Maitland's Vertebral Manipulation

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MAITLAND'SI .. mmmJ

Vertebral MANIPULATION Edited by

GEOFF MAITLAND ELLY HENGEVELD KEVIN BANKS KAY ENGLISH SEVENTH EDITION

Maitland's Vertebral Manipulation Seventh Edition Geoffrey D Maitland

MSE. AUA. FCSP. TACP. SASP Mapplsc

Edited by

Elly Hengeveld SellPor

ltac~r; Int~rMrionol

Kevin Banks

MSc, BPT. PTOMT. SVOMP, IMTA Memb" Maitland T~chcr'sAsSe pubIi!ber; .... a llCe1IClO pcmuu,nf 1'ln ~i"hI"

~ln'rle/rnechanic.>J.

~pinal d,sonl,.,... Manipu"'li,·.. Ml)'liiotherapy, il is de-.u,lus an Important role to pta\ Wllmn!he recm'~ and ~Nbi'ilationproceso>Tk ablbty 10 identify and "leal" Ith s..--grnent.>! mobili!) U!V"inncnl, ni!UlOOyn.utuC d)'Sfuncti and musoele ,mlxlL1nc{', for .,...mple, "-'quires finely hml-'" although hal'ing cxacth \hie ....1TM' teiothc.apy \{) enhance ,heir skills Mld e>:perls 10 check and refinc their skills and in hun appl), such skills clinically to help maximi'" p.ltie"t ",'Co"I' ~ .... ronsoderab~ guid.aoce conammg d,ff~""1 ~ of the work. oarnt.~J tht' tcadung of ph}"-';lOtherap} >tuoil.,lic and neurological disordl'N;. Later he oonlinuro working part-time m the hospital and p"r1-hme on hIS 0....." pri' "lccllnic. After .. fe.... )~'il~ he b«-a"l-.e a parNImJ ,"~tin$; lunchtimt' climea! SleSiSions and d~ions With James C",""" .. noJ hi~ staff From this tour G D, \-laltlilnd ~"blishcd a friendship with Gregory P Gri..,",~ tron1 1110.. UK. They had t'~tens",,, correspondence about Iheir dmic,11 ('xpctiencl's and this conh"ul1l1

0\-'"

..

wh.."" how lInd whl~h k..,h"iqll~'S to pcrfonn. nnd a,J~pt th.-'SC to tile individual situation of the patient') and .. total (ommitm.. to Ihe patient. M.liUal1d 1\.;>5 held " ~ .md ""h...ui...· comm,t" ...",llo , .. riou:; prnfCffiion.,1 lIS.'lOO.1hOf>S:

'n'

Austrnlian 1"Y"'oolh".aM' A-.ci.Jlioo {APM whcft, he "-015 on IheSlate branch comnunec for2~ \'t.\1J'li in \ ..OOu5 cap.1CitiSOC;i1l1on (l:\IT,\) .....as found...,j,

810graphy

of .... hkh G. D. \laitl,md is a founding member and inaugural President A1Ithis w(If'k w(>uld f!N M\e l>een po;>;oJl>le" linout the kwinS ~uppnn 01 Ills wife Anne. thl.. rnotheT of Ihcir Iwo chikf"-.... john .. nd Wench: Anne did most of t..... graphic art;. if! MdJlbn..l·s put.licdlion", l"J'I ""teed in Ille 1".\1 of Ihis book. but it ;s understood to mean a form 01 A~So.'Smenl

(see A,se-smt'nll

GRADES OF MOVEMENT, 5.,... M.,"e"'''T1t HYPERMOBILITY. Sec lT1stabllity. Hyper-mOOlhl)" I~ ,In ~,"-""S" .. rang~ of mCl\emC'1lt (e>."mples bein!; hype"",IL'1lSioo of th....lbo" Of ~..,) for which the.... is romp"'te mUSClJLuronlrol thu~ prO\idmg~tabilitv" li\STA8IlITY. This lenn is USt'd onl) 10 meao ! move during "'''''ry pas.siV"dOO dcl,,,(' mO,'Cllll'nl. 1'-TRA-ART1CULAR refcrs to llw.'slfUeture(S) (f1) from thc~bchondral bone to th subchondral bone of ~dj~· a'lll joinl surfaces, .nd (b) including e'n~""1!ling ",ilhin the joint spac~. ,ncluding th~ innl'f c"P"u1". PERI· ARTICLlAR ref...... to 5lructures OU~oi' tIlE' joint. act....enol 10 ,..ld mduding tho! au",," rnpsule LATE.'\lT PAIN. s.,.. I'"in.

LIST.

~

J'roiol'di"e I:lI'formil)".

MA~lruLAnON.

l1li5 term is

~

in 1"'0 dislilld

"J}'ed. 11ll' h.::1"ITlll are not essentLilllO the prptf'd by medic.. l pmcl,hon"N if 'upl'"r 11mb ne"ral mOH'mcnt tests' or'''PI~r limb neural t"sts', ULNT, "'''''' llSL'Cl, OVER-PRESSURE. Every ~litll has a J>ds it.. ach'l' range. Further nor· mal mO\em""t c..n be addL'Cl to thil; pilSSive rangl' by a stretching applkatiOll of o\'eT-pn>ssu~. This O\'crp"",,"ure rilng" ""11 Cau..,., " dL'g"-.... of dis produced by an~ mroll5 otho!!" thdn the pdrlicuLlr m~ ~lated 10 tlt.ll pdrlKu\.lr Slog· mcnt's mo'-em.... 1 is a p.1SSI'-;> ITI(l,'cmenl. It includl'5 both mobiliLllioo and m.anipulahoo,

~mmt

PHYSIOLOGICAL MOVEMENTS, TI>o.'.c a.... adi,,, and pa""i,;> funclional mowmenls. P,'>oS,,-e physIlr lo~ical inll'rverlebral m""cmem (or inlcr-segm""I,,1 movemcnts) is lIob....."i.1'"d 10 I-'I-'IVM PROOUCEfRErRODUCE. '01.1' aim of physical ">:aminatllm is Iv provoke, with lest mO"eml"llIS, etttler an abronrm.'] I\.'tipol'Li$ (protectiw deformitv) (;lin gcrur without 'so· alic' p"In. Iletter kTIIb are LIST or SHIFf (str P"80 131-132 ,md 350). do.>formih~

",nd m the

RADICULAR PAIN. ~ I'ain.

REFERRED PAIN. Sco.' I'"in. SCIATIC SCOLIOSIS. 50...: r"'I*t wx', ,.mdl,-"'l ~.J.lm-t~ lfilnwlr rlrli,>11TSS. MtJIlIJ7I. ,

t~'bJarlbox'

n",."a..q..ny

,mJ MrlJto;;lmiquC$ ~ing uslic litl('~ u;;ed b}' sum" m 1. COlllmuOllS ~n~lvtical as;('Ssm"nl mu~1 be carried oul during Ihe ~rform"n ~g There musl bean awal'l'f"lCl6 of Lllenl """"""Nliooru.lhal were not

idePI al the time of the JOllnl consultation and must ~ clanfied befl:R seloe usN ;n man:" wa}"$. \lC,hCd.l~, il can be used loosely 10 mO'an ~\(' mm.11 8mpliwde manip~lalive thfLlSt let"", to tho:' ~ of lhe mU"'Im.",tlthdt ,t '5 al all time;; Wlthm the .. blhty of I~ p-,tM'fl1 10 p",,'enl the mon,."..,,1 if he 'II'" ''''-'.10 d\OOSe$ («< PTe!"'ce to Fil"5t Edition).

lI!obzal O'lS~re performed ,n such ~ IIlinntr INI lheyan lit: ~t(lj bv tile poItJmt

Tho:' IWO type.; of mobilization ..n>:

('(InC\.'" r"""'"

THE RElATIONSHIP BETWEEN TECHNIQUES AND ASSESSMENT Marupulal,,·.. lrNtmenl c.ln be di"ided inlO four ""''''

I. ['"S.enL w,th lhe tccluUq....'S and their itdap"'-bilil)' koiOl; 1;1\"" lheirCOl'Tect relationship 10 the ...-hole. In tact. the greal emphdsos on pam and other alllCd s),mptoms. This ('ffiphasls .... eXrLlmed. 10000000hl.. wllh the other aspo."C15 of It\I' con· n-pL Wlder the ~ ...Itl hct"',ll.COUf':iCS thai consl5I lI\iIinl} of lU'lhcrapi'>lJ>' lJUIlds mu:.t bo.' 50 ope!' thai Ihl.')' tht... r I......h rnq...... until ttl~1 ocm.,,-e !hebasK:trealmo.'f\ll"'Chnoque mll>ol indudcC"ery mo lotill conili~.ltion Ic'Chniques inciudtd in lh" \l.'xt of this book W"I'\.' fi ..... t pracHsro in FranC\'(",'C:ami~'r, 1&'18j,and

it i~~"rt,~jn thatlhe 'boneseIK'1'S' of !X'nturie; ago (Cl'ri.. " 1Y7Si» 11.1> (',,!so praeli-....t t....,,,. \\'(' mu,1 al",,,}"!; a~ln('lwledgelhal'~ is no ",""" thm~ undl'rthe ,un' (E«le:.ia~n.'s 1:9), and thai

all "'" do IS ',",'uk ,he ro.od mao.. b)' cf,bed ..,~.. tho;> cl!fllunes Wen!: pll.-d ~ atop anot'-, the ho...¢'1 of It-.. pile "ould ~ l$tounding E,'en 1"","- "II tht- possibilities would I\Ql tw,e been exhilu~1ed Th\"I'l'h; an 'ffiIIlor of d,ffurI!fll t«hnoqu.I"'u.>bble numbt.'f vi '-,In,,lions 'I h~s !iUt\>o."i;n,,-,,> been SOlId during ~ demonstration 1"'.. ln...." 1 .... f a f'l'hent, 'You dldn', ~ach U5 Ihill IlXh· "'que 1t' demancb kno....ing ho'oo.- to n:wlc It>f"l'st} I" or mo,emt"llhal can boo osed a~ a Ire.umenl 1~'Chruq"e Cugh-.anl;" situation Lnder Ihese circurnst1lnce>,. thlo tft:hniquc wIll 1M.'hou1d the ~Io\", 5mOOIh te;:hniqu... be performed? If w(' roru"dcr IIv:- "cry pamful di50rd('f, II should unlJ.illh be psachrooic di:,t)n.Jc." hkh is ani!, pron,ked b, mO\crTI"nl at the end-of·ra"8'!'~tretchpo>oition. il "ill probably ~uin1:1. siretdung. t me-physiology of pain. as IS .... td... >flll

III",,,.

lb."",' facl5.aklni.' dt-'INtnd thaI,..' -.hould nol be dOS' mal>cor riSId ,,,~>nuI whkh w"cun make spr SUgj;'.'l;ta hypothesi>. In ~ummal')' th~"" 1 1lIt:'re is much we do know 2. There is much t~e Ih",~ we know. 3. The", is much more we dn.ooI knuw 4. We can J11ilke "/lI'clllntkm, 5. We can propose I'''IIQII""",,,. l1Ie four

m.>U'l

are"" of mrdic,.1 I and ,....,,In· ingful dia8"0,is, as well as arriving at a de,.. under·

standing of both the sl,'le and slage of pathologi...1 ch;>nj;('S and lhe ",k",nl b,on>l'Ch.lnW::.. 1 implkanons. An example of ttus is giwn br );lacnab (1m). Of 842 patioenb opo:..at;.>d 00. for disc pathology, 68 w~...... found dunng Sill'gl(all''q)lorahon to lome cs lhal were not abnormal in Ihe way anticipated. A•• of Ihis Sl:r;l'" of palienl~, fi,'1-' T\:,'sons other 11I"n disc hl"''';,'' lion we ... del~rmin~"I:I for lhese p. TIt", ~' are ~ imporLmI rt"awT!, tor employmg Ihis reat"re of l',,,.. ; :ompartmcnl thinking:

" ,"".

,," ,

ev,,,,

1. It cnabll'S manip\lI.ltj"c lreatn",,,ll,, b.. ""od, illhe di,lgno,is i, nl,t prI'Cisc, pn" Idt'd it is ktl Me ansing In)lll a neuromU5 .uit~ble ior tJt:"lment by .. physiotlw,.apist u~n~ p/lSoSke mm'em'~lt Within du, (ontt-d ,he manlpulati' e ph,·siotheraplSt. ulld('rstand,ns lhe patholog,c.-l MId biomo., the 'symbolic semi'p"rme-able b,,~~ l\",'il' Tht" dividing hne be!>..."" the 'th,-~)",li«li/sl''-,(;' ulati"e' compartment ind thoe 'c1inic.I' (omp.,rtrneflt ., the 'brid. wal1'. It is not a solid ,,·all; it has rna"y

7

~AnLANO'S Table 1.4

VERTEBRAL M A = O " " - - -

The 'pcfmCiiblc brid wall'

op;."fWl9 kI aJk"..,·lhough15 to tim,- from ...... (ompartmentto ~ ~ (T;;LW I.':).

THEORY T~bfllJ Ilh,I"lrate< ,he relationship bctwem t/lelh."-"hear kOO\ ",,~t feature of me conc~pt 01 this le~' Il'!>t!i "'Ilh lilt> ~1a1..' 1n... "t, 'V.c must not gel di\erted by the !heo~al aSfX'Ct5 of .. patient's dISOrder such thai it is to th.. dctrinK,U of the clinic.l1 aspect', ThffI';< ~1111 an ..nor· mous amount ..cdo not know, and till' fhcoory m\l.~1 be ~'t.~1 In a b.,lnnced way. 1\"0 ltxampll'S follow. "The first c"ll'h.ui/.c!l ex""",,," .. attention being fOCllsed on the racl"'l;"'phs a"d not rel"ting the"e findmgs to the his-

'marked osteodrthritis' SIlo: certo,nly d,d ha'e gl'OOiS joint char>gl'S, .. hieh wen' ob",o"s both chnimJl}' and radiologically. Physically. she h.td. 35 I"'" cent redllC" non in r~np', p"in on Sllrtch,nl/- and considerable rainless d".. CI'll"tus dunng .tel;'"" mo'"emenls. When mo, 00 passnely with the j;!mohulTM'.... 1joinl surfiK~ c«npres5ed, cnepituS inc~ and dlSa)mfur1 (not "",in).,.as plO\"okd. mar to ~ot of l>} mploms 6 ""«"ks rn-'YiousJv, although she me.-".>he n"d an arthritic shoulder, 5hl! did not ronsidt:l'.;he lud any reaJ dil>abililv. The 'majlv su'}:l'n" option ""itS b.osed on the radioklgic:al findinp .. hid\ ........... inlerprded ~m;call\·. It would be unroiIli:ltiw:. 'no:/ud"'S tM ptU3ulions iIIld ~b1( ronlratnclJcalJOm for llNt'l"Oe'l Olr orllft C'OII"~rtlnml.ta.JdCOIIta'n l~t d'NCllI ~ [hr.tory. """' nd ~IOt'lSIIO ~ .asscwd ...... rvalualrrnb h~r hair or Il'ach fa, eI1OUj;h behind her b.1ck to do up he, brn»iere for 6 wl."'ks, She IV"~ h;>ld dUlIlhe only ,~)ti",J..~ vpcn to her were 'm"jor surgery' or to 'put up with if, She n~fuse. !he :>polen phra:>e:I"O",tiul knowk'db'" '" a p"ticn!"$ presentin;; ~y"'pl",n;; and ~;!lns plnces """ther dem"ird on the manipulati,,, pll)";;;olh",.'p;;;t. who mu;;1 employ a ~pt'C;al pattern of IhinkinK "hi~h ""lu,l"\"5 "cry can>iul oeleoction of the \\(1rds aoo

A

""'rle .'>.ampl" rna"

Ima~il>e

help to make mi. point c1eu. a physiothcTilpi.>! pre5d by \cfllateral fl,,~,on and ..~t~.and lhal on foO\ an! fleuon ht.- R.'llis an arc of n'n" is perlo.med in a Jl'OSIhon of roughl\,)(l of lrunk f1ex'on. 'The r.. ngt.al back pa,n One of the quiclans ,,"" familiar Fo< e>:ample, in the foIIO\\'Hl~ li,r of aspt'Cts imporlanllo e""mHl.ltion. t....o (number< I and 2) Me not cvm",only u>l'd to tho!ir fullest ,'a!ue,

Sometimes the only 5l~ lhal can bf, found 011 e~m,nabon a", palpation ~Igns. "'lule- all pb~io­ klogICill.lnd functidetermine \\ltich structure or mon'mcnl component IS in\'oko.'J>ed observalic:w'ls). This is~, but rnany manipuL,. hI'" phYSlothcr~pi.lS do not appreriho thill arc ,,>00 who...... a J"'S'Sil-.:' I,.... mon-..nenl, uwoll-inl; s;m"llll.1ot'OUS n"", ~I of ..I ""'~t two joml> or ~ following In'atmentIS c ..... r-c""se mmy paticnl§ do not hal'e what th,'y call f",in, so tll" wmds di,r:tmrj,Ir/, an l ~nd ci,olOl t"~~e ..... i\h

ClIttCAl. -:t pallen... Can "",... diHerenl KI'lOS of "",in "ilh,n one disonkt" App....'Cialm8 the implications of ·pain-lhmlly.-,.-ange' ·ft\d-of-nng.... ~n', 'Ialent pains', 'pain inhibition', and und",,standing the 'irrilabilily' of a d,,,,,rd,.,. Wllh lIs Impli,ations fur guiding trcat"","t e) Milking 115n-judStmtnt,t1 m.ll\ll... Utlin .. p,tlitnt.., y'" questim them.. Th" i!; a '"efJ' dcr:l.:mding 51 d 01 self-c.llidsm. 8. 1 ,,( thoe''''''g~_ Co'ON..,art~~

""'II t an...rysm

M:mo'ml" • conlr.llI1,hcabon to mom.puLIl...... It " moe that the p"·gn.""'r prescnls ....·o::h.lf\ical and tl.'du1.ic..I prot>Io.'Ilb. but il markal pain b dl.... rty orismalinj; within the spire thl"f\." i~noA""'-""ute oor ~ manipuLaIJOll pn:>Vid...:! ral cilroIJd artery dis· ...,5e, particularly iIJlY~I..-ordl5l"rbaJlymptoms of ,'cry long standing 'md then app,:tlv SUrn" unwise jXlSIU'" or by a reps lobe 1"fOWC:tCUS6 Iilc>ir pain in psychologl{dIIC,m~An expLmahon U"II 'somelcnse P"Ople get p'-'phc ul,;.,ts, whi\eolht.,.., I"we Il'I\5C nl"Ck muscll"':l alld a p;,inful ",-"Ck' mar be und..,.... !toxxl and accepled, w,lh obvious ",lief that the C~ll,;o;, Is nothing more st·ri"". Sometimes ol double ;'prro~ch is r~' provided tlll.·y .l'" abo lold l/lallh", ha'ea nUnOf organic condition Ihat ,,1.11 probably re,;pund to ph,-,icallroalmenl.

21

23

3

Chapter

Communication (with a contribution by J. Graham, MS, SS, FRACP)

CHAPTER CONTENTS Non-~rbill communi~tion

Vl:rbal wmmuniCliltion

26

29

IntcrYkwing 5lr.iII'i 28 Wording 'lulls 29 P:ilr.lllclrng

29

Bias 29 Brr-.lly

30

Spontaneous information 30 Kt'fo"'Grds

Errors in

30

v~rbal

communication 30 31 The reason behind the question JJ Misint~rprcting

~umin9

34

Verbatim eumpks

34

Immediale-r~on~ qu~tion$

35 I. At initial consultation 36 2. Oarifying wbjmivt" assessments 36 J. Subj~ di~renm 36 4 At su~u~1 lrtatllM'nts 31 5. Non·~rbal ~ 38 lCqwonh JB Sp«ifkity 39

an.., of the mOl;I important 'bpecb of thb cone"!', of "",,,ipulat;.-!' pfll siotherapy. as SIMt.'o(.'SOoIHl'nt, and this has ~n further t.-mphasilC'd b, extending the s\\bjO'd into ,'n"li'tlcal ,lso;essmmt ("',rp. 12-1)), It is. as hM bern ""id,th,' k.-ystoneuf th"",m""pt, and ,f the keystoncnCffO"p H prob· lem, knowing thHt this very matt~"r '''Ucsts U\,lt wme spt.'Cial extra information is '"mb-dd~'',

.•" "rl; 11••1;, r, lit... il

~(tJm'{ i5 il..:~',l'1{aJllr",

d;fknjrn'" """""Iy Mm.,~.

Hmri","'''1 oppm' h.mit,· for us tu notic,' the possibilitiL'" for understa"di,,/\ nnd for misunder::t.lnding our OW" ",,,rds and intonalion_ l1\c skill mll,1 be denlopl'd tn a high i",,'el if a r,1I'ent's rroblo'rn is to be understood ,,'ithout any d,'iall being mi£sed. SKIll In communk'allon is nect5,-;an' If . J to begi\..... to" paricnt•.., that an' I"Q!6ibility (>f being mISUnderstood "" il'0I-ded The ],eJ,rT\tng or tIus art or.J;,ii1 r'l"qu~ p.>t~ humiJdy. cllri'}- and .self-cC'_, the phy"otherapist should 10II, ....I/cll 01111.'1 115 10 K'" arllJt'llllS ".\lIf;IIYIl5 p''''-';Ib/r wll

''''ltd ~"d "''''lllt(J/''rI'.

if vIII'

(So' En,CS/ euwrs, 1m)

Lst...UF~ is rtfrij, c1 roursum .". IhIll is m'trrr it II Jtr- mn'rlf/lwring, Htrtrmg IS / ; I~n""s dnnIlnih 1It1f'11lm. H,."ril1~ is rwUltnrJ, (;"fc""'K l$/ln .,.""in'd rf,snplmf' (11or ,,~, 21 "UI:""

1982)

Lere arl' of course m.l1lY non_, erl>al S1gnal$ltlall\te consciously used by the ""lient and ",hid, uo not ah",ys ~g"-'" wIth tt'c;r 'Nbal ml'SMges. It is \'~"'y import~nll[l "olio' the "L'l'baland 1I\.lIl-,erbaJ mt.'SSage; logether and 10 be aware of ",hen IhL')' match (ClllIgrurory) and whm lhey don'l m~kh (in, 10 be ~U'>pLCiolu of the new u.e.-"pies, ,j,if.. ~1 charadlTl$lJ(S, d,f~1 k"e'" of intdl e;~, and nt'~ nu.1rKe5 correct"', brcau"C' hL. rrame of n ~ ;" prol;>;lbl, qUite differenl from Ilt'~ 1'1150 pil" the P"-'C~lon of lhe inslruc\ton, il is common for a patient to bend huther and furthcr, fedm" mof'\' and moee discomfoet. During the bending fo""ard the i",henl tThly, 'lulle "n(()nsdou~lr. dl~play a ""f""erbal mess.lge such as bi.);inning to purse his lips. If this is5CL'Il br!ll, IN ph,...JOlher-olpblcan Jooam mud> aboullhe pat>enl iba p"-"'fS(II\ ~ ......1as I'lis problem For CXilUIflk-. the mantW!l" in which the I"'hcont milk... his iruliaI5pO!11en15 alone, it i,; likely lNt each of th""", IWO p;.tient:; wili ""'lui'" difl,,~t t"',lt:rnent Such milial sponlalll'OUs comments wilt &how the pall,",,!'s athtude oowards Jill. prob~. and 1l1oI" abo indicat., h;" 'I'""n thN'Shold' a~mg thlS_ Pt.'1haJ" the 'ch,1ngmgnljul:": IS A"l~Io.>d ,nsome 'yay loa chang..

One ,en- important element of the inil1al inh.'1'\'leW is inslsht it pron.J..... mlo the lind nl p'. ....... lho.' pabenl is, for this gUldI.os to !hep.... en... ~nupt hun m,l\' rna\" and ~'ponding 10" p.~tOenl" ,mswc'S, the nlimber of ind"'idual words used b)" the manip"lati\"e physiothcr,1piSI ShOllld be kept hJ ,m absolllle minimll"'. 11,i5 i1"(lJds ronfus,on in the mind f tho.· P.,hl'fll and miSUlldcl"Standmg.. and it also «.'n,;o....... ~ time. Ilo"eo.·~, ...·hen using ron'('1'STd Can a51: II question ad"'twrely, lind th.ol """,,,,"ord1\"'11 nnt (Irll\' 53'·e hlTM'in a,,1J~ the question, bu! will .. I~ ha!otm the answ~ becaUSl.' the p.'tit.~I's thinkIng ~ are thrust imo Ill.> quick answct"~iIUdtion.For~mple, if a p.:tlieIl.! has >aid Ih.1t the polin 1IJ"'l'00s ~~ both ~ig sk,' IS Be: a"""~ II a I ti-s of po55ibI~ ~ ,n tilt

non-,

SPONTANEOUS INFORMATION Another important -,'I' qur:.:itm,

romrrlOll1C3llO/l ~

Usc 'mlbad. loops fur dlmlOhon and ck..... mdmt;ondillg

ERRORS IN VERBAL COMMUNICATION Thai JX'Opl" run into d.Fr"""'IJlties of misund"l"OliInding is indisputable, but thl' whole SUbjL'("t is 1'\',,11)" much easier to undersl.lI>d whl'll we examine Ihe 1,.,1Iow;rtS id~a:

11", wap i'!101 tit( U"ilQry till,! Ih.1 ,;t..1poinl is that people opemleoul of llxoor internal maps (modL'is) 11t..,."e41>Cie'llkroo~"".·~mlO_'"

lr>lq,.."'n.....po:iJ'o'eoltht.ethc"hoI.o family fIodsolroUnd lohclp "',Ih dre;slO,i;. "'ol.l\;ang.l"t(. n.. ph~~r.p~ ",-'O"(h lObe \mmuntasl until II is p."'en llut,. f...mp~. the emotion.l.l elemcnt is a m"ior f"'lor III thc P"""'slenc.. of h... ~pnptoo",. FIl,."lllcntly s,,~h judgement"; ~Oln only be made (and perhaps .'/"'111,1 0111> be mOld,,) in 'l.'tnlSpl'("t. It i" i"t"r. esting th.11 M,I..... (1978) makcs lhe "ta!emenl thai the

"mll-

fta' of find'ng 0IIt loOmtI"ung is stroously wrong, or a 0 ~Ik fo' tb:' ",nloat and as50CQted proftsSoOrls ha~ralt behind rt- q....",.,on...l And do the)' know whal I"do w,th an JIIOj"l'T """'-'Ihn' g ~.2. lst pmr......) is pmb"blv Ih" k£,\' to mol'C\'Olhim 1"1$'-" o"t of bed111m th~ probli!'H m,,~· r,., an inflamuMtory disorder. or ..I least hav" a I~rge mflammatory £omponent. lheret'on-, qws.r"",! \\""t other su"""'tiVl" qocstion $houk:\ be asked? 'What happens ..·hm}..... 9-"1 Ulli of bed'? A.I/S"oLYr. his back Should be notabl} stiff, not ""C. t'SSarily painful, it should tah- in ,,~c('SS of 1 hour ait"r rising refore ,t wea ... off, and it may not atway. mmpletelv 10lJ$d, help the physiutherapi>t to adl;.,,,,-, the d,l'U, of '-llior>s II is IT"OOt'l" ....al~lk to undenJlAnd thai we cannot avOId malmgassumptions or h}~-but if "·e mak" any ilSIIumpho,..; ""phcit to ou~k'~, we are on a good position to know lhat I""y ,,'re assumptions. and to know when Ihey Me wl"(lf1g IIr confin"cd or in need of chanJ>ing. Thl>y w,lI alsoshow how accuracy can bl" aduc\"l.'d wJlhoul the p.>timJ be1ng made to feel be Os being t..... loo .os an ,m"""ile, and ,,·ithout imtating him by ""cessi,·" n'p._"I.ihon of quc:;tinllS. In fact people hav" enornlOUS amn"nts of informatL(II1 ston.>rl in the compuler thm we call the mind, and illS ... gmuiroc "",pt possible way to word it J.. IVhal d,fferenl "..,..·cn might she &"t.

Communitation

4_ I low the ~ble "."Iy to h..... quesbort'i might mflucn.... her planning: ahead for dle roed question., II IS probably the bst of ~ thott f"kki Ol.It the good ph)'Siotheraptsh from the Ie$~ gaod A mi;t;ake that ocru...... t.a,nee nwnipulati,·..

,m

ph)'SlOl.her "ns""er is us,.., lly tn be dJ5CUSiSed in tt... followlllg groups:

lom't~>d ITIO\ "men!. Co\f\

1.

tmm«lii\t...~~

questitln.. in

que>llOllS - immediate crrtam of' the p.otin\t" s

~ to

staremenb. 2. K.........ords - words that Indicate a plitJns: ..) During a retra>pectl\ll' asso..'5SlJlC.'I1t b) After "a.;:h three to fi,c I"-,,,tments c) When prog~s hilS slowed or stopped d) Following d break frQlll treatment. The g"-~ltl",1 pcr10"''' what would nil'·" rulppt.·ncd with ·hemming a .lirt' before treatm ..nl.l-rom a communication [' tMl an! sl.. "'m,"'~ l.f f.ld and "hoch. if aocepllod dl fae,," ,,,h"', 8"'" r..be Impn!SSions. Foro.ampk', 'oUIm'-

'Wh"t is it "bout the pain th,'t n",k,,,,; yo wmploul>I rel""-...:I by trl'.:Iring hs hip.

""ere

"In

ins

lilt- qll~tion. '1-10" hal(" \'l)lJ ~~ the patient 1IIiI)''''''; 'Bt.'1!tter' must bl> loIkw-ed hI' '!kotWr than """"'''', '8l'nt,.. than rrlllfl?". ~Ilct\l.'" mdllll; .,.~,.. [n .:JctuiIllo>ct. 'Ill,",.., ltun" v",!' m.lV be nwdmng bo-Itff 2~·hour ~11"" he had foIlowiOj:; the treatment (of "Itich he had bero ..... mt'dl. n... folloo fn:om a «nical dbord..... (Jl' a glmo-humeral lii;;ortk,r. Oun"8 the 'il1bf;.'CllH' "",mmabOrl" the 1h11i,~.1 m;l\ rn.'ke tho: oommmt, 't k,,-~ it ",,,5th '~Ilh ,!UK-I.. m",-,,,ncnl!.·. 'The immedi~te-fC5pon>eq",-'S­ li"n... hi,h the p~iothcr~p;'l nm""ll'I..,,;";

Q

·QUld. mo"ementsof whal?'

""d lh,'n, (o110W1l1g thul1derslood nor ignored. I'or ..>.X.unple, h" may say" 'When J g(.'! the P'J1Il. ,I 1"",ls like a pi'lCht' are ne.

(3) Q

IT

T1n:;~i$~t'{'n?'

'Abitstilf·

fT n",,» i".......,.flJt'r '" lbul his n",m frr/lc w"Y~ on ,,-hich ,I might be (tiffel\.'l11. Tn fact. the patient's anSwer to the '!\ood Or b~d d,ffcrcoce· q,,,.,,!ion mar "iv" more answers thilll{'Xpt.'Cloo

4. AT

'Hm,!tasitbo:o.'n?'

A

(8) Q

"Is th,ll unusual?'

·How h", it box,,?' 'Worse .

37

38

MAITlAND'S VERTEBRAL MANIPULATION

'vmnit" is.J. ~t:ltrnl('f\llhat must ALWAYS bl' c1arifocd in dL'Pth """ny 11Illol"S" p"tient ",,11 m.,ke lhis n....pon>t. whffo. on mo", dct.lilat ,m'ingmon:o

!'Of'C~'

IT

oompltA

All of ~ abm., eumpJes 04 immediale-responsl" ques-tl,,.~ .-()Illmunicalion, lout tt..... ..... "",n,' ("O(.J.mples when the t:! U'mf

tI.-'Sl D>O\L..-nml

n..

ph}~pro.t

1N1tSl '1uaJil)' such ""'p"-"'6OOfb. for l!>.omple. in ~ to the que;tiorI.H~ h;os ,t been'"', It.. !"'timl "'"'y "-"'-POnJ ~1Jl\p1y by ... rinLH~ hi OO5e "The inm-.'\iiate-response que;,tIon '"

/I)

'Thdl doesn't tool- 100 ha~ beo>n w~"', de.

