and never be complacent with what you know.
Me: What are some things that you hope younger clinicians learn from you or take away from your interactions/instruction with them?
Mark: I hope that with my teaching, therapists are motivated and challenged to learn to use their eyes and hands for more specificity in assessing and treating patients.
Me: Why do you value specificity this much? I ask, not in a critical way, but because I really value specificity and would like to hear other clinicians perspective as to why it is valuable.
Mark: I find that often patients have not responded to previous medical intervention, whether it’s been P.T. or Chiropractic or surgery because of a lack of specificity in their treatment. It’s concerning to me that many of our prominent peers in manual therapy have been promoting non-specific approaches to manipulation and attempting to pigeon hole patients based upon clinical prediction rules. I find that the current clinical prediction rules may be applied to about 20% of my patient population, at best.
Me: Also, if there was one or two things you were to be remembered for in the realm of manual therapy, what would it/they be and why?Mark: I hope that I will be remembered as an eclectic manual therapist who tried to take the best ideas and concepts from the giants in the field of manual therapy and especially Osteopathy and integrate them in a cohesive and understandable manner.
Me: What is the best and worst advice you’ve heard given to others (or even yourself)?
Mark: The best advice I was ever given was to attend the continuing education courses at MSU. The worst advice I’ve heard repeatedly is if it isn’t evidenced based don’t use it.
Me: Why was the best advice to attend CEUs with MSU? What made that so valuable for your professional career (or even personal life for that matter)?
Mark: MSU in 1984 had a teaching faculty second to none in the U.S. I received instruction in Muscle Energy Techniques taught by the originators and first generation of instructors. To this day after considering all the courses that I’ve taken in my career, the Muscle Energy Level I course at MSU is the best course I’ve ever had and has been the most applicable in my daily practice.
Me: Regarding the worst advice you’ve heard repeatedly, why do you think that is bad advice, can you elaborate a little?
Mark: If I only practiced evidence-based P.T. the way some people have defined it, I wouldn’t be very successful. I have generally found that what I teach and practice does not appear in the literature until about 20 years later. We need to remember that evidence based medicine has three components, research is just one. The practioner’s experience and patient satisfaction are the other two.
Me: If you could challenge others in your profession to something, what would you choose, and why?
Mark: I would challenge others in our profession to open their minds to new ideas and techniques that may not have evidence to support it, but experienced therapists and patients know they are effective. I personally have found that I’m 15-20 years ahead of the research that is coming out today to support what I’ve been teaching for years.
Me: Please tell more about this. Can you provide some details/stories about ideas/techniques that you’ve found are 15-20 years ahead of the research?
Mark: I’ve taught for many years the importance of mobilizing the mid thoracic spine into extension (FRS correction) to enhance facilitation of the lower trapezius which was confirmed years later in studies by Josh Cleland and Jon Lieber.
Mobilizing the thoracic spine and rib cage has a powerful effect on the cervical spine and shoulder and are techniques that I presented years and years ago. Therapists still don’t realize how powerful mobilizing the anterior rib cage is for treating spinal pain.
Me: If you could only treat one body part/area/region on every patient, what would it be… and why? You can use any techniques you like…
Mark: If I could only treat one body part/area it would probably be the thoracic spine and rib cage because dysfunction in this area influences both the neck and low back. Treating this area also addresses the Sympathetic Nervous System which I feel is often overlooked.
Me: Can you give any examples of how treating the thoracic spine and rib cage can influence the Sympathetic Nervous system?
Mark: The lateral sympathetic chain ganglion sits in front of the rib heads so that when you mobilize a rib in an anterior to posterior direction you directly stimulate the sympathetic nervous system. You also shorten the intercostal nerve with this technique, similar to using a counterstrain technique for these nerves.
Me: Also, if you could only teach one thing to every patient, what would it be… and why?
Mark: If I could only teach one thing to every patient it would be supine pelvic clocks because with this one exercise the patient can move the lumbar spine and pelvis thru it’s full available range of motion in all planes.
Me: If our followers would like to learn more about you and/or your work, what would be the best way to go about that?
Mark: If someone is interested in learning more from me they can Google Bookhout Seminars for a listing of the courses and locations where I’ll be teaching.