ijlTITE~"QRn,
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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"hpi!iOd,os of uncompliCil.loo
l>I"
~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"u
li"X'fw:
p""'in~
""'" rrr....ll.v .\Iol'IJ.U1J•• pIrysa."~Fl>tJrom A"SlmJiIl, /fa- Mn e1frpl~/1g"J'I.°III~ thru~'" oJj J/'<M'r /millmcy !mlll'I/lr mart' ,'rr'lglh Mind II~'",. TI1eI/ a"ollot i,lemiclI/ l.·itll III unt;119'I~ In 1965, one of M.. Jlbnd'ji wishes Came h11..; With the hdp 01 ~h 0 ...... C.......a..'Y, Hei\d of !he PhHlolhcrap> School South A=Ir..i...n In',,ululI!.'' of Techno!· OS)' and thl' South Ausl1'lIlillccpt of\lallipulati\'e Phys.othcr,lpy 'IS il!x-eame !.:nown emphiiSILCS a "P"Cifi< w,ly (II Ihmking, cQT1rinl>Ous c\'ah",li"" .. nd i1,;,;e,.~ml"'" AII!>/",t.", j'lIlr>l1l1
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 ""te;,/['/1' u·;thin tilt di,fi(nJ
,..odin' c{ Jt/:l/~IC'l/IIh/'raI'Y ulld ...~ "" If mMrl1'll' oil," ~1«Uf/llmbof II.' prP//'5mzl"f /uw /l'(iic';" .. UVrlll spclllll;( 01/1
ill ~ssi\"e ae
..
~_
COMPRESSION. This is Ih"al'l'r."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 to all lllol intra-articular slrue· tur(',UC5
p~ures Ih"l
xvi
GLOSSA~Y
!h.>! 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 pr NEURAL MOVEMENTS. This 11-,"" is!lti1J nolell'llrl)' dral (,lna1 a) duT;a h) other mminges 2. Folamin.o.1 canOll 3. Pt'npheral t1sBueS a) neT\-.'$ h) lIlM'shh..II.-...s c) support"·,, h....Ul....
d) osseofibrous IUnm'!s, ptf'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'L<e in an appropriate ~i'e or. whcn ~"Ullcd to lllI! diso 3 Mobilization 4 Manipul<Jt,w: Ihffapy 4 ~
relationship bctw«n
ILdence . ~~~
"ppropria(~ wording 9 listenif'g 10 wmmation 11
lech",qu~ and
R,lat'''9 m .. tm~nt to the history. symploms and !>19m 12 ~~llt ..lId anatytj(al ilssesment 12 Two mher~nl capabiliti~s of th~ body 13 Summ~ry: the 'C(mccpt' 14 _
4
asscssrn~l
T(c~niq~~
5 mode of thinking. the primacy of cJiniYT II ~ (1(10 ........ Dun'llJ ,111$ N1V IIrnr ........ 16 (.lX} _';ipII&iIOO lI'1lrt",s rrgu14rly .... rhUIJ be rd~J
upon to Mtmi""lt.lr "I JtusI nl~ rr«t tDdI dar;; 1Ir..f Illb lWlilJ "",""11 illrrJrnu(l( 1 III 10000000 ItID"'J'ull1",ms. More 111.'11 40 }·..a~ OIl, IIti.> I> >lilI ",IMi\'('I~" unchang 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 l
Inltod~~tlon
phb>U'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<dogy; they mav
,-"'en be b,,'lC'd on
supP'-):iiliun~. In Il'latiun 10 lre~t· m~~ll, many m,\lJml Ill'alments are mitially administen."I:I empiri(allr; onl~ L1! 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 sp<Xu, lahun§l>r 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<no\o.ledb"C thai .Ire
p;>rtlC\llarly applicable 10 1re:t11Tll"fl1 hy m;o.nirulali,e phr..olhcrapy are omatomv, ph\"sooIOffi~ biomechanics and pathology. In all of these, sclenllf", invI'S!lgalion conl"'''I'-'' Il' milka' disco\·cr;cs. AU vf th"' fo". an~1S of medical knowil'dge coIlI,';n dements uf knowns and unlnowns, spt!€ulation~ and hypothl'SCS. A diagnuo;lS is arriwd a' by rdallng the dinical (.,;amin.t!ion of ol pam...' to lhoc knotvltdg... in ~ four main an:01S oi medICal knowlc<Jge. II LS somehlTlt~ difficull 10 n.'L11C a r.aric-'nr~ 1I"....ry and the eX.lmllMhon findings to a precise> 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 e; in rlr ~r"""""l.pf""Il!' tlrsnj~>l
\\",7< r/!,rrIl'Il/ prtrivu; in'''1)/1
phras.s ",,--.I "hoen "''''.:lking o. "-"COrdmg in wriling. Tht> phraseolog:.· on(' uses dean) lhoe way one is thm)..mg.. and Iherd,,", If, for e=mpJr.>. !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 functi
1'\1"."< think of 'rmP'om~ withoul thinking of range of mo,'emenl,
1~1),
r"l1ction~1 movtmtnlS that l'at,ents C"n demonstrnte to repnxlua: tnrir S) "'ploms, 3. Tht Jtandaro 'C5'f nUl\'eml'1lt!>of J01Il~3nd \erl.obrill canal and nt'Urill ~truct,,~, 4. Couphngd,ff.......1 'no'.-emlffllS. $l'CjU{"f\Cl'S and
2.
po!>ibom.
S. D1ffl'l\'tltWlti01lIe5ts «>determine \\ltich structure or mon'mcnl component IS in\'oko.'
t.C'Vtl' t!"nO:: of pilin ""f~out tl-inklng of ",n!l'l', Ntva It' 'It of ..nge wiltloull~,"k11lll at p;IIO
..... lkto,led eJ<Mninalion
cN.ng
RElATING TREATMENT TO THE HISTORY, SYMPTOMS AND SIGNS tnfOfmallon I
Solme timt' ~nK the clfecl olln"'II""",1 ba..<ed on in the pall'-'ll!'s syml'tonl$ and signs, is a pn_ mary lealu", of thi~ concept oltr('almenL Ass; ~ 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 o with till ~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 115 maNpulativc IT.... tmenl must .. I",~yli be flexible, n....•.. r d08m~li( and n pfOll'(l~od loy Ih.· u* and .. xpla.... tion 0{ lhe ~"T1lbolk semiptnneabln-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"rbaJlelf is not" COl1lr.indieatiUll tn manipul.tion, and somel1!lh" mosl worthwhile 'esults "rl." obl"ined in older patients.