~_

Do you mean il

r1iUlft"'=~f'V'lIIl'JnJ"'''''Il('!~''Tlll(rlilol!l aOn' u1k'TI IWfillJ>llnl Il'l' phy.;",,1 e",,,,il\o'lioo, whL'" Ihe p.'rient·, mowmenls are bdnlo: k'SIt."d, the pulient n",y screw up ius "yes o. m"ke ,n ,'ppmpri.>!e cringing mm'CmL'fl1. '¥he" such ",,;meL'S 01 ~I,"";our OL'Ctlr. the phy,iothe"'pist must relurn the p.lli'~l1t's joint 10 a pain·fn.X' po5itiol1 nnd im",ed,,,tcly ~,k'

!lUll,>, Ira, /1,.. 1=1",..,,1 /1'(I",i,/II,· "rilal~

"""1'

Ihrnibution of lh""ymptorm.. Other common nu."Ula.'S thaI n.~IU"l' an imm.,,,hdteresponse question are: th sJlmplu"",he felt from thellme immedi;>lcJ.. following the l.'~tlr~..,lmenl unlilthc mo""""t the qUC'Stlon '110.... haH~)'OU~?' is.lSh>d. Tho.'P.lh('llt musl be pem,illed 10 My Wh,11 h., feels is flL'CeS"lry, pnl';dt'd lhe physlotht'rapist d.,.,,; ,wI I"", [MImi .1d?' or '00 yo;, ft~1 IhL,lasl tn."lm..nt h." nhld., y01l any WON'!'

rrequenrly dunng qut'Stionmg .. patleOl wm use a word or phr.ose lh..l1 Ius a .-.pt.'Cwl slgnifKanoe. FailtIn' to m::ogni"" the. ml.".:lftS 11>..1 ,m opportunity 10 impre then" /Ililj bee11 sore 'since Mo"day·_ jrr~"'fX'e Mo'ld.ly" 'Well, bl,ocause it is achIng just the same a!> it w ........ henl fi~t began lreil~L'

The

1L5f rould

goon, but"lltMI is I\{'G'S>"lry b to know,

1. I low to spolthe bnl'uafle limitations

2. How to get Ih ... p,ltil'l1t to ,n the fact that, now. the phvsiot/wr"pist knows

c""ngoo..

two Ihings: II"r techn;,!u" dId not improve th" patient's symptoms 2. Her teeltnique did produce SOI'Cl1C."5IS, ",hich holS no! 5ubslckd, I.

rer

Therng clanfled, a wrong tl'Chruque m,ght ... ell be used. There .on" mlIny l/u!anlXS of ke}·WOrdS. such as '110, l10t much·, or 'no, I10t {'Wllv', which indi;l'(:,md group M pal;"nlS. ET

~1l"W"r-qLJ~li,,"' Mll,latinn

I. If the p JillJ ""l ,,'iull 1'",,\1k.1 il TIlether thephysiother~pist allow,; him to continue as he chuo,""s, or eilher brings him ,..., ck to an;;wcr her question or gently coaxes him lo answer some of her other questions, will d~pend on Iwo thin,\;s. The Il10t is, how much of his talk is likely to be talk for talking's sak('? The Sl'Cond rdMt'S to th~ aJ110lU1tO! sponta'>iour of a patient ~ s' mptoms.l.nfortunatel}', tune has to be!iJ""nl if the ~kiU is to be Jearnold, for I'lOIItin~ li1i1oCf'1e5 as " ...11 as ('>:pem.'oce "The Information ~uirnf, ",lati..., to the beha_ jour at a p.ltienf.ss...mptOD'b, is,

Q A

'5 roo do "'wc SOME stages w",," it isn't achingr

A

'O"I)'aIRightlt.-cha!;I'tI..Lda)"

TiwrrordCm;5TASr rrlJm IUt'J bylli/lmls is ooufUv "'\:'rJ;: tim at:"'V> Mi,mr,wify"'l1 IT '1J;als new eINT. H.. IJimbtrX pnxn. II labo 10

",Id

At""

,llh;.idt7J Qtl,~ 11I~I/IrI, .'ifftrrcr...clle t..""t ..... Ialel; only to the beN, iourof th" bacr.:..clw

n....

IT ""rl," ill II" illl"",jro,lr 5IIid 11i$ /taet.ldlr :1'r!~

ll>

ro"'~\Jrrd :Nil. 1M mOlt~"':UY 51rD71"'''' fbi.;" 00n~ "", !lv,ht filel lloot. jurpri;,;n.~ mm:1\'T plZl~'$ S5Ol-Tf.r..lJ', Thr 'U"'./t1", .. Jw.' m,d '"" Iilf"Iplllrm /ITt i'Kcml.\"l/iMr, To 1I;'t!t ·,j"'}'RIIl'S hI> "SIr rl',colllll' 10 j.'e ,'ary at all dming Ih" day"

A

'Ys,t,oru,.

1_,...of/"'Wl"·l)r·Q.Wl51"'--"''11 ache. ro!!I"r. '" 11> :/\'/1 as. lit,· ,itrmg /wili.l;; for mt, 1J'''folloll'lIli< q".. ,t"m 11I115111rJ;hurlocffwllm tfrlil. TI.," J b" I:~ lud.\-mtmI .."""'II!ft'JItI.~11O>iI. Some ~ m.l\' COIbId..'I' lhe abo\e .. 0>"·"15 ...., 100 good to be true How........., as lhoe ph',">lMr"rrsl Ie...... how to ask kl'Y q",-""MJnS 10 elll,)t sront.~1\O'OU:S ...,Wet'S. so IN! "ns"er; "'--'COmMom.....b .ll'C'of gre.~lef ""ILK' for ..".,..,ing progns>. lolhe ,demng doctor, The bd,.lIiour of lhe ralll..,r~ symplom of .I,ff~ may .. bo be :.ign;fi'iourollhepaini> Following Ihe sub)ccti,l'U !iorn'iIm' Tlw plwsiOlhcrapist should be e~pA.'S8mU(hlolhephysiothl'rapist,provided..nelis­ alert 10 these expl\58lOOS and, more importantl\', IftlSwllh her mind as well as her ea.... Dunnglherooshould respect them and ad upon them Sometimes il suJlahOn,@'\'en-possiblead\anl.1geshouldbetakenoi ise'\·en~rylob.lLan«'lhclmportan«'ofthe all a\'enucs of both \ erbal ,,00 non·\ etb.JI oommunlC'" rM't'dlOdeterminetheonfonnahonagOr\. Thl' more palJmlS one ,"""", the quicl.er "nd the u~thep.1t>ent.Ondt'«'mtirungtNlthe"'lteris ~xro...tl"lhe_ml"rltbl"t.............. the ~ Imporunl, she could temporarily ......u...... 'hl!;dr1llYl/~io'l'dwlrlr"""dml(ba.-kul/lrdsl!li1'

Q

-..o...·lctmesee~ouix'f>dIo~ ....rleftSide'

And..., thel"Umif\oltlon ronhn~

!iOI'fM'oftheans... ersand,if,lisqullesafelOdoso. dclerSOll1l"oft","examU\ahonloalalcr~She

could ask lhe patienl 'Can ) ...., "nd y....r Nck. c"ry quickly g"llhis mf5S 10 wrinkle the mu~k~ Mound his left "Ye, Ihe vary Ih" questinn. On tt'Shng tile fourth ml>vemenl, immlodiateresponso-muslbo.· whc during the p nlaY bcl\il,-e in one l'Il throe ways; 1. "The 5yrnptomsdec",,;.,,~;'lnd dlS"lppOf1 al ~h ~"cre "I)(I1I11I1lrIl1tS rtali"''!!. To I'~1.~ !he~JelrmJ1"D'

A

'10", I ,J«J {if"$1 10 k1w", III u~"" """,, ITt' hi/!. 'mproved IIIld Ihe in'pro1Ym1'JlI oakrrrd nit! 00..' much better ~...,,;;,llolll dJIIInsrs m Il'.lntxJ: symptao./.>

II t\II'l ~ltiotlt'dspottlnl1roush; I tID h.r.y !",TI!C..lor qU61llJrls rrlalrd 10 h.s >ymplt"'rs llral

J alII bk, lrr.-inK rrrordnJ 1Ja.m .lId "",.w ""'III 1'011I/5 IMrh ~l'1t'ib

", hl'> lasl tmll"fl'nl

A

. And ,,-hal h,a" happened 10 the bu!tlXk ;>(hlng M\d ,ilting 0"('1" tt." Lut -I d",,"" 'I thin}:: II'S k5s0.1ting •

Q

'You think?'

"'The aching dOl'Sn'l boI:her me dunng the dn now, .. nd when I gl.'t out of !>I'd in th morning

...

'WeiLl don't sir a lot .... eT'\-- d.a\, bull impl'e!ioSlon ii's impr \a:;I: -I days-'

,rltt'"

ben~"t"?'

inS'

ha." the

ll~ r;,;'rnol!e tl",t he i> WlltiIH,iltS I" impll7'

fr.wi,,'1 chi!il1S arm'" I,ds slill 'I'rpror,;"g, _IIJ al III ""t "'~I'(J, 1I1'1""'rs Mlf15frx1 prim.K)-of the ,ubjel' ddined?

69

Ideal spine 69

A.V\"ragc spine 69 Abnormal spi~e 70 Ne'N/oid liss wOl.lld be If pas-

SIH mm"cmcnt tr.:.ltmCIII Wl'rC 1.lS

an_..,.

8. Inrluenee or aymptoms and pathology on ..,mln,tion and lifst treatment 1 Is lt1e pain _ a ? (Ills/No) Of Iatoo'? (""slN~) GloB 111ft (l)(amp/fl 00 wIlfch !/toI baud. I. LOCJII S)'Tllptom$ I. R.peated MOVEMENT causlng pIlln - 01 go lust bIIIyood f'1 ~, S-rtyolpa,nsocau')t'd 101 Dural"," belore paO-lliUbIidIJI; t> RefalTad'\:llhef syIfl7loms i. Repeated UOIIEMENT CiIolISIRl;I PlI'" - 01 go fU6I 00y0nd referral 01 pcun . • S-liy of Pl'In so caused .. Duo""'" betore PMl s:t:>s::tn 2. Does Ihe nature 0I1he dl. II is u..... ne.>df) for hoer to mdl\·,d~' lnO\'oI'f'I'Ioerl~ in dl':alI FIf'St. and I'l'105I importantly, eumi..... tion 01 the pabml should I'f:\'eal which particuLu int""'L'11L-bral lo!\el or whIch neural romponffit is rt'Spon$,bk> for hIS ti)'tT1f1loms. lind ",hilt .-fleet the disord.... hM on his mo'·... ~lS It is by n!SIoring lhese mow,,,,-'IIts 10 normal th.1t his ~ymptoms will Jx> reli...ved. Slxondl,', abnormalitv of loc mo\"cment of the faull)' C~POIlb Can be used to assess the joml rJ\O\'ements """nt;oll,-d 3\)(1.·..: amons the pnnapal ones are the

Assessm~M IS the k~yslOM of dkctive, informati\'t tlutment, wit~O\ll wnid'1treatmo:nt ~UC=les and treatment failures lose all value as lurning expemnees.like tne keystone, a,,,,Slment i5 at the summit of treatment, Ioc:king th~ whol~ together

mo, emenl tests producro b\ Pl'l!Sllures on the palpable p.orls of till" \'~. ~ all! dl=lCObcd ill ddail in C""pter(,{pp.I50---162).

LISTEN AND BElIEVE ~ physiolherapi~t

mu'! ~ prep.lrO"d 10 listen!D the patient attenth--..l.y and bell".-ingl} II IS .. draordiRaf)' how ofm'a docto... and physwtheraposts do not 1J..Jero or do notlisto...., carefull) l'OOUgh, .. nd rert.1mly do not list~.....' 5uffK:ienl depth,. 10 their J'dl~b. It is "'rang IOmak had a :>5 per Cl'III n.xluetion In r~ng'" ""in on strrlch"'So and co""idl'I'ablc dry cn..-pitus during ach~" mu~e-­ menls. \\'hl"n the .ilould.,.. was m... ed P-U'J\·..lr with the glenohumeral joml surf.....es con,~-.,j, Cn.-Pltus """ increased and discomfort (not pain) was prm·oked. Prior to till" on..d of ~\'mpIOr1\.'> (, ,,«ls pw>'iously. although shl" """". shl" Iwd an arihritk should...., she dKl not haH> the d;".,.bilit.., 1hc' 'm.>jo.uhri"tlo.. tilt ~ofC2 b'd,ltfl1ly.lh.r,,,,,,-,,,,,,,r tons! tiU' 'l"". pallent'. co-on ilnd 1110" """miner' sktll in inlerpm"'g Ih« patient'. ,effi,,1 "nu r>on-\l~rNlI ~ignals, of whi al lhe time of the first

I()

quo:o;.hons. and

~

TI:ympt(lffili or whal CilU5. tholt '00 dO'il t'--d art rel.,kd to >our prol>ll'l1l, or i1'" ummportant. You mUSl tell meaOOut them; let ml' bt.. tl ... judge.' 5. 'Can you""" wNI an importanl role you ha' e ill lho' lrealment of your disord"rr'

..

In mllnipulath'e physiotherapy, ",Sloss",enl has lI\itn} faCe!l;,llll of which will ~ d':.(Il'lSt'd. Il(l"~"'\",,r, th,,~ "re IWO dlffencnt kmds "I ,",'lOSSll1ellt thllt tIl ~ t/ft:~nl ~te; at tile bfglnning of ad! =5ion. dJ"llCJ the ~ of a ~..q ..., afie- ~ t((ll'*l""' hzo; btt" ~ at c:orrpletionrrfil ~atll1fl"l 5a'>IOn. onra 24-hour penod i......ed,ale '( foIloW'''9 t~e last t~il"'erl

ASSESSMENT AT INITIAL EXAMINATION Thl' fi.... t of th~ IWO applKllOOns ;s di,cuS5l,' the mltial ">.am",~li,'fI of ... p.ltient, ~n

assessment

i~

m...de of:

a) The diagrlO5is, indudmg lis hisroll in I"rms 01 the Siage of me di>Orcll'r and .ts p~t st._bih" b) 1ne ..·.. n; in ",hid! it atfl1Ct~ tlte pat"",t c) The:o\ nlplornaotic ... ~ tolt"'lt lTIO\ em""",.... being the ~ t p.ut of a tot.1Il?oOlnunahcn. 2. l'hroughout treatmenl "".....h a", made of th,., change> rhat ocr:ur, and lud!-..,menb arc m.ld~ as to their dO"gll'l", their n~k" ..ance. and the influmnl in thi~

Mea

ThCI(' arc other pmbJ.. ms ns>oc;att..J with cli"'g,1(l'l'. For ...';"011'10', lin i"it;...l dinSnosis may nl.,;,d to 1'>.'

ch.lnSl' nchW\'ed ..,Ih tn'alml"rll Tho:! ool~ way kl gaUl this pruflClased on accu..,t., critical ;lSSl'SS1TlffiI. "tml.'d wIth this competency. and as:l member of ,I h:am, It\(, ph~'Siolheraplst can offer curbtnJt e~jX"Ct k) get fewer "",'Ui1S m(1I\' slowly Ihan the c:q>Crien«'d pcr:;on. and titer mu~t Tl.. ~tlhe Il>mplallon 10 !I)- ~hort-R'f"'C!i"e r.lSeSSment a) At the begtnrung of e",h fourth Of fifth I..,dl· lI1t.'f\l sesinn (ohct> 001 01 ;n_1 done 1 con·

bl

finn the dav-Io-d.lv ~ t ) \\"hen thedmounl or ","'of progress has ~Iowcd or st"PP'---d (to determine the "'.bOAS and pt.1n

lh.. ""ioo~) c) Following a" ;l>6 HQo,·{'\e..., if lhe findings lire relatOO to the ...-pectahoru. of lhe 1n.·atrr>o."'l tt.'iq~,

u... a5ses&Dl,.,.,t

bccrJr"",. ,{'p, d,SCf1mlllillon', m"lu", .. nd ,·aluabl". 1be paths for'lc"mmg 1.....1such.l pl'eS/iment wange'S to ~nJlyll",1 as>.es&rr>o.-niEarlIer in this chapter, th,' following "",as ",,,reslated as ocing th" a",a~of gn.'illl'!>l gn,wlh 1I1 :ll'6l~m""t I. Communication 2. I3eha,-iour of p"in, mist~ncc nnd muscl" spasm. 3, Identifying normal and llbnorrn~1 finding"

COMMUNICATION

aslen~k.

Following the physical e""minallon of Ih.: p..I;"'flt aslcl"isl·choe.!lCil..l-(.'C•• nomi(: factors - ,uch jnfi"",,~.spali""l." ishlng III pl"al>fore ....""tarh II learn to do lhi:>, shc.oould !he P.llic.'nt 5" ~1\lpid ttl ha ...• bizarre symptom •• alld it is iniqui\(>l" 10 label h" j:on. the.- poll:\{'Ilt fl't--'b polin as .... bnnp h,. bod} bl\d. 10 lhe uprighl ~taninll position iollo\\ m.: IN mo, ,'m'-'Tlb FOI" ....... mple. dun~ ...... m'naf1Qn .,f tht-' I""nk nlO't'mt-nl~ of " polDent with Iral low b.>cl: pain hos lnInl.. o,."iQn is tested. The fanse rn.l~ be full and 1'"",1""". ,..,t,,~ he rt'tums to tU upright J'O'"" ilion from the full\' fk>.ed pos,tion II '-"'peri............ I"" bOld: pain dunnK an an: "r tht-' .... turn m", .. ~n,. From "n .,..,.........ITI'-'Tll ""1Il1 of ,-il''''-. if. folio" "'!: Ire~lttu:f\1 the pain fell on th.c rL-'tum mo",menl to the upright p",ill"n dfh'r n,."ioo i$less s..\"t'r~.orif the arc OOctlmes smaller, lhi!l inJiCl\tl-'s irnrron,rnenl.

Release pain ntis phcnomc"'>J1 ,scommon in thecervk~1 sl';nd~nd the thur.1Ck spi,,,,) ",ith r",t"tion, ,md III th" lumbar sl'''''' wilh I~t('r.ll fl('~irm_ It occurs .. Itnns!

solTlelime~

e\du.;wlv with elderl,' patients. Whl"l\ lhe spin o'lat, all arc full '~OlKe and painll'SS. Howe,-er, imnlooiatel\" following the (',a1Joon to lol."ItI,: .. i1I .. ~. from p.a1i.....1 \!o. tho., p would toe Ic...I,' And tIm.... consuming. They are Important. and filmiliaril}" with the dif· f"""'l way'" pain ,an belwl .. ,,;th JnO\cm......1 m.Jk..-.I"".....,mi".,... dL...1r'oll> in c.arryUl.g them out A!;'C5l'>mI"IlI '" madcollhc time ",J,."n for the surp' of pam lO occur, lis il1ll"llSil) .. I its ~al.: and Ihto lime .., bon for il tu I\.-'CO;eI of l»·mptornsand lhe diIlllJlJSh,njo; of s}"mptums ,n seconds; tht ~ i~ ~ tht Si:'\"ffl1V cI the svmploms at tho.-'tr ~Jt.; and the rtUrd is a»!'Wng quabi} of lhe ."mptOfl15 calJS(C't,l n..."..." I;ost Iwo ..... po=onal judgement:;.,. I\."Iu'''"8 rn.u.imum arrrecialion t'>l the pallelll's ......... .......b.ol communlouiQn 1lJese th....... jud~...... muSI ~ intima lei" hn ....od 1"lIh th" caUS1llS ~I mo'..emenl or pos,tion -thai Ll'. w;lh j\5 stn:ngth, .mphluJ\!, sustaincUrT ~t the l'fld of the a,ail" ~b"" ranS" of mO\"l."ml.'1lt. Tln, furth•.,. m","ement may r..-sult in .. marked incre,,* on the left ru.'Ck pain. Some r""ders (1M}' doubt th~t sud, detail in ex"min.Uion i~ n(X"css,lry. The answer to these doubts is tfl.~t th" findings s:ive the physiothcr~pist I' !:\,ide .1S to the treat· mCf11 I~hni'lue to US..,;;ng the pain. 2. II till' p..li"nl's ..cIi"", "'''S!' of roI~hon 10 Ihe left l~ unchanged although il bt.'COTnl" S} mplum fll..•• ~I,d Ihe rcspono;c to U\er-prl~"ru is as il ""as ~t the mitt ••1com· pI.lm of Iwo dlStinctl\' dJfiWrlt ~Inods of headache. The pall.,.,1 must be .1dequaldl q....."tioneod to det....mine till' diff~, and e.tCh p.lln should be eum.incd, tre.l~ and asso-ssed irl(kp"nd"ntl} Patients h~ve many de:l('riptions for p~in... )'\.'1,t IS ,urprising how often till....• U~ ,l1n;l.1r terms, mOISt of which an: ",.,dlly rI)COI;nI7.,ble, This ;s so even with 1'.111enls on dIfferent countrk'S and Wllh diffe~nl cultures.11 is probably stilting the ob"ioll' to Sb r"-'C1ous' or '11 k·d, unsofe' urua"OIJrable romm""ts. ."t. p.lriem U\~ng. 'II rt'C()\"en.'d moll' qUldJy after rennls than f would han- e~p.-oct('1.lhcnt:; 6houlrl be """rnilll'ci Ilcurol"I';ically doily br lhl' I'I1)'slOlherilp1st. ""d ,lUi W"T":>houId then dvxl ",thi.·r """'risk,'angcs OIla~1 pilln "00 ''''nrSion.. lhat his symptoms ~ undl.ln~ hlM......l......... hen hIS m,,'.-or..,nls a r e - t thequ,,"tyof .. particular m"'·...mcnl IJ1d)" "ppl'"ar fro",!". In bet I.... p"1i..ampl" to mm·crn""r

;--".~",c.--c"~,,-,,,t;-.-

Figu.. 4.3 Pre\~nlition of theldtooMood.V

ho.,.

Assessing changts in pain

P2ft".onuY)]'

c~__

~~in

felt ",itll cervical 'Ol.tion to

-

,

':l

Fi9~'"

•

'-

'.

4.4 Pt.~nlin,on 01 """, - n'pclrtw '" ·"nchi"!lro·f.lt witn c(""cat '01iticn 10 lhe kfl on I'IcdnesOiV di"Srams. F(,nt d1.angt'\J becau .... 1 Ile beg.on lre.. rmenL or as I............ere he h;Kl hj\'-"1WI'l1 d",s,arn to the th ..... "'N,II;(W\~

fu1 f,alun.> for ~t is that. ~1though the pt'TSOO'~

S" ....'I'Il1bl,lH·,.:lnd l.I:Ilng F-gun'44 aslheorigin.ll presm-

joint

laoeHl.the mo\"rnent is stilllimlll.'d by tho!' lI,rerunh" of the kx";ol ~in but the positions of P, and P:lLj h..~,c cha"l;N, as lIb impro""m"nt is of ~reatt". This i§ particulnty...-k-

'ani., pre"'lOUIi USol" of the- techruque hdd1J,;.(,n produ· on~ ~al

prog.-..

BEHAVIOUR OF RESISTANCE ResrsIafICC to IrI(WmImt ""1 man;fcS! I i I loss of tllc fn(tlo1-f~ f«ling Ihrou~h the 'angeod ablwe, e'\'en

rho\Jgh the r.>ngc IS full. Th... ,e,,~bntt ma" be .K'nllTlponied by crq>itus. although Ihis is by no ll'Io"e the §tronger the .... i~laI1 U''''''Ml' oflheir urlrcl"",-d state 60lh th(' musel,- 'p,1.>min'ng the rango.' (If fIlO\ement auibblc inlhe'er1ebralc.a""lsltvcture.s(lheslump~t

"'I'f\

,lescnbed 00 p, loWl, SQr'Jle people, the \QUng. ha"ea marh-d I'l",tri,t;on \\ithout" ll('C("iS,lnlycaosingp.''''

~ tobo-

so"J'ho> spirksofpropk-m the first.subdilisionareonl,·'dlSol(h'anlaged·,MaUSf.'IIl"lIother "-'S"nblht',ndl,lduals..-gmentsfittho.>'ide..rglUUp Elderly peoplt' dIScomfort 011 the oppt itc side "The eJl;ttionCll'atcdb)SIl"i'khing the ;:en icll rotatl(ln ;as discussed in lhe pn'('fs>stm a~ the-. ma\ or mal root N,'t"l\adadeq.... ltre..tmt'l\!.)·et""ho.Ka"ptthe;;e sl'mplonts oIlS ~ng thcu" normal dcsplW the lact that they LOt..nen.· w,lh their normal !if... On "",mUl.ition. thrir joint mo\"l'ml'lll an' pamful when ~In'l"wd .antl palpalionfindmgsan.>ob,ious.

This group LOdlldcs peopk- "ho;;.e

ABNORMAL SPINE l1lc 'abnormal' .pinc is a .I·ml'lomatic SPlI'IC for whICh

Degtntrativtchanges Th~'

first (If th.. thl'l,(, subdll'l'ions 0,0.'. congcni1.l1 "r ,.Ct]uil\'d struclural ,1nOmJ!leo;) is quitc diffcrent ii' kmd 10 the other two, ..ndsllOUld bl-thoughtof and

tllep"'rsons.-",k.lrcatm'11t_Ot1examm..'hon,~iKnificant

romp.\r"ble s;gns will be p.llp.lbie at lhe"I'prt'l'nat" inle""'rte!lr;,IIc,d.l1lctitlc·abnormal'iso>I' ,lh""mlal joints,which.ilSho'lSb'-'(11_l.lloo,llldybctot.1UVp.llnl(";.s

This w.e.lling into "omup5 IS 11(It J f.-.:riIOUs acl, II ;,. a re.u,~t1( Slluation and h'6hlighh Important dink.JJ rnnnt'ctIOllS bctw~,"", S\'mptoms .md e\.a!ll""'hon finding.~ lholt c.m be~. "The ,.\lUI" of the dil'ti'O". ~TlI ~r,ng5lies in our ~bilil\· to roerogn..." thedifklerocg. lll~", thn.lugh lhe inlt'Tpreta.tion of th., findings, Ihal Ih,· n',lli'tic Iolwl of lrL'alm«'ll m"y be n minimally sympl"nl.ltic 'a,oo.. g,,' ,I,ll" 0' ,I pain·fn.... 'a,,'ra6'" stal" rMhcr lh.w an 'ide'll' St,lt". Unforiurlaldy, very fe'" p"opl" ,n',,, th" age of ,j.(] ha"c" 10t,,1 wrnplcmcnl of 'ideal' inlcncrt"br,,1 joint>. Mo>t I"-~'Ple, for one reason or another, fit inlo one of th,· 'a'cr.,sc' groups. If" ~;roup ~(}.rcar-.lble Ii$\1'\'

chang~

"'QUId not haw:' beeft as 'old'

a, those in tho> pair>-~ ·a......./:.·· group. Diff......... l;.. ..hon ~-wn u..,·new' and 'old' ,"",nses under the:.t.'

ornunstant:6 b much "1Ofl'difficull. The abnorm.1liht.~ sought b,' palpation a.... ot tho> foIlowi"S kind$: t SOtl·II'suechanl;l.... 2. Bon" .."omalo.._.

3. \lnH'mlTlldb"",mJlihes.

SCft-timu.· Ch3ng .. ~ Till"'" ch"n!;e. ;lrt> to be f,,"nd in th" Ii~ar"e"tou~, c~p· sul~" muscular and c(>I1,1t."ti,,, l~"""l'!i as Ihickening or lIlu>cle sp,1>m. Pdlp.,tion Ii th{'m will 'eveal Il'tlderr"..s:.. Th" abMrmalities .~f 'fl.'el' in hgJfllentous, ca!",ular and CQnlll'lpaling oli capsular thlCk1Un~ around lhe J'\-gaporh,~~1 joinl ",U be 1oJ,.,rn"~,r,:: J.;.Jinst IeJI!M;I. the~ are •••..en "~ria!Klns in the NmJ1('!;; 01 the leather) 1'1,,,1- Thico..rong from roOA' rea-nt,;~" III a!>Oftcr or SJI'O"f."" fccl, "h"h ",...-tie.m OIdt.T k.lt""" iM. lln.:I.e;'ing wilhin the mll'ICU~' lissue is usually me p.lin for 1100/"·"),,,, re.",.'" sometlling mu"t h,nc 1I.1PI''-''''-'lI 10 II, and therefore ~ ...... changes of ""me kind will be present

t""""

II reaTlt "--.sue ,1ta~f"> ha,~ oo::urred m an 'idel'll' joint, I,,",onh- fi"d,,>t;:5 th.ol "ill be d..-:ti"d by palf"'h..... e>;.lmi"",lion Wlli boo oi the 'Ile'\'" "" '"",,,,,1' "'nd. ~ with,. for e;ympJ.e a 'P'~"ll'd anUe 1£ ~ recmt tt".sue chang..'" ha,e occurred in an ol!iymptomali~ ·~Hr.U;e cenic..1 ""nt then on "..... m· illation b). palf\illlOO ~ ,,,II be Ill'" Ii."u" chanSO' sUl'lY'in'p'''''''' on l"",oM,,,r 'a,~rase lb,Ud by palpation being applll."d in "

II\dnlli"l" lhat prudo«!'! Intervl'l"tl'ln'al mo'.emml Abnor· m"lilleof Tl"IO\'ClI1CI1t should be qu"lIfied in terlTb not ani} 01 t~ available range of mo\t',nenl. but .. t.;.o cI anv (h;m~ ;n the llOI"ma1 ftec-runmng mO\t'mtnt through the r .. up 10 the end of the .l\ai.J.lble ranI:\' This may be dbNrbed b., SIKh fiKlOl'!l U Mthnb( ~ , stlffneso. ,n suppom:n· capsular and li&,mf'TItow ,;tructUI'8,O€ prot..ct",e mus.::1r spasm An 'old' l\\'pornobiht~ h.>s .. hard end,ft..~ .. I I~ hm!t of the r.. n~e, "lIh ffiO\ement before the lurut of the r,lnge bcmg a smooth. fricrion..f...... mo\tm,',l1 A 'new' hypomobilily. on the other nand, tws sllfrtlCl.,. fotl",,·,"K 1......lm.E'.1 'lul'stion should bl', 'Wk,lIdo you fl",1 ",aslh" effecl of the last t",.1tm"nl?', The ,,,ply. 'Bootie" or 'Worse', ,,",-'Cds further clarification. Fo' ('''dmple .1 pM;,;nl mdY, in ",ishill!!: to I'mph,1Si~" the d purpose oi the .."...:-s:;1ltcnl is to detcrmint wh~lh"r the worsening w"s due 10 lreatment (which is ., known quantll,,) or to other faclors. Ii it is du~ to olher faclOr!;, the degn'(' oi th.' cau...• mu~1 be deter· rnir'ld SO thai il can oc rdall"d 10 tlu>d,'p,,,,,, of WOIlief>' ing. b)' Ihls lhe dq;reeof ..1.. biJitl' of the disorder being lreat{'(l m.. " be laml.1f tllc p;ohl'nt's;lr\sw"" 10 '''''!>en' is. 'Who:n I gQl out oIbcd ne~1 nlO)r"TlIng'. thl'auIDlJ\iloc immedi.:l~~ is, 'Does 11 Ol,mcti",es lluctual quoestion has to be pursl>l'd; 'DId ..uu do anything rtstero..), ",hieh might hoI\(' Jggrilull"d it?', 'W_ rou more bl'\"d I.... n usual ,·estd to gamlhe infor..... lion bl..~ng soughl, and 10 show lhe1 po6t.,,-ol.. tnal ttu /II Ius fir.>t \isit 1.1"'- Fnd.:ly. follo"'in8 • limIted """"',....t"'" he "o1S !matl"d u.lng .. grad.. oi lumb.lr l'\btioo foe suff",ienl Ii..... 10 prodU(e a change in the 5}'mptoms CIt' 'I~'Tl5 if il "''''re lht.- nghllaitmque to ..... ~ "'JS a..mall but dl'finite ,mpnnemenl, showing th.llil muJd be the righllechnique'. The ~ trNtmcnl "as on Mood..". and lhe fol· IOWlllfi is the conYl'fsahon Ih"1 was n.-q~11'\"d to determ",,, the e/feaI .....

Q

'Ynu -.lid 11\111 \'Ou were bad 00 Saturday ",i1ft100 Sarutd.l\'7'

A

'I dun'l knO'....•

Q

'Did you ".am ...., 'lin3 bad 00 tho.Salutd~y momingCH' "i>S il Late. in the d.. v?'

A

"I don't lu"",. I Ihlnk I w .. s all righl in Illt morning, Ilhln~ It ",..S I~tef in t!u'day.'

Q

'Dld you do ~n} Ih;,,!! that could

h~l"e mMf'

il

b~dr

1\

IT

Q

':\0.1'1'1' only been .... ,Iing .

d«l>lI....,'ilh lti5 N'GIIV '" lw.nJ :l'l'tJ::.

He' i; 'lIJ/ IY",

IlllSleYrs;

litis

'l-.lIal ""ere you dOlllg during lfwo aft"fTlQOTl?'

A

·Oh.~bn&:

Q

'Did~ougetupatalP'

A

'\\d!. now ~·OU como!' 10 menrion 't. m, WIfe did ga OUI about mldd,;;,yand I w,"" at ~ 00 mv O".-n, The phone ... ng four Iimt.~ .. nd I h.ad to MIS".... il. That lTIt'iUll bending do....'f110 redCh the bClephone b.'G1lZS'(' of tn.~~I""'nl fur bu~illl~ or ulh,'r ,('a,;o.)n~, it IS useful to ask him III writ" down IhI:«>",e a h),pochondriac. bm thi, i~ not Sfl. .. nd el'en if it we,t.' the ad,-anta"l'$ of the '"Ittl''' reno b a H1ridncc of Of'imon. "hid> cannot be resolnd, botll opmions m\bt be

"""""'.

C>ccasion.ally a patient will ('Qn\rI'I('llt that toIlowing ttlc Ias.t lreablent he fdt e~ln'mdl t..~, "nd p. fact mdn, ha, I-' ~ for as Ion!; Ib 3 hours.. Thh (!{fuct usu..Il.. occurs lolkl\\ing the imhallre.ltmMllS. and can be rons,dcred to be a fa\"Ourab~ re-ponse to the lreatmenl The abo\"(' is the ~,,!'iI the dS5eSSm''f)t. It ma,' n.'old as though 'ho' p.>hmllS worse. "h«ond, an act.. rna, de\ clop during lhe performinS C>f thl! ledmiquc Pam (O!'II in rhythm ",ilh the lechniqu..., I.e. p"-"-nl (3), may d .., ng... in lhe follO\\'lng ,.."-~~, L

From a pain-fn.~ .tMt. th... dioorder mar begm to hurl in rhythm ",ilh Ihe 1I.'ds}x,fore then sl.3nbg 10 OOcrw~. 1l>e ~in m.>\ ronllne In ci«rN5ol' .. nd eo.cn dbaPp"'ar. 11 lhl> 11llti.lUy irrrn,ins pain;'" Q!Ilf pm of tt'G.'I.1 origin.. ll"l' rodVUqUl' l~ not eontmued fo< the 30 sccnods. Howl!'\--er if it b local Sr"lill p..l1n or ne~rby n..iem,-'qu~ not only verb,,1 communirntJOll bul also .-."'".........'$.~ of lhe non-verb.:ll nuances of beh~"iQUr, Ihe pJllomfs abilily to) relax rno", and tl", IL"Chnique being ';~.l ...r top.-o,lsses.sment, it would be hoped tn,,1 Ihe pr during the perform,,d to p"rtic"IM disorder,. For example, if she is treating an eJd"'ly pilt;cnt with genemJ neck pilin tfull c~n be reprodlleed "' Ih,' limil of ,11 mo\'emenls, all of which M~ stiff. she can a,;.sum" Ih"t the......... iII not be much ch'll\ge during One treMme"t 'l.,,~ion although there milY be considerable impro,·ement o\'er two trNtml~lt ,essions, In th,r..' of IhI> (Ot'l"S0mg facto,.... the t...".,c..n be done"l (JIlt' _ _ ion. If the "ffi(>Ull1 of I.... almenl i.. linutt.-.,j, Ih011 Juds,·ment.4._ 10 the effect of n treatmenl " .....~ion am bo:- made All of thl" d"I"I1s "-1:"'rding .my atlillylleal _ _ menl ollhe ~.w,en,, not lmCumnwm for~ p.~l;enll" l'l'Ply d"y "fl~r d~y thlllllt": is f""ling much belt.'r. Tlwn, when asked "fk'l". >.'y, four t"'"Iments, '110""' do}OlJ. fl",1 noW«(>fIlp"rc.:l with too.'fo", ",e Sl~rtn:t rn,.,Imc:nt?', he may Sl il n'l'lainl~ ",n'l any" ....... '. Su ttw ph"......-:JIherap.:ot moliZXJlml'le. iI p.ll;"nt's pleAn I~Mmcnts can elMif)" the s\,mrl! hdJ"'d him mort' Ihdn

tlIhel'1'~

8. W',,, It a ISl~'m.,nt m~1 I"h inlo account th" r.lnlt" uf mo,·emenl th,lt ;s likely h' t>... nurm"l fflr 111i, p~li"nl. Th" role of treatmmt wHi be to .'liminal" the painf"l a,jX'CI ot loint nln"emenl 11,,, "",d-re;ull "ill be ,hghlly imrrm-oo mo'emcnt, ..lthuugh m.wements ,,·ilI T\.'fll3in shit in all d,n...:hons lmportanll,. me nLock p"lIl" III !la,e !'onnls and .... ~ oonrinucd lobes' ffil'kwn fra' oyer tIus inK.......... thcefl,'Ct of ITNtnwnt h,·l..ar-Gl1. ·1 N>IT arc occasion> wh...... pali~"ll Wllh chronic 'y mploms yet JiUI" t" find on e",lJll,nal,Of'l of mo,",,mL1lts m...y nol sl,m,· an~' ,-.. tldd L~'" III polin for .. hieh thcv ....,.1' gallW\l ,,'II.. f ,,.,Ih d fu-.. lreatments trom Ll\ ~ip"lal""'" If tl>l.lri"n of a patienl. the Utxlor may ID rna),;,' a dd"lIuu,.., d",gno!ilSo Ii the pni>&em OS a musculoskeletal diedb...".."i,.. Tudo th"S"CCl'Slif"lh lhe ph,.",olh«apist r>eed. to "'.11"101-' both tl>£> n«k and the shoulder in Ihl.> lind of dda,l mentioned e.m1CT III thi~ """'ptl'r SO 1....1all joint "'S~. ~th cen.·kal and glt"nOOu....... ral. an:' ""·.... Ied on detail. She oJ>ouId then In..'Qt thl- ct"r'\'>Q1 arca first and. a: lhceffed oIl~ Imllmcnl roth on the cenical.md. on In.· ~hould""Srhcula. st.1ge of .. pat>enl's d~ ...-der; il may m(',," an~ of I....• folk.,.,mg

I, l'm'in); a rwgau't b), for ",~ .. mple, lreahng .. stnlct"", \'igorousl' in il pa.rllCuLlf m.>nnl'r tu pro"", th,lt there is O()\hlng "'n.:>n,l; with it 2. Sl'lldmg a pali"nl home wilhout In'atinl\ him 10 pro,e Ihal Ihe progress, "'hich.l«rrus to /\,,.,'"' bl...." achi",,·~'Ii mMlen', d,d you do anrllung diffC'n'rlI or

unusual wIWh cook! ha,-e 00en n'SpOflSibk for the implV\~m('Ilt in your symptoms?'. Aft"r a long delib.,.-.. hon he responded, '1\01 thai I can dunlof'.On ask· ing him if he had periods of fR...." "lillion at s.ly;ng he Weall thai an unamfuiied asscssmL'Ilt of th.. symptoms could be dearly associ.ato.'d or diSilssociatC(! wilh treatment. In fact the pil~ this is too tin... consuming to !leo! ,-alue. sucCl.'SSful tn."ltment compelsthi5degree of ~ccur,1Cr; il i> L""""-"ltial if the physiolho.'rapist is to remain in control of the lreM",~nl Sill.:.tion_ CiY"n Pr;lctice and o.'xperi~ncL', it is not a lengthy proco.'durc

"n..'f'C

83

Chapter

5

Prognosis

W~ und~.fSla.ndabou~th~pati~nt a n d l

•

l

au~slions regarding prognosis 86 WhlllisthtdiagnOSiS? 86 HOWdoe.Slhttfftctoftreatm.entinfluen«:

the prognosis? 90 How do predisposing factors mfluencethc prognosIs? 90

Thischapler is writllm lor manipul.:iliv"physiotht

'urhajOrrmsuch that the phy'ical findinpcall bcad(k..:l to make featurcs fit (see pp. 57-56} ilnd then. by showing what eh'Ct each single modality of trNtm('nt (or IMssive mo'-emenl treatment technique) hasunthepahmtandlW;disordl·r.th('picturt·ismade morccomplctc The m.mlp"].,ti'·e physiotherapist mu.1 al .....ays k""p her mind open 10 ALL the incoming information andremainempatheticto'f,,,-,I'lhep',ti,,nt'ssymptoms soshecan'walktheirwalk',butmaintainanenthusia5tic and positi"e altitude. Although it islempting to startformulatingaprognosisattheinit!aleumlnation. thi,isstilltooearlyforfocecasting.Atthe"-1rosJl'eSll)on.eOf"ma,"bet....o. Thettunklng process is then rrlated to:;

• \"i!h whal rn(rI·c.omenl and hQw is the pam rrprodU«d~

• Doesthern(rltmenlll1\'oIwstret • Arelhcsymptomsl'lOWrI'I()n'orles5e.1§l1y prm'okaP • Is Ihcbac:kac:hc worse but the leg: symploD15 ha\'e """,'

With a low lumbar disorder, the spine'sabilily 10 m(we freely during a rcpeatl'(i mO\'l'm~'111 from full nexion 10 full t'xlt'nsion will indicale lis stability. Once iI full rangc hasbst' symptom~ bl.ogin gradually, without I~ being any known ~membmxl ~aSOn. By dd\'ing inlt) the.. hi$lory it isn-\eakod thai theys\lfferro an injury (spr,lIn, Slrain) many years previously.IA'Spite ha"nll had a good nlSpon...;c to In-atment at the time, th,s has la,d down the foundation for gradually de"eloping degen. r~mrk>,theiniuring rrlO\'emeflt may hnc been a repelJtl\l' mm-emcnt __ tlllood b),.:ulassoembly·..roe .. orloY ~twoe:ump1e5 .. ,II1eadthettw.>rnt. For example, il may be thai the patit'Tlt is unabl.. tolumh,sheildfurtt~rthJn7('f'totheldtwilh. oulcausing pain. although he can tum emtofilintothcfaclorsthal guide the diagnos,.. ? Whatistht'causc'o(thtsourcc? To T'l'itCh the stage of being able to complete lft',ltmml and am,-eat a prognos.l5 is IoWlderstand theJlOMible

89

90

MAtlLANO'S VERTEBRAL MANIPULATION

underlying ~ why IN>struetun!has b«ome IN> of lh.i! symp~ in other wonb, what is IN> '(1lu~ of lh.i! !iOU~' IT""" U, Part Two). As ...~Il as

sou~

tr"um.lI,ili.'S~ryto~llo!m5lJU(:h.pIlII>­

lure, musc\e ...-e;okne.l or tightne!lS, h)~htyof ~ of ;on lfIlef'-\'t'rtl'bn1 ~ I INking the othersodeofthl' srgmenl worlth;ofder.or Ihl'segrnmts aboo.'e and below ~ liUniLtrly .. «....-ted Some up«'tsloberonsideredrelotetothestructuresthat ..... Ihesouroe(ortheCiluseofltwsource)oflhesymploms 1T'/lk5.l). 1lIe e~amination emphasis is on the d..t..rnlln· alion of the range of mO\'l'ml'nts and th"';, symptom resporlSl'S,wilh:

one

I. I'hysil)logialrno\'eml"flltl'lilS.

Functionalmo...t'ttlt-'I1th."Sb ), Combmed ll1O\'.. mmt lests. 4. P,,5Si\'e xceI8Or)' mou..menl tests. 2,

I!IttIr~eaNrru\,iti5PAI.PATlONth.llisth
examination can be dividL-d mlo file parts 1

'Kind'ofdisonk'T

2. Sill' of symptoms. llehaviourofsymploms. 4.Spt'Cialqul'Stions. 5. Hislory. 3.

Thespt"CifksubiectmaUerofthl'Sl',foreachsectionof the spine, islistl'Tisgi,·t'Tlbclow. Fromfhe"eryfirstqueslionasked,regardingwhat Ihe P.1tis\'ery opportunily 10 e~prcss his reasons for Sdtoundcrslandhowlhe disonler feels 10 thepatienl in his terms.

The subltfy:;~:::~==============

i.ii_Easyt"pttwOlr~l....,oracut ••posodt

C. The ki""ofruminlltion(ayourr:uminlll....,oftM_! 2 OcIyou«Pt'C!ltcoI"lI'Iylhejotnl.lI'IUSde ... lJtIler.tnlClu'r ..... btcomtsymptomatic,raldiscsa,equitedifferenttothosein the lumbar spine (Twomey, 1992), A 'list" i, nol unoommon fo,thehernialL'-d inle,vertmral disc, but lisbare nearly al."ays COlllralaterdl The cervical intrddiscaJ diwrder may be more commonthanisg''11erallythought.lx'Causethesymptom.. tology St-'CTTIS tu fit with Cloward's work (Cloward, 1959, 1900),es]X'Cially,,~thpain fcltin lheso::apulararea (...'t' FigNI'I."S 6.1 and 6.2). lflere is almost alwars mus,c1e weakocssofthc triceps with C7 nerve mot in\"olv~'Tll~'11t (C617 disc), which is more oommon than C6 nerve root imohement(C5/6disc).Rea.."tin,·~'Stig.,tions(Twomcy

,md Taylur, 1992}show that lhe cervical discs are significantlydamagt-dinwhiplashinjuries. Thisscction is an ovcr-simplification,and isintcnded only as a guide for the more common presentations. n... reader is refcrrcd to Bogduk(I987) for further debils Clarifyingthchypothcscs This section follows the 'first queslioo' in much the same way as does the sectioo concerning structu....'S Figu~6.1

Di""'9.nicpain,

~f.rrfdfroman"'io{surfac.

otlow",,,,,rvic.ldi,,, (A.produC'dfrom Clowa,d,A.B.!1959)An""l, OfSu"1 f ty,l50,t052-64 with'indpt,missionof aU'hor.ndpubli$l1.rs.l

106

MAITLANO'S VERTEBRAL MANIPULATION

,.)

'I figu," 6.2

DiSC09,oic paio.lol

R ~rea. Being able to point to ~ spol usually mWll> that this is th......xaet sil oflht' cau>t' of Iht' f' lI.rotller.g/oc'l'-IIQtlda,rotllrt.

He also refers

10

'Jincs' of pain and 'clumps' of pain

'These~aluresare,'erylooselygroup'--dbylherapists

as being neural in origin, and inc1ude neuropathy_ The t"'obest texts on Ihe SUbjl'Cl are by Butll'T (1991) and G.wve (l988a),both of which are considered rrull1dalory knowledge to the Maittand concepl

BEHAVIOUR OF SYMPTOMS Changl'S in the sile and intellsilyofa patient'ssymploms should be related toactidtiesandpo.;itions,and 10 periods of short TeSI and long Test (Ihe laller being throl1ghout the night). During the questioning il is e"SI'ntial to diffl·....· ntiale the bl'haviour of the local pain from that which is rcfer ...>d; the two may be as:;ociated or they may beh.we in t0laJlydifferent paltems, tile lallerindicatingdiffercntcauSd pain.Jt is then necessary to know Whl1hl'rthe pain hasspll'ad gradually, or whether it involved rl'felTL>d pain from the outset Symptom~ that ha~ de~lo~ furth~r

'gradually' need

c1afificatlon

In questioning rcgarding the historyofa patient's symptoms, it is necessar)' to recogni7.e that the pati..nt may havl' two disordl'rs. A new problem may ov"rlap with an older, longstanding one, and every effort mu,t bemadetodiffl'J'Cntiatl'betweenthecontribution"ach ismakingtothcpatient'sdi,;ability. A patient may pr~~nt with ~ymptoms that can com~ from two disord~~. E~'Y effort has to ~ maM to differentiate ~tw~~n th~ contribution ueh i~ making 10thcpati~M'sdis.ability

Sometimes a palient prl""'nts with symptoms that fit thelaterstagl'Sofarecq;ni7.abledisorderwilhoutrcal" izmg he has an associaK-d history. and themanipulalivephysiother,lpist ma)' ~ogni7.e thai it is qUitl· unusual fora patient to have these as his firsl pll"SCnt· ing symptoms. In thl'SC circumstam:es, the patient musl be pr=onlers. All of mese have ,,-'Cognizable patterns of onset and development. Ligamentousandarthritic(-otk,-osk}disord..rsof the spine have elGlctly the Sccept.lble as il sunds -Ihe-re

Howlongha\"l'}'O\Irpalll·fn.",inlervalsbcen?' 'Ilow many times

h\'C

you had trouble?'

'liasthefrequcncyofcplSOdeschar\b't'do\'t'fW laslroup~of)ears?'

hasto~.reasonforthe1 be sought which, ",hen;added together. atl'rom· potiblew-,Ihh,sn'achingfurtht'cupofl"adisabling him so. Inl"reslingly, 2 "'l""ks prior In II'oc cup of lea tneidcnl, while oul on Ihe farm the f,umer's small c.le had'puncturc.l-la"ingnojack,thefMm"rliftedth" comer of the car at the appropriate mommt while hi, son changl..:! lhe ","'-""I. There was no sign of back trouble CIne week later, he had 10 drag and Iifl a

'\\'hal kind or I ..... tmcnb ha"e helped you best sof"r?' \",Ih the prl".lerll hlSlory ,I lSes"enllal 10 know till" Pn'.lg~ of the symploms from the lime of on5Ct k' lhe present moment, ilS w",n "5 kllO\\",ng theeffl'C1 of ilny Iwatment Ih"t mil) have hem lIlShtuled. Qut-.... Imns regarding mroical history and socio--conom" history ~hould also ~ asked. Table 6.6 prol'idl'S' 'l"kk rcf"",tlOI for thegcncr,,1 poinlsme-ntioned;5pt' cifichistorics",iJlbed,scusst.-dlat"rinlhefl"Il'\, chapl"rs.

122

MAlTLANO'S VERTEBRAL MANIPULATION

Table 6.6

P1i1nning tht 5Ubjccti~ cumination

with tlw paben!'5 hneollhought at any gin'n moment. The gool is to make sense out of ~·erything the pall..... 1 in an rndea,·our to 'male f..alu",", fit' Having "5bblished the lund of dJ5Qrd...., the patlcm 01 questiorung can be directed along one 01 threo> paths. sa)'"

t

....... ..,...."

--

I

""tmllofpauhiW;wy Pltttrnofpretllthfa" pain to the abdomen and lhorax. OinKal inH'§ltgahon hits shown llut the InlJenclVN...1 disc L~ upable of GilUSUlg 1oc31 ill'd rekm.-d pain .."ithoul any 5lgn of herniation or nenf' root COIl'IpASSion (Oow... rd, 1959). It "'ouk! ,...,... that th,sJ'ilin;" lle\'eI'"more pl'OnOLlflCec:l in the distal 5O.'g' rnt'nt of • dennalOrJle. Howr.w. when herniat,on of dl!l(" m.berial com~ a ntn·f'root the patn is commonly fell more sev.......1y in 1I dil;tal an.-a such as the clllforforearm.Sympl0ffi5ClInbereferredinIoSUper· ficial a"'a5, wlUch may become hypcraesthetJ,c (Glover, 19('(1); into u,.., muscles, maling them lendcr; or 10 joints, which may then Iht'TTlsclves become painful on mowmenl(Brain, 1957). The plan can be ronsldert'd in four SL~ticm~, which are menlioned below, and tho.-y must be lhought of as having two gools. T"blt 6.8 shows thaI lhe physical exam;n.ationhasn\'OdlSllnctgoal§' I. PART ONE is mt,reIy reliltf'd to detemumng the

structures that art' the source{s) of the symptomJ and 10 finding IYM)n'rr>ent d,rections that a~ ilbnormal and nl'td to bE- i1ddres6ed in treatment.

2- I'ART

m'o

is d,l"f,drrll'e'lF/'lI!Il/l"': Ct>--T6 a) Kightcosto""rtd,."ljoontsTl-T6 b) Intercostal mo...·m"nt betWl'("l\ the first and sixth ribs on the righl cl Sc.:lpulothorack movement on the right

d) Righi glenohumeral joinl and rotator cuff c) Righi elbow f) Righlwrisl

2.

The jomts that dcl.'5Se> as a conductor or the composer, butlhal does not pre"ent the team of all four w"rling logether 10 produce ~ good "'"lilt. 1l>eir Irames of relerence are not the same. nle humility and fral qmenl

can

bed"'ldedmlothe'oIlowtngseq~

1. ActI'l.'teSt!i a)Acbu' lJlO\"t'mef\ts - 1l'lO\'l"lTOeIlts wludl lhe p.1lll.'nlcan perform Iort"produao M pam (srr pp_1V-1331 - ph"~KHogicallnO\'ements - combml.'d 1l'lO\'l.'lTll.'f\!S. b)Au~d",I"\' rests oAS§OCiatt'd with acti,·.. 0\0\ .... rm'llt 1615, 'or "umplt' joint rompress)Ofl teSts and treads. Amm ..ment ","""t bcclasso:.'(l (()T r(·corded) as norlIlal unless the ranh't' h pain frce both il(;li\"Cly and pas~i,ely; ,IS well, ""er-prt'SSurc (01') applioo at the limil of rang" should nol cause pain Olh('r Ihan normal responses. Rl'Cordinga rangc of ncxion as bcing normal would be 'F,I,I'wh"l't' the first hek (,I) refers 10 ranl;", and the second tick l't'fcrs to pam "-'Sponses. Amwe"""leinl\llltJc,tiasloe'dasnormalonlessthe ",ngc is Pilin-frccxtivclyi1nd pa~ and w,th ~ add'tionofpaSSNewef-ptnSolI~lttlle~ml!oflhe

adivcrilngc.ThcrttOnl'ngoflroormal_mcntin follow,ng the sut>,octl\"n.amination and planning. a d«i5lonn.."..· cbtobemade .... Io .. ~thelt"lllnO\.... rnml5 01 the phrso.:al e-..ammahon 5houId be taken 10

~la!,ontojt5ri1~q.... htyMldsympton:l~is

r«ornrncrllkdas,l,l

~hrrutoithea'''iIableranp''(InO\·''lOhmlll.or

..-hetherI~shouldbetakenonlvlothalf'O'ntlnthc fMISl' .. hen pam comlllt'lllCeS or stam 10 'rlCre;llSl' ldlienl ...hile 5upponing his ...... u1df.>r,; to p"" ef\1 h>s O'·crbaJ· annng (F~". 6.1;"). U the pos.tl>on oIleStlng lumbar I'>.!mwon ~ perlonned as.now.. In r,p'" 618, ou·..· rrelOU.... COIn be e m ~ ..' Slnsk' wgmmti. Tl>e Wduuq~ J"O' odes !he eununor .. lit> .. ny dltferences mend·fuel'......t 'l:ymptom ~

ph~"Siotherapi.st.!hepolJo'nl Giln be "'Sled to rotate 1m peh"is to the left. \1O""'g;om1S In the Slme din.'ction yet doong ,I in dllferml ..... )'Satl produce qu,tediffer·

enlp;Un~...ndshouldbein\·esbg.abea,·c completely l'f'ro'cred; the sogmncaJ'l«' of a cutTl"flt prokd1\!' dcfomuty ...ould thcnbeko5&. Foreumple.ifll p;ltienl on ~tanding is §t'eIl to howea lumbar kypl'oo8.i~,_of Ius deformity rna)' be of alongsl:and'ng natul\'. particularly if previous l'plloOdt'S of back patn han! been 01 ~lmiL>r severity A~ such dclormity doc.! not usually rompleldy disappear, at least 50 per CO!nt of hi,. prt'Sent lumbar kyphosis is likely to be unrelatl..:1 tn his present pain. Anoth('r common (')(;Imple of 'old· mi~l'(\ with 'new' is an an: of list that is visible during forward f1e~­ lOll of tm-lumbar spine 11le;e are rarely if l,,\·l'l" totally "hml.... ted by treatmlonL Thm. is much )"t'ltobe expl.un( laterally to the lefl and then 10 the riFJIt. On pctforming this mO\cm,>n" if pain is pro"okcd wilh lateral flexion to tm- I between the bonv articut..loons and tm- MrucIUR'S "·lthIn tilof' rwuroll foramlOoi and vcrtebr..lca....l \I",-ements of IIlof' \"l'r"-'br..1column do not occur m isolation. bul rlltner in .. combined m.lnner Some aspects of this ha\ealrl'ildy been m'"15tlfjak'd{Farfan. 1975; Rolander. 1966; Troup" 0/.• 1968; Loebl, 1973) Grefll·rson and Lucas (1967) found that a~ial rolation in the lumbar spine was to the left wh;ion when the ll'lO\'cmenl

thc""me of lalet'ill

Wm'"ln9 rotary and lateril flu,on ~_"ts "I varying poSitioo§offlexi()l1 and cxlension nelps 10 CSlabli~thd in extension or f1cxion rersonallaboraloryob'ier\alionsonunp~r... cd ]umb.:lrspi.... sp«imens(which ... en.o ...' mI,)\·cdwithin 24 hool'!iol dealh;lnd then frmen} would seem Ioindiall' lnal the dlJ1lCtion of rotation IS lJl the OP~l!E'

dir«tJOntoWlwhidllhcspinelS lar....;ollyflexed l"II1?rdlcssof whethef the spme IS In flexion, l'xlffiSlOO or fIl.'Ulral.l11ere doe.; appe.>r to ~ some ,arianon. """" L"\"cr,dependmgontheprtSt.'OCt!orabseoceofdhal.:ld on the superior articular ~urface of the inferior vcrtd,rae, whi1l' tl,e interbody spa(e is rmmJwed anteriorlyal1d widml-d JXl'>teriorly_ Rotation 10 tho:- left C;m cau...esimiIarmoveOlC1ltonthedght"ygilpoph}'llt'aljoint,asdOl.'S left lateral flexion This causes an opening movement, which is Slmil..r on the right of the intenertebr..l joint. TlIe movement is similar in that it is an opening mov("ment on t...... right, but it is not an identical movement. The fact!; regarding .. ddailcd 3",,1)'sis 01 oombint-d !OOI.·mwntscanberelatedtothep.1lImtswhohaWp.:lm on mm; ement. Some 01 the rombmatlOru; of p.11niul (or pam·free) tnO\"ernents follow rerogniz.lble p;Jtli.-"rf"G. Basicall}'. then! an> two tra:- of tnO\·em m«hanicall) di.sordt-red.1bcy are regul"r "nd lI"n>guLu; the regular patterns are liltL'tdung or comptesl\4ngpant'mS.

~uIJ'~ttetmofIllOYetllellICOl"lb.IIJ!lOIISa~

~trtlct"ngOl~poll1ffilS.TheyproOuce l.Im'~fmcr«menlSltthf..,t~rtdlratjol"U.wl\l1f

prodUCIng

mitar~ptoms

mo\·cments produce the symptoms. 1be te\.'er.;e is the casoe if the symptoms ill\' produced on lIlO\-emenl to the OJ'POI'iteside.whenihepattemlSl5Iretchmgpattem. Ex.o.mple5 of compressIng regular pallert\'!i: I. Right cervical rotanon prodUCl'$ nghl supr.t5C.Ipu1ilr pain. and this palO ~ made "'·orse when the same tnO\-ement IS done III ("dens>on .:md ~ when done in fIe"ion. 2. Cl'r.. ial .....tension prodUCl'!i right ~urrascapular

pain, and tim pam is lMde Worst' ... hen right roQ. lion l'iaddcd tothe~tensoonandmade ... orsestill when right lateral flexion is ~Jed. 3. Righllaleral ne"ion m the lumbar spine produc:o::s right bUllock pall\,. whkh is molde worse when tJus mo..-ement is don pattem5 01 m,,...ement!; thai include ~ ' ml»·ements with ph)"5iok>gica1 """"ements_ Twoex-ample5of reguL:tr patterns an'": 1. rain and restriction of lTIO\'ement on ""tension of

RrgjJ'Drpatt~m5

ThL'Sl' al\' p-'1ttems in which movements produce simiIarmo..ementsat the iot"rvertebral joints while produdng Ih" 5CiIJwlth~lJIO\/'W\(n~

Notlt: T1lIt ,mportaOClt of palpation ~ beItn l:'11\phiIsu.ed throughout this booL bemg so, palpalOl'y ~m'Ntion t«hniqlle!i must be included ,n e\"ery rombmed mo,emmt test tlwl P"""~ or reprodU(t5 pain, It.,.betfocthepalpation to bltJKIdcd at themd~tlOll of thlt rombuled ph)'5iOlogx:oll mo\emenb, .... ther Ih.in sandwidung it between phys>oklgKal mo\"t'mCflb.

nus

Palpiltory alIm'/IiI!JOtI tlnN mon'ulmls, his book Milo"'" ofCombrni'd Mowmtnt~ must be reJKI. T1lIt bookaJwronl;linsdet,bon the!iclcction oftechnoques in treatmenl managt're IS a diffcrm.ccal change "'hen, on __ - lion.thepat"'"tdoesnotflmch.ifthe~m­ ;..... gi....' 5i1 shil.rppbwlth;opomtedobjec't{suchilSa pin 01' nL'ed1e).espIlOoll1y If t..... pb produces detectable inderttabOn.IIl)W('\·edbyp.....aonu­

.....ntly one mot. l1le root 01' I"l'.IOb quoted are tt.found to """e grea~ clinol s i ~ (Flguft' 6,20). While the pabml lief supme. W JlO'"'f 01 the appropriate ann mu>C\es can be ~ quickh' In lhe order sho...n in Tabk6.'.liowe'I'er, ... hen aSllt'SSmg neurologicalmusc......·eaknes5.lhetestsm~:vneoed10 beextendedronsiderablylO~inthee>.tentof

...ealkneejerk...ilhthepatiently"'g5Uptne. thephY"lothe.-aplSlmU5t$hghtlyflexthepabenl·S~

toappmxim.1tely3O" ..nd ensure that the quadriceps 1$ relaxed before lapplrlg t.... palellar tendon. When the response is "'Nk, some remfom"l"l'lml may be gamed

by asLng the patient 10 gnp his hands; together in a rnonko!y-gripand pull Strongly. If the ankle jeri: istcsted while the pabent lie prone, the distil end of his hbl.!l should besuppol'1ed to flex his knee loappro"malely 30" l1letl'f"ldo-AdullC'5is th...n tapped. This renex acti\ity IS increascd when the patlcnlknecls ..reclonfullysupportedlo...erlcgswilh his k-ct ol'cr the edge of thc rouch. Normality of rl.'ncx ach\'ity is not romplt'le withOlJI applying .....'pt'dled Iilpping,al least six repetitions. to aSSL'SIiany degree o(fallgue,nthe brisknessoflhe

138

MAITLANO'S VERTEBRAL MANIPULATION

---

:}~=

........

== .....

TIiI::IIlI

IIIu

~.

n

.......

C7TJlC8(II

caE..-~

"'- U_ ~-

jer1CO.