Th~
Table 2.2
Vertebral
ca~ses
DevelO{Jmemol
Sponrr.,.lohsthe.i, Scoliosis Hw,molJility V.ti"", uncommon di'orders Deymptoms of ,'cry long standing 'md then app Itlmbar spitle. or intL'rmittently on "n outpatt~l\t ba"",. Traction in bl-d is lJS
InUrmittent traction Inn,rmittent traction on an outpatient basis is p",!er.1bly given daily. a"d can be applied 10 the cerv,cal or lumbar spine. Cervicaltraclioo' for patients with arm pain thuught t" be due tu rool comp...."SSion has Decfl lhe subjecto! a thorough study (Brilisl, Medienl !o"r,wl, 1966), This .,how~-a that drtually ",,"ery patient had marked relief of pain during tf>c application of the traction, which was usually applied with the head in a flexed position. Oflen Ihe pain rel;et lasted lor a matter of hours, bul the treatment did not influence the natural history of the mndilion or the long-term results. TIlTce-quarters of Ihe palients lmpro,'ed sul>stantially within a monlh whelher traction was used or nut. This means thai inlermittent Imchcm for Oulpatientssh.)"ld pmbably be ~,,'~od for p,: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~'t ;os easily
in c«Tlmunication
between only ,,",0 pooplc l\.ormal wn\t'fS.)tlon. thereis not as Mmpk and straightforward as mi~rht De thought Tht...... arc two inter\'iewing skills of whICh therapists ",ust he .. wan'; th,.,;,:, arc hl'aring/l"tening, and !l«tng/looking. Ther.'pists may well hedr whal the} f'''peet to heM rather than hs!I'd II on ,-,.leo-tape or aU.-tlpe lind pl"y it b.\Ck tn ""r;o.'l."" ,md to c"""truetive pt'Cr5 or SUpt:'rI isms. SUlh ~ pritCtke can gh'e a 1>"'''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)
L
1lw fi",t aSJ"'C1 (If rommuoi""ion that muSI be Sl~ is lI'w l'IOn-"erb,1 or 'bod) Llnguage' aspect II ,s th., "'"" qrlll .11)11 of communicalion. llIe im""ct of "on",.,rbal ,ign"ls Is usu~lly stronger, quicker and mon: dil"t.'Ct Iha" Ill" impact of word~. The siJo;nals are fn.'(juently more inform~ti,"e than words, and howe the "d,·,\"I.lgeuf t.~nsm'lflllg m",~~ U a .u~S(i(>Us ref1e,( action before suffio...,enl lime ...........a!""-'O.l to (~the MI .....Qnk. llecal.lSt' non-\"erbal communi. (;otlon is reflex in !)'P" and tlwR"for-f, less easaly roolrotled. " an be to:~l a cure, or you "ill be dl>es, ,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!llo> hand 10 l!XJIre;5 IheoIe ~ Ho....... ,.... ill no slap> should IJw, in~ bot- .illowed 10 S;.'1 oul ci Mnd. By aIJo".·in)j the patiml il dcgn.., of rontrol...>d Ial'tudf.>, 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!11<ml'olls Olfflmenls aboul hI» problem leIb thc l>xamllll... lilt' n-lah\"f IITlpot"tilrlre he plil(l"S on eddt of lilt- Face., of his problem For .,,~mpk, illwO P.~timb
arc
tllklllfl aboul lheir shoulder prubk>ms, one patient may thot hi,; ~lTIl i. too .lillto tuck the b~ck 01 hi> shilt into his trousers, while the other may Sllcnt is talking "ben,. ~n asp ..... skiJs in ~ wonhng nl q..-tiQn" th.al the pb.'JO!herapbt shouki Jearn il ' ~ ' is to bt ~ 10 'Is maximum dlcel The first of thoe:\le is that. unJ.:0s6 (are is tal.en to pI'e\"ef11 ,t.the pf1~henrPlSt'S qut."1I01\S 'nll probabh hI".,.l blas_ II is mo:o;t impor_ tant that question. .hould nor bo:' b"lSt'd in any .. ay tuwards the MIS"'" koped for_ I" fact,!Ius .tatement (an be carri fl.rtht>r- if lhe physioth third In:atmenl and Ih" ph~~i{llh",apisl is hop"'~ tt",t 11,,« the pallo.'Ill l >OlJlething Jilc, 1\0, ..."",1 not much "n\'wa)" To ilSl:, 'Are you feeling ilny Ire~tmmP' ""ll innuenre hIm (esp«ioJlly if !he C""'~ .ut' mlllllT... l) to" anh !>il\ Ulg.. '¥L", ltwnk ~·ou.l Uun!. t am', ra~ than giving ho-. the n>QS1 in'port.:mt mfo;>f11'Uhon rontained in !he fil'Sf n.~, 'No, w"ll not" much ;m~-w.. )~
bt.'ttl.'l" frofP the Last
or he USl'Sa ",ord, such as ~turdav', "'h,ch mU$tha... e bl'O.'Il stdled for a rc.uon. The rN5OI\ ;;hould be sought wrule ,tlSshU fresh m tl'M'p"lient·smind. To follow lhe p.olio:nt's Ii"" ofthoooght b iI b. policy than following one'~ 0\,,, l,"",of thought-
""It.. .
S~mrn;lrv of ~w'Y~w,ng >lills;
lklain conlto! of 1M int.rv_ ~;m.u.~ lilt p;lI,mll~allh. il'lfol"1lallon g,....n is
BREVITY WhL'fl ~sking qut."hOl1> 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) 11Jt..,."e41>Cie'llkroo~"".·~mlO_'"
lr>lq,.."'n.....po:iJ'o'eoltht.eoro.·ror~'>fs9hp-oco>.
Ellor
5thjll"••" PUTTINGTI1EI\.'IS\\t:RINTO\\'CJR()$ r.tra,stot.t>otslt'01.tO"oc......-.gtt-.e,JeS,"" ~.,Wr>:l." """dI:IoJI1lort>opft:au"" of difficult VuI ,,, ,"1"\' {irrum_ "r.lncccant'l'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$ VERBATIM EXAMPLES It "'as ....rv g.-atify-ing to I'l'ad thai )1acnab (1W7), in his bool &d:IIchr,lI} import,lnl to portray it 'n ..-erl>.lbm question
and MlSWt'f fom'. TI,i" {rom a m,"" of Macnab'ssl~lUrrl 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... follooU~Ii'''~Inc:nb, 3, Sub,o.'CtIIC d,ffcr'cn,ns.