~jw3bavclhckntt Thr~tlIfnob,~_"""'lhcp;lt"mfs

!own llugIItoplKt'l\(I'

loIndorllhcoppclSlt~\tl>g~_WIl.;e1hc

p;Itleftlhokls"""'jwWlOtloflfttfullyc.e tests thai can be applicd lomo\etheSlructun"Sinthe\·t'l"t~tlral canal withoul aisomo>'jng the inler....ertebral joinlS art' fcwin numbcr. Straighllegraisi"glC!;ISlhcfrccmo,"cmentoflhe low lumbar and s.1cral nerl'e roots and their sk'Cvt's within lhe,"ertebralcallal and mle,,'ertebral foramen. Although Slraighllcgraism!i n:stricted t04O",a" be

Tablt6.10

NtNt-rOOI origin for mOlor supply (M) and relaltd ptripht.al ne Ntsupply(P)

R~i'~tory

Oi~pIlr~gm

Ned

Shonfie.OC'l Long fie.""

fkJcion

Ste.no.m~~loid

Shone"ensol"\ Longe.tensol"\

T"Pwer L.... tor

+ rhomboid~

" ""

Se,.. tus .. nte,io. I3elno-h"me,~1

e.t rot AOdLKIion

Inr",spin~tus

fSup",spjn..lus

1~Itoidl ~t fCO~-brll.hi"hS 1f'ec.M~jora... Int(,n~ rot~tion. (

..1 Idd\ll:t,on ...tenswn

""'" E.tension Rulon Supination

~r\d

~i:ern

SUbsc..pul.. rere:s m..jor

'·'"' ' I

Lati"imusoof'i

Tri«ps

B.arnioradialis Bi""ps

Supin~tor

I'fOn31orlercS Pronatorqu.drlllUS

j

e.tenSOI"\.arplrlld. ul.c.. ,piuln is flexo' c...pi di_3Ii~ fie.. o:arpluln3ns PlIlm.. rislongus

~e~:;o~~~~i~i~

(

Fle"pl'Ofundus Lat Fle.. profundus Mrprrio' glutoal ntNC; Sl' y SuprrflC brof.alue 1\10'\'"""",1 of the dura] ,n'estmenb 01 the $pinal

,,",-'ralforaIlll!n,andttusll!Stsll'lO\-emer1ts w,thmttwfulllfotlgthofthespine.ThettstiscaU. t1wtheraplSt proa."lldsas follows; 1. The paloenllS aswu to SIt ...e11 t-:k until the postenorknee.reill5 ...ed~agamsctheedgrofthe exanunabon couch 50 thai urufonnit~.. of the test po!iIbon 15 lI1OlImtamed. In ttus ~ 5itlm« pusibor\,hoel5~toroepor1;anypamordiscomfort

(figoo"'6.Z1)

2. HeisthenaskdlOletlusb.x:kslumpthroughilS fuU~olthlracicandIU1'llNr6mon.,,·hiIr .. tthe same lime pl'e\'entmg hIS hNd and neck from fle>.ing.Onoeheisin th~p:tenslon tNt might tal.e place. as ...ould bethecascifth.!oomexity inc."aso-"y are nluch slower, Then1ore. when lhe slump tL'St is used asa techniquc, care must bc taken nn Ihe firsl day and asscssment o\"er24 hours is Ihen nCCL"'Ssa.ry lodeterm;ne whether thcstrengthoftheteral) w,lh the limb stabilized to compare th.. symptomalic changes. This is also Elwy'sbasictcst."Thcserond basict""t lltili7£s shoulder depressi nn:umstill1£l'5, pasSi\'~ tests of mon,'nlef1l of ~ inler\'er!ebrdlwgments an berwgal:i\'~ Inrnntra5t tollus,ifthepabenl1'la symptoms = g fl1Jlr] ~ in...... ertebr;o.l joinl, in lhe absence of o1ny iIbnorrno11Jtv offnO\ement of the pam' _b\~ struetun5 in the lertebral anal, then the testsbypolpation,,'iIJ;o.lwo1ysbepositi\·e.Thc)mdl be dillicult 10 ascerto1m. but Ii I"" d"wb('nS of It\O\l~ mmlarclestedproperhasdecibt'dintht-foiJol,.-ml; scctJon.-Jl'ClSlti,·1' signs of p.lln, restiictiooormU5Cle spasm "'ill be found in one or mol\' dircOry movements of the inlenl'rkbral lI'inb, whered' the p.llpabon movt'll1el1t tl'StSCdll bl'dirl.'ctly rclatL' .JCCt'S5Orymm'eme.

and~fort

•

Assnsl",foocfta~'~IC1I\pctl!tu~orC\ltCkntt

•

~ngforsoftt,uutcftaI\9"5.W~rf"~allO

of~aling dttp,~"eraltoloahlM

•

AssnsillCJforbonYllnomahes.~g.sp;nousprocn! position Ind rtlat,Yl:' d~pth

.00000ngfOfmovtrntntanomalied at followingtrealment scssio"s forchang~'Sto the findings. ExC('Ss]\'e .weat· ing i, not a common finding, but when it isnotcd it add, 1o theother~"Xamination findings in identifying the level of Ihe spine in"ul\'~'O!dlo if.an abnormality is kit then-

pe-rfurmed Iwo or

~!hegener;1I.andmore5r055,mpn'SSXlnt­

beeng.ainedthroughthefullpadsofthefingffsUl' thwnbs,.tIwproct'dunl'shoukfbe.."..atedbulthislfme usmg Ihttipoi tIw p;td ofonl) onedig.t of each h.tnd and emph.aslnng the t"X.1m,~tion 10 the arNS w"""' d~fromtheroomv.lh.a,·et-nfound.

A 1N5OOiIb1,- .acanatedeit'm\l~toon of thes,kand

Iyptof~~bnorm.ahtyshoukfbe~sothat.a _

dtiililN determ,~1tOncoin I:lI' made ... ,.... lnc.- most common fU'lcular pdlar alorll'Ul'mo"..Inh'n·ertel»'alle"els. S. Hard bony thICkening and prominence 0""" the zJIK.lpophyse.aI;Oints. 6. light.- of the ligaments or localW'd thickening ol.a'>«tlOn. fhcolOc.thtloOft-tJsWtctl-anges.l~toughtfttocy

alC;thtmort.cccntthcya,clhcloOfle.thcya.c

ltoickening alQund lhe apoptoy""'! al>! "\.,,,~ \'~d~hons ,n lhe l\ardness uf the leall\cry fuel. Thld«"",n~ from mUll! """enl stresl;es will be SQf\'OOU~ ratherthantlw.5O\lrU,t5f'I'_1lwdlSC'USSlOl'lr~

anotherlS5Ul';tIwpootJenthasSOUghltrc.almentforlht S)"lllptoms. and is prob.1bly W'I.I,,'.arcoflhe ~s) behindthem.1fthepillJoenlh.osh.adn'CUrnng~es ofthcsa~symptoms.thec.auwofthesou~canbe

e>:pbined to him, and the requlA'!mCfltsofappropnottc trwtment (tNl 1:5. lodear the assumed caUSC' n well as t"",ling thc~) "'ill bor undL"r$tood by tl,m.

Alhictcncd or itiffalCadoeinot II«d to be pa,nfpOOtaneousonset Qf n·rtebral pam and!ioeri.s treatment for it, how dOl'S ~ e....1TI1J'IeI" dlffermtu\e betwt'm the findm~ that rebte to the present problem and the- findin~ that would hn.. bftort Pl1"'«lt befow the 5pOOw.eous onset of the- ned: p"m 7 A Simi!.. . difficult) ari5e5 "'hen att.-rnphng to detf'nTl""" the degJw of dit;a.b'hty that (';Inbeattributed toa rea!f\t 1l1jUryand thrdqi;..... that is attributab'" to pre-e>ostmg )'CI pain1es6 'a,,,,,,,,gl'" iOllltfinding!;. 1'.'= ... oU t _ m.n.~_ If an interve111'bra1 joinl suddenly ~ painful for no oln'lOUSdlS«"nUble ....MOn, it 1$ still lJ>Otit hkl'ly that tlS:Wf' mangel> Iu,.. 0C'C\lrR'd If thesf' recenttlSSue change ha,".. OC'C\lrred inan·ideal'jotnt"lheonlvfindlfll)Sthal ..iJlbedetKted by p.tIpaticnn:aminanon WID he 01 thE- 'fleW' or 'l'ron n:amination. the md,anont!; that il isollSSOC'i;lted .. ,th .. ·new·disorder. out tNl a hypomobik- JOInt O!" a h}"pct"-mobile joint 15 no! ~nly a pamful joint. I"'e..-ertheless, the qulIhty of ll\O\ement and range of mO"ement must M~~nto(~rtrbror be "PPn:'Ctak>d befoll' attempting to ",late the ..bnor"",hh/':ll found to the possible cause of lhe patient's Tesling mo...ement b)' palpatIOn imoh'es techniques thoot arc u",-od for trealment as w,,11 ase"arrunalloo."The S)'mptonlS An 'old' hypomobility has D hard Cfld-feel at the tl'St seocks information not only of rang", bot alSl of the limit of Ihe range, with mo..-emenl before th.. limit of 'end-feel' of th.. range, the bl.'ha\'iour of the p;!ln the range being a smooth frktio,,-fl'l-'C movement. A throughout the range and the quality of any resistance ·nl....' hypomobility, on the other hand. has stiffness or mllscleSp;!sm that m.,y be p~t. Such inform,'tio" is determined both for lhe ph)'siological mowmL'nts occumng earher '" Ihe rOO to ..t~I~.lfthep~.,applM!daslsinglo'

slow ~"" the ,-ertebnl ........· _ 1 w,ll nol be appneciated It aII,if,t is appbed tooqu.dJy. ,t can be ontel'prelL'-ement, then eKlftlt should be ~ ()ccaosion.IlJyafuU~tmavnotbeposs.iblf!untilthe

-.d

~tion. beu~ pain with JnO\''lodenluntilthejoonthasreack'dIOthc first eo;ammabon ID plus I)

~\.Ifl>nal"'~tmayOlllybo:possibkat t~ 1«vnd

e""..'nauon. wtten the wuew~ have

lUctedtotl>efimVla""",,~ThlSlScalledl~

'0 plus r aunsmenl

"TIle costovcnebral jomts arc tl'Strod on the same manner asdt'SCTibedfortht"mtervertebralJOmts.exccptlhat thcpressul'Cisdirected through the anglc of each rib in tum. Thefourpnmarydi~bonsinwh,chthepres5urcs ~re appliL' ,arying thedir«boo. of the atxn·" four mo•.-ements (ib folJo.,...... and by '''1)ingthepointofrontxt .. ,ththP\4"tl'riorly""llw.".n

prvass, 1ht' dll'l'CllOll (l/ I~ JnO\emeflts con be ,'anc'd betwC('f\ an Inchnallon Iowards tIw patient's hc..t (fIX"'" II};/I) and an ondtnabOll lowardstus le pahL'llt's Wet. towards his head or, e'"" IT\Of"I:l importantly, through an an: whichendsasapostero-anteriormo,elJH,'(ltaga~t

IhelaminaorarticularpiUarofthesamesideofthe ,·ertebra (Fig"'" 6,J9). Figum; 6.~.~! show the dlft'Ction of the ll1O\-ement applied to thepn>CeSi5l5 iUustraW'd '" F~m;6,J7-6J9 When lest1ng JnO\enwnts b}' ~l~tion k'duuques, the ,....-tmra 5hou1d be thought of as being a "f'hen' lNlClnbt JnO\ed ,n any dtr«bon (f'lr"",6,4J). Similarly, when mo...ng one, ertebroI lry., !io1~'. a tral& 'er.;e!yd,n"CIed ........"ftMfllagamst'tsspinousproeoes (Figu1f' 6.44). the ll1O\'ingelf«t il has on othef.5l"Ctiorl> oftlw,l"r1dJra5houldbe\isualizedffWtrto.45). Ha,'ing nsuahzed the directions of n'lOnments of the,-.,rn,brabeingmoved.,tiseasicT'lO'isualize .. hal happens to the .. ertebr~ abol'" and the l"ff1ebra belo.... (Flgur1'6.46). As well illi ,-arying tho> angl6m pressu~ appliIXI to the'·ertrt>r..... t.... pollltofrontMtatthl'inter..ertC"b,al joint should al50 be ,',uied. For aamp.... if the C2I3 joint is being ~~amioed by pC factors, when p,,-'SCnl, may follow one of many different pallems. Pain, for e"ampll', may be

fectl)'free,w,thl'eSlSW>oebcmgfcltatthelifl\ltofthr range The amrlltude ,,00 stl'l'f'lgth of lIus slight ..,,;ist. ancc"lso\'ary ""idI'ly (,.".. Appendix 1). ~ "ariabQnJ alsoinnuel'n'thel}-peoftmltmerllteehniqueusro. Muscle spasm;,; till· th,rd ,anable U\ nolTllill joint mo'·l'fTl~'flt. l1>e rangl' of mo\~"",,,nt may be lim,ted by \"L'T}'strongmusciespasm.orthe!iopol.'otflmaybl"ofarype thai ise,"ident only if a joint mO\'eml'n! is performed in a particulM way. For e~ample, if th", joint is monx! slowly and ca,dully. no nl,,~le ~P"sm is fdt. bul if the mo"cmmt is qu,ck and jl'rky. spa~m protects the joint from mo,"em"nt that wQuld be painful. MO\'l'mcnt5 u",-od in trealments. therefore, mus! be modified to su,t

figu,"

6..,

Hgu," 6.42

Po,t.m-ant.,iorunilat.,al pr.»"'. inclin.d

l~t.,.lly~nd m.,ji~lly

(a] TransV(rs< p'(SSu,".lb) Indin.d IQ Pl"1..., ~nt ..iQr

160

MAITLAND'S VERTEBRAL MANIPULATION

Figu,c 6.~5 Dircx his chin to hi$ch.-s.tandasscssth(>ch.,ngt:>insyrnptoIJIS.lftht:>re IlO change in thcsymptoms. ovt:>r-pK"Ssureshould Ix> applit-d 10 the nl."Ck flt:>xion ~nd the symptoms is

Oifferentiating symptoms from both neural and musculoskeletalwun:r'S

One of the most difficult kinds of differentiation ~1~rswhenneurallestsareposili\"easwel1aSjoint

rea~(r;gurc6.49b).lfthebullockpainis

i",,,..ascd by tM nt'Ck flexion. the disordcr musl havc $Omc dcgr"", of canal/foramina componcnt; ifsymptoms do "olchange,thedisord(>r would s(''em lobe fre.e of any can~l/foramina component. One point to remember, however, is thal in Ihis posHion his fool is notdorsifl(·xl.'d The 'slump ll'Sts'can also be uscd lod,fferenliate bet',","'I1ajoinlcomponentandaneur~lcomponenl

One of the m051 difficult kinds 01 differentiation, whkh is relatively new and very much harder than lhe previous diffeK"'l,liations, is trying 10 differentiate a pcr:;on·sproblemwhrcntiationoftht"contribuling strncturescan lake place. Tht:> trt:>atmenl of MrsC. scfvl"Sasannample.

F"tg....,6.41

Dhon exami""tion 1l"91ed a promment thorJ1ger,w.. ~ina ur th;>t was hit from in front ..nel she' h,l her he;Kl ()Il lhe windSCTftr>, She had suffered symptOll15 01 vanable ",_Iy bUI righl-sided only...nd she- had not responded to ..ny of the tre..tments thl:' doctors and phys.lOtheriIpistshad;Klrninisten'd()o,erthe3weeks prior to M'Clang .......ipulatne ph~~otht..,..py 1......1· ment. lhesymploms had bee1 gradually increasing; lhl'\-weft'nowmthl:'right~oflhe.rm~faraslhe

..Ibo¥o The only gu~ irKhc.tion for her prob...... Mns neural rathtr than;oml ...as thO' fac'llhal arm S\"lT'rtoms w~ ,"')' ,;ogut' m thl'I, dlSlrihutx.\. and tht're ...·ereno e-TOOtirril.UKln!Wgnsoneunun.llJ(lI\. Ho¥.'l:'\ \iNC.1s had thereolal Sll;J1S and S"mpiOOU ot a ,uinl component.!iO II .... ;os lhe aIm of lhemmaJm-almo..'fltslobeonmledlo\\ardstheO"l'\icaI5ll':".•"da56ol"55meflt,...asrepe.. tedl)·perforrno:dfor roth lhe «'nIkal md>calors "nd the neur~l indic.IOI"5. TIM! inItial trNlmml was oriented towards lhea.'f\ ""I ~plneand theT3/~ are.. (tll'..lment was !he palpatory din.... , t)·pe of Il'Chnique. which produe«t a ' ..ryquick resporlS('lO all ccC\'ical mo,"emcnt but did not producc IInyeh,\ngeintheneuralmo\"Cmcnta,tenskedsiglU). Ha"ing proved this, the treatment was lhe" ~witched tou·\."jjngthe"euralmo,·emenll\.'StriC\ionsandthcir I'-,i" "-"'pon"-'S. The lechnique ch~n was the First of the three standard tests (Buller, 1991), ~nd although thesesho... ed changes in th......ural signs by about

:ro---JOpercent,therewercnochangestolheO"l'\ical signs_llo"·e\'er".,,·henl1l'Uralsignsha, .. beerlpn.-smt for .. long time 11K')' lI.'nd 10 be man" difficult to treat. llwl«tutiques"''eredla''i;oo around in'.rious ...·.~ butwilhoutanyfnourabll:'clfect-MT$C.woukilo5e thO' gain in thO' neur.l Sll;J1S on euml""tKln ""thm 24hours.'Tlu5p.lltemdKlnolalt... TIle nv;1 Step ...-as to po6-ltKln the ~tienl sup,.... ...,lhherheadlater..lI)'f1e?c't..mherright arm held In the po5-lll"e "\Imber I c~1 po5-lllon. was then treated bydouble leg stn.ght1eg r.. JSlng. gradually pushmg the range of the straighl1eg r.ising unlilil reached thelNllImum{'1\k'nlofparnlo ....1uch I ....asprepared toea") ,t.Asthb ...,asunsuccessf\l1 In .nducingimpro\"Cmt'1ltineilherneuralorjoinls,gns. the It'Chrtiquc ""as changed 10 hanng her l)"ing supinl! bUlwilhbothll.l\Spmpp..'dupintostraighllO'gr"i$ing positions and thl>n u mg the cenical later..l flexion ttodmique to "-'Produce her ~rm symptoms_ This was ..lsounsuCCC!>l>ful. SO I thench.1ngl'd thi'lll'alml'flIment. thecer\'iml mOn'rTKonts had improved conside...bly but tbe upper limb neural movement was unchanged. This told me that Ihe firsl rib area playt-d a part in the cervical componenl thal had no effect in the upper limb neural component.

I then lay Mn;C. pl'Ofl('with herhcad fully laterally flexed tn the right and her left arm in the upper limb neural position, which was the same as the testing position. In that position I performed unilateral PAs on the first rib and tTansn'T'5e process of Cl, directing the movemmt in a PA dil\.'Ction plus a caudad inclination. This produced only local p.1in and no thoracic or arm pain. Following this, all areaS had improwx/ subjl.'Cth·dy and thc physical range 0/ mo~ement in both eer,·ieal and thoracic and neural tests was improved. I then repeated the technique but In a much full", lateral flexion to the right for her head, whkh I held in this position with my knee. The t~'Chnique produced local symptoms that spread throughuut her left arm, particularly at the elbow and fingers. On rdea~ing the PA part of the t~'Chnique, the symptoms provoked by the technique were as just de5Crihed nn the first rib area The technique l\.'Sullt-'d in an improvement of all component>.; t~ thoracic wmptums on U'rvical flexion had "onewmpletely, her low extension was full range and asymptomatic, and her left arm nt'ural test was almost asymptOlThltic as wdl as having a full range. Shecomment~'cen how much of the impro\'('ment she retains Radiographs From the physioth(·rapist's po,nl of view, an e~amin­ ation cannot be considell.'d complete unJess certain facts have bet'n clarrfied. For example, if radiographs ha,"e bt.....' rl taken the physiotherapist sh(llJld endeavour to see them so a~ 10 u., more aware of the state of the spine u.,ing trcat~'OlhrnptSlsometimesfinnl fk>~, ion, lhc marurul"li,c ph)"Siothcr.pisl must hug tile pahent's head bet...""" her two hands, Iler arm along· ~itk his h""d and her trunk aj;ain.t his head. Her olher arm should hug firmIY.I\,,,,,,,thcrtrunk,solh.:Jtllle paticn"sllead and ht.. . upper body and arrM can be 'ccmcnIL't5

~1an\· prupIe!ot'el1\\()beIie-~tNl tl'l.'iltmentbY~

1I'"t'""",·eon"'lInece",;mlvin'~'·esstretdUng.bulttu"

isnotal .. 'a)'So,olio\enc1'the Importance of f{' too quick or too slow it will be impossible tog.lIn allY f""lol n\()Wmflll at tl1ol'jolnl. lnsk'ad. the mm'ement will 1m hkeshakingor slretch· IIl& Il"Spectin.-1} Allhough It would be "'rung to try 10 f'St.:lbIish .. ny OtTtedL-gn.'l'of flexion in ordl"l'10 g.llllthe mid·posihonoc'\..·eeo the limilS of flexion and extensIon for the lowl$t ren·ical IIlteI'Vertooral jOlllts. EJc.\ctlrthesameprindpleappli~lothelechniqu~lJ(

Iraction. longitudlllal movement ..nd rotation in the lumbitrspine. WhCfJ mrn'ement ~dc:llrod in tIv Io..·t'l' IOtnt5thelumbarsp,neshouldb.-posl!lOnedrow.uds fle?tlOn,and when thc upper lumbar Il'U'lS.re bo..'Ulg moillhzedthcpt:JMttonoithelurnb.lrsptneil5 ....hole istov.ardsl'Xte\Sion Oinral tip: To pt"odlltt m...i",,,,,, mow:IMnt of il norm..ljointln .. nyonedlm:t'o~whf~ ~ildil-ing.il i~ enler to 9oi~ the fulltst rongt'. With lust effort for thep/1ysiother.. po\I .. ~dwithoulslr;li~IOIM"'odet ifthisjoi~t ispos.\I01lfC1 as rn:;Iras isilvillilble to the "'id·~I_of""sothrr13"9t5

ptlformat«hnoqueadequattly

wtom p"actis.ng teehmque!; on one

113

rolalton.1ateral f\t':loon or traction (.. nd in a sm;oller IT"tC'asureth'silpphestothcleduuqut'Sln.'ol\mgpres-

otnOther,

ph>w-

Ihrrapists!ohouldparattent>onlodetailsolpa;;itionIw~ theie skills ha\'t' 10 be moo:hfoed when applied 10 pal~lls - no 1"'0 paticn~ h.we t..... same build. nor do lhey ha\·et..... !iOH'1I"-'fII. When .pplymg rtus pnndple to ,he cenk..l SpIne, it IS c1e.... thai if the head and .....,.-k "re kepI in normal alignmf:!nl t~ 10.·.. ~'StCt'r\'icalintt!rverld,r,'I;O,nISwillbcmuchnca"-.,. t....~rextended than thcirflcxLod ~ilion.Tht'TCf(W, whcnusingthctL'Clutiquesoflonlli!udinalmo\'t'ml'I1t,

In Chapter'J, ....tching fordisturb.once tn "'" normal rhythm oImrn'emenl is em~ 11us IS lfCJw.lly Import.ml ,,'hen perionnlllg Ct'l'\iul and lumb;.. rotdtiiCb of thehandsareusedloproducelh"p~ul'producedbytht'thumb 3. The palmar surfaet' of the central area of the dIStal phalanx. The teduuque used an be made mtlOl' cornfortableshll by using tllu; area. ObVIOusly it is noIas informauveaslheothL-r.;.but ,t is (or can be) the best and most comfortable way of IrJn$m,ttmg the p.1lpatory technique to the vertebra 4

bl' ustd in two !l;I~c sets of circumstanas: tIM' treatment of ~tirmn... Of of pam ,athcrlhan,uiffnr$.Thcme!hodofthercchnrquew,1I

T~atmentte"'S'ures onthepartsofthe,er1ebrat',itisessenlial that they are not performed painfully. Thoen'! is a difference be!>-'cm tho.' techruque being pamnJl and the technique "'producing the local pilin, If thl' pat~nt !cds $Orencsa or superficial pain with th" technique. Ih~'I1 it is ne«>sSour fllr the contact point of tho.' thumb tll be modifi~-d. fIgure 7.3 shows four Soi'Clions of Ihe thumb thM un

R'9"ttlumb:Ioo,,,,,,,'ac'po,nts

be u,;al to trJnsmil the Pl"{'Ssur\' 10 lhe ,·ertebra.

The antl'rior surface of the bas.;, of the Ihumb. The llse of this contact point I~ the contact a~a of the tL-ofthf'goab for the paper was lQ describe the dUferml amplJtude§ d passi\~ TnO\'mM!nt treatment thai coukl be used. It "iIS Mis6G3nne whl!ga,e me the idea of deptcnng the original diagram for the diffun!nt grade!l of fnO\ en>enl. Manyl101>,cl1lU'l()\·allOnS .... \"ebo!en~50ncethen Grie•.-e. 19lIl). but the Ol;'dit for the baSIS d the nlO•.-ement grades muSI be Ml5S Ganne's, ''/hen using Ihl'cen'leal teehruques of lateral """. ion and rotation, relaxahon and fi""r control will be obtained if the physiotherapist ~radlcs tl>ity to ha,-e wbsidcd. 1bc manipulalin! physioth.!rapisl det"rmines this by closelycommunicahng with the patil"tlt. IVheretlpon thull of passive movemen I As a trealmenl technique, a poslern-anterior pre>sure may cause pain and by sustaining that pressure

Whm treating pain Ihat is pK'SCnt only al Ihe end of range, or when lreating stiffness, Ihe technique should be a smilil-amplitude slaccato mo'-emenl at the limit of the range. The treatment movement slrelches Ihe joint slructoK'S 10 the Iimil of their rang", and is held Ihere finnly by Ihe manipulati"e physiotherapisl for as long as 5 minUles. The slaCCillo small-amplitude o"er· presSU"'-'8 are applil..J for a t'me and at a strength dictatlxl by how chronic the disorder is and th" dcg"'" of discomfort mtend,xllo be produced by lhe slrelch The pressures referred to above arc not performl-d on only Ihe one vertebra, even if it is only movement of that single vertebra that reproduces Ihe patienl's symploms. If T8 is the vertebra al fault and posteroant"rior pressure is Ihe oscillatory lreatment lechnique, the treatm"nt movements wOl1ld, at leaSI, be applied to 17 and 1'9 as well. This is only a general rule, and ;s open to wide variatiofl'>. Ilowever, when the pressun"> are used 10 treal a somg to be appbcd ~ thU!i l,aidIng any 'm.-w hokhng' Foreum.ple, if the tre.atrnenl teclu\iqueofchoicEo is lumbar roI.iIlion done in side I)·ing. the b.-'dmique may be doneas a IV to treat end-of-rang... softnfss. and this mayea~_ pain. By intt"l'TUpling thoom)'thm ...·ith a III of large amplitude, he Cilnno1 pll'dict the chang. Ul a rang.... The depth of a smooth. f'\'l'fl mylhm u-cd 10 lreat pain is changed in response to pam fl."lt durlllg lhe lechnique; lhal is. t.... technique is 1Tl(l\et! back in t.... range-to avoid JMin. Similar'y, If it lli tnlendl-d lhat the Il'chniqu... should be perforrn..'d as cloo;.e as possible to Ihe- point in the range ....hl'n pain begins. il is n~ry occa"onally loearry themrthm a FraClion (urther inlothe range to S{'l-' thaI thl' posilion of th... oo>cillalion iscor...'CI, Illhet""hnique issu«essfully ch~nglng tht' symptoms and signs, th... pain may recede, allowing the rhylhm 10 be tah", dl--"pl.'r into the railS\.' by increasing the range of movement.

MANIPULATIONS Khythm i'j al50 important in relation to manipulative t""hniques. Qb"iously manipulative t~'Chniques art' P'-"folllled with speed, but ",'m though the ~ond'posiliort of the manipulalive movcm\.'nt is constant for a partkuL~r ~t of conditlom, tIw stdrting position may vary. Onee the posilion to perform the manipul"tion has t:--n adopted. and it is detl'TlTlined that the desill'd symptom responsoe is felt when the 5111'tdl position of the tl'ChniqU" is tested, the strt'lched position can be eased. The decision i then ~ .os 10 whether the manipuliltion is performed from the strt'lCh pa;ltion or from a position where tIw sl~ch!\as bo:'en sbghtl)· but ~gruflantl)'reIeascd.\\'tuche\('rischo6en.themanipu­

laboo is taken to lhe !IoImt' end·pos.tlion. From lhe strdChposition the;amplitudol't'ihny;from thereloeased or ...ased pa;ition the ampt,tuM b larger. but ooly beca~ it is startmg from a posill()n further back in the ranp'"o not beause illS gomg furtho.-r into lhe range

RHYTHM/SYMPTOM RESPONSE Follo....ing e"",mmalion and a5St'5!imertt, a particubr techruque may be dlo:o;o,n With the deliberate mtention lhal il should reprodUC'l.' I cakubled degree of local discomfort. nus may be the eho~ for two rcasort5 1. It is anlicipatro thai the symptoms will d{'Crease as thc t{'ChniquC' is continued, and that they maycomplctclydisappcar. If thisdo..'S occur during the pcr' formanceof the technique, the patit.'nl's mOVCml'flts and symploms should sho.... Impro"ement .... hen reassessed.

180

MAITlANO'S VERTEBRAL MANIPULATION

2. It provides further vaJuable object;"e examination information to know the effect of reJ'C"tcd movemCf\t in a particular direction that is painful. For example, if a particular mO"emCf\t is performed with a consla"t rhythm ""d the movcmCf\t is pai,,1CS'> at first but a" ache develops a"d worsens OVl~r a period of say 20 seconds. it IS obvIOUS that the statl' of that joint disordl'r is worse than if the movement had cauSd di5C{)mfort at the begi"ning but had become pamJess wiUun 20 Sl'Conds Itisimportanllhat.wilh~ryt~chniqur,thr manii>'Jlati""pflY'ioth~rapistmustbtfully.w."'.t

all timts ofthrrff~t th~ ttthniqu~ is having (Ill patirnl'l enra potin plL.lli the concurrent rcrogmhon of the ncuro-mU!lC\lIoeild specifIC techniques to their pnmary uses in each§l'Ctloo of the SpU'l' (TRI1kS.l). Thesc.-tabll'Sare

thefolloooing: I.Gcncr"'asped5for~l«hruqU('

Nquei.

2. Aspemofthcbechnique,tself 3, The re.... tion of selection 10 ~ dJilgTlO5on

Un;I'tton,(fltx.WIV frotrIthtwcltofpainJ

M'_S'fI"IPtorM ... lhtprtSt~of"'tt'Utrttbrll"txionrnlr'i(l>on N"/ttMQltof>tlrltd.a.llIltrlllydlSUi:outtdSV"'p\OIIlS;u"'laltnl\'

dlWhrttd""'l'l.... ifl""'r!Y~lIt

pt'-isf!;nqrdsontht ... oIpai or th.. inl(>gr~l p.~rts must be lhoroughly understood. A disClI55ion of Sl:'lecting tt'Chmqut'S will follow

CURRENT KNOWLEDGE OF PATHOLOGICAL DISORDERS n-c:arethree:aspectstoooosider: 1. MO\mcnts:andlherel.Jtcdr~'W'/pill"response 2. P"II'l-wnslh''''S1RKtureo. ..ndtheirpallem«of ,.~

1. The pathologK..I d..-deB ..nd illfUl'};

MOVEMENTS Physiological mo~ment considerations ~

lTI()\'mM'\'lt!;

I\~

10 include lTI()\'cmcnts of the

\-mror"" and ltM>Ir functJOnal structures. mo'-mwnl!l of lhe .sIructu~

In the \"t'I"k'bral canal and mlt'r\o"rt\.--bral b'amtn.1, .. nd mQ\ emcnts of all the neural componothe'raf>lS1S to ","plore thisC'Ofltmumg

forehawthl"cinating p;oin. or tinglina: in the refwred ~rN, Sud>;o respon5oO' derNndi rlSpKI. .md p""olmg the

TI5f'OI'SCSshouldbea\1:lOdnts """y pl'Q\'oIoa> d,stally re-fenl!d symptorm as "n ,mmedLate response to thetnO\'cmenl wllhout pm\'Ol1nal p.>,n, Though it maybe f>l"CCS6;Iryto pl'Q\'okthtofMlnsJightly with a IrNtmC1ll,it should be done only ,f t..... pain I'('\'crtslo its priorl",'~l on releasmg thl." tcchnoqm' 4.

Whcnl\:fcm.'ed and tl1ey then cau"" referred radicular pain, wllh or withoul neurological signs or changes Tile disc il,.,lfCi!o cause refern.' inten~'1'k.rol disc i5 progn'S-

siH'ly degeno.-...atmg withoulany bkelihood oIl...·O;", rompromismg tnc "ertroral caNI or inll'n·t'l'tebTaJ for.. ~ or whether II 15 progressmg ~, ..rd an C\-entual mlerferencE' with the elI",,1 or mmi""l stn>ctuAS.. ~..~th the

HERNIATING/EOOlSC

rl_ _-LI- - - I Loal Ind vag...

P1U\M.....-lOOt

but long

mtrrcd5'l'l"ptO)lM

rmrmlpa'"

fonner,each~i5acmmpaniedbypaininroughly

thesamf'areaeachtuJ'I('.and the pam does not spn.'ad furtnl'rC in tht'ClI5('oltht'llUTIWrandcell'icalsplJ1l.")lhan tht'buttodt (>J'I..odC!I 01 pam. It.lStheseh>oklndsoldl$:d~lhal .. re!iO common m OUr l1'I(ld('m SOC.ches. and ,115 m their con§f'n,.. b,(' IYYnolIgcmcnllhal the marupulali'-c pnys>olheraptsthas50muchtooffcrl"hed~on

5ri0cb0noltedmierapid,yetatlhcprcsenllimcthesymploms (and therefore the disorder) rnay t>e quite stab1l'. its stability t>eing indicated by the lact thai thepaticnt is,forexamp1l',ablc to continue with manual work without worsening the disorder. UnderthcsccirculOslan(esthcpresentingsitualionisa stable One and, although the usual (are is taken. firm le symptomatic at or near theendofarangeofmovementifchronic.The'stretch' pain and the 'compl"C'SS' ree of stability uf thedisorderhasa vcrydecided influence on theselection of techniques, and therefore will be discussed later in thischapWr. The sck'etion of technique is guided by the diagnosis, with particular referel1ce to The p.~thologic~l~nd ml'ehanic~1 changes invoked. The mann"r il1 which the diagn(l!;;S manift'Sts itself in terms of the patient's symptoms and abnormalities of mov~ment.