2. ClARIFYING SUBJECTIVE ASSESSMENTS \........." d"'l"rll'I"ing till' "ft~'Ct 01 t~ ~t tn.'.11ment. t.... p~r1rp«t51,... rr>ed altt-.- firsl ;trw;! ...ecoruJ I>OR$ ,...hich shoIlld be foJk'''ed up, such as til 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$~
Q
Is lhal unusual?', or 1lEfore beginninlt tneal\"OtI h.1\"e had da\'S "htd> ".-.e m""," bctll:T, as you"'y Satun:l.:ly .. a;;?'
mmt. oou d (~I
Q
Ho",h.1sltbrenl'
A
A 1ot,Ior bt'iter.lrs incMlible'
""".J.'
£T II scrm 1....>OO\I*lr I<J lISSU..... 1tI' lIltS Il1NJt sulJ5l3nt",! '''lpl'l!~Jrnl_ ~"J 0"" ,I r_ 1>ro/lnNy ",/~tl'll /c:llrml"'fllt. /ionnw./ oronoa if/~ (C1Is,d,.... ~ '" rurrd aud aOfS n
Ir""'rue,,l?
Ti~rrf"n'
II",
i",m",lint
Slrongl~
Q A Q
.1IlLS/mts:
Q Ii) Q
'00
,'OU me,on c 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'!;. or an hour or sot
1\
't would ,,'y II ~to1rtt."d to lx'Conll'.>Ore within "q"arkr of an hour.'
ET
WlwI "fcd, I" br ,tdrrmiucd ;~, i~ 1111' Wn'!!I'" " ',,,',11,,,,,,1 ,,,n',,(,,,,,: '" 'di""rdrr S(j"",,,,,,,'
Duri,,~ tho.> 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'
Ihr
,~actly did
f~~l,t?"
you feel and wn.:,r.- Mn'}""OU beenr
1lw,'I;o,rruk_ Pd. 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 thrticular ro,tic"t .. howas not a good witness.. Her m,lln symptom WlIS aching shoulder
,In
Q
'How
h.~\·c youlx'(;,n'"
A
'QuilL' wdl1l101nk )'0".'
Q
'How
A
'J",t th.. S.1m,' - "",.., ~i'1ce Monday'
1uI~
your
~hO\lld"r Ix",,,?'
IT There nr!' IltV' lI'iI1S~ 10 Inldl "1! 10 and "'" I,m·, Ol,e ~ ',IJ,r' anJ Ilk' all,.... lS 'Mmwuy'
Cornmunial'
,\
Q
·You h"w rt"fem'd to the should.,. as ocllluS pm·ious!v. and toda)' you are tallcing ..bout sorenesr;, are ~ dlffenmt or a... they thl" same ftoeling"OO you are just using difft"rrnt wonb1'
Q A Q
A
"Ott, I don'l know.lr·sjust thatil hasbo.....",son-·
Q
'Was II
A
'lsupp01\'110"'" may "-,,,rn Ill\' I,i,;"l to justify p~llril1b the 1",1I'~1t for clarification. Howe..,,-, it is ,..:ory Important for the manipulilti'·e ph)'sloth.,,-.lpb! 10 ",. olCCUtate. beo::"'!? mq1lirV "111II!Plllf The pa"~.... t us..od the word sore~' riltl\cr tho').n ·.dung', which shouJd a\crt the phY"'oIherapI~1 to the facl thaI tl>en" /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 pT m» mr inrikl1ll/!;l' I'rrcll':lal"
uch will be discussed S,.1 all On the WEDNIS-
.
",0, I\'ebcentn'inglo~mberlf[dld ~")
thing.. bUI I CJn't ren",mber- ,on.. time I coold h.we hurl II
FIKSTa""U'
II
A
[T Tlwl slhat /M'rl''ft11t''1''''''''''''wlvnl. .".Qllm(' pr«lispos;~ phy,ic~l actiYlILlS IJlI!r m~nl,,1 ",-orie"l"ti"". It may ,llso n.""ult in ;"i,.ing out m, ~ rele"d"t pkll Ix",n duing any U/\,USUAL work on
ET HIS r'''I'''''';'' i'ifcrs 11101 il did,,'l slarlla'/ ",,'t'k, b"l awl's 011. 17", melllOti /ila/ will m,W 'l"ickly
A
that Wednesday or about that time?' 'No'
Q
'Had you been doing any HEAVIER work than USU,lJ?'
A
'No,'
Q
'Had 1>ether 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!<J" ",I;l>t ·,j"'}'RIIl'S hI> "SIr rl',colllll' 10 j.'e ,'ary at all dming Ih" day"
A
'Yellll I grt !I.. a,,~-:a'T "'Q~t quidJ,,' I II lTV IhlS fiTS!' Q
'\\""t mal...., II worr.er
A
11 just grts "''OI''''f' A! the dol\" goes on:
Q
'00 JlJU IDe.ln tI1en',~ nothing you l..now of wltich ma\.i", I "''itl..." and pt:>s,t,oru,.
1_,...of/"'Wl"·l)r·Q.Wl51<JJ1/it... l more.'
"u"
"rJ;hurlocffwllm tfrlil. TI., I'm qu'!>" 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;fility ~nd degre I'" well pIarm<x1, b..""auSl",bly !m"" !m,! ill Il'e 1",1I("k ,m,l!<Jr Ill!' talf ACClmu-y ~,ul tim!' MI' II", es>mlial f,wo", IIml i"jI"r"cr )/,c lmrd, usrri ill 'Il<eMiOllino: Imual"",! t/,e 'Where?'
A
'In my bUllock'
Q
'C"rl rou show me the part which i, affal CQmmunt.-alion was d~!'iourollhepaini> Following Ihe sub)ccti<e e~amu,,'tion and I;>stmi! eslabhshOO,lhl'lrealmenlt,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.· wh.cept,on is that. ,,,11(>
I,,~ ,,,,,,m,'111 is ofmlw I",~ lI"d tr,~rrf'rr 1/,. /tr!1,'r III ill( a"ONSE AFTER A TECHNIQUE IS PERfORMED (DURING A TREATMENT SESSION) To d~termine the ~ffect ol a teduuquc, both Ihe ;;ub!i!e.' -'
Q
·Andn<J\\·thatrou·... upnght.isltlln~"l)1"«' asa result ofh""ing bent forwardsr
A
''\k)'
Q
'Before
' OU Nd ,)J'lr trouble with ,-our back.