This rel~tionship - that is, the diagn(l!;is/symptomatic presentation ~ is the primary. all-pervading and n~\'l'r­ ceasing guide to th~ sl'l('C!ion and modific~tionof t('ehniquL'S throughout treatment. Tru~ though this ~tatement is,the term 'di~gnosi~' n",-'ds to bequalified l'atiel1ts having a diagnosis of 'disc herniation with nerw... root irritation' may have different patterns of symptoms ~nd signs. Six e""mples of different patients may help to make this point clear, as it is very important whl'Tl rdating the selection of treatm"nt tL>sisoft/rei",li•.;;t"a!palie"t

This definition. which refers only to pathology. should be expanded to include similar wording to co'"er th.. purely met, a mechankal oomponent, Theanalytical assessment will determine the diagnosis in 1'\'lrospect What information dOl.'S the manipulative physiotherapist ideally want from the doctor', diagnosis! First, she.-' wants to Imow what the doctor thinks is the causeofthepatienl'sdisorderandwIMlledhlmtoth, the patient nul' ha.,i' pam in his low.... back, right bullock and right po6tcrior th'gh, ... ~tt."/1dmg to h,s knCl'. Hi' rommenhi 1t1.1' the po!>ition that prondes hIm ",th greah_'St ea,;o, is to lie on his h-f, sidl' WIth hIps and kne...'S ne"•..:! and his right kn~ restmg on the bN. Tolil'on his right sid,,;ncINst.'S his buttock and leg rain. This may indicate thai h(' should be positlon(od Iymg on his left side and that the plccting of tn.'alm"nt tl'(hniques when the physical ex.ammation findings nuteh the manner In "hich the patient is ..Ifl'dl"d by hl!ldi~

SIGNS

=-

_

The s'gns ref to the physKal exmunatioo finchngs.. They inchcall' hethercanal. .......·.........lSilrl' on\·ol\ed. whether nen"t' oonduction· impent's symptoms can IX' ,nc...... sed or dl'Cr'Nlol"(f ~. eqUillly s.ignificanL With rl'S"'rd to seI«hon of tcchniq...., the following I'Qmpk> should l'''pJa,n the ,mportance of examiNtion findings as rompall'd WIth the importance of the diagl105is.. lwo palll'l1ts diagncJ5ol'd as ha,·ing 'dis left plus IMeral f1,,~ion 01 his head to the Idt, only faint scapular

""".1'

tinctpar1S:

2. Examrnation of ph}1o,oaogical rr>O\·emenlS of the onteo-ertebral!iegll1t'll15.whichinfl'f'S' a) Rou~ anatomIC..1tnO\emen\:s (Oexion.-I'~ten­ sion,Jater';l/1Jeuon and roIal;on,also..sp"rtol a functiUMlly demonstrated mO\"t!mCfl.t). b) Expandoo rhl'sioJloglCill mO'o'crnenlS into rombinatiolb of movements grouped together in varil..:!seqUle, and lhcir resporee 10 polrtlcu.Ur tre;ltment tec:hmqUCli is pn!dirtable-

The hostoo' of tht' dt'gener;1l1ng dISC is reJKlily rtCogruut»e, p;lltK\lwt)' ,f the patient hils had !ie\'t"tal pPi$Odes Theprogre;soonol~dlSCdISOldeTIOprodu­

cmg

net'\l.'-root

-"".,,"

irritation or (Onlp~on is cqu.ally

Whenapalicntp~tswitha~"IUZ.il.blen.-guL1T

pooll,,", of l'p1SOde!;, and the pauem of symptomatK I'I.'Spon5o.' 10 examination mOH'm..",ts is also of a m"tdl,ng ~uJ.. r patlem, the two together """"gillen

andronfirmlhepallem

t""

Whl'n mOl·...m"nl p.111~rnS arc rt'gular, the SCll'..:lion of t,-,\'ards the f'l'lI;u~r m:cgniz3ble p.olun. ~ ~Io tn>almenl ""II ob\iousIy be kss

pnl'dicWble The hIStory of the \OO:;;led tnlCf\'fi"rtcl>ral joint is .ootho.'T ....... mple of .. recognll.....1e histor.-, and on l"..lmll",hon ;, is found the mOH>mcnl sign.~ ..Iso fil a regular pattern_ Under t~ cin:-urnsl.ances "gain.

,h.J'

the t~atmenl """ponse from a p.lTticul mo\emenlj which do not filan)' paltern. Ilrian Edwards (pp, 1ll-1J6 ..nd 221-222) deals til :1S n.'l>"rding the ,..drnichnlq ..... It ~~ Ule corn"C1 ....~,'C. tion. A woroerung p;l'" responseexlending progn..... si\'dy over a period "f 20 wcOfld, of thl- Kl'l\tlr st",tchiog technique 5lI~ ·~t/fIIC"-

tllm;7 AI lhe time of the ,rllrial examilUltKln of a p.t-tient. sp",,,1 mowments mily provoke relC\'ant n.>ferred pam, and movements of the c... nal Siructures may also pro"ok~ thes.~me relevant pain. The dill.'Ction of mo""ment chOSl'n initi... lly should be on~ lhal mewcs Ihe foint and leaves thecan... l siructures ...lati,ely undisturtx'\:l. Only when I~

cult 10 ,...,-pnxl.- by spinilI mmemenb th.m b) Cilnalmo... _ t S -

S.

ShouldllpllY"rok1gJ The cho~ depends upon ,,'hich of the two pm. dut ~ignificant findings, ThaI phy.ic.. 10gic... 1 move"....nl h,ch"'ques can mal..1OI1 Iclt and rotation Iefl.llow·C\tr, the arnount of the flexion" Iattral flexion and rotation, or till' emph.lst!l on one of the thrt'l' dll't'CtiOOS, depends 0I'l lhe p;lin response d~iR'd. If I.... aim is to a"oid p.aln. then the amount of f1e>;;0I'l, lal.......1Oexion left and rota· rion Ielt is modlfi,>d until lhe pain·fn.", p'''ition is found. To ta~,· this dis£"l"dshouldbe§\o" 5 The rhythm shauld be bmOOIh. 6... Theduralionoft.hetedlniqucmustbeshort, ITUtJa.llyuntil.the$hourresponse;"~

It IS in t1tis area lNt grade I and II mO\emmts are so ".I.... bJ... As pam~.grade IIIll'\O\emmts may be w.ed Point (5) refer" to tht' rh}'thm of the wdulIque; rh)Ittrm' arediscussed m dct.>d on page 176. 1'1'1ww 51iffi-t> is dam"",,,'..nJ IIw"'ulllJ 5tnKfu"" IIrt

"""ll....unntbyl",ulllOlordlSt'tl!lr

The end'Of-raoge pooiollion should be chosen. The technique ~hould be fIrm. The amplitude should be mainl)' small, but should be i"tcrspcried witi1 !OOme larger amplitude mo.. "m''fII~, ~spcedcanbequickl'r.

The rh),thm n......ods 10 be !IOmewhat staccato. DIscomfort should be respected, eflt~al is (or the malllpulativl' phYSlotlwrapJSt to d(-'\l'rnune exactly all of the details that form th~ examination of the history. th... symptoms and the drcumsLma:s under which the p.~tient feels thern,and the signs (th.Jt is. the test mOl'emmtfindings n:lating pam n:sponse to range of movement) (TI2/>k B.7). Ob\'iou,ly, ill other aspects of e~aminatiooto CO\ (or ronfIO!llS:

l1\\'oommon presentation of disturoances fitting tile abo\".. headings arc often impossible 10 t.. ll apart at a onon of tes TJ\O\·emml. The

IIl0\l."""",tscanbeu!il'dtolrealfj"egroupsofpresent.Il1onoUlfol\OWS;

1.I'am. 2.Stiffnt'Sli 3 l'ainassocialedwit"stiffness 4. MomenLlryjabsofpain. S. Di50rde15directlyn-latuld blo hrmlo. t thebegmJl1ll8.or!M)~toma~~tofl ul.... of lIwrdlll.~~lIIOn'rff«I ...f' 2.ltl5~r)"todecidt-whethc-rllwll105tpamful

_ _1

oe.. r{notatllhelunilofthf'prirnaryphysiologlaJ nnp~be~OI'..'hethertheln05l piluUul and n'StJicted (iz. pnmary) p h ~ ~I""""ldbe~

3

sIe(IS ..·illbO'tabn..~",norrwthScrib.'d lor treating the pain-with-stiffness group Huwever, within \his category of disorder, there are Iwo further ways in which tee of two bask patterns (stl' p. 194). The first is Ihat it progressively degenerates and causes symptoms from its own structure, and beocause of Siresses it places on other structures associated wilh the mechanics of the intervertebral joint. The Sl'Cood is that il progresses and herniates inlO the vertebral canal Or foramen and irritatl'S orcomprcsSl'S the

209

210

MAITLAND'S VERTE8RAl MANIPULATION

neural slruCturt$, u,..(erred S}'mptoms. tIw)· .... ill not tun" a latent qUollih,or. ifprl'5en!. will be of short duratIOn and not ...... """ 5. Thenema)beassociatctions of mOl'ement andqualilyof mOl'emenl lhat a"oid pain. They shmlld prod~lCl' an impro'·"mentinthepallenl'ssymptomsandreo;tricted mo..emenlS of both cilnal and inl"r\'l'rtch dira1ion of the romapl5l should gently bull'd po!S1tKlf\. and find the one she should use 11.5 the MId muled 10 the left

dccre_.

~'mploms do th~

mcn:_

mobdizahon technique MobolL7~ngmtothepall1""""din.ctions"'IIS1!lelhe first choice. H(W,'M"'-, there a.... lirnoeswhen ltus approadldoesnolproducelhedeSlJed prognsos, Under these Clrd lOoneth.llcanbeconlroliedtoprO'..o!.ean ble minlln.11 d~I\.'eof discomfort. \Vhco such an approach is ~1l.'Ck'd. liltle should be performed at the first se.;s;oo OOc,lu~lt is the 24-hour rl.'SpOnSethatpro\'idesthl' inforn1.1lion upon which adjustments to the t~'Chniq~lc soscl~'Ctroshouldbcmade.

When Iheso:: approaches fail. thc n"xt choice should include moving the Colnal struclull'S. This may be ach,C\'oo III conjunction with moving the intervert~ bral joInt. or may be performed with the joint stabilized m a pain-free posItion. The firsl application of the leol:h"'que should pl'O\'ok" only the most 10m, mal of referred symptoms fora "ery limitro 1I1TW. and an ~mt'Ilt after 24 hours then prO\ide'< the (";"",",tlal .monI'liltlOl'ltoguLde progression ofthi' t""hniq...... If the d~er has ""onenee;. ..nd berefOll' nc·C'l.'SSary to know th,ll;

~

ill\" Ihre.o associated

~uiremenlS for

selecting

Il"duUques in tre.. lrncnL The first IS"S follows.

A decision regarthng 1iI'k'ctJng the initi.alledutiq.... cannot be made until ~ follo""ng information has been dctennined from the eumin.aIiOll of the patient I. Thediagnos~. 2. TheprognoslS

3. The present deg~ of stab,lIty of t..... disorder. 4,

The manner in which tht.- disorder pali~'rlt and his daily llCli"ltK'S.

aff~'Cls

the

S The site of the symptoms and the symptomatic Thchistoryisina,tablcands.lfephasc. The current behaviour of symptoms shows Ihat the prl.""'nt.ta"e is totallyslable,

3. If thcrc are any neurological signs or changes, that theyarcold.,tilbleandcertainlyloiallyunHkdy tod"I"rioratt'

"-'5ponscsassociateLiwitnr"ngl'Sofmovemenl' a)'End-of-range'or·through-range·pa.in. b) So;-\'"n:-or 'nuis.mcc·\-aluc:' symploms. c) Reccnlorchronic. d) MO\·cmenlsprod~onlylocalpainl·\'~'Ilinthe presct"lC('ofrefcrrl.'lJsymplo.""

Tablt 8.9

Principlts of trtatmtnt

associat~d with difkr~nt

diagnosis

DIAGNOSIS

I

I

Mrcl1anical blod:.ing

ugam(ntsand capsule

I

Mo""m~nts produce rd~r,,-od symptoms indicating th~slru.tu",al faull and its de!;""'" of damage All 01"'-" imporlf'ld requirement is to know that Ihe mail! BAStC joint techniques are rotatiun. lalcral flexion, palpation techniqUl'S and longiludinal mo"ement (which indudl'S traclion), and Ihe BASIC canal techniqucsare str,'ight leg raising and 'slump' tcchniques, and ULNTs(s«pp. 144and 24esclecledforaparticu· lar re..son, and Ihe selected tcchnique must be expected 10 produce cerlain chang~':S. If the expectalionsarenotachieved,thereasoncouldbethat The lechnique was ineffech"ely pcrformed. The reason behind the scll"(lion was wmng The communication channels are nol open ~ Ihis could be the reason why thetl'Chniqul'was ineffl'Cti\'ely pcrforml'(od ~llhough Ihe pt."riph...ral ,ymptoms h~"l' in f.lel di"'1pP"~Rod. So we know that Ih~ an.' signs of n,·wlution. On Ihe 01"". hand, if On the th,rd day the Int...n>!t}' IIlcre~sed. further qlle'otioning of 'wh) du you thlOk It got worse?' or 'what hapJX-nN around thilt tim... for it 10 gel w~r mal" I\:....' al that the pat,,~nt performed an unlJsual ... sk/~Mi\ill prior to W wor'dtn:atmcnt,~changcfrv"l_

tf'C!'l"~tolllOtMra"Mmadf:_qlllddy.lf

w.. iIn~1 osnptdrd.it-.IdMWftIIIg 10 cftang~

frv"I_

Irdl",qlJ~ to

afl(lthcr unt,1 it is dur

th((rdl"lItuo:isnoIMing~~

Although II has oo,n suggested that Iwo ~ppl~atil)f\S of ~ mobilizing t~hnique are suffkien! hI shO\, the value of a It.'l:hniqUl', this is nul alwa}'s so The whul" point of a~",-'SslOg between tl"ChOlqUl'S is to ha'·... a m... ~ns wh"Il.-'by th"ir effect can Ix· mC,lM'Il.od. Dunng the inillal ... x~mln....... " ..;d,; .. ,t.. ,,.."·,,",,'i.. ""'I""';"""~">om. fkll 1«1'-"-.If. The quostion IS, ho.- mueh unptm'ement In ~ pal.....I·§ signs is t"ROOgh to Jusbl) ronhnulOg 10 use ~ particular mol"l~tlon teehmque 7 1lus is diffICUlt to Ie.1mf'Jd, lfncc lS .....'U'§sary. Gradl'Sof mobili:tahOll5 been discussed (Itt p, 175),aoiological and accessory. r-.OI only may the physiological lIlO\emcn15 be rombined, bUI also the accessory lI'lO\·emm15 may be done III a rombmed phY~lOlogical J'OSII>on. It IS us~11O find With regular pallernS that the accessory pro«ed. Although dealhs have occorrlod (Smith and Estridge,I%2),itmustbert'ali~edthatifthenumtx>r

ofmanipulationscarriedould"i1ybylaymanipulatoTS is rumparLod with the mortality rate, the danger is extrl.'mely small (Brewerton, 1%4). Coupled with this is the fact (Liss, 1%5) that similar damage resulting in death Ciln occur with daily activitid contraindkaHons in the SCrl5C that the conditions arc unsuited to or unlikely to be affect(od by the trcatm('nl. On thesre not enough to prL",,,nt fr",turcor serious damage if forceful proc~-dures are uS«! There a", no sign:; to warn the physiotherapist that an osteoporotk bon.. or diseased Iig"ment is about togi\'d readily, then stabilizing exercises should be added or substituted early in treatment. lfpain is aggravated by mobilizing exercises, they should be discontinuedandstOftl~l'f"'II_l

1- ~.-.--..cs f*"Im,~ SpetialquatlOflS 1. llont!lrpllllmihawarty-..ttddiu.-

I"«rtrlnlMkry)1 2 llont!lr/llt>tnlhawbdatt'fllt.ngi...... handsandlor

~ptomssuc/lilSstJffnas.~aclacMOfd,ni~Tho:

fM.Of....,9";tdist""-nkanl~l

S1t~.ndclncriphonofll\(svmptOlMoft~~lpsto

1.I3mtralhtl1l1o.nd~lMinl~>gIItlosstf'l>td'lQI""'toryl.

~Ubl~IMSOUftt

4. Whattabll1s.~bto"9Ul.~fortMandotheep'OI«t~~0;!5tablishOO.lhl­

physical6dminaliorl is much"""",, straightfono"ard" By astuteobser... tion,.an'ppraosalnnbrmadeol~lmd "'_~tion-thatl5,tht",gourol~~bor1­

and Ihl-kirt0d5ol\lc§l mon:'menb that ""II bl-used WhentheS)'Tl'IJ*lII'lS'~5l."\-en"orthed~i:5uTi·

tat>w,l__ p

lI7).oril~his«x) lndio'Il"'-n;. w"""lhc'di5ordl.'r isdu....uc.nd pam ismod· eo-ate,tesllJV\~t5a .... talo.enlOthelimitoitherange" TftW 102 is a gwde for the ph)"'OCll aamination..

PHYSICAL EXAMINATION

_

OBSERVATION

~.Jb

~-~

"

Ft!ill"~

10.6 I""~,

I) c.,rvivcmcnt';ofthc

~rvicalsplnc(fan9c,svmptoml"pon,asharpflKklTlO\~tm""yoithe

,.,

Fi!lu,el0.16 ~quer'lC'l~bt~f1O*1"ght.Rot"J\.. ... f---LFE

"fht, p ~ of athftomatous and artmosclerotlC changeli oomplicate5 the SituatIon, as do marked u!"Kf'!1('l1It,,'e changes in the cervical spine. II IS Important to qucstion thoroughly asjX'Cts of the po:Wl IS adopRd. and ""Ien§ion 01 the hNd on the neck is added and sustarned while as&o::5ISlI1& ')'lllplom!; bolhd~andilftertheproceduf'e(F'SI/"lO.ZS). Ti'Sl' - Ex!lmSion. The patient loeISUf"M ,,',lh his

head and Ill'Ck exlt"l>dI'd beyond the end of the couch. The rNnipuJau\'" ph)'SIOtheraptSl holds the head In the manncrd,'SCribcd abme, and full ""1Cf\S1On 1$ perfom'ledanda~(flgu

... l0,26).

QUALIfiED ASSESSMENT ClIoreful asses.by ce!tam mo"emenb of the arm (neck and leg) cau5f'neuTallIKl'\·ementinthe(l.'f'Vicalspineina~imj_

lar manner to neural mo,·....oonts such I1S lho.soc ao:hie\'ed by straight leg raising in 1M lumbar spine tie has shown quilt' dearly 00 cada"el'$ at lIutopsy lhal,inadd,!ion to tnO\'ement of the shoulder, l'J1(l\'ement of the elbow when the shoulder isp06ll'J(1nOO in IIlx1uctioo and ",,!erna.l rotatioo i5 ..cromran...·d by ffiO\'emmt of nen,'" roots III IN "~ral ~anal a..nd inter...ertebral l'ofamlJlll, H.. has shown llbo thai fOO\emenl of the left shoulder and Jri'tdbuw CfNll.'5ffiO\ement of the """.., I't)Ots lind bra.dti.>1 plnU!l on the right5ideofIhe5plne.~test!lII~."mportanttNl

\ ...1>etherOl"notthertare.ny~)·mptomsOl"~Igm;of ,-~iLor in$uff~~)', nv.mpuLotion,..a ilUddnl lOO>~t ~'md IN poItienf$ coolrol is conIramdic.atl'd in e-"eryt'klefly poIlK'I'It .. ho h.u nvrkd ~1"~cNngts.T«hn.ique must be limned to mobLliziIbonl; used m conlm...l CIlnfU~hon Wllto ob!;en"ilbon$and qut!Sl>eIes5,Jwolpful'nformahorllSoftengamedwhen a pilbent spoo\.ilno.'OU!oly rommenb that he ach~'e5 rehefofhJ~$ymplotoibes f\lrther neurody1\amic: testmgoftheurP"" limboo Qualifoed manipulatiw physiotherapists know th.at some patients han with his forehead resting in one palm (palms overlapped) and his neck SO posilioned

~rvial

l'igu",10.38 SofHissIl,polpotioowithth,.. fi"9""

'fl''''

Fogu", to.39 Soh-li'SU,polpollOflwithlwofillgl:f!O

thai there is no 1.:Itrallevcls. 5. H.1Td bony Ihickening and prominenceO\"er the Jateral and posterulatcralmarginsofthearticular pillar. 6 Tightness of the ligamentum nuchae. or localized Ihickening of a section of il.

Bony changes ilnd position tests Bony points and intl!rspinous spaces are palpaled nexl. The lip of the lhumb of each hand is used 10 palpale the bony oUlline of the spinous processes first. There are 1\, are common. When 1 ' - bony prominet1CesJrenotcm·crL'd by sofl spongy hssue, lheinler· prelat;on is Ihalal1hough they indicatcosleoarthritic (-ly felt pain. Ies5 m,qumtly rclers pain inlo the suprascapular a",a. Transverse pressures agntC mo\'emenl al CS. NC\'crtht'Icss. they should form part of I..... c","mm.alion procedu~ for symptOnl$ a......ng from the lo\..t'\'" reo·k..1 spine, despl.... the fld lhal more luTlt' is required 10 disa= the findings at this le... e1. It is !iOflletirnt'!i nece!iIS Ihe"Pinousp~'llfortheamountofopeningand

ckll'iing tnat tak0.5 place

;\8 the head is man-d badwards and forwanis through a rangt' of movement of

261

....

MAITLAND'S VERTURAL MANIPULATION

Hgu..,lD.55

Il'!nwno:btlol_~LO-1(b;1"l('tltl1lc.­

_otm5iotl~loIPin«r9np,.(tlI.(dand(dIPirftrgnpappbod

alstarWWlpos.l_

IS-:ZO- To prod""" tht ma",mum men'metl beh\'l'l'!l a;andC",lt..-fourth~·ic;aI\cr\('braandthosebeklw

it are Sl>!l>ili;red by pressure agatnst thean!eriorsurface

lllO\.·ement IS produced ;al the ~-e1 being leslo:'d, ;and thai the lTIO\"emcnl is the maximum available

,,f their left transv~ processes. The position oflt..- '111'

;aICofoscillatiof\withintN-fuUrangeofforwardnel'J1d of the (Ouch and supported in the physiotherapist's lap. With the pincer grip (Fig"re TO.55a) she graspsbehv""n adjacent transverse P~'S with her thumb tip medial to the stemomastoid anteriorly. and the tip of her index finger at the same int"rvl'rtroral level on the articular pill.. r ~teriorly.

Method The physiotherapist raises and lowers the height of her

lap (by extending and flexing her Im~) and thereby flexes and extends the patienfs h('ad and thus the neck. producing movement down to (and not beyond) the le"d of her pincer grip. In this way she can f",,1 the rmge of movement available. C2-7 (lateral flexion, closing)

non-p.~lpating hand, she givl'S support under his occiput. When the lower cervical movements are tested. this support extt'flds under his neck (Figure 10.56)

Mtthod ik'ing careful to t'fIsure that intervertebral movement can befl'lt, and not just the head on the neck. the physiOtherapist fi!"5t laterally flexes the joint frICtionally away from her palpating finger then pi!rforrm the lateral flexion towams her palpating finger and asseslit'S the move.......,t at the interlaminar space. The opposite movement is then pi!rfOTrn'->d to aSSeSS the dosing capacity of the space. By this means the excU!"5ion of lateral flexion at that level on that side can dearlybeevaluatoo. TIle palpating fingertip must remain motionless in thcspace; thuscarc must bcexerciR>d when that hand is used to produce the lateral flexion of the neck C2-7 (laltral fltxion, o~ning)

Srllrtingposition

Starting position

The patient lies supine with his head "-'Sting on the table {'On a pillow or in the ph~iotherapisrs lap ~ preferably the latter. The position chosen should facilitate relaxation, and support the head and neck midway between flexion and extension for the joint being examinro. In this position. both lateral flexion and rotationarefff'l'St. The physiotherapist plact'S the tip of ht-r index finger ink> the inter laminar space d""Ply enough to palpate adjacent lamill3C. With both hands. p.utkularly the

This is the same as for the 'dosing' test position (FiguTl'lO.57).

Mtthod With the patient's head cradlro in the phySiotherapist's lap, she pivots her body (especially her pelvis) on her fcetto produ,e the head and head-neo;k movement !rre;pt'diveoftheint{'rvertl'brall"velbL-ingaSSl"SSCd. the movem~>J1t startsasa movement of the head, which

269

210

MAITLANO'S VERTEBRAL MANIPULATION

F;gurt:1Q.561nt~~I.O-ll~""'­

""'I. ~ nght wkl. lal 5arUng """,1-,""""kf3l nr-.

101dt.11ll~lMlpItirogr . . . fo,O-JMltIts.Qr1Jng,,,,,,,~ kl ....... lJtIg .. to:nl~""'t~dclwng.O-Jatltlt

............ islN.,., contmued down IOmovementoi theneck at the Ievdlx... ng~.

C2-7 (rotation) Sfortingposifion The 'starting position' is idenlical with that dcscribal rorlatcral ne"ion, ""cept for the palpating finger. This isC".rril.od a fractiofl laterally, and a slightly bruadcr conlact is made. 1lIe tip and ad~ollaIL..al margin or

theinde.; fin8t-'f"palpal"tht·marginolthezygapoptoysealjoint{fig"... I0.58}. M~thod

The head is

pivol~"j,

away rrom the side of palpation.

aroundanimaginaryC{'l\lrala~ispassinglhro"ghlhl'

joinllx.-ing tested. The physiotherapist's hands p..... duce the movement in II Slcady oscillatory rashion. giving movement down to the jllint but not beyond il.

C~rvic~llpinc

'I

FigY",10.56 (ronleckinloadegreeolflexion.ThlS mak.e W t«hniqUl' possible in a pain-fnoerange

The 06dllatory postero-anterior pn's..sull' '5 applied to the spinous process in the same manner as hasbt.>en descrihedabove.

....u

/.oro/variations The degrt.;s no l'I.'aSOTl whr it cannot be used either as a verygentlegradelVwhen themO\'ement is painful,or as a grade JI when treating pain

ment fdt is noticeably less tlmn that felt in the normal eervicalspine The technique is of p.1Tticular value when pK'SS",", over the vertrorae produces ~""en small amounts of mus-t........ a~l(IlOI

U~'~tflill

"'frtfbnolprnsll'f

ljl Ex.tm~ of t ....am.ent include pain simuLahng 1l\IgnlrM', page 42-1; and shooting occipital pall\. page4..~

Postero-anterior unilateral vertebral pressure

"1

Storting position The patienl lies prone with his forehead resting com· fortably on his hands. The ph~iotht'rapist stands towards the side of the patienrs head. She plan's the lips ofller thumb pads. held back to back and in opposition, on the poslerior surfan' of lhe arhcular pTQ('{'SS to be mobilized. Her arms sl\OUld be directed 30" med.i.lIy to pl'l"l'enl lhe lhumbi from slipping off the articul.u plOCl'56. The finger5 of the uppermost hand n$liIoCTOS6thebad:;ofthe pat1Cl\l"sneck and those of the other hand rest ilround the piltient's ned:: towards his throal. Most of the contact is fell with the underne;>ththumb (Figurr 10.64). M~thod OIiaI"torypret5un'dlrectedposteru-anleriorlYil~inst

an artlC\lLar prtX't'5S if done \-cry gently wiD produce a ~nll of Inowmenl, bullo pre...ent any Ialeral sliding at the poinl of rontaet a gentle roru>tanl pressu.... di~ medially musl be maintained. If lhe mo"e1t1lero-anterior unilill.::ral verlebral pressure is applied to C2 WIth the pJtienfs head straight, il is lhe C2-3 joinl lhal is being euminf'd. or mobiliU'd when pilin is a dominant feature. If, hoo-·l"\·er. the pilllent's

278

MAITLANO'S VERTEBRAL MANIPULATION

Mn/lod The movement is produced by a trunk and arm action transmitted to the thumbs. which act as springs. Although the mobiliZoltion is created by a posteroanteriorpressureagainstQ,itisin fact increasmg the rotatioobetweenClandC2.

u", This technique is of\'alue for suboccipit.1l symptoms or headaches arising from theCI-2joinl. It is usually perform~odonthesideofthepainorrestriction

Bilat~ralpostero.anINiorvertebralpressuren Startingpasition

fig""'10.65

T..ting for .b""fmaliti.. ofCl~2 rotal;on on

th~leflSid~(rC2,·ndrC2in30·RolnCD)

The patient lies prone with his fOl"1"lebrae. the nL'Ckneeds to be held in a degree of nl!Ck flexion. The lowerthecervicalle\'elbeing mobiHzed,thegreat...r tht'angle of neck flexion ,,-oquired forsucc(juiff'd to emphasize the flexion at particular intervertd>ral levels. For example, if the middlecervicalareaisbeingtreatedherforearmisdirectedapprox_ imatdy horizontally, whereas if the lower ~rvicallevel is being treated her elbow points slightly towards the floor. Whcnthe upper cervical area isbeingmobHued sheplares her left hand On the patienl'schin and raises her righl forearm SO thai her dbow points slightly lowards the ceiling. Under these circumstances she works both lmnds in an equal and opposite direction 10 emphasize the stretch in the upper cervical area

US~5

Lateral flexion is used in patien\:> whose symptoms of eerviealoriginareunilaterallydistributed,e,thercraniallyorintheneck,scapulaorarm.lnsuchcases,when thismobili7..ation isbcingused for the first time itis done with the patient's head laterally flexed away from the painful side It can be used towardsthepaioful side, butlhL~isusuanYOlllyofvaluewhentheassociatedstiff

painful laleral flexion is towards the painful side. Mobi1i>;inginlalet"al flexion is oflen of value in improving a limitation of the patient's aetiv(' range of rotation.

M~thod

Preroution5 This technique is not one:'ielected early in treatment. particularly in the presence of disc pathology,neilher is it a techniqu.. that should be used "ery ~trongly for unstable discogenic disorders. U5e;

The main indication for this technique is stiffness in forward flexion in the absence of pain or when pain is only minimal. It Can also be used as a technique when this movemenl "--produces Ihe patient'5 pain in any area aSSOciMLod with the vertLobral column. This means Ihal if left buttock pain is n'produced by neck flexiOll

287

MAITLANO'SVEATEBRAL MANIPULATION

Figu•• l0.H C.rvkJlll... ion.(a)lowcrlbjUppo,

In

the supine poliitiOfl, then it can be us..>d tomobllilc

lho.'f~uhystru(luresinlhelumbarverh.'bTalcil""l.

~n~ra/ romm~nt

TcehnlqllC'5CI tabilized. \'Ihen tr"Il5"erse pressures arc b(>ing u....>d, simil..r olCCUT3C)' 10 00l' k-.cl c..o be ao:Iit.'llt ....hohas .. smallor

Cervical spine

289

.1Chieved by vertical adjustment of lheoccipilal strap in relalion to thc chin strap Aswive1hookinthl'spn:aderbar.asshowninFiglm' 1O.75,isnotanesso.-ntialrequin:lJI"nlbulilmaM",for oonvenience.ThetrilClionisappliOO hest through double pulley blocks and a rope,Wilh a mechanical advantal;(' of four. small adjustmenls are possible withoUllosinganyfedofthctrilCtivepressure.