how far could ~ou MId (o....um.?· A 'I think that'§ as far as t could ....·er bend.' fT l\tll.9I b:;I i, _>forrzwnJftfn"'l$much~ /tr. bMIug pam is 110 w",~ prtJt'CktJ hti 1"..71 III(l{It1!lfIrl. NUMJ kt liS $« upptnl'd kI
_
If, ho.....,..,r, lh"", has bo..'o.:n p~~, the .. sse:;,.mcnt m..)· be made in IlK followinll manner' Q
Beea...... some p;lhents .re unable to think in tIu'5e terms, it ~ ~ . lolldd I(l til(' question- In doin& so. It is better to bOils ttr q..:stJOrt toWards an unf..'ou....vle ans...er:
Q
'Well. a.... ytlU less than halfway to being com-
A
'Oh no. I'm more thAn Nlf better !hank you-'
pletely better"
lItt'otl"",..............,/s
And 50 Ihe routine continue'S tt mOlY be useful, lid sil;'"6 compi1n-d" Ith tha:;e at hIS fllSl, i:sit.
treltment session!! to Of1 al ~h ~"cre<si\'e treatment Ihat he is foelmg bctlt'f, 'Yes. I ~m s"'"' I'm a bIt bctl~·. ret al the fourth f~.llment );Cf;Sio", if he is a5~cd how he is compared with lhe finn dar, he will 'UID' and 'an' and ilo..-:.it;lte and finish "p by !;apng: A
'Well
. rill not an;'
wo~"
II is fur reason, such as this Ihnt lhe n.:iI\lSpcclh'c as.~cnt
WHEN PROGRESS HAS SLOWED OR STOPPED Makmg a reilppr'IIS.11 of the eff(.'(:f or treatment at .. sla!;e when r~r~s ,s 1'101 "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" impll7t'mlrf.v i'!fl"r",jllg him all'o.v .from Ilk' arls"",r I am ~xp«lillS'
'\.
'Oh no,
A
'\1y buttock aches after ,.'"'~ ~ sitting for a
I'-r
Q
'Sitting for how long:>'
fr.wi,,'1 chi!il1S arm'" I,ds slill 'I'rpror,;"g, _IIJ al III ""t "'~I'(J, 1I1'1""'rs Mlf15frx1
MptI"'''' If''t'S~ ""~ rrl4,('S ttl
'1II1[ pm't II«' 11m- rrl41t"i ttl a'hm
I~ gaiJHvJ I~
,,"PIVI¥7n,.,rl and u.~~111U I", I;; eM/mllmS to ""pM", 1J... In"ff "",1.1 pror>r 10 k InltH,V. .., Q
lip rl", cal/fin;!. 'Ilow,stheulf?'
A
'O~,
U'I"" elmr
that's all gOl'e'
fiT TIIIII mrst' ...,
rm,,'l''Y
~n'
'When did
a5ki"s abollt ;p':mta"eo,,~ C'Sl'rcially if lile j"m""k amI coif IlmYtly linked.
IIWI' make
"T~J/,
l' ddined?
69
Ideal spine 69
A.V\"ragc spine 69 Abnormal spi~e 70 Ne'N/oid lisslh" off ,,..,
~nd
to its f"ll",t adv.m!.1!:". Huw NI, patient> 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 d<sorde< 'IdIcalIea:udon? (I'M.'Nol ~ PathoIogyTf,rry - ~dy •. • , Eoasy 10 po-owoli:A ~ or ac:oM aposodII 3. N .....e...,~lions.. ('lb1llotSpagly
C. I.
2.
no. klnd '" .umlnwe.n
Do ...... _ ...... wiI..-::I1O bill gende 01 MOderalely llrm wiIh yow l!ICa!TW1aIionolltl8~? Do """" exped a c:emparnbIs s9> 10 be - , . or 10 tIlIllafd 10 ind? Wtrf?
~rn
D. 1.
no.
.tJJ$( oll/'lll SOURCE of Itle . ~ : Auocl8led ".amlnallon neUfQimuscubskeletahnadiclllllldofs teading 10 the cause ol!he & V ~ Issoeiated taerors nus! tM aamlned .. As Nasons "Ily It'll ioont. roo~ Of odl.. Slnll:lure _ becoroo symf*lrMllC anG'O' t>. Why the joint Of muscla disordef may reeur'? (e g. poolIu.... musda ombalance. musel. hypennobility, mtabilily; delorTl'llty;" praumal 01 distal jon, 1I1c.). Tlla ellec1 01 the lisorrler on """' stabolliy ~
~I
2.
po_. Obeslly. slitfness.
E. Treatment 1 2. 3. 4.
Which lhort·term or Ion\l.!elm goals 01 t,aatment are ""rsuad? Do you ",xpeel to be traatlng pain, rOOSlarlCa, I'l'8Bknass or inslat>dity? Ara there B")' pracaullons or conl,aindicat,oos which need to t>e respected? In planning tha TI1t:ATMI::NT (ahar the axamlnatlon). wllaladvlce s/loUd be inc1LJdad 10 prevonl Of I_n fltCUrrooces?
At!fIllleng Guide (11198), ...i1h ~Q\Itmonl diSOfde' I'! ..ell I'! ~king (ho, rou-,,"'" tht SOOrtt WIll gu,dr t,eat"'."! proc.dUfO Fi~u",
Assc:ssment
In Chdoo spa'''' durinS 1110\·,m"''IIt or atlh.. hmit of rang...
,,,,a be ~ for •.Ange and the bo.'N. IOU. ~ ~)" resuftir1ll; p.oin. ~!laInl" n'l(J\ emmI .~rntt11 need. to be..-le of the neural s!n>C" tuft'S. Also, in 1M dailv managl"mel1t of ihl" n'rtcb.al dil\Qr"d«Q. it b ~t ..l to lno,," the Slilte of condu.... bon of 1M ner>'es in dto;;e pahenls "'ho5c symptoms indiul" invnhemcnt of the rol'1"\-e root. Many !e'>b 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-<Jpl.... t>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,' .. lil/C ph\'Slothe",pi" will lell the ~t,ent that his probl~ ,s ""e .. j;~-" PIlule, and it is ~er job to m~ke 'ill t~. plCCes fit'. She """ds hIS help 10 do t~,s, anod II,s he, ability to mmmunicaic Ihat male, Ihe dIfference tlctwcen her bring $lJe~"ful in helping hom wiln ~is problcm or nOI
1. Dum'l> 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'
pM:ur~
2,Vi,u, 3.0,."1I,,.d 4. Cold, d"mp, 5, F~milial
d,a~gh1
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'
S. (ft'"r Ihe 2~·h()ur perioJ immediotd) followm& thl' lasl tl'l""ln>Clll Sl5SIOO (becausc this i. of'ten 1M most important infOfmllt;'.., period) 6, As a n'lnl>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(\
are
~.
equAlly
~TV
fur
~
diffet\'TIt
components of the php;ical eJGIminatm finding$. This is m
Although II is not .... ithout value to 1,'0 through the ol ~ I as a mechanical process, illacks il IS rJ
odi",rimll\llloo' and lead> ~t nowl'Jen> HQo,·{'\e..., if lhe findings lire relatOO to the ...-pectahoru. of lhe 1n.·atrr>o."'l tt.'iq~,
u... a5ses&Dl,.,.,t
bccrJr"",. ,{'p, d,SCf1mlllillon', m"lu", .. nd ,·aluabl". 1be paths for'lc"mmg 1.....1such.l pl'eS/iment wange'S to ~nJlyll",1 as>.es&rr>o.-niEarlIer in this chapter, th,' following "",as ",,,reslated as ocing th" a",a~of gn.'illl'!>l gn,wlh 1I1 :ll'6l~m""t I. Communication 2. I3eha,-iour of p"in, mist~ncc nnd muscl" spasm. 3, Identifying normal and llbnorrn~1 finding"
COMMUNICATION
aslen~k.
Following the physical e""minallon of Ih.: p..I;"'flt aslcl"isl<s indis sho"ld ~ identiiird with an astrrisk. An "xample of thib i, when cen'ical roLolion 10 the ri,.;hl pro'ht.sse5slng .. pat!cnr'.
threshold of paln , lX' .. >o$isled b~' firm!} -trelching one or t"n III th., patiomt's IIl'nJ!iII jo:nt'i;lnd noting their ~ _ Kl''l.'k-' (1967) statn:! lhat n J'I-'r Cl'T'l1 of po:opk Iw"ed ph~~iologic.l.llo\,·F"'in Ih~d. 17 "'.,. cent Iw,... .l. h'ilh f'lm 1h11"Shold,.md 60 per cent Iw,,. .on .., ....ag"'. nonn.>l pain Ihl'C5hold. For thoi! dinid,n, lilt-' ~ Il"lIU.I\.'Tl\l-nt IS to lJ5kn, 10 beIK-\,. ;mel bl' -a.... to ~ unJl'....t..nJinl; ,,!wllhe p,Jlienl is tl) i.ng W ""p~ If the m,ll"pulative phy,.iottw!l'3p"" c,mnot up b.>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"
Rtcovcry polin In this calo>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<J5,tion should be su.tou....-d for a .hort lim~ ,""'" 10 'i 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\!, sustaincfIQR;O.' ha .....lil1· and m""" bo' "--'ft1.""be.-.,d when one L5 plan· lUng an,1 car')lng oullrealmeJlt, and in asse.s-ing the effl'Cl of the last lreatmenl. During any lest ntu'·(>Inl'l,1 Ihal Ul'''''. pain. the mO\·.... menl and Its polin re;pon.es should bt: asso..'t«'d fully ,l"U wilh care 10 allow a~Sl'S>Ulcnl by """,,,,n'II1,,lion to show if Ihert hn, 1x"-"1 lIupro",'n1l-"'1 f(,llowing a tTl'M,,,,'nl tOn "--"
If the tl"t'atml't,1 I.....hnique is of roo help, the signs fouoo on r... ""amin~tion will nOI hal 0' allcred Should the tre~tm{'l\t I\,oJ signs donot occur synchronously.lhere .11\' hnws, p"'lio:uIarly if th" p'.ti.:'nl h.15 S"\'CTC p"in, when the Sil:l'lS m~y show improH''Ill~nl withoul the patienl lx,,,!: able 10 apprelSns indic~te Ih~1 lhe liame trealm.... l shoI.lld bE."
,,,t!
65
66
MAlTLAND'S VERTEBRAL MANIPULATION
t~---'':'''''';========------------l't'fJ'eol~d; impro·.....m ...m in the.- 5\ mplorns Wlll5('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: iI', just th", ...,me - I thinl< I'n, iu,t ~sIl'
~,'§(lof
rrio:¥a'l(t to 1l$6S tr\.~ in d !o3bility n in ...... ' IV and q...nlJl"/ of ll'lM'IT .... t
rust~u.."ealt\.i>fcham;o,,,hik~ch.mg.'''' Weil!her changes or immedi.llcl~ following the
the
cn..nge. ma~e< ~smml d Ifhcull II"" ..nr. the hdpRelJlIng themo.>\'-"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
Figure 4.10 Rodl"'l13p11 of «"ical ',,,nf of a 76-~e31-ok! Worniln. lho... '~ con~n;tll fulion tx:lv,.~n sc~od and ,~ird !IVc:il1 ""[,,bra, C~I'J!'M:Thrrt: Isa CO"QCMI fullon of C2 a"d J C6 and 1 a06 Tl.'ld 2, F• . ..-hi nnrm.al in l"\'l'f)" "''Sp«1: m..t is, nflnl' i> di>.ld'4I1tal:,:d Il1 olny' ""y b~ inl"'-l)', ...........00 Iftr, rig; from the spinal ront "nd ,heir c~its from the, ert,...."l Col""!. Such anomali"" mu~t be' taken "'to conslder-
gi''''s
atloo"hcnassessingtheO"S'Jtiofap"hcnt·srd.'r~
pain. Figurr8.1 i.a good cMmplc. I'l\'fi"ed andpo>t·fl\('d pl('~"",-'Salsoform partuf the anom"li('S 'hat ('"isbl-"'Snorm.ilorrommon,ore',m .abnormal, I-et do noC ""lUI"" I"""lmen!.; I.\l.an)~a~unablctotouchtheirtoe 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,U prol't..."i!i and po>.Il0R5f ,....nebrae,.." bt.> (Onfirmal by X-rd'''' If" Jl'O"'itional finding IS IongsLlndmg. Ih,
and spa"",. Such abnolllu.lIt;"'S
can be dclermint>d 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 sllfrtlC
nv
""rI'er
"'I;
th"TJ"~.
Pain rtspOnSC' """ pain n::;ponse felt by the palienldunng the p ..lpaboo e .... minahOO 01 h ...~ues and mm'''m
"""" physiotherapist must be prepared 10 accept IJ..o pCOIl,-,crted and d",heilrtened. She wHl lind it "a,i"r ill a(cept the bllun.. if ,he can reply,'Good -oot thM] "'Mted to make you ",orst'. bUI il shows m.1),. 'If 1 can m"ke you Wllme by too much or too hed")' mubi1i~ing 0/ your spine then I should ,t"nd a good chancl' of bo.>jn!!: ~bk In imp""''' ,I'. Thd 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/fer
n>aI .....
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.'G1lZSle to underst,'nd th" "ffrxtof the treatment in the p"tienl', terms. It is not tedious, it is challenging and stimulating Ii the vital spontaneous inform"lion sought is not torthcoming, it may bc nL'CL"lS.lry tu ask the di ...." t qUL'StiOJ" 'How did yOIl I~...l when you got up first thin):; the next morning cornpilf",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.'Il Concenlra"on. After 10 'iI,'O,}nds, while lhe l;xhmque is sllU oonnn"l'd, ;> comparNm is made of It.. rhythmic pam. If it i, ;nc"-'ilSlIlg. the td to Ihe ki".t of IN-alment and the amount of Ir..."tmcnl.