Treatment Trmtment may be administered in thn.'t' ways: 1. Conslanttractionrequirescontinuousbedrestror the patient, with lhelractionapplit'd 24houl'$01 the day or 1Il cydC50f I hour of traclion followcd byahalf-hourrestrepeatedthroughouttheday. This type of traction;" maiJlly used for patil'1\ls withSl;'d, but if then: is no Impl"O\ett\CT'lt O\'er the first fe..• days ,t l5unh""ly lhal the patlt'flt will be helped bywC()lIStant trac:hon, Tr.achon at home may be used Intermittently foUowing the hospital traction. ll1crean.· many J1'O!>ihonsdl'!iCTibt'd in the lileralul'\' for applying Iraction to the cenical spine, \'arying from full fle.:ion to full C>.tcn~ion. Basicall)', the positic:h.wllv iTlCft'MUlg until mO\l'mml can be felt bo.' the fin!{l'1' ~ the mter· spmousspaa, ThI505C1llatory lracbonshould ronlLnu~ until the right ~ure is founoJ. which is minimum a.mountrequin'dlopnxluctmO\'etr\t.'T1t ..llheml\.'T\I'r_ tebralle\t1bcingllt'ato.'d.Whmthasprt55urehasbeen sustamOO for ..pproximak'Jy 10~, the palient's symptoms are re~. TIle following chitngcs in symptoms w1l1 indicale h.::Iw lhe pn.ossure should be furtheralleredandhowlongilsoouldbeSU$tilllled

I. Whl.... )C\'cresymploms ilrecomplNcly relieved by thlsgtmlJe pressure,lhcprt'!i5ul'\' must be redured byhalfandthetractionllmckl>ptwlthin5minu«'S bec:al!So' the patient is li~Jy to hav" a severe cxilccrbationlaterunlcsslhisl'('ductlonismade, 2. IfsymplomSha\'"lx'\.'rtp.~rtJyrdieved,thetraction shouJdbe~ptatthislevcJandsustallledfor5

minull'!iiflhepillllWasscvercbcforolraction,and for 10 mInutes ifilwas moderatc 3. lfthc symptoms havc not .. Iten.od, the traction can bcincrcased a littlcand a furthcrilSSl'!i!>mlOJlt

291

=:""""presureshouldbe5115ta'nedf~IO

4. Symptoms mack'

"'OfSI"

by this genlle IrKtKln

shouldbo!giwnhaJfthepl'\'S6Ureandre~

If

the symptoms are shU wor.;,t, changt'!i of pallhon of the head-neck rela.honstup by ahl'rauon ofttll' harness or 5,lbng po5'llon should bo! carried out and the gentler traction I'\'applied Iflhe symptoms areshlJ wor.;,t, then one of two CQUJ'!i('5 rerrtil,lt5 open; if the aggravation. is not 100 great. the gml· Ie5Ilract>on Can bc maintained for 5 m'nute or less; if the aggrn'ali.,., is more than mmmlaJ, tDClion should be dlSC011hnued. On re-assessmg the nextday.onIyifthen.~tothegcntlepn'SSUrc

shows impro\'emcntCtienlswhoha\'edi~fortduring traction

Ireatmmltothenol"\t.Whmthetr.Ktionis~the

pen1S should be re~, but II is abo important to .._ tIM' symptoms and tIM' igns

on I1M' day following treaunenl. Follow-up treatment c.. n be ronsidered in two Cilt·

5l.''''''''

TrKtion in flexion

{CT

tI

51ortingposition

l'gOfies; thosE' pat,enls WIth pam and lho!;ewilh mooerale pin. Treerefore,although!IC.. I0."5 that Indicate strength of traction are necessary in n:oseard\ pfOll'Cls and In hosp,tal departmenl!l wllE>rl' staffcNI"'8f'SOC'CUr, II ISC'5I5C'nbal to reahzt'lhal tfiICI't'e

traction \'Ia the spTNder boIr wh,1e she w thr p5t the arlKUlar piUaron the right "I that leo.'e1. The ph)"Siothl.'np1S1 ~ cornbmes " pu.>h lIgl1inst the articular pillar WIth the righl hand (thus displ;>CU\g the neck to the left). WIth" lateral flexion of tilted to the left by the physiother· apist's left hand until the sln.'1ch can also be felt under this finger. "The right wri~1 IS held flexed 10 til the heel of the hand away from the palJent's ngt>t ear, thereby ke'1"ng the mllI'l" latl'nll ~ofthepn:oonWphabrulklbmragamstthc~­

1.ar pil1ar AI the Qme tUlle the physiotheraptSl dlle=b her n-orm in hne WIth the plane of the .. poph)'5e"1 joint under thet>.st:oftheindex finser. Toperionnttus mMUpuLtIion ....>tth nurumum effort. the ph)")oiother..pI>ot should croudt O'\'er the patM.nI'S head to hug It and ho«I both arms finnly lIgamsl her sides (riprr 10.85)

Mtthod When the physiotht'rapisl is sure thai she has the joinl fully st",tched she gin'S a suddlon thrust Ihrough the base of the right index nnger along the line of the ril;ht forearm, at the same lime applying an equal counterpressure with her left arm at the head and neck. "The aim i!lto produce a sudden "In.>tch OIl !he apophyseal joInl opposite tlw fulcrum. This stretch may result in a crack-like sound

Inttl"VCrtdlr~1 joints

0-7 (tr.IIlSWl'W thrust Iv

opening - )

Starting position

nus techniq~

will be de!icribcd 10 open the joints on lhe left-hand side. The patient lies supIne with hIS head e:!dended oc'}'ond the head of the couch and his right should.... near the right-hand ~odgeof the couch. The physiothl. .apist supports his head in her left arm, holding his (hin wilh her hand, and ~tands by the right side of his head. With her r.ght index finger, she nnds lhe int~..· spinous space bel\H>en the IWO "ertebrae lhal she plans to manipulale. She then places the anterolaleral border of her thrusting proximal index finger phalanx against the Mhcular pillar OIl that 101."\"("\ on the righlhand side. She then roUtes his head to the left lila ~ of small-amphlUde oscillations, I~K ~ ran~ until the mo)\'emenl Gln be fell to tat..e place al tlw joint to be mMUpulated. ThIS rotation ....-iIl ury between ;IS and 55 • depending on the ~'e1 bemg mampulak.'d; the hig.t.e.- the Ie'\-el the smaller the roGlion. "The right palm is alall times lep! at righl angle lolheskin surt~, The physiotherap.st, with nrm c0ntact held agamsl lhe articular pIllar, tHts Ihe paliCTIt'! head back towards his nghl shouldl"f WIth her left arm. This movement is a combination of slight eXlen· sion with lateral nexion. The mO\'l'TIlent is continued until the joint can be fell to be tight under the phys'otherapist's right l",nd. Al the same hme thai she tilts back the patient's head and neck, lhe rhYSlOtllp1Sl through her right hand 10 m5Un" that the oghl degmeof slack has bem talen up ~ small-ampliludl.· thrusting lnO\eml'TIt5 an" COUI1tened boo" l!n~ l!pping ftlO\eml'TIts of the pahtTlt's head, ..-hlCh IS held In her left arm. A small... mphtude marnpulall\l" thrust with thebody transmith.d through the nw>1 hand directed to.....ards the left and caudad l"fft'Chthewchnique

&ttnsion-Occtltratlon injuries lncontras! to the vigorous techniques descrilx'd, mobil. ization must at times Ix' el(\remf.>ly gentle lO be effl'C' ti,'e. Ono:- such example is nlensiof1-ilcceleration (' ..... hiplash·) injuril'S in the minOf category. To learn mol\', t'!;pt.'CioIlly In the area of injurics. Jeffreys (1991. pp.26-29)gl\csexcellentdctail

Whiplash injury typically oocurs when the mJUft'd per5Ol"l's car is luI directly from behind, especially if the injured. per5Ol"l is Iook.ing straight ahead and is lotally unaware of the impending blow It is encouraging to ~ that fIex>on and lak'f"al fIexJon lKn'leration injuries do ·iseeral components. It is important to take gn'~t

302

MAITLAND'S VERTEBRAL MANIPULATION

ca~ in determirnng the ar9 of the patient's symptoms and theu'behavlour, partKularly In telabon to theeffoo of l1$t on the ~ A pahf'l'lt with "iscrral pain .... N'ly

Sftksl}ingdownasa~tiootoadopttogainrclicf

r.lbentswhoNtn·LI1termmentdifficultywithbreathmg are be mon:' I.tkely to /\a"r an inle!""CQStal.. COlitmerteb....1 or intervertebral problem than a pleu....1 dl5Of'der, There.re many manipulators of the \ertebr.l coIumn who confio:: chams

4IT' in close proXImity to thcct~to\"l~rtebnljOlnl5. E'-Ml!i (l997)hassuggesk-d that arthnticCO'-lO\-f'l"IebR.l jointsGn cause m«tr.anac:aJimtationofrhesrmJ»theticchalns. Subtle autCJl'lODticlo}mptoms. t5p«ially in the limbs. may

~toe.~ofsuchmechanic:a1irn\ilhorL

3. \.lobilizationormanipul.1ltionofthelhon.cicspllll' and ribs may be necessilry after thor.oc or open

lnspiralion frequently cause pain,"piral1on does 50 far less commonly, I.nd if • patient am;..·('B lhitt breathtnglS unaffected twshould~;lsled to t.lk.l' in;l deep breath, gradu.lly W'liffmg lI'IOn! and more mto the lungs to PI'O\"l.·the point. This 15 becaw;e, Ii Ius symp!orn§ a~ mild or inlenruttent.. his normal ct in mmd, p.1mcularly jf thepahent'§p.1inisdlStribult-'dlniinarealhatincline. parallel 10 the anatomicill po!>Ition oflhe ribs Also, the first nb can ~ §mgJ«l out for lbo typical pattem of PresefltallQn whom.stJ.ff or liOr"I,-ins. but thm thl'y come b;td. lIS strong as~...,. for no apparent n-ason.ln o;uch cases a strong llwolvemertt of theaut~ nomIC nernlUS systl"lTl 15 ....·Klmt. 'Desenslhza\ion' of ~I\'" Symp'thetlC outflow by mobl1wng the thor.JcicspiN", ribs and related I'IeUnl tiSiS\H:" isaften roquircdbeforethcdisordl:'l'sub,hzesandthel1Jl(.'l}\·ery~(\'nghl,I995)

FUNCTIONAL DEMONSTRATION (AND DIFFERENTIATION WHERE APPROPRIA~ Although thepr nghl f(Jl'(>;lrm behind his right shoulder and hi>r nght hand beIund tIw

TQNe 11.1 lisb tho! elYmination te(n-=-yUI~"""~pain~

Tapll5t!whttlf.E.lf ...... llot"lttl9lft...,.1R'd. ~anoldliWKt>on(whttlf.E.lf&lIot"&tI9aft""9"lNl:~

Coonbtf...:l_tteb. Act~ptnpl>ttaijotfltttsts..

fintfib. InttmlStlo~(05t_l'ttblaL

Pl'MtlT.-T"F.E.lf.FIot" CanlllslumpsittinglltllS.

Sop•...., hssMntttf; ... nge.pa;n!badc.nd]Of.ek.ftdl. SU(I~SjlOfIl!yl;tJsj,

Fotstnb. Ntu~

.... m'''ban~~

........

......... pmpIItr3l,....tltm.

....

""""",CrT.f.F.lf.Aot'.T••T,,Rol"

'Palpation' Ttmptf)tuft.nclIWtl""9 Soft-tiswc palpatl4ln (musclt Et inlt'fSPonOllI space).

PooitiQnofvtl't!'bt'lt.nd.ibstspft'i.ltyhl.ib. PaSsivl'KttSlOf'ilnttMfltbnlmovcmtnt.COItOvt,ttbral.nclinltf«lSI.lmOYtmtnt(!-··Comb;Mor1'spectfic;oUy,

~--..H1.-,

f"""'1l.1c

....

ThtnrrtU1eclIO'9It

\IIilt1read!ut;h.ITlId

lAJl'IlJctu.;tting,ww ..... ~.181·(E}

'h,oousrotalJOrlpololtJom

5,

RotationCanalsobeas&eSSo.'dinlhestandingpo6ibon, with or without the hdp of outslretched arms or folded arms. Such rotation IS mono likely 10 detect mO,'emL'Tlt of the lower thoracicspint With the patIent in thcsithng posilion and with his armsfolded,askhim to'hug'himself;rot"tioncanbe lestee erect orextendl'Cl position of the thoracir spllU',and thiscanbeoompared with the same rotation but performed in the nexed posilion. Over·pressuno 10 Ih.. movement can be performed by continuing the rotiltionviapressunoagilinstlhe!iCilpulaandpectonl areas(figwlY'l,z"j Upper thoracic rotation can be performed in the§ll· ling posihon, with the p;otlent c1aspmg his hands bel-lind his oroput and the phys>otheraptst ~tabihzin& his )o....er thoracic atN. In this po5JOon, if the pabenl lu..... tusheMiandshoolderstotheleft.I... lthhishNd keptinastilticposihoninrelabontohis~the

sp.nemUSlbein~·oI,·l"dinlhepalient·ssympt0m5

main JTlO1,'ement will OCCUr in the upper and

(Fig>IrtJI.Jc(OI)· \\'hiwintheJlOSltionde5cribedabo\'e.thephysiothenplSt cl\angl5 Mapplicittion of O\-'er-p_l'l'

thoracic spine.

fromtheupperthoracicMl'ato~icalrotationto

THORACIC FLEXION, EXTENS.';O;,;;N

the nght whaleat the same llmeallowing the pabl'nt totdea5"lhe upper thoracic rotation slightly, and thechangeinsympto~isasse55l'd.With this dwnge of O\-'i"r-Pl'l'SSUl'l'. the l"Il1phaslSof the rotahon 1~",1Nsed from the upper tho';IoCic:al'l'il and incK'a5ol'd at thecen-;cal area (snFigwlY 11.JqEjj

midd~

_

Upper thoracic fMoxion and extension ill'l'included in neck Illl)\·emenb. and \cn...er thor-

"'" _~bOn of

acicf\eJcionandextcnll,on.a~includedinthee>WlUtl­

BRIEF AP;,;PR;;;A;,;;ISA;,;;l,-_ _

ation of lumbar spine lTIO\"roloI"Tlts. Midthoracid at the first consultation, its repetition may sensitize the joint at fault and thus make the same transve:rsc pTC$ure provokethe referred pain at the s«ond consultalion-Le. on 'D-plus+I'{D+ I).

------

DIFFERENTIATION TEST BY PALPATION

When trans"erse pre5surcon.""y, T7 to the right pruvokes the patienfspain, it maybe necessary todete.-

min.. whether the symptoms are arising from the 17/8

intervertebral joint Or the 17/6 intern-rtebral joint. The techniqoe fordoing this hasbecn dC'SCribcd fully on pagel62.

PASSIVE RANGE OF PHYSIOLOGICAL MOVEMENTS OF SINGLE VERTEBRAL JOINTS (PPIVMs) Ashasl>cted, and then-.fore the head does not l.aterallll\e. butl7ltherisd~upwnds.u.k'r .. lRexionis~

duced by the ph)"$OOlher.oJ'iSt lifbng the patient's hNd w,th a huggtng Slip oi his head, the ma,onty oi the bft bcingachie-·edbytheuln.arborderofherlefthand against the underside of his cenicothorxM: juncbon (Figul'l' 11.10). To tl'St Lateral n("J(ion in the opposite dirc"'ion, the patlCllt must lie on hi~otht'l' SIde. The palpating fingcr (..-..els for movement betw"....n the two adjacentspif1ousprocl'SSCS. Thl'lIpperprtKl'SSmoves first, and when the lower procL'SS starts to mO\'ethi5 will signal thec~tcnt oftne lateral nt-xion at this parba.llarinl"'.... t'rtl-b.alk'\el

Thor"cicspinc

Figurcll.9 Int;io../extcn.ion)

Figu,cll.lO Inter.ertcb,,,ltnll,,,,mc"l C7-T4(1atc,,,lfte>;ion)

C7-T4(rotation) Method The starting position is again the same as for fl,;,xionl .. ~tl'OSion. Toproduce thc rotation properly, it is n(.'CC';o saTy to ooncentrate on moving the joint being examinctlwithoutcausinganylillingorflexingofthehead and n~'Ck. Movement of the upper spinous process in relation to its distal neighbour is palpatl'C! throogh the pad of the physiotherapist's ind,;,x or middle finger,

which is faring upwards against the und,;,rsid,;,of the inlt!rspinouS5pace. With tne patienl"S head cradled between thl.'physiotherapist's left forearm and shouldcr, and his lower nt-ek firmly gripped in thc ulnar border of her hand b,;,tw~,,-. .. tlu! little fingcr and the hypothenar eminence. she rotat~'S his lower cervical spine towards her. This i, achieved by elevating her5Capula to its highest point whi],;, maintaining a stable thorax (FiguI"·ftn ~~tspmouspl'llaS5eS. MO"emmiof the patient's trunk is from the neutral po6lbon into

Stortlng posmon Tlw pabent SIts with his ....nds clasped bmind his nec:k whi~ ~ physKltkerapt5t, ~nd;ng by h", left ~, pbrectacarpophalangeal jolnts, the pres.suR'can be transmitled to the pads of the thumbs through thIS S('ril'S of stron~ spnngs. This springing action at the "'lnls can readIly besem as the body .....ight is appliN during ..... mobilizing. Locolvoriotions The dt-grt'e of pressure required in the upper thoracic spine to produce mO\'ement ;s far grt'al(>r than tNt l"«Juired in the cen·ica.! sptlY, and slightl~' slroogt'r than that"""uiredforlhl"rt'lJ'WJ\deroilhethon6l: "'~.

TIled~,&reeofmovement JlO5!iible in the middle,nd luwer thoracic spmeis cCII\sidl'rable, and it ishereth.Jt

il tScas;csl to learn a feeling of mol·('mf!nt. 1'hl'degrt'l' of lnO\'ement possible in the upper thoraoc 5pme is COl\SIderilbt) limilN. and th~ is p.trbCularly betweenn andT2.

10

Ches~W~;::~"f'IJll'(Tl()-12),""'physiother_ U~ IIpist's po5ltiondcpendsupon thesIYpeofthepatient's ~. Either of the l.1lter two plllioilions described

r~leriorcmtral \'l."r'tt:'braJ pressUft" 15 as useful for thl"thoracicspmeas rotal>on IS for thecenial

Thoracic spine

Fi is particularly useful for pain of unilateral distribution in the thoracic area. In such cases the pressure is best applied against the side of the spinous process that is away from the pain, applying Ihe pn.'Ssure towards the patient's painful side. When using this !l'Chnique il is fn.'quently necessary to mobilize the ribcage by a postern-anterior pressure directed through Ihe angle of the rib. If progression is needed. the ",anipulahV(' physiotherapist may need 10 c1(>ar the roint signs by using pressure on Ihe spinous pror,-'SSon the painful side and towards the pain-free sid.. Examples of In'almcnt include pain simulating Cardiac disease, page 421; scapula pain, page 426; thoracic backarhe, page 440; traumatic girdle pain, pages 441-442; and abdominal P.lin and. vague p.lins, page443

Postero-anterior unilateral vertebral prcssurc(rJ Starting position

The patient lies prone with his head tumt'd 10 the lefl and his arms hanging loosely over the sides of the couch Or by his side. To mobilize the left side of Ihe middle or lower thoradc spine (approximately T~12). the physiotherapist stands On the lefl side of the patient and places her [mnds on th.. patienl's back SO Ihat the pads of the thumbs, pointing towards each other, lie over the transverse processes. l1te fingers of the left hand spread over lhechcsl wall pointing towards Ihe p.lti,-'l1!'s head, while the fing,-'I'S of the righl hand point towards his kd and lhe thumbs are held in opposition. Byapplying a lillie pressure through the pads of the Ihumbs, they will sink ;nto the muscle tissue ad;ae""'t to the

321

322

MAITLAND'S VERTEBRAL MANIPULATION

~~

11.16 llll.tbl.[et ....

[d11l1cncicrqion.T~vtmbnll'f1"W"'l-)

'P'flOllS~unblthelnnS\'erwp~isnsJChcd

1l'M' metaarpophalangeal ,om! of the thumb needs to be ~hghlly f1exed and the inllhistechNquelSusedmtheprelt'llCeof the pressure must be studily applied and not

~

hum«l.inordertoallowtimeforthe~lorelaJ(.

Postero-anterior unilateral costovertebral press~lre(~)

StortingpositlOfl The p"timt bes prone withhisarms byhlssideor hotong-

trans\"eBIl'pl'OC'e5,loeNblethepresosuretobe.drninI$Ierfd uromfortably u possible (F'gIlrr 11.17).

Mrthod Averysteadyapplkalionofpn.'SSureisnen.,;s.'rylobe able to move ~me uf the muscle belly out of the way "'ndmakebone-lo>bonecontitct,Asthispl'OC«lurecan be quite unromfortable for the ~Dent,. can mu"t be gi\'enlothe~bonofthearrnsandhand:lto_blea

~-IiI.eKt1onIot>kep~altheelbow3 ...ndthe

thumbs. Th~-'lX'ethefHhngofhotordne5sand5Oft'­ . - betw...... the p/'l~"'PlSt's thumb$ and the P'l'tient'slrans\·_p~lhallSp...sentifthepres­

lure 15 applied by inlrinsic muscle itdion Once the n.oquirW depth has been INChed. the osollahngmo\'emenlat the inler\'ertebraljoint is produlX'dbyiflCre,lingandt~ndecreasingthepressure

produced by trunk mo\'ement. l.oCfJ/YOriations Ileca~ofthesuuctureandattadunenlsoftheribcage,

11 if not possible 10 product' \l'f)' much ll'lO\'ement With thrs mob.liution. Some people may find it easiCl'" 10 carry 01.11 the mobllizahon using lhe hands (as described for the lumbarspinc)insll'adofthelhumbs,bullhilshould bediscourilged asthc thumbs hal'e a greatcr degree of 'fl'eI'andcanlocali«themobi1i1.ationmo... a5

can alsobc lesled,bul os Ihese are nOI pari of the "l'f tcbrolrolumntheyarenoldl'SCTibedinthisbook.11ley

ThoraClcspine

FI9U~

11.21

(oJ.(!IIand(dPrtsWrt~pplitdlothefirstnb

ant~riortv

a~,

howc"er, descrioc-d In Prri,>Irmll M.lnipulallOII

(M~III~nd,197Oa)

A Il"Cho"tue

~rlonned

wllh lhe pallen' supine is

de.lCT1bedbelow.

\\~('f '"",Imenl ... appht-d 10 lhe thoracic inler"('f!d>ral pots, the inclusion of mobLlizal>m of the

toint. This mmbiru:alion may haSle" the

,rog=

fatl'

of

Ifpamisinan.>fern-dareaoflneriocilge.thesymptoms may be ilriWlg fT'(lO'l some abnontwlily bmo."""" adJK'l'f'1 ribs. Palpatlon will ~'eal abnorm.1lihe5of poioIhon and of tnO\'emml bro.-"""" ad).>renl ribs. This iSpl'CI of lreatmg costal paUl IS de5cnbed in Pmpllmd Md in such a way as to alJow the thumb to be nexed al lheinterphalangealjoinl and adducted and slightly opposed. at the metacarpointerphal.angeal joint SO that it lies in contact with the patm of the hand. lhe proximal phalanx being in line Wilh the index finger. The index finser of the right hand is placed owr lhespinous process of the vertebrae being rotated

(Figure 11.24). The p.1tienl·s trunk is then rolled back-

wards over the right hand,and the lherapist leans over the patienl so thai the palient's flexed forearms are tucked into the physiotherapisl'schest (Figure Tl.25).

Mf:thod The mobili7.ation is lhencarried oul by the physiolher· apislroHinglhepati..nt'strunkovertherighlhand. This is done in an oscillating manner Mobilization ofth~ ribs (R2-12) Thesame position is adopted as above, with the exception that the righl hand is placed SO lhat therighl flexed thumb is over the angle of the rib. allowing lhe fingers 10 be directed lowards the lhoracic spinous pl'OCCSSnts ....hose thoracic symptoms do not appear to bc aggravated byactivc mOVemL'Tlts of thc spine or when nl'\Irologicalchangt."Sareprest'nt.Similarly,itisth(>

Mrlhod

palO. When,,'"er mobili,-in~ IL,lOn. and the positioning of tile patient i5 controllLodby thiscur....e. Throre'icillly, the dirl;'(:tion ofth(> pull may be thought of as being al ngh' angles to the upper and lower surfaces of the mll.'l":ertebral discal the len-lth.1t 15 being mO':ed. 'Jllto kyphosis usually mfluenct'S the pc6l00n fOl' uppw thoracic lrarbOn morethanrorthelo........ lhQracic5p~

l"UJ1lr~of5UotheraplSt stands belund. To pnwide

...

329

330

MAITLANO'S VERTEBRAL MANIPULATION

Fig~rtll.29

'..a,Oftofl~

mid-tl\otxint's right cla"iNlar area. These fingers aoo siabillze the vertebra. lhe nexl step is to flex lalt'l'"ally the patient's hed 10 the righl until lhelensioncanbofellalthelhumb Wh,!ema,nlain;ng IhelaleraJfle"iool_ion,them,ddle~IIonbt-tween

flexion iIJld extension i5 found by rockinglhene"'ithoula p,llowand hnksha$ hands beIund IwI neck while the ph)'SlOlheraptSl standsbyhisright!lide. By grasping the patltf>I's left shoulder in her righl hand and both elbOl.:s In her left hand. the physiotheraplS! holds the p.ltient in this position; she release her hold on the shoulder and lcaru;;O\'er the pallcnt 10 palpate for thespmolls pr0ces6 01 the lower ,·ertebf"a form,ng the inlen'~

braijotntbelngmampulated.Stillholdi"8thepat~1

irlthispo5JOOn..thephysiotherap,stmakellaf~tw,th

the righl hand by flexmg the middle, nng and Imle fin. gers into the palm bUI Iea\'ing the thumb and index fmgerextended. Asmall pad of m~lerial gras.pt.'5ilionbetw('(!n flack pain f.ilto tilkeinloacrountthewidevaridyofciiniCillproolems th~ pati~nts present wilh. Grouping of p.ti~nls n~eds to~ mo"'~ficifthcdfi:ctorman;flUlativc

The manipulative physiotherapist should payalten· tion to patients refern.'C! with lower limb 'joint' probIcms or lower limb sporlmg injuries, Topickupona spinal rontribuling factor insllch cases can bc "agudy

lhe phys>cal eum"'Olhon she may nt."fd to look for tesl mo'ements that pro....d .. dJff..rent parts of lhe sympIOITI$. if there is any hkelihood lhal lhey may b. com-

~aledinthebuttock..

:~~~;"~lstn>cturesordLffer\."'I..spectsofthe

When a p.allent ha!i sym~oms that radiate mto the legitise5lSO'Tlh",ltodffi'nmnetheSlteanddepthdthe §}"mptoms. ... hile al the same time diffenonlialmg belween the kmds d §pn~oms that a p.1henl who frequently""" cramp or not), a "''''nn fa-ling or '" coldness. II is aoo neress.ary 10 ddemllllt' whetht... pa'ns in different "'reas increase and d Olb1e 10 hland Imm...halely but has dlfficultv wilh hill first kw Sleps becauiit' of se,ere ll'g pain. The lall"r patient luis a disorder tluil is far more difficult to help th.,.. lh.. fOnTll'r. Other aspects of the behaviour of th.. p;,lienl's symptoms are hStl'Cl in Ilw 'General' and .Particular' sections of Tnbl. 12.1.

SPECIAL QUESTIONS. As \ anv indicabon of cauda eIraight. lfhe has difficulty getting in and out of the car, it may be thenL'Ck flexion (a neural sign) component of the movement that is lhe problem ratherlhan the straightening process of the

lumbM spine. Coughing and/or sng

I'PIIIM F.E.Lf.RoI'aIldF/(inm'b"tylnts. &;""nll_ of aiM!' r.kYo"t factOt'i OTH(~nSTS

o.('Ck·tastIlO10'S·fo".portsofr.INantt"I'(X-~bloodtcSIS)

343

344

MAITLAND'S VERTEBRAL MANIPULATION

OBSERVATION When watching the p.llient's lumbar movements of f]exion,extension,laleral flexion and rolation, notice shouldinHially~lakenofthegross5pinalrangeand

the pain responsc to the movement. This may wdl ~ the first asterisk used for a%e$mcnt purposes_ The ",-"'ond aspect isto notc(during the movemenls) the appearance of local intervertebral mo\'ement so thai if lateral flexion, for example, is limited, the statement may be recordl'd thM Ihc limitation ocemenl indicates thaI the disorder has not besame proct'du... is perlormed With rolation to the oppos,te Side, and the palJml then I1'tums to the Slraight position. still susblinmsIus fuU Rexion.It~ then explauwd to Ium thaI he IS, a~ rapidly as pcw;ible, toretum to the upright pos'hon and pass beyond that

346

MAITLAND'S VERTEBRAL MANIPULATION

to a fully extendL'd'sciaticscoliosis';Maitland,I%I)duringanylestmo,"ernenl,thelestrno,-ernentshouldbe repeated with the physiotherapist countering (preventing th... dcfonnily laking place) the prulL>cti,·... defonnity and assessing the change in pain response If the pain response inm.-ases dramatically, thedefonnity on movemenl is dinxtly ...,Iated to tilafspin. fi.xion. (a) From al:>ove downwards. [bl ffOln below upwards

347

34B

MAITLAND'S VERTEBRAL MANIPULATION

IIII

Ill]

~j /

figu.. 12.!'> lumbar.Mvclrmiorll... F......"""dow~'OQrds.. ftll Ffom bdow Ul"Q'lIs

Figu,. 12.6 righlhip

\

if it

Figu.. 12.1Lu

.......

ipInr~h.."....... ~~lOn

O'OUtiontot~Itft.I F1Ol'l"""-dow~ward5.ltllFfombeloM

lumba' ~I'" la\rf~1 ~ ••lOfIlrfl. (01 ~mm abovr downward.. lbI ~,om brl..w upwards, Ioitch,ng I.ft Io,p./d D,opp!"9 tIIr

lumbar

rot.ltion from below upwards 10 Ihe righl "'produc~ so;,vere rishl calf pain and Illlmbness of the righl big toe, but rot pt'lvis, the il1te,,·erld'ral movemml starts from Ihe lowl'Sl moving joinl and t:h patll'flt 10 arch further by intemuttently Ioudung hIs shoulder$and chest WIth her Iclt arm. lluSlSdoneol5 hght ~ combUll'd w,th a 'erNl romm.tnd, COttMant ron\.i>Ct with her hand and ann must be At thesa.me time she ~ her right indl'I< flnse'"and thumb in ~§ame manner. It lSestil'fInal for the phj!>l'Otherapl!itthalthepallentmalIltau'l!iMOll'II""''''''', but she Can pl'Onde the patJent with il dl'gl't'eofsecu,lty by allowtOg Ius hair to touc:h her and left suprucapul.u area Wlthoul ho!r laking the ""Clght of Ius he~ and neck (Figurr nSlrl. When she knows he 15 at the hm,t of his rangeoft"Xtension,she then applies the on.,·pressu", by carrying his thoru bac:k..,uds with her left arm, pi\'oting the further edl"flsion 0'1" th"postero-anterior pressure of her right index finge, and thumb, with her nlock increaslng!hl." support ofhjs hl-ad and necl"

.,oiOf.t'f" SGlpu1lr area 10 prevt"l1t any backwiln:I rotation 01 the thorax.. the phys>othenplSt places the lip ollhe pad ollheindeo:or..uddJe finger in lhe tntersptnOUS spKl"lobe tested. whrre It an fed lheildpcent margins ol ""0 spinous ~ To IYIp ~palf' l1"Illft'deep!yw,lhout Iostngsensibility,ttusfingeran be...mrom.d"'"ftthen.lilbythemiddJef~

(Fip"I2..J4).

Pas&'''' lIlOVftnmt oilhi' spine IS pn;:duced by rocking thepatienl's knee back and forth towan:lslu.5chest throughanarcofJO".o.er-r u~~houldbelpplied at the linut ofeo:tension lO_any backwan:l sliding

of a 'ertebra, which nu) indicate instability The test mO\'t'mefll is produced by a side-Io-sid" movemO'fll of

MAITlAND'S VERTEBRAL MANIPULATION

Rgun.12..29

PaipabMIoftho~t'lIQllOh-~

fi9un.12.JO

M:fflllIOSI:mor~

Wl,.et~on

thPph~'SOOlher.Jpbt·5pe"is.c;orrying the pahenrsIcgs with m. The p.1-lpating h.Jnd CIfl, help 10 ~ the lIlten'C'ftC'bral nn~ by pres.sing agamst the $pu.... when the p.1-t.......t·s \eg!; ~ ",leased from the... f1e,ed position All, ope.ung and closing of the intt."rSJIlllOUs ~p nn be fdt w,th the rockmg of the pat'lI"r'It's pel ... is .nd Jes.' The arc of 30" will be with the lllls in relati,ely Ies6 flexion when palpalLng mOl,'ement III the upper lumbar spine. and ",labvely more flexlOll when palp.HIllS for moH,mL'nt in the lo....e. lumbar sp,ne.

along the duenion of lhe

femoralshaftso~10 push.

Io...·er \"t'nebra backwards beneath the neishOOunll& n·rtcbraaboo.·eit.WhenlllStabIUtyex15ts,theexces6ll,~

lnO\"l'mCflt backwards of the lo....er spuwnn beaJlPft'" dated by m p.1-lpatlllg flllgff SImilarly. dunng thr a5Sl~lInd appeao'anct'01 dlK ~ and the intel'\"l'rtebral forllnunal', This knoI'o'. IfttgehelplOlIltheronelalJOnofrongerutalandd.."",. opmmtal abnormalities wllh ph}"SKal findings.

Slumptl.'5t Testing for movement of p,lln-senslti\"c StructUfC5 in thevertl-bral canal,asdishnct from movemcnls of the lumb;lrinte"'l'rtooraljoinlS,isthcmostimporlantll'St that ~hou\d be included in the examination of all patirnts 50 lhat it can be dl'lCTTl1lncd whclherthcre is normal ffi()\'t'Tllent Or noI.

The -Iolump ~, ',() called beocause of its agn.oernent with tho- term • ~ by engineers and ardul«t!l. is fully ....ilh dldgrams on pilge; 144-149. The description of thi.\o test w.as J>lacnoneaspeoct ofthetensionedseo::ttoo\Srcl~,Forcxarnple.f':llk'fld­

ing the left kneoc may be hm,tro by 30" compaM:! wilh e:f thc wh(ocl reprL'St-'flts the vertebra. We tend to imaglnt that when we perform the simplest of lumbar rotatim techniqUe5,the centn. of the movement is the axle 01 thc wagon wh~~1. However, if the pelvis at its highesl superior Sllrface is pllshed forward, as occurs in p;'l"" forming lumbar rolation, it is the same as pushIng the

Lumbj, spine

J7J

, , f"'!JIl"'12.43

O\a~poloItIOI\SofPOO"lSAlndBc"m"'i

rotation 2. Wh..t effuct do I thmk l.am h;wmg on ;ony pilthologic.1ld.i50rder? V....... tion§ of lumoor rotation tl.'ChnlqlJe!l a",

1100"

d.Ie ItlSqu,lepossibietodothls, ..nd lhelt'dlniquellishownanddt~onp;lgc37landin

Figwrr 12.50. And tim. 15 not l.lking into «ounl lhe 'inst.mtancousC(Ylln'ofalOillrotallOll'(F.. rfan,l973), wtudl III a separ"!f.'COl'"I§ideriition altogt'ther. Wh~n Uunlung of JX'rfonnmg the rob"on m differenloorQfUll axes, as would bc the casc when JX'rform· mg thl' rotation with the patl~nt's lumbar spml' in flex;on orexlension;or in diffl'n'nt sagillal axes, as in lal~talflexionldlorright,lhcrcarccndlcssthingson

which to ponder. The aSfX'Ct~ tl'at are primary in the clinical applicdlion of the rotation Il"Chniqueare: 1. Amlp"rformingtheNllJliontupro\"okeorease the symptoms a)Whenp"rformingil;or b)Afl~Tha"mgJX'rformt'ed for the Ihorax to be stabj],~,ed by the hand on the shouldcr, but thiscounter·pressure is not one Ihat pushes the should...r and thorax back. wards; it is ralhcra holding action, which allows the thorax to foiJow Ihe direction of the pelvicmovemenl but only toa iimited degree DuringtheoscilJation it is often desirable from time to time to roll the p.llient's trunk back and forth. without altcmptingany increase in !he amounl of rotation, to be sure that maximum relaxation is being obtaincd and that all slack hasstiJi becn taken up With thestcehniques the axis of the rotation is beneaththesurfareofthecouch,asexplainedonpag.. 3n (Figure 12.43). The same comment applies to the descriptions of the local variations. which follow However, if they are compared wilh the lumbar rotation lcehniquedescribed on page 378 it will be see"

375

376

MAITLAND'S VERTEBRAL MANIPULATION

th.at the centre of the rotation ismU(h nearer thewrt('bra than the hub of the wagoro wtwel,

Locolvoriotions The sen5e of ll1O\-ement than can bl' obtililWd here IS quite IN-rked, and a noticeable degree of (wI can be Kquued d~,k' tht' fact that the Ie\'erage is 50 grNl. ThI5 is aided by ..'atching the patienl'~ lumbar..,... of ll1O\·t"nlII'f"It througt-J.t the procedure Rotation w,th thor lumbar spmt" towards extensIOn is bl'tter used wt.en mobilizing the middle or upper lumbalr spul". and rotation m..·uds f\e).IOO is best

technique. In ttus "",nt tilt' ca~ of t"" pam is bemg "roled and nothing is b ..... tension ltI ..... straighlll'g raISIng by plH'tlng on her k'l't 10 boI.h mamtaln knee e>.tensionand~theangleoilupflexJon..

Pr«ourions

nus lechruque should

not be used until other taitniqucsha\e bt.-en lried and II i§ known thai S1raighlll'g raisingl5a Ill'Ct'S5'llry part of trl'atml'lli. It should not bedOlW''''hcn radicularl"'ini$n>produ«'d in the lower leg. unless the I"'in is long§landing and IIw di§Orcler $table, Ex.1mplesoitrealmenlinclude:se\'en'lumbarnel"\'e root pain, page 414; chronic lumbar neI"\'e root pain, page 418; il\$idiou;; onset oflentlw!s on hi§b3d:on a Iowrouch WIth pil1ow5p~ under Ius head, while the physiother.;lpist sUndsal the foot~ of the oouch fa.cmg the pabenl and gl7lSp5lhe patient's heelsand ankles from theout§>de. ~ palient's Icp a..., bfled, while maml.;llmmg some 1T0IctI0n, 10 a height th.iIt will .;Illow lhe lumbar spine 10 n'U" in I. posillon ntidway between flexion and l'lilm~oon To do this, the kp need 10 be r.. ised appn;u"m.;llely 25~ from the honzonlal pl.;lne. It isad\-isabk: (or the phpiiotlwr.. pisl 10 stand with oocfootinfrontoflhcOlherandcmuchrorwan::lso\'er the patIent's feet. The physiotherapist's body and arms are Ih..'fl in thi: position where maximum pull can be giVl'fl with minirnum effort (Figurl' 12.52) M~tl1od

All loosenl.'5S of contact between the pat;"'flt and tlw oouch is loth'fl up by gently pulling on the

Figu~12.!>2

101 and (II) l.onglhllhnal tnOYl'nKnt

palient'sankles. Longitudinal mOl'emenl is Ihen producedbythephysiothcrapislflexinghere1bowsalld extending hl'! shoulders while in the crouched po5' ition......."Llh gentle mobili~ing lhere is no movement ofthepatientaIQngthecouch,butwithst~

Lumbar

gradt-"Cause the pahent slides a little along the couch. Th" patient should not make any elfortto pre"ent this mo,·ement.

Using one leg (.--(b:i)

Sto'tingposition T1lepatient li~",on hisbackona low couch with pillows under his head. To mobilize. using the patienl"s Icft leg, the physiotherapist slands by the Icfl side of the couch towards the foot end The important part of the technique is executed when thepatient"s Icg is straighl. II is better, therefore, to take up lhis position first, so thai thephysiotherapistcanstandcomfortablyinancfficientposilion.n.e physiotherapist grasps the patient's left ankle so thM th{'lefthandisplacedundcrtheh~l,graspingitfrom

theoutsideintheareaoftheAchillestendon,whilethe right hand is placed in front of theanlde with the thumblyingovertheouteraspectolthefoot in front of the lateral malk'Oluswith the fingcrs sp",ading Over the inncraspcct of the foot and the medial maJicolus This should give a comfortable l.'flcircling grasp of the ankle. Theph}'5iothcrapist placeshcrf~tina 'walkst,mding' posHion opposite the patient's lower leg, with the fLoet pointing towards the loot end of the couch, and crouches forwards over the patient's left foot.Theangleatwhichthepali~'Ill"sll'gisheldshould

allow the lower lumbar spine to lie comfortlbly in a neutral position midway between extension and flexion whiJetraction is maintained on the leg, and the kn('('shouldberelaxedinexlension. To mo'-e from the position dcscri'wd to the true starling position, the physiolherapist flexes the patienl"s hip and kneewithnut mo,-ing her own I.,.,t. Theamount of hip and knee flexion employed isgovemed by the gentlenSition, the physiotherapist applies a gentle. sharp

Flexion is often considered a movemcnt to bea"oidl-d, but the'" are times when it is a necessary part oft",atm.,nt, both with the "erygentleand the stronger techniques. Four techniques showing varying strengths ared{";Crilx;odbc!nw.

382

MAITlAND'S VERTEBRAL MANIPULATION

First starting position The patient lies pronE" arms by his side and with his head tumedcomfortably to one side. Thephysiotherapiststands to rus left side at the 11"'1'1 ofhis thigh,facing his pelvis. She leans across the patient to grasp his right antl'TOSuperior iliac spinl' in her right hand while holding the left anterosuperior iliac spine in her left hand. She places her right forearm against his lower right buttock (Figurt 12.53). Method Using a very gentl,;, pulling action with her hands, the physiothcrapist raises and lowers th,;, patienl's upper pelvis slightly. Thl' ffiOl'em,;,nt is facilitated by pivoting her right forearm againsl his bUllock.

Second starting IJfJsition Thepatientlicssupinewithhishipsandknccsflexcd and his feet resting on tile table. The physiotherapist stands alongside his trunk,facing across his body, and passe5 her right arm behind his knees. She reaches across with her left arm in front of his thighs to link hl'r hands together on the outside of the farthest knee. By lifting and pulling with her arms, she flexes his kn~,,-'S towards his chest (Fig"" 12,$4). Method The physiotherapist uses both arms to flex and return thepatienl's I,;,gs; this gently flexes his lumbar spine andthenallowsittounroll,Mostoftheactioniscarricd out by her right am1, but her left arm assists the flexing action, By virtue of the position nf her right am1 behind his knees, she is able to exert a certain amountoftractionalongthl'lin,;,ofhisfemur,assisting

Figu'~12.S-4

Flnion:=oodstartingposition(F)

thc flexion action on the lumbar spine by raising the pel'-is. The oscillatory flexion action Can be perfonned inanypartoftheflexionr,mge.

Third starting position The patient silS with his legsextendro in front of him and his hands on his shins. Thephysiotherapislstand~ d05c1y by his left side, with her left hand o'on IF)

383

384

MAITLAND'S VERTEBRAL MANIPULATION

Figu,e12.58

techniques cannot be used underthesecircumstanccs, but are valuabll! WhLTI fl ...xion is limited bysliffness and is not hindered by muscle spasm or pain

Accessory movement in flexion (e.g. IN Lx FF 20' do~L41

Starting position The patient rL'Stson the LTld of the plinth with the end just proximal to his anterior superior iliac spinl!, and lies down Over the plinth. He then bends his knees unrler the plinth to allow thl' lumbs370-371 Themelhod is identical to thatdL'SCribL'd on pages 370-371 for thepostero-anterior unilateral vertebra pres:sure(l'igurrJ1.57)

Uses "This1L'Chnique may be usdul as an end-.of-range mobiliz.;ltion if flexion is stiff. On theotherhand,itmaybe valuable to use as a pain-relieving technique if the fMtient is most comfortable in this position.

DEBIliTATING lOW BACK PAIN CONFINING PATIENT TO BED There are many ways in which extremely gentle mobilizingtffhnique:scanbeadministl.'TCdadvantagrously.

Rotati()/\

The first tl'ChniqUl' that may be considered is bilateral longitudinal movement (scc Figurr J2.52)caudadas~ gradelmoverJlCnt The following techniques can be performed in ~ very localized and smooth manner.

Rotation

stortingposition n.epatient lies supine with his hips and 1meesromiortably fleXl-d. The manipulative physiotherapist stabili7.1'S his knrior-superior iliac spine (Figure 12.58)

Method Bothofthetherapist'~handsworls a backwanh and rotary mO"ement of his right ilium. The teory mo,'emcnt directions. When a manipulative physiother"pist does this, it is seen lh"tsheismobiliz" ing. However, when she is seen to use a longitudinal direction {by means of harness and a machine of SOme kind),it is St-'en lobetractionand not mobi1i7..ation.The second false impression related to traction is thai il is thoughlby many that the slrength of the pull must be greatenoughtodistractthevertebraebyameaSlIrable amollnt. Many surveys have bf'{,n caTTled 0111 to prove thai a force of 136kg(JOOlbj isr""luirect to separate the vertebrae. Otht'r writers goas far as 10 say lhateven with that force thl!reis noseparalion. 1'heseattitudes are indeed unfortunate. £.ulier in this book. the text refl't'Kod to grade I muvements. Also, reference has bcen made to the rhythms of mobilizing tcchniquesthese references relate (jrst to extremely gentle It''Chniques,andelw(X"fllhepalienl's thorax and lhecouch Therefore, bolh lumbar and thoracic s..·ctions must be fll'l'tomo\'~.llmustalsobeJXl'>Sibl"'lofixlhefrkti"".

fN:eroll top in a Slabll' posilion toallmv thepall,,'nt to lll'ton and off the couch,and to enable it tobc u;.o:.od fll. other treatm~lIlS. These requirements ;,re met ill lhe

roudo de5cribed,and the modif",allOnSGln be, with do"elhng toan as rollers betYo·em the plp.·ood and the lop of the couch.. n.e thorae.: plywood sectKJn is i6cm ()(lm) long and the lllmbu S hNd of the couch. the U-p~ is 10wL"Il'OnS meet, ....'thoul the head end oflhe thor..ocscdlOfl bfting. The foot end ofw lumbar section is pn....cnted fromlifling..swouldbtlheca5l'ifwpahents;olon the lumbar S«tim roe,Uff ,I!> head end than the oo..'eI, bythelockmgrif«tofWU-pi«e. The lotal L"OandeffKioenlfriction-f"", couch ~ m "nid. and thoe labourrosts aO' o;ery smoili. kau. many rhy~iotherapislS are deten'cd from acquinng IrkllOn-f...." , lumbar Iraction eq",pmenl by h'gh prtCL'S and by equipment which is 100 cumber· some lon must be dISCOntinued. If, h,oo,.'''''n;. the svmpkJm'!i do not renoam wor.;eand thesignsdonotdctcnorall', w traet>on un be ~ted. During the seoond trealment, an ment should be made of thr "eight thatcan be ..ppll('d "'Ithout increase of S)'mploms, k) be able 10 compare Ihiswilhlhep"",'ioustrc..tment.lfahighl'r"·cll;htl5 possible, then fa"ourable progress has hem made. When lhe strenglh on lhe fir.;td..1y was reducccl oc'Causc symploms we~ completely relieved while lhe patient wason lraclion,lheprogn:.'S!;ionisguidl-'das much by changes in the o;c'erHy of any temporary exacerbation thai foliowN lho- lreatment as by the changcsinsigns.O\..... lheJ"l'riodofthcfir>tth~or four stretches, the lmpnwcment in signs will probably be.smaJi. \\'hen SIgns Lndl(,)1J!' that traction should embnue, any lTOl;n'ase m the treatment should be in the length Ntlme ..nd not III the weight. When thertis no ~tion folJowing treatmenl or afler the durotbon of 15 minutes,the ....eight can be gradWllly oncrNSoed Lndet arcumstanas other lh.In the Iwo lust dis~, weighl and tune ColI' be tncreascd. logether, Generally, the a\ .....ge Weight 15 ....ached between JO .. n.J 4.5kg. HO"'l"\'er, OCC;I5lonally "'hen the rail.' of plldd~'fl mov~ment of very sm.,ll range. T1w p,,-'SSure required to produce this small movementisconsiderablyg"-'aterforlhelumb.1rregioo than for lhe ...mainderof the spine. To incrcasetheeffecti\'enes5 of the manipulation in the lumbar spine the pill;"nt's trunk Or 1~'gS Can be supported in extension, thereby increasing the lumbar Inrdosis(Fig"re 11.69).

IntervertebraljoinbTlO-Sl (rotation C) localised manipulation

Stortingposition The paticnt is asked to lic on his right side while the physiotherapist stands at the side of the couch facing

the front of the patient. From this position it isadvisable 10 tell thep,Hient to ll'lax, explaining thai he wiJ] be put into the "-"qui,,-od position. The first SK'P is 10 flex the pilticnt"s left hip and km·.. until th.. dorsumof the foot can lie behind his right knee, and thC'llthe straight right leg is put into slight hip fl~"Xion sufficient to place Ihe p;!rtkular inten'ertcbral joint midway betw~'Cn flexion and extension. The piltient'5lefl arm is extended at the shoulder and flexed al th~ elbow 10 allow th~ forearm to rest on his side. To actucve the ne>.t stcp, in"ol"ing rutation at the intervertebral joint, the patient's right arm ispull~>d towards lheceilingto twist histhora>. until his I.. ft kn .... lifts from the table. Carcmustbe~xcrcisedto"'-'Cthatthejointisslillinlhe mid·flexio~xtension position. Theann is then allowed torclax in an abducted and laterally rutated position out of the war. The phyjiolh"rapi~t I"ans O\'"r lhe patient. threads her left fOll'arm through the triangle made by the patient'~ I..,]t arm and tnmk. and plact.'S her left upper fo...ann against the palienfs lefl shoulder. Atth.. same time. ~he plac,,'i her right upper fnreann

Figure12.69 f'l>sr.ro-ant.,i",,,,,nlral vert.brall'f~SSUr~ Ilumbar) localistniquealltinglingmhistootdisap~ared

Mr Lwas

Btcaust t~~, ?disco9~nic?, component was improved, and also t~e radicular symptoms wer~ I~s [plus calf pow~r impro~ment), Ittt SLR was us~d as a teclmique and aft~r four treatment sessions oft~is ~is left SLR bccam~ full fang~ and pain fr~~. How~v~r, th~ rig~t SlR still telt tight and did provoke minimalldt I~g symptoms. It wa~ decided to do rigllt SLR as t~e treatment technique. The tightMSS cl~ar~d and r~main~d clur tOf 4 hours.

seem~d possibl~ that th~ canal signs would not imprOlle in parallel wit~ the joint signs. and t~at t~erttore SLR str~tcl1ing may bo: r~quir~d lot...

The t~c~niqu~ was r~p~att'd, but more firmly and for a IMg~r sustained ~riod. During th~ ~rforming ot

treatm~n1S

muc~ imprOlled as were the JOInt mOll~m~nts. Sitting was also impfnv~d. His calf pow~r was normal. During this stag~ of tr~atm~nt. a scan revealed post~rior disc protrysions slightly lateral tntl1~ I~ft nf the post~rior longitudinal ligament at bot~ the L4/Sand lS/Sl

'symptom-relicving'positionanddi'ectionto avoidprOllokingpain.

une~angt'd.

but

comfortable and felt he

butSLR,althoYghimprov~d,wasnowherenearas

t~~

• On r~aSstSSing his movements alter t~e technique, joint mov~ments were imprOll~d bYt SLR was

f~lt mOr~

rouldstandwaig~ter.

After four such

J, Thinking a~~ad to furth~r treatment t~c~niques. it

•

furth~r Impro~d.

unchang~d.

• Symptomatically, he

Treatment Because it se~m~d to bo: discog~nic (getting up from SIttIng) wit~ a nerve-root i"itatinn' 1.

Movements had

• SLR was still

compon~nt ~~mt'd

2.

FollowingthetechniqYe: •

MrL'sdiwrderwasollvioYslyatypical.Th~di:;c

t~e

SLRoncac~

leg and

endin90fft~escssionwithafe~at

and rotation trc~nique.lt wal had an review all as~cts in a mont~ Th~ ass~ssm~nt aft~r a monl~ r~~al~d t~at h~ had nOI only r~tain~d all of t~e imprOllement from treatment but also found h~ could Sil, stand and b~ much more activ~. H,s movem~nts w~re n,,11 and almost fru of any discomfort H~ was r~vi~w~d again aft~r 2 months and di:;chargt'd. Aspcouldscckto

cSlablishascricsof~lcv"nlfindingsthatbuildintoa

Cilscimplicatingthesacroiliacjoint

402

MAITlAND'S VERTEBRAL MANIPULATION

However, by encountering subtle clinical clues, lhe manipulalive physiolrn,rapisl may build a case 10

A true sacroiliac joint strain or sprain is unlikely to pro--

implicatelhe.>acroiliacjoinI.Mo~oftenthannot,rl'tro­

region is bilaterally painful in the abst.-nce 01 pre!,'IUlocy Or infl~mm~tory disease, the symptom~ are more likely to be rde.rt.>d from the spine, Schwart-.t.eretal. (l995) found that groin pain wascoosistenlly as.ociated with sacroiliac disorders identified by anaesthetk block and MRI techniques, Howe\-e., the authors did not specify whether the pain was below, above or in lhegroin Referred pain and as.ociated srmptomsrelated to sacroiliac joint problems are not always consistent, There may be pain and IIchingdowntheinsideoflhe leg or under lhe teslides in men. The hip joint may 1",,1 'out of place',and the whole 01 the leg may fl'el heavy_ Symptoms often overl.lp with those lrom neural tissue, lhe spine and th..' hip The symphysis pubis normally prcs.enIS with p.1in oracl1ing locallyO\er the joint with relerral into the groin or down the inside 01 the legs_ Aswciated symptomssUCha'iCfl'pitusora fl-elingofthejoinl 'shearing' with walking may be prescnt

spectiveasscssmcnl will bc the final dNem,iMnl-and evenlherlshcisIlL"'-'erentirdysu"'lhalrn,rinlervenlion has influenced the sacroiliac joint alone. Thcrdor(', she should st.'('k to cstablish a seriL'S of relevanl findings that build into a casc fmplicating thejoinlAlthough lhestatementthatfolJowsisonlya relalive statement and ther('forc hard to evaluate, the author's\'iewisthallhisjointisnollrn,mostcommon mL"Chanical50urceofpain,e\'en when the pain is in the sacroiliac are.., Mostpaticntswithponsctt1o:dlhclastbotofxlllng. A fI!09r;1mm( of !r;l0WftSI: ~b6ominal ~nd prlvic s!ab,lizlttOOu..mses .. otSllso,m;I,g~lo:diJSp;lrtof~ hotll(progr;lmmc

THE SYMPHYSIS PUBIS

If the piltil'1l1'S symplOms suggest a symphysis pUbtsdlJiOrder, pain is likely 10 OlXur in thea"'a of tho>

ltftanteriorsuperioriljacspinecaud~.

rightantcriorsupcriOfiliacspirl(ttph.alad

Srorringposition Wilh tho> patienl in supine Iymg, the therap1Sl stands onthepatimt'sleft.sidco.fOfUilmpk-.tho>tlC'i."lofher right hand is placed ag,nllSl the left anb:!nor supcnor iliac spUle (ASIS) from above, Her right elbow is po,nted lowards the pattenl's left shoulder so that tmdirection of mO,'eml'flt of her r'sht hand is caudad on the ASIS The h,te,o••nwiO,c.nlf.lro«:ygnlp,,,,,,,"

Figu.. 14.3 Antdinlothefollowing: 1. Brief5tatemL'IltsS umlateraland theCiilUM' of the}Win 8 Iiklytobethedisc

J. In the presenre of marked neul'lMogK3ldI.Inge treatment must be gentle and caubouS,;md_ ment of the neurok.lg>cal ch.an~ made wily

Firs/day lumbar 1"Otill1on. P'l'hl5 rotaa,.,J to right. w;as pn-formel uoablelracbonmsteadof~tlrioctiQn~~ ~

oscillatory mOon

Trtatmtnt

and st..-..,ghtleg ralSUlg had """mtamed the- S,ioIII\adIOl>tsomeo'whalhad~gained.Jtwasthl'n

decided togi .... thetraetion and lea\'.. outanyotht.... treatment. The traction w .. s gr.. dually lncl'l.'ased daily in wt'il;htuntil 25kgwas bt.·,n/:g"'cnInr15 minutcs Follrtrrnthdoy By thl5sbgethepahent'5symptornsw..reminln",1, hl5forward flemU!sor""llocis

longus a.nd toI' .....1!enwr.; w~ nomul, and the tibi.Jlis ant.erior" . . . airno>tfullyn.'CO\oerrd.

RESIOUAllNTERMlTTENT NERVE· ROOT PAIN Exllmination History four moolhs previouslr, this woman aged 35y"a", hadwhalshesaidhadbccndiagnoso-odasadiscle'lioo wilh " ...rv{'-rootcompl"C5l>iOll. She had IrilCtion. which reliA;ame e\ident. The seali06'S dISappeared on n.~uming the upright position. Lalffill fIo!xion to the right performed in tnat range of forwolrd flexion th.JtcauS('d the.coliosis ... as,tr)' limited...nd aUSl'd ~lighl bllek pairL All other spi..... l mo\t'men15 stili, bul they were 001 OOIKeolbly pamful FlmI pres5lJ.... O\er W "ertriJral roIumnilid not ca..-;my pUPor mUKle 5pIISlTI. bul then- Wils" general f~mg of intervertebral tlghlnes5 III the lumNr "f',ne Rid-I straight leg raisulg iacUd 20" of mmemml and wlllpainfulatthebac.. oflhe..-hoJeJeg.Rcl1excs,s........... lion and muse, can ari>e from T4 or C71evels 2 WithsuchscveresymptomsandwithalJ movements limitL'CI by a marked inc",ase in arm pain,lraction would be p....ferabl.. 10 manipulation. 3 With marked limit.,lion of movement and with" def;nil.. P.1infullimilationofforwardn.. ~ion,lhe rL'Sullcanbeexpectedtobeslow 4 Aspainsubsideswithtraetion,andn..xion bewmt'S free, mobilization could be used to haslL'J1 the R'Sult.

Ninth day TI,e pain had eas. Some degree of relil'f remamedonreleasingthetraetion.

is common, and it is sometimes difficult 10 determine

Third day Pain had eased a little, and rotation ShOWL'CI a liltle impro'·emriJ

Fourthdrry Thepatientreportedwith .. llofthedlSlurba~tNt

acrompany an .. tt..ck,. but she did not N\!' the US'-Wl throbbingheadp;l"'- The palfl 10 the nghl ofCI had re-appeared and beroml' more f\OIIc\'.. ble Gentle trllct10n in neutral was gl\"efl for 10 m,nutes, and ttus eased the feelmg of naUSN and c1e..n.>d her blurred ,'ision. Tbese S)'ml'loms did not Mum on relNsingtlwtractiOl\.Aflera5-mmuten"$t,thl'tr...:tionwasrepeared. FifthfJndsixthda~

The nausea. although It.'$S, wa. still pre;ent, f\'!uming 2 and -I hours ~ti"ely after thl' fourth and fiftlt dlly'st~atmenls.

Traction was repealed in two penods (one of 20mlnutcsand the other of 10 minutes) on eaatlyea~andmovementsbec,'m only h.ld shl;htright frontal pain with tl'Slingrotation in the posit;on of righl lateral flexion and ",xlension Transverse manipulations lothe right w~ ,,-opeal(.'d. with5horterrest~betweenastheybecamelessnecer PWS:>t t..·oapplicallOO5oflhl' rotalion,butO\wall the mO\'l'Il1l'l'1ls made further impnn'l"nll'Jl.l F\exion and right lateral flcxion W('ll' full and painless. Rota!>on 10 the left increasin with rotation to the right. One strong rotation was then given, but this time to the right. Assessment was made difficult by sorencss from the rnobilizalion, but the patient was told that he "'-'lod not rest at home.

Third day TIll're was no deformity, and only right neck pain with full right lateral flexion and full right rotation. The patient was manipulated twice with rotation without traction to the left, after which the movements well'painless.

CERVICAL JOINT LOCKING Examination

History A girl ag~>d 15 years had, while playing bilskl.'tba.ll. suddenly tuml-d hl.'r head to the left, and it had become stuck in thispooition. She felt pain on the right side of hl.'r neck. She had had no prcvious neck injury Or symptoms. and was not otherwise unhealthy (Figure 15.11).

Physica/findings l1te patil.'fll was unabte toextl.'l,d her head or laterally flex Or rotate it to the right. Examination by passive intervertebral movement showed the C2/3 joint to be fixed. Treatment

Guiding factors 1 As iloc;l 5tep. 8ecaU5C' m(I'\'ernmt

ronstdered to

"as requi""'" it was dcridN to use ,ntermittent uriable traction,..and 12~ wasgl\en for IOmmutes WIth a 5-seoond 'hold' penod ",nd no 'rest' penod. At this low weIght she f,,11 ~ic\ed of pIIlO, bul said thai if II Mdbeenan\ stronger,t"'ouldhaH·!;."enlwr bad. pam. On ~ng the tr..nion thew was moderat,. back 5Ol'l'fle55.Aflt'!"ashortn5Lthep.o.tll'ntl1'JXllil!dfftlmg better than before the traction. Forward f\e>.1(>0 was nottcstedbe 1. wminahOn is tooluruiOO tohcconch.1Sl'e,bul at

least thesrrnptOlruj ..... Iocalt:«'romfortw 1lh3Qkgoftrnetion.Tht'duriltllmof trachondidnote~ct't'd15mlnut(,; After the fifth traCllon (on the ninth day),nll movements wert' full and p.linless nctively, and the patlcnlhad bco:>n able 10 carry out houscworkwlthout dIscomfort

431

Figur.15.14

Acut.b.c1:painronfin,ngpatl.nt.obed

432

MAITLAND'S VERTEBRAL MANIPULATION

Firsrday

The only "---chniqUl" pn."v:l.". wun n.'o lugsNdl hme, Right slr..ig!>t k); raising was then normal. The pahent '" as S"en adeo;jU.tlt' warrung tNt some ... uct"rb.ttlOll nuglll OCOJr dunng the nt'l-.1mm••tionhl.' hado1shghtProt«llH'sroIio5ts.w,ththedispLloomlent of his shoulders betng to his Ieftside ForwardftM.ioo w;os'·eryhm,t«I,and thlScau5eful treatment m,'oIv,ng .. h.at he called 'adJustmmts', he went to hislO("al dO("tor After .. ""l"l'k of bed rest faik-d 10 help him, Ius doctor suggested a further trial of manipulation (Fix"" 1515)

Thirddoy Th.,re was nO exac~'rb~lion, and Ih" p,1tlent had been up most of th" day, w.,rc also fewer symptoms The scoliOSis had returned, bol right later~l fl"~i,,n was fuU and painless. Forward fl""ioo was shll limited.

n,,,re

figu"'15.15

llbunod:p;lln

hamples of treatment

PhY5icolfindjngs The patienl's symptoms consisted of a fl1 by mobiliz.otion or marupulabon. How'hentreatmenl il;~ful.uIIisadm....IS/o>r'ed In a methodial and ~''e IniUUIeI' (h., A'5U11 can be 50 conelus!"f' as to be of adunbge to the rri.,..m,g dOdor Frtquently it ..,CJb,,'ious thai a pallenl rtqUIre5 surgery and would oat ~ 10 ronsernIl"e ......,.~ure. Although this is SQ, the W"Of"d 27 years had a S-year history of troubl~ with her lower back and intermittenl symploms radio aling into the buttocks and hamslring area. The unset had beo>n insidious. with periods of back pain during the fir;t 18 months before pain spread into her leg. She had been abk: 10 CQnlinue with her domestic ",ork throughoullhis time Two weeks prior 10 admissIOn to hospital she had ool'n cleaning f1oor·""'el curboard~, and after worlon is 10 be used, then the It&! side is the dominant side from the point of \ It'W of both signs and symptoms

First day Rotation to the righl was administ~..,.j first asa grade I mOV'-"JTlenl. However, this irritcesinflexlOOand ........·as unablf'1o flex Ialerall) 10 thclcftat IIll. Rl,;htl.l!l'1'al Bexionwas appro-..imalely 50 per cml of fuU rangt'. and she only had IOOofe"'tt.'Il· 5ion.. Straight leg ralSmgon the left wasJO",.md on the right .. a~ 45 , ~k»'emcnl produced by presliure O'·l'r the fourth ..nd fifth lumb.lr spinous pl"lX.'t'!i/;('! was limited by 5OpI!l"Cl'lli in all directions, and at thIS pollli "M strongly prot{'Cted by muscle spasm. There were ooneuroklgicalchanges. Treiltment

Guiding factors I. Symploms Ill\' likdy to be discogenic in origin; therefore lhe lreatment t""hniqUI'S mOSI likely to .ucO-.'l'd are rotatIon and traction.

Fi9Uf~

15.19

Bil~t~,alleg

p,l,n

438

MAITlANO'S VERTEBRAL MANIPULATION

Scm (2 In), and her Icfll~ler... l ne:S. Following Ihe tn,atment, neck flexion had increased byafurtlwr 5° (making a total imprm'ement of approximately 10"), butthehair-l'S5-FolIowingthis.lhepatient . .·itS p,'en traction in two periods bstlf1g 15 rrunUte:§ and 10 nunule:s. The ....git'of pull on. thecet'Vical haIler ...;as approximately D' from the honzontlll .. nd although thI' pattenl had not had any low bioI:k p.-rn. the fIt=d h,pand knee position w'".-doptro.

!iOlTl{'

rhirdday Dunng the d ..y following t",atment the pilhcnt's b.Kk wasSQ.....,butshert'pOl1t'dthattheaochew.. s~SI'\-'I'1'l1. Stiffncsson risIng had .....mainal unchangLod. Rotat,on was now only slightly hmited, bUI still caused lefl· sidropain, Thc..... waslcsst~'f'Idcmt'SSlhanatthebl'gin· ningofll'('allTllml,and the..... was now nomuscll'spasm ['ostero-anterior ct.'TltraJ "crtebral pn.'!iSurc was .....pcaledgcntlyasaoontinuousoscilialionfourhml'S, and was interspersed with trans"crse,'crtebral pTl'Ssu ..... pushmgagainstlhe.ightsidcofthespinous pl'llfi'Sl""S from 13 to 17, pushing them towards t....' painf.,l left side, 11"s was done three times. ROblinn blxamefullandpooinle it is the main techniq ...e for the Ihoracic area and lx'Cau:;e symptom. spread 10 bolh sides

First day I'OSlem-anteriorcet1lral vertebral Pl\.'SSurt' was given very gently owr the spinous process('t"I\ for assumIng that thepalienl was(']!herwor.;eorbe!· Il.,., the previous day's tr@atment was repeated She wasaskedtorcprotherwalkingt~tbeforebll'llkfasl.

Thi'dday rain was !Loss scvere with walking this morninl" Leftwere exp.-'riencro once al5SOm (600yd) and onCl'at 740m (BOOyd), As this indicated possible sid~'hipsofany ibnom1alpl1~llfir.dlngo;~ti.c.pajn.rMl1lnce.

THE MOVEMENT DIAGRAM: A TEACHING AlD, A MEANS Of COMMUNICATION AND SELf-LEARNING The lTK)\'ernent diagram is intended $Olely

a'5 a teachmg aid and a means of commurucat1on. When uamirung. say. postero-an!e'rior movemml of the 0/4 inter\"ertLobral ;o;nt produced by pressure

ontnespinousp~(stI!"FigurtlO.59).new­

comers to this method of examination will find it difficult to kl\OW what they an' fl't'tlng. Howe'er. the movem..nt diagram mah'S th..,m analyse the mo\"emL'Tlt In tl!rffiS of range, pain. ,,-'Sistance and muscle spa5m. Also, it makL'S th..,m analyse the I1lQm,er In which these (actors Interaclto affL'CI th..

446

MAITLAND'S VERTEBRAL MANIPULATION

MlM:menldiagramsareessentialtath~

understand,"g af the r~latiarlship lhat th~ variaus grades af m~meM have ta abnarmal jaint signs

11lC movement diagram (and also the gradL'S of mm'ement) are not nt'a.'SSolrily L'SR'Tltial 10 using passive mo,'ement as a fonn of treatmen\. However, Ihey are essentiallounderslandinglherelalionshiplhallhe \,Jrious gradL'S of movement haveloa pati"nt'sabnormal joinl signs. The",fore, although they are nolessenlial for a person to be a good manipulalor, th"y are L'SSCnlialifthl." he.ld facing " ...,ghl forwards; simi\.ul)', if the base line n-presmlS :ZOO, posIlionA is ... ,th the he.ld turned 7O"1Q!he left (.tS6Uming of COI.II"Sl' thai the nomuJ "'l'I'""~ n~ of rotabon ~ 9O"Io ...~~1

~

Compkt..... of .. _'.'...Md......

0lhr.>r,·.. n.a.tionsofthe~UneA8MedeKribed onpagt"459-460.

PoonIB~IS\:tleu:trMleofpH5MrrIOYmIt'tlL

and~"""""beyondu..

.... _ofxtJ'...

PAIN P,

As!herntJ\-..meflldiagr..misllHdlOdeplct ......lcan bl."frit .. henexammingp;u6l'·... rntJ\"rolII'llI. 'I must bl." deartvU1'ldentoodthatpoullBl'l"pl'l'Smtsthe treme ot PASSIVE MOVE.\IEI\.'T, .. nd thi>l tho:. lies , ..nabh·,

~~:~ponanlh.beyond the ......In.'me of KI..... The,ertical .. xisAC~lstlwqlUlil)·Ofinlls

Ihe"""",mumqw!ll\'orlnlensltyofltlefKtOrlQwlUch lhe ...",mUle' os prep;ared 10 !oUbj«t lhi: penon. The word 'maximum' 10 "'1a11On In'mt"1'NI'" IS obnous; ,I me.. ns poml C l5 II>l." m.lXlmUm miens,!)· of paUl the e>:aminefisprq>aredlQf"'O''Oke ·\'!.uimum'in",labon Io'quahty' ,,--krslQtwooth.-T..--ntloll p.arts. Theya"" 1. ImM"'lIy - .. hro tho.' ... ,,~mm •.' r would Slop lhe

t6Iingmmemo.'rltiftl>l.''painwilsnotnt.' an

Theirutial fact 10 be etabtishN is whcthesenlal .....,;,I (II" only on rntJ\emenL To begin the e~~ 'I IS

-.wned heonly ...... pain on mo...emenL Thefirslslepi:slDrJI(»·... tlvjoinlslowlyand~ fully inlolhe rang... being U5ted,ask.ong the pallCr\l 10 I1"pOrtlll'lfl'lediatelywhenhefeel5an\'d~fortal

all. The posilion ..1which thl5is first fell IS noted Theseron in diff"""'l p"rts of the pam-free r..nge, gradu..lly moving further inlo the ... n~ up 10 the point .. hen> pain is flr.it fell,thuse:.tablWUng the exact poo.llionofll>l."onseIoflhep"tn..~isnodangerof

ex.acerbationifsufflcienle.. rcis~;mdiflhee:um· merbe~rsinmllldthalitis!hev...ryfuslpro'o'oc..hon of pain thai is bemg sought. Thepotnl .. t whichlh., occursiscallroPI,andismJrledonthebasehncof lhediagram(Figllff'AI.J) Thus!hcn'a .... t...ostepsroe;labhshingP,

exacerbation or lalenl ....aclion.

2. Nalllrt-whenP,n."Presentstilt'onsctof,SOly,butlocl pain, bul as the moveffil'nIISCQnlinued th" pain .p~ads down Ihc leg.. lilt' l"Xamlllcr may dcdd... tn stop when the pro\'oltod pain ~3I:h~ Ih" lo...... rh~m.lringofuppt'l"ulfa~J

1bis meaning o{'nlouimum';n relation 10t"loCh rompon...nt is dis.1 stt'p is to dt'~rmin" th{' avaHablt' range of movem{'nt. This is don{' by slowly moving th" joint b of tl\{' movement diagram, IT IS IN FACT JTS STRENGTH. When the studt'nt compaK'ShCl"'L" and 'p; with her instructor's, Ihedifferencl'Sthal mayexisl will teach her thai she has been looheavyhandl'tlortoo'kind·and-g"ntle'.

L (e) QUALIFY Ha\'ingdocidl-dtostopthemo\'eml'OtatLbe'CauSl'of th"p"in's'maximum'qualityorinlensilyandlhe,,-'fore drawn in pointl'l on the lin" CO, il bee line AB of th" mo\(>m"nl diagram(F(~w·I'Al.2J),andifthisblockis'resistaIlcefree

of musc1" spasm', at point '0' bi:'tw..""n Zl and Zl (A Zj

Oz,

B(FiguFl'AI.12)),

lhest~nglhoftheresislance

i

f" I T

~ figuroAl.21

_z,

"'"""la.....

h

I

t----

A figu,.Al.22

I,

.

....

"

liB

lO,....,w_~I~It~WffflI.

I

Z,

0

II

Oltf.,.nt,alin9,osiltan~tromspasm

will be ~~a('tly lhe 5.1me irrespectke of how fast or slowly a mOHmt"'t ;5 oscillated up 10 it. Howc~cr, if the block is a muscle sp""m and leSl mon'm~ms all' talo.en uptoa point '0' "t differ'l'l1t speeds, the strcnj:th of the res,st,,"", will 'ncre.lSO' and be greater, "Ilh IIlCrt."il5eSmspo.-ed(figun'AI.ZZ). AI!iO,lIny lJ'l('JNS('m5lrenglh will bed,rec:tly pmport'OOolI10 !he deplhin range, n-gardll'SSoftlwspeed with whICh the ffiO\ ement is carried out thot b. lhe ~feh.. onepointm nvwement"t11111wlI}·sbo.· Ie!;sthontNtfehlltllpointdeq>et'in~ .....ge The fil'5lof thll'twoJoan.o:bofmu-eIt-merIt ,s .'aned ,nspeedllndmpo6itioninrheranst'

s,

'.----'

Tf,S,l

.... 'I}

S'llV-1

. ...

fiqu..

....

"'.23~~_.SptiIoI

Teshng Ihh k,nd of spasm IS done by ITOO\ Lng the ;0.01 10 the J'OlIlI at which spasm is first ehoted, And 11\15 poInlLSnotroon

~oo5elineuS,.Furthe!"fnO\'enwnl

is then .1Iternptt'Cl If mA:umum intensity is reached bdore the md of range, spasm thus becomes a hmillng faclor,

l- WHERE, l-..;;W",HA",'

_

Thi, limit is nott'" by Lon the b,'sc line, and S:z;s marked \'('rtkalJ~' "btl"e L on the line CD. As with 1'1 and RloS:z nt...'omcca:;e"

whm the ioint disorder is Icss Sl.'\·crc, a lilllcspasm that iOCTNst'S slightly but 'wver prohibIts full mO\'emenl m~yb,hoo on theb;tso, line will 5lgrufy whetherthespa!>l1'l is easy to prmole.and ""Il abo g"e_ indlCalHlr\oI ,ts strmgth. Two e:umples ue drawn 01 the exlrt'rnes that may be found (Ftglltr'AI.2""' and Ill.

MODIFICATION There i$ a modi!i'). Thus the diagram for u...t lTIO\elTlent IS compiled, showlngthrbeh.a'iourdaUelements.Jtislhen~ lO_any.e..!I;y to ~ that Rl is appro>."narl'1)' 'r before P, Bcc.aUSl'of the inm'a.>ed span' allovow 10 Il'pre5ll'llt the elements of the mo>.~t, the btfMtolour also is far ea~1t"r 10 demonstrate.

,

RgurcAI.)7

The~uremenlbet...eenLandB.

2. lhe measurement between Rl and L

TheIal.tS-oftneeuttftWn

t,C[~""'-llO' p'r~)

I

1 A

A,

--P,

"

F"ogurcAl.J1

u.in9al'Wldifoftld..,.am

L

8

...

-

F;gu,.,At.J9lb. . lir.... fdby50ptI'«rlI.~""1t'I .....""lIlifiedd'i9W" IlliO' knttl\uion}

Appendix

2

Clinical examples of movement diagrams

CHAPTER CONTENTS

Step 5. PIP' beh~viour 460 Step 6. R) 460 Step 7. R1R2 behaviour 461

• Hyptrmobility 459 Step 1. PI 459

Schcucrmann'sdjsu~

Stcp2.L-wllcrc 459

•

Step 3. L _ what (and define) 460

• The spondylitic cervical spine

461 461

J

Step 4. p' ddinc 460

------STEP 1. PI

HYPERMOBIUTY thIS ... ~ampll'

is included

the expll'SS pUI"J'O'K' of d.anfpng th.to m~lions thai crist aboul h)'permot"lJt\', ..nd thc.- dl1Kt Influence that some .lll!>ors and J"'".lCllhol'll"l'5 afford 'I in l'l"5trictmg ,,,,,,tmern If tho> lnC)\'e7~). before .... nng ilo«ome ~,"ful. ..~ h}llftmobile, the 0050lC form.11 of the rt'IO\tmenl diagram would be as shown In (Of

'The method is the same as

In

Ex.1mple I (p 467;

STEP 2. l - WHERE Tho.- nwthod is the SoJ.mc as In Eumple Ilpp 471--472;

_f'g,,,-rAL3).

f'.i;"rrAlJ

;

1 figu",A2.1

-

t' tel

Mo....,,,,,,nt dlag",m for hyp1L'OChonJlilis ('Scheuermal\l\'~ disease')lspre;rntl""rnbl'l'urelheradiologic"erlhanfor OOl"p.lrncuLu,nlervertcbl'illlel,et).ta hme when he considered thai he was normal the diagram "'oukl be somcthing ltkt" thai shown in Figu'fA2_1O_ At the lime when he had had Ius nghl-s.ded cervical pam. the lTIO\emenl diagram of his Cff\ical rotahon to the righl d,ffel'l'd ",small bul Slgruficant wars from theal){}\'.. (FigurtAl.Il). Th.. diffe~are:

,,',II

l. l'lP' (a sigmflcant change in the pain M'fl5alion) 2. RjRI(thealteredbcha\'iouroflheresistaoc..) ThdfromlhCSlandardlwobifidproagitUlI postero-.nte,iorrnOliemenl,oont.ct point On lawai side ofltft bifld 5piMu,proesoonl.ctingeachofC5'st>ifld'P'",""SPfoedHion. Imagine a piltk'Tll who has lefl suprascapular symp101m that are prmoked by cornpreol6mg type mo\'f'""""IS, such as6\cnSion, !at.... al flexion left, fl)I.ll,on left, and crntral po;!'tero--anlcnQr lIIO"'CfJlol!n!S on !he left articular pdLar ofCS'

si!lnsandsvmptomsandthf:~ntdiag'ilm

1.Ifthecrnt,..,I~lfl1Qrmo..-.,........ tsa....

J"'T'" formed w,lh lhe pal1cnl'"5head straight. the mo...~..

menl diagram may be as In Fig"'" AJ_6 2. [f the Silme 5.lglltilJ postc",,"anlcnor mO\'~'Il1~'nt is performed w'th the hCild rotak'C! 10 the lefl, thed,agram will be different. as shown in Fig"" Al7.

-

l. SagJllal posll'Tll-anlerior mm'emenlS fX"formed with the head inlilleral f\e_ion 10 the Iclt ""''' ha,'" the rn, and d, most dinicians ha"e no doubt that musele sp.lsm is p"-",,,nl. Some authors have said that when the patient lies down, the spasm goes. This is no mOre true than ;s the interpretation of the lack of fMC response The problem seems to lie in the fact that the spasm that goes on lying is ",Iat pam m his lo"'cr back and has d1ffinllty gettmg up from !he I}ing po5ItM:Jn. he will USlWIUy find hi>. own method forgettmgupthat~1Zftonpainlfhcis unooble to find a so.bSfactory method. then - ;md onJylhen-shouldihc,bo\·cinstruct--.slJol':pv-en to help him. 2. "the patient's method and ~ 01 d1ffinllty

ahibiled whde getting on or uH the treiltment couch is an In''aluable -.nent 'asrensk' I'atients will not causc hann by therrstruggles to get off lhe lrealment couch. no matre!" whal means !heyuS(',andtheassessmentvalUf'cannotbeov'eremphasized

EXERCISES

bythl:P.ltil~llw,",,-'flhcpt'rformslh.eexerctsesalhome.

record lhe Symploms and ranb'ccf(iSC'lshooldbcintrodu~singIV.lndrelsscsscd

'net"

du,i"9lhctlcatmcntscssion

l1>arefi'emaincalegoricsofe>.ercisesforwrtebral problems.. They consist 01

ASSESSMENT

I. Stabilizing exem-. Piticftts"'lhlowbat.plIinfi""~.owrl~of

2.

gortt'IllJU9M1dllownfTomatldmthf:lylngpmltlOn.

J. Exm::isestoincreasemusclepower

n.iscan~

... if!YilllRblc~t~ltrisk

Mobilizmgexm:isocs.

.t. Exemse;toincreasol'the"fl'-"l-'doillCtionolmu..ampk'. lhq insisl lhat ",hen .. pah~l is asked to gel up from the lying po!illlon. he should tumon lohisside. f\ex his hi~ and lmcc:> 10 a ngllt angle and then lower his legs lowards TablcA4.1

Examplcofl't'COrdingultrasoondtrcatmcnt

Co"stant US 1 Waltcm'O\I~r arlrcula,pIHa,C2-. localwlrmth. 'Soothil'lg'

aOmo,'mo"

I

romfortabl~

O/E Rot' d with the longef" muscles. which spread mer many segments. Four poinlSnt.-edtobem.:od... • In principle.exerciS 10 be gin.·n 10 ....'I.'''n lhe range of l1'I()\emenl of pamful anhnhc or .spond\lilic jomts. Iht'y ~Id be pe-rfol'ml'd on a non-.... ight beanng or penduLu po6llK)n. They should be ~ fn.>eIy, slowl}'and p.Jln~l\ • L'ndel' mast CIrcumstances it doe

~

mailer II

~ise5C'ilUS for more INn half an hour al~ the ~ programme. the t"'~ INV be n'l(xhflt'd ordlSCOl1tmued Wltil a later stag..'

....'ducro.

s..·immLng

is ~ I as 11

aU fi.... Cilbl'gOrieS of ~Caullon must be U5il"d irutialll «) the 1"'1;,.",1 US o.ncre~ during the exercise. Thereflll'\'. when Wsc p.:1thology cause; pain, any introduction of f1f!x'l-.n dl'milndscaution. PILLOWS,-

_

RECURRENCES Many arhell..'S. books and p,'mphlets haw b;...,n writh'n on this subiect. and the only pUTJ>OS beo;auSl' he is con,incoo of Ilwir pos,;ibll' \'alue. 11>c word 'possible' is especially includl-d b«ausclhestJte of lhe pllthol"l:\y may be such as 10 pre....ntthcm. pout that excrciSC!i can play to prevent n'("llr· ...."l"la.'S In low lumbardi5COg{'f1icdisorders r""'.'dscarI'ful thought ExercIses should not be gin.'ll ruot;"..ly for all

n.e

Wh~,tvI'r prmibl~, fccomm~nd fUlh~f

pillows for

pititn!';withncckp;ain

Some pah"n15 have ('S Iv .k",p On his sid". 11.;on that enabk5 IUs lumbM spuw to re>I

inthesulteda\lmdedorlle:enls haw ft'CUmng ern ica.I or lumb.u srmptoms that §llIrte lIldedelrbceau!ICoflhestareofthedis-ord...r.butiftheyam,tlStothcp.:thL'I\t'sadvantage.ln lryingto pre-'l"Ilt re.:urrences, thtS IS one of the ll>Olit important points_ It is a point often negle.othl'rmembt:rsofthelvNsehold can bc taught t«hnlllUCS that can be performed on a regular basis 10 keq> the symptoms al a reilsonable 1e>c1 for thepillll"1lt.lhe rnanipul..bw ph~"Siotheraptstneed onl)' 5l."e the pilhcnt when an e>;..x;erb.:Itioncannot beclea""" 2. There Ire other p.:ttients for whom one treatment

sessione\·eryol-Swcekslo..>epstheirsymptomsata belterl'-...·c1thanwouldbethecas-;"flheywercnot gi"enmaintcnancelrealmcnt. In b.llancing out whelher home treatment or maintenance treatm"nt should be inslttuted, the manipulat;"e physiotherapIst must h,,-'P in mind the re.llityoftheoft-quotcdphra!oe,·lelsleepingdogslie'.

473

Appendix

5

Physiotherapy for animals (with a contribution by T. J. Ahern, BVSc, MRCVSj

Ctrvicill~rttbrillmobiliZiitiolllllldtr

CHAPTER CONTENTS • Training

lIniitsthttic 480

477

• Case history 477 • Spinal mobiliution thtrllpy:with particular rtfl:ftncttoccrvical~rtcbralmobmzation

undCfllnacsthttic

418

ThIs chapter, mcludmg lhoe contribution by TJ Ahem. aimslohighlightth.epotenlialscop.l of animal physiothenp\ 1llIt ~"ills of non-wrbal communication, ~StI\C.'l'iI,

_ l a n d rna"'pulationlechn'qUoC$ill't'w,xhly Iransf bk- from the human to the anuNl woriel 1be t tmenl of ammals, therefore ..-'l!un the field of physiothenop," 15 no dIfferent from the ImliUnent 01 po.>ople '01 ..11 phyS.«her"prsts, howe......., an.' good at non-\,em,.J rommunlC.. ho:.... in its !;lrnplest form. When 'n'ating arumals. il 15 unportant to almost instmtly establish a Qnns rapPOrt w,th the dog. cat.. dum-

p.U1zel",horsc.-,1ltC. 1I;s for this I'NSOIl lh.ol the photograph of Amanda (Frgl"~ AS.I), with the gt."nl.'fOUS appl'O\oll of Arnanda and theCSP rrontli~ Editor,jarw Tonkin. has been mcluded in this Icxl (Sutlon, 1996) F"",/I",t' ,~ the magazine of the Chartered Socil'ty of PhY~lolherapy, and Amanda Sutton worthily won the Frontlineu.cclll'nn'A"ard.11lereare .....\eral n'a.'>Ons for wanting to includc thepholog:raph. Havingll"lid that, what stnkes you most? Look at Amal"lda's eyes. They are semi-lingcomfortingl)', wrappt->S. Some significant changt'S, mostly as a direct result of improved spinal mobility. we..... reported as early a:; 1-2 weeks artcr a singlc trealment. Problems included: I.

ReducM cervico-spinal ROM, resulting in altered gailS and a reduced ability to under·nex, bend laterally, collect or change gaits smoothly, occunl..:! as a dill-'Ct ronst-"quence of reduced spinal mobility.

2. Behavioural changes OCCUrll-..:!, mostly due tocxaggerilted respon..r>l,.SW.andRanotvAIIU"""

MnbaoI""'.... cfAw,.,.il...r,-S4t

II.;UIU'"N.(I'lIDJIn.. .... tomr'""'CI~~oIl~ b.:-lorSpi",.nd ."',rum.3rdedn.Edmbu'l\h ChurchiIlU'Ul,..st""" lk:rd""",lrami/"" null cfA""''''''y.I),l,383-3B7.

482

MAITLAND'S VERTEBRAL MANIPULATION

6R"'''. R. (1'l57).Thetrcatmentofpain. 501lih Afriam Ml'd,cal J~II",.1.31. '173 B....lN.L.andlV'LKL.._.M,(I967}.C......C"/SpoMylosisand ~~~:;::'~ige•. FARF"''', H. F. (1975). Muscular mechani.m of tho> iumb•• spine.nd IOC position of pow.,,-and elfjcie"'-")·.Orihopalie ClinJCsofNorlhAmnica.&,135-144. FmJSTE1'J.B.. lA.'lCTON./,,/..MEliOS.R.• ndSoULLElt,F, (1954). EXp"'rimrnt5on p".in referred from d""psom.tic tiSlluf lumbar "cncbral de.anll''t1le01. SUrxtr\', Gy.UI.AlD.R.(l970).IlJiJ..--IcM"""'I.p74 London,CoU,... rOOt.l",,6oolo1l.G. D, (19&1). Sonwob$h

...w.r.l/l»tnMi.l2JJ

"""""" .............

I''''T'''TA 5.(1%0) Funl:bonah~~sdgooupllJ ./Jeo-entfDn,sol"",mmalwnmU!oCb"",_#{

PlrylmtIwNpy.56,

P.......,.WA.(l97SI.~"""'t.-yIlJIlttSfnot·T1orS,....,

\Lvtv..-.v,G.O_(I"'Go)."""""""'M_ipor 'P""' .. ,th sJ"'Ci~ltl'fererl«!(ItJ...~hnngeffuctofJ'Oil''''''.5.. lI.. url, R.•nd M[\-'[I, J. (1%9) V.. ncbral.rt.. ~, rom.p~,ons",Coofra ...... andlumlwlr ~A~.... "'''''--',\1td.ocifW.1,.258. Stlw.J.tA5r,1(..LAmwo-.ILWl'~L.ndCou>,L(1

__

~""""'followins"""""lm.>RIJ''''''

",...",'" 11tr"-"'- AWnI ~ _ . 2«,1.3.

".."".

"T\o'(-...cn, L~ndT"u~J-(I99-l)Thelumb.>t5f'tt'l';

>t1UCtu"",function..l!"ch.onll"Sandph~~f')

;~~_""'mal",,,,,,,...,,IttTaPV.J.. biIH iM...

nw.onL(l9'n)AnalOmyofthr"""oal'f'U'O" "'-mlillp

fl/1Itr f..w-.- f'*"-t_ fIIOH""""'''' Ma".. n....,.st.(S.r...... ed-I\.,I.lJSAlI'O'-fT TWtJ!o(£".Sf"M< ~Ndl,,,I,,,.p.214-219

SM'rn.K.A..ndl',r1UllU:.\lN,(1%2),,,"e,,roIogical complk:~riron!l"fheadandneckman;pulatioo·lolfnullof t~

AmmrlfOf MrdlrQI A•..,...,t"",. 182. ~28

SMYTlI.M.J,a",IW~x,tn.

tnlt.'I'\·~,!~b,al

dr>e, An ~,perirnln:JP"t"i,l~

E.(1986) Enm,nahOno/IMpJt\.ln: ........ ~Aopfr,..tI('-8odh,"f\1 J.oj..... ed,L Pf'l~2S6..''''''YOlLGntlW''51r.. non za..J,(ed)(I'18l).AT""""~.s,.""",,~'hM"j,,,,'/

l:trllron.p.l':i9f',...... YorLikuftn('t'·\lueI

£uo;w"". M. (1\165). I!n.smforlhef1'IO()

409

example SO Idealspine(IJ listening/beli..v ing55-57 musclespa.m.beha"iourof6S-69 neurological changes 66 pain_Pain prog"""isar>d85 quaJifieonol~21~,

115.216

thoracic:tpiM312-313 '1lraIllChiIdol~tv',..mniqUl"as ~,ln-176

ph)~"""-

1lfto\"'Y ..wd"'l!sklllsJO 'Bnck .. a I I · _ ~ ~ ('bnd..-alI'j 1Itltln.o..-od 114

~oI-..n-73

f"dol80-81 f"dolSl.'SWludJtwol....,._m-V~

_

~_tft\tnI,~

~1d«'YD'f'lO'M2SJ.-254

~V""'215

mu_283-28-I tnIn>'_ _

...

~.I"..,.....

_oC~"'plllom2Jl-ll2

2:H-2~2

undcrcomr-oon 241.245 ,mdor.l ca""lfin'mobr;ol /or-.."I...... 2~9, 253 ~l'\'al""'234

ocril"ltC7.~".....,,1OI1 271 o'cr-rl\.'SSurt'(().P)H>,236.237 1"'~1\'.. lWXt._"yinll'l"\'L..-tLob,al Il\O\,.... ,,--nts(I'A1Vl\b) 2~25ll

1"'!O;" .. ,a"S.. fph)'silogical """·L-mmtsofsingle "'ltecti",ex.mm'lions 104-105 .....I""Disc.inlcn·crleb.al DiSQrd"",

_.J""

~::~~:~rl~ com!X"""'tsU6 c...rn:nlknowkodgc 187-196 definition xv, xv; diagno:si.87-89 discogcnk .... Disrogcnicdisorsptnc 338,3.19,340 lhoracicspine 302 Di'.ziness and cervical !>pine 2~>'-247 Doctor,roleofindi'Snosis/ prcscribmgI7··21 caud.""luina,di""• ..,18

Org'lnj~.::':':;,rs1'~I~n"oIVing prcS,ulllcyl8 psychologicalf""lor:s 20-21 spinalcord,disc"..,18 'crtc>!>... I.rlcrillS

c:;g;;painrespn>e 188-189 pain-sensitiveslnlCt",,-"S/pain p.ltcm~

dura/ ....."·.,.root,l""'·el92 inlc~:';';aljoinlstructUrt"S

ncrvcroot/.>SQCi.l:U>(~opWl c..-V~_:u9-JJO Loler'alJIO,JI4,31~l17

pftYl"C"'lnanunonon306-X19,lIO PPlV,,",.3J:}-..114,l16-317 Functi.on.old~mon"'r . . ion'''''tI

127_128

~

....r..194

",lalKJnshipo195 'lobiljlyoldi5Ord",1d

. . .> IIoop,toJInnJon3ll8-J1J4 friymplom.and.lgntj curnmurlic.llon 24 lIordc ... subj..di'·.. ",amin.'tion l()J....l().l Intr.disorde... 1{)4 lsomctrkl... i5 oclivc~nd pa,sive 121 as.~mcnt 01 ,rm and leg musd.... J39-I-I0

Jefi"-'J'~,Eung

86

Joints

~~';;;;:~noix~i",ements I~ difierenti,hoI1teal .rthritis/arthroslSl'.19 pa'n·seru;itJ'eslructu...../p'in p.'IICm5 19(J Joinlypeople47lJ ju"enilcdiselesion lumb'~~""l7Ire.tm..'Ilt cx~mplc

Keywmds JIJ,3S-3'J

L1bUltoekp.in luml>arSJ>ine.lrciItmcnlC>.iImple 432-133 lA/S(luml>a'spineJ_Luml>arspine lA/Sa",as

Latcntpain6J-.6.1 Latcr.10e,ion cc"'ic~I"Pi",, 287-2S8

"",

pain bil.llcr.1437-138 insidious 419--420 poorlydc/i",-'-anteriorvertd>ral pres,ul'nJS2

..,fIoJonJ51-3S2 tnl.ollrRllIroonIritJ'\2-:\34 LIlmuuonleft 3S+-J55 lractKJn 3M-J'H

-,,,

fnctlOfl-freelr~rouch

it~"larNS:zt,()

loowrr.rca2tJJ 1nId.....uon26J ~ubompItaI...,., 259 hypomcbility71.155

f'llf'100nI~IS5

It'a,,.,·Cf'5e'·Meb.... lf'I't''S'' , mobili2.>lionh.'Chnlq......

3il-3n _81so'C~c... illI" """,18&

~~89 rrftorrodpain 186-189 i>I~ngOl'romp"'S80ng

pain 188 pa... 'v" .....

r"',"'''t..,;!:>

p.lll"msutMovcn"~'Ip"'I1,·"",

phy.~>logkalconsid"'ilions_

1"'~";~""'~b ~Jac...pon1(1.l

,'"",""a1can;ol uwrrtrbral foramm.o14"'.~1 '1o\~10~,'''-'"tolarul

__

pb~lnU'

l28

"LAI""",ipvJ.;otionl.lnlloer ~1181

" ...d,·opasm

booho,·"",.on""""II~.I60

'1yOlQl'l'll':$ ~teofsymptum>

1O'J./I1

mod,fieod 454 ~""'puLollOn ~-OC".. lspinl'_Crnical sptnI'"

.....ipubtion(en&.\') doofiN'dn",3 fonNofl71 lumb.a"f'I.... _Lumb.aropi..... marupulation(Crad:>on/""Iensoon)314 C?·H(La!l!1".1n..,.ion)314 C7·HtlO,.." "",)ll5-316 cen'oal.p",.. 2M--lTI lumbusponl' 36G-36lI oro.p'to-allanull""'l

(""-ion/n·tensionj265-26f>

~'lor-.IgoellJ7-I8S

Ocalappbc...... 0 1 ~ 1Nllun&91~

diasn

pain

~rmplornbl'haviour

In

l'roI.pooedd,,,,,Ill5 Prone knebl'acil 188-189 ""in·sens'I,,·rstfUCl"_/pa'" p.lllems 191)..192

495

496

INDEX

odp;o.in(ro.l!J) ph aleu.nun.lttonl)7-138 ......1i..:"'S""'402 II.o>"'-pain63

K

-

m'ittunsl78

.....

bet\;I."""oI68

""--

w,lhSlr.>lghtlo.'gratstng 379-380

Slumplo..'St

1«-1~9,/46,

~lul~",,251.1S1,253

lumtr.r-ilpllV 361-3611 ~~""'tlOn!l of slump e-ibom

phYSlCllI~,",nahonJ5.1-J5.5

!loUtion(thor.ocic'poneJ G...Je V lNI\lpubbOn 3J2-3.n

commUI\IC~l"" 2~

l~l~'l

Soft·bI!5~~

mobll,ul>On.depthcl218

mobil;,~...,leduuqueJ5..J26

bonedwl~~ 11

~lCalJP"'"'

prog-.. ....C'd!~50

phywcaJexanuruobOn Dl M'!V\t!I 31S-316,311

mlOl'pKh\f~l.q_iofts

s)"InpIom~dUfU"ll;lmItmmt

Rh}Ihm!I'i-6.I76-I79 latmt""itlrcsponspu>e)283-28-1

~1"riQr.urlan".ol"'ning404

00"'-

C2.1a~I~,21O--271

CndtVmarupulat>on 2'J3 atlan....."""'ljcOnt296-1'I'i "'lff\~,......,.N1 ocop'..... tUnl4ol,..,.293-2904 pOr""ila_al.'ft!Jrbral

".....,m Rul.rdisorders 1OJ-1(l.l

...."Ural~ymplorns 104 periaJticul. r l00 Subjes"-",,,"en' 2t~, 215,2t6 T""hniqu.,,; appli