3. n .., rh\thmic pain In,iI' increase /Qr the fiNt IlJ-.3O S«'OI>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.-ol isaskoo ....hdh.,r lhc lechnique is caus",!> any all~-'t','liOOl 10 th" symplums. nus inlonnali"n is n"",~sary from thn.'" points of vi,'w; I. Th" p..ltie-nl may hck pain. It shouJd be determined whether it is the symptoms bd whether the fXlin isdue to the pr","u{\' ""ing U5'->d or Ih" mOVl-ments bein!'; c"'ilted, The physiotherilpist mar choo"'-' tu LOIltjnue with the some technique ill Ihe Silme grad.'. and a,k the patienl S('ver,,1 time> during the perform,,sponse that can be determined during treatment, II is a difficult as""S,ment to make, because ""';:'understandings lx1ween ph)'sitherapisl .md Pi,ti"nt occur eil,ilr- It is usefuJ to know wh"n performitl!' il tl'Chnique whether pilin is pro"oked at the limit uf the oscilliltion only. and the easie>! Wil} for th1 to make thit; assessmenl is tn 5.1Y to the pilti"nt, \\'hilep"rforming the tl'Chnique, ·Dvt-s _ 11 _ Imrl - cad, - Ii",,, - fp,,,'I,?', Anothl'r way to ilsk is 'ls it in rhythm with wh"t I'm doing or is it " constant feeling that is increasing as J conlinue?'. The word, in ilali~s are ..,id in rhythm wilh the stronge,t part of thc' I"",'tment tnts were tesled in sland· int; ilt th" bt.-ginning. they should be reilssessed in stilnding, It is inconsist"nt to test movements one time in standing, another whil~ 5itling in a dl.lir, ilnd a third time with the fXlt;~nl ,itling on the treatment couch wilhoul fOOl support II is hoped lfu,t the subjeIgn" may"" l?i['ff"llod to takl" pIaa quicki}: slIe should ""'*....,. Iht'rn ilfwr f\Jdl ilrrlicMioo of ~ Itrlmiqu..; if lhc fll~ of dunge is not il" rnudo as dc:>,r..'
Tho 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 di<Mde'f". lhen under some orcurreed. 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""Sccpti(\,1 and mclhodical mind, a mind with the ability H' be opan~-e may
result but II may not, il mar le.l,c me in exctly the same pos,hon as afler the trxtion Thm.. do I ask myself, 'Wcll shall I In wch .nd "..rn .. I""hruqur, O[ j" thlS iust getting me dl.'q)ef IDto confusion'
OR 2. Would I bebetreroft to ..... .-.'~..t"""'t allhi~ point and _ the cif~'CI of lhe traction 0' ,"r lho;, 2~ hour assc»ment prriod' I mighl rlfld, ,{ I If\' rot... ho". lhat Ihis product'S n mark«l chang... 111" On" Ihing I do know for certain is thaI. if I In.·al· men' at Ir"clion only {or loony,l cmJ>~)1 /J()SSII.'IJ IiOll" "-'Covery.
3. Ford"g olK.".,lf not to ).;i,",-' Wily 10 Ihe temrt'1t1Un "f trying il """ond tl!,l." of ~m'-'flt, it w,,~ decidf'd flO treatmL'11t and 10 .." iL'w in .. d.. ,~ 1IJnc. b,-..::ution of lhe plan would B>eall 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'O WHAT it b. Having n:ad l'L'Cl-nt obst.-rvahOnson thlosubject[fwomlj' and Taylor, 1987;JuJlelal" 19&1; Durrell, 1996; Phillips and Twomer, 1996) then- is "ne..'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 hasb<x-nllChic\'ed,lhe mO\lemt.-nt of the spine is
lfil ispossiblt'IOlocalizclht'structure,tht'll we must
oI:>st' 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.>r{s)canhcal.
skl"t"I) Ilhly bcbclow ,Wl'ragl' in t!1o'lfg"'neral fihlCSS It'\·d. whkh may increa""lhdr \'ulnerability loproblcms.
Gt::ndt::r A man's physiquE' is usuaU\' dif(~nt to a woman's of
Slrn,lar "ge, and they will tiNl ..·,th ph}"!;kal
st~
A physiolhcf.. ~-Sjlttific diagnosis is COfIttmcd w,th mO\"Cmcntd;soemtofilintothcfaclorsthal 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
lrealmenl ~ llusl'l't5tlresthr 0lCCUr;K)' of the assessmenl, which is essli'1lb4l to prtWing the ,aJoe of each tn!alment lechniq~.ll>e..._ menl process IS c>cplalf.oo Ul det,,,1 in Chapler" The idl'al n."Sponse.o treatment is gradoal imp..,....... ment to full p.lln-froe mOH'1l1ent in thn.'t' to four trealme.1IS spread O'l'TJ...4 .....""ks If there is a quick "''Sponsc, e.g. full ,,--.:o\'e')' afl.., one treatment, Ihen ..ithcr the joint signs ha ..... not 'c1ear\>nent In Ihe subit-",tiveexaminatoon.lhearea of symplOms may not include the neck Palpatiem is an important part of examination and i, enormouslyinlormati'lle The main findings by palpation are Ihe following' • Thickening of tissues around the articular pillar, fn'oing of the ti,.ues in the interlaminar trough_ This interlaminar area is normally a shallow bony dip; abnormally there is no dip but rather a prominence, which may be Ihick and hard (indicating its agel, soil and spongy, or cystic • Prominence of lhe spinous process of C3. • Limitation of Cl/C3 intl'rsegmental mo,·ement, especially with a unilaleral PA technique directed 3lJ-.4O"medialJyon the ipsilateral side • Reproduction of at least part of the area of the cervical headache symptoms, or local DEEI' pain, Can always be found with at least one of the many such palpation examination proct.'lh,O--< DEEP pain
rcspons~
i, not accd.:>chesuffl'TCr5wiUh.l\'eaoomponentoi
cervical !lOUrceofsymptoms, bul lhl')' cannot be diagnosticallycalll'd 'ccr"iciillheadachc'.and this wc musl acccpt as fact
International dassification ofimpairmenl5, disabilitit":!o and handiCaps.=(la"'D"'HI'---_----=----= The World Ht... lth Organi....atooro .... tabll5hed the 1001-1 in 1980as the following (WHO, 1980) • Animf'4itJ'W?llisil",'lossclnorm.Jlitycl ps~·chologic.al oran;atoltllcal structure or functJon. • Ad~i1ltliisanYl"l"!llriction.orlackoi..t>ilit),to perform;octi"itrinlhoemannerof,orw,thmthe r.angeronsoderednormalfor... hllmdnbeing. • A htmdialp is. disach.nlage fora 1\""'" indi\tdual, resulting from an ,mpa,rmcnt or d_bill,)', t1wt hmltsor J'1l"'cnts the fulfIlment t-t' a rok, dependmg on age, sa, nt r.l1'lf:~a,,,,bbJeinthedifferentpor;il1ons(Bn!'lg.I978)
ThelK'CUracyclprognosisasafin.alan.alyticiillaSl5C!i!rmmt dl.opends on the manipulali,'e rhysiother.pist's UuJlI In examillation and treatment, plus her )·ca~ of cnt>c:alex~.
The ideal gOiilI~ of t...atment """, to impro\t: Ihe heJdache symptoms and 10 I\'5tOl'1.' to normal. a~ (,le a~ possible, the physical ~igns (especially the neural signs} that wcrefound lobe abnormat at the ,,"tsct Thehistoryoft~cer ...icalhcadachl'Sisu'uatlylo"l;, and thecnd result will probably bea compromise. This c.n be an Impairment.
2fXXlIC1DH-2 bl..:al11l' IC~: hubilityor acli";tylimitation.
ProgflO$is
• Structur,,1 impairment. but with a possible (or probabl~) likdihood of R"CUrrerlCl'S of subj
responselO"'-..,t"""'t,backpalnw'throughing()fSlll~l
of the !lOI.l!'Cecan bedetennined and chang«! fa,ourably, prognos.is 's good. Lifestyle changl'!!l may be
ing), and the rrlOft'oI t'-that ane-p"'St'l\t, the
appropriilh'lOprl"\'l'fltrecu~
thesepre;mt. thelTlllA'ch.mce therei:sofprogre"Stllg to a radirularproblem ""th neurological dwlgei "-"1"iring
If the SQU~d the arm pain is dearly only dISCOgnuc, w,th I sponlanl'ou!i 0Il:'il.1 such. ha,·tn& p;>intOO the ~ O\'l"r I WftI<md. and being wokm dunng Suncby rught WIth ned: and arm p;>'n. then the prugnosos15itut>allyuntel...ole Todanfy the progno:l!IIOo it i>~1Ode!II' IS poor. More dl.", rotatioll. .... hich opens, the joinI01 the alfectedside. and/ortractlonilll'uscful.If thep;>lI' is rontroU.able this ....ay and respondsf.:l'ourilbly lO ~Iment such that by the thllt! t.....atment the dIStal symptoms a..... minimal and 'err occlHiioNl, the p~i.isgood.Exlt"nsion(the"'Juringm()\'crTl('f\l)
may be the lilSt mO\"l'TIl/,'nt to 'clear'. To providc a good prognosIS. c1carmg the extension mov~m(,l1t i. para· mO\lnI.ThetL'lienl 7. The behaviour of the Slgr'15 and symptoms in terms of 5e\'t'nly and ",Ie of refeTTal. The more distal and "'-'·'erl',M1d the poorer the resporu;elO treillmbent i1Symptomatic, ~'lng thedisc structurally heled andsbble J. \\~t1ltheproblem"'Or'lm.w,thsymptoms beginning 10 refer into the buttock ore'""" mtothe 2.
pos«'riortlugh'
Will s)'mptorns spTNd to the loes' ~al population ~ "err ((JnUTI(Jrl.. Might neurologi(;ll CHAJo.'G£S 0ttUr? Atll'mplmg ~ for a tugh propomon of Ihe;;e, ...~~"hfTe1JllW1-bOOlin'·oh·«l,I5OO1reliable. Ii the jnler\ertebral d,scClln be excluded. dt'osKJrlS E,~ w,th all the ~ at our dlSp0501l. 'lNlgmg and n"giIrdingtheprognoo.lSal't'SlmplfT, ~.etc.,\OYdoOOlseemtobegett'ngmuchrloso!r E1der1) p;>lienlS who ha"e extCT1Sl'"e radiologKll1 changes and suffer an epl50de that starts from a tri,-illl lOilChle\'mg.xuralep~ mcidentare,~d,fr.culttotreats~Jl).'The)· Ma~aprognosisiseasier.... hen't(anbede1ermined,fthtod,scism'·ol,oo. requ' ..... afe\.·"·idel)'~g""llel .....atments.U,;ualhat theend ofthetreatmmt the resutt isonecl anongomg To begin w,th. a dl'taik'l1el1t's tow lumNrdison:ler is~tial in formulating_ ~ble dISability. Othcr low lumb.lr pains Cim arisE' from the z)"8"f"J"" pftW"J'iJ. It is not uncommon for a peroon 10 be ph)'l;CaljoinlS,thclig.~'1\C1'lous,carsularilndmuscuIJl' unawa..... oftheseo.·..rityofthepainuntilthemominl> afterunusual,hcavyorsustainedworkinlumb.1Tn....~ tissue, and oth"rconstructional Impairments (indudion. It ill fa"ly safe ground to believe this is theeilse ing those affL,ms to be an iru;ongruous answer lolheque.,tion,lht>n the fault may lie in lhe way thequeslion waSpul.lliskinctertorephrascor explainthequeslion than 10 reslale it,even if it was so simplypulthatthl'errormusthavebrtnlhl"patilTlt's. It is essoential loapproachl'ach inlerview wilha degree of humilily and charity.
The subjectil'c.> 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 subltrder (t'Specially if information gained relates to the R-cognizable pathology dlovelopml'Ot). When the stageofthedisorderhasbccnestablished,thecurrcnl stability 01 the disorder should be determined. If there arc wide variations in thescverily of the symptoms. Or if the site of the symptoms \'aries widely from one day to the ned, this will indieate thai the disorder is con~ sidered to be unstab1t'. and therefore the physieal exam· inationwil1n(-edlobcmodifiedlo3\'oidexacerbation
If the behaviour of the symptoms, when related 10 acti"ities, indicates that exacerb3tions are both easily provoked and 13kea long time to subside, the irritabilityoflhedisorder is high. This indicates that thephysieal examination oftt'St mo.'ementsshould only be taken 10 the point of onset of symptoms. Neverthcle5S, it may be wise to lake the movement minimally beyond that point to know whether the further movementeitherheighlcnsthesc\"erityofthesymptomsor ext"nds the spread oflhe symptoms. Thett'Stmo\'t'menlsalsoneedtobetakenonlyunlil the onSCI of symptoms if the3ctivity that pro"okt'S the symptoms has 10 be interrupled bo:ause of the inter>sity of tht' pain. The disorder is not ncci'S&nily higltly irritable if the symptom. subside immediatt'ly, but
::t~~:~"'::~:icie"tlyfot'wre 10 require cautIOn with
If the patienl"S'l'f'llptoms a'econ~idered irritable or :.e~re, tIM' physical e.aminalion or test movements ~ho"ld onr,- be taken to the poinl of on:.et of the ~ymptom~
Hypothcscsrcgardingstructurcslnvolved The right-hand side of Tablt 6.1 lists the kiods ofstructUfC5theexaminerwouldha"eiomind Further the examiner should consider Ihe ways in which theslrucluR'Sha\'cbeen used and the differenl injuries which may have consequently occurred (Table 6.1)
Added 10 this list are many olher elements (eg. muscular. postural. biomL'Chanical, ergonomic, pasition"I,clc.}.Thl"}'arcomilll-d from tne present disSOOdt.
wmi.... tion
symptoms _ """"rticular. mtr....rtinJ!ar, """,ral and d~
F'tnanicularSfructlJres 1'huildsup~nlllC.....seof ymptoms;bulonlyif there ... ~ joint surface component to !he disorda 11""·"'~-'f",ifthedisorder;"chmnic,boththeduratlOll
And the5trengthoftherompactingn«d tobeincre"s.ed Thi$ diffi'rl-ntiation test may need the addition of a tiny C,lrdinal movemt'nl, or the comparison of pain
~Sibi1ityo(thcn·bemgadl');rccofr..ft'rrl'dsymr· pro,'ol<edbythcc~rdtndlmO\·"m,·nlduringsustained :'Ioqu~~l.ing r effect is quite rommon, and if present i.
indicativeofadiS(disorder.Thc'aflerdf~'Ct'meanslhal,
having performed activities in an unfavourable manner, the palient may not be aware of ib having any effect, BUT will know all about il by the following morning. In the cervical spioe. lhe progress is not the same as descrilx-daoovefo.thelumbarspine, In fact. thecervicalinter\"e.td>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
Rdearly in the subje.;tive examination. because the answer to Ql makes it appropnate, The S.'me applk'S to 'a demonstration'. Which may bespontaIl'-'Ously introducedbythepatientasheexplail1shis'mainproblem'. U this d""" not happo.1'l,the procc'dure is to say to him 'Is there anything you can do, or any position you Can putyoursel{into, that will bring on your symptoms?'. or 'Can you do something here and now which will bringonyourpain?(assu"HMg,ofcou~.I!UllpRin,sporl
ojhisma"'p,oblml). Aimed Qs help to prove or disprove the hypothesis Most of the time,questioning will be paralleling the person's line of thought. During thi; time. the exam· inerwill be gaining infonnation regardmg tht"stroctun.'S likely to be at fault and forming a hypothesis. I-Io,,·,--,,'er. the lime romes when specific questions need to be a~ked that are directed at confirming ttlt" hypothesis (or pro"ing the hypothesis wrong) and filling with the structures thought tobccausil1g factors.
SiTE OF SYMPTOMS The first step is to clarify the ~rc~. depth, naturt', behaviour and chronology of the symptoms. and to recordthemona'bodychart·.Areasofsensorydislurb_ anee should ~l.., be included, as should brief comml'1'ltsregardingareasofmaximumlOtensltyandlype ofpain (FiguO' 6.3). Refercnce to such a body chart provides a quick and dear reminder of this patient's symptoms
Thearea.depth.natYfe,~haviourandchronologyot
symptoms, as well as the ",tation:./lipsMtwecn symptoma",as,sIlould~rcrordcdl>l1a'l>odytnart'
The area and depth ofrefcrn.>d pain m;.y som'-1imesbe related to d"rmatomes, myotomcs and sclerotomt"'. and areas of paraesthesia oranaesthe!.ia can indicate a particular nerve-root invol,'em""t. Further infonna· tion resarding referred pain is given on pages 188--189. The pattemsofpain distnbution do not provide the answt"rs as to the precise structure at faull.and nor is th""'totalagreem"ntonwh~tkindordistributionof
p.,inisprodua>dbycachpain'"SCllsitivestruclurt' There OJ'{' also discrepandes between the academic findings on research on nonnal structures, and patients' descriptions of their symptoms. It is fair to»ay th"t no p.lticnts po.'Sent with symptoms that can be identified as arising from a single structure; the symptoms always arise from a mixture of SOUrces in combination Rcaliringthistobeso,thesiteandl>eh;,"io\lTofsymptomscanprovideanindicationastottlt"groupsofpain_ scnsitivestructure:s that are likely to be involvt>d;al1d thephysicalexamil1ationcanprovideanswt'rSregard_ lOgtheextentoftheim'olvement, It is important to d'-1t"TJTline, in the lumbbralspaces. Some authors describe all deeply felt paillaccordingto sclerotomes, I-Iowever, patients are able todifferentiate beh·.L't'n pain felt deeply in the muscles and related tissues, and pain felt deeply in the oones, joints and ligaments Myotomes Many p.ltients who have ",ferrL-d pain arc unabie to ddine the margins of their symptoms bel;alJ5(' they are deep and vague. Nevertheless, they are able todifferenliate between superficial pain and deeper pain. Myotome charts, as u5ed in thiscontexl, refer
109
110
MAITLAND'S VERTEBRAL MANIPULATION
Examination
Figu~
6.6
~rmatom~
chan baS(jj on arus of
,~ftr",d
pain
...
111
112
MAITLAND'S VERTEBRAL MANIPULATION
Figu"'6.7
Mvotomfthart
to areas of pam (paintal, 1960), not motor supply (FiglH't6.7).
Sl:lerotomes A distinction should be ~nized between two din. kalprcsentationsofpainfeltdl'eply 'in the bone'; one is deep pain associatl-d wilh the shaft ofth" bone, and Iheotherisdl'Cpp.linassocialedwithperipheraljoints
Figure6.6 ScierOl0mcchart
lhus indicating a possible diagnosis of discogenic disorder.c"entotheextentofindicatinglhestageofprogl\.'Ssion of th" disorder. The two most commonly founda",asofsymptomsa..,sh"wninF(~"re6.9.The
symptoms usually h,we a 'agu{' dislribution, and a", fe1tasadl'Cpgn"wingacheorpain.The",,,,,,,·ariations of the;e two area,. and Figllrr6.lOprovidesa useful guide to the possible variations
(Figurr6.S).
Thoracic pains
Cloward area~
Pain fe1tin the thoracican':'il isworthyofa body chart of its own. be"Sllt
fl{lhr"..ht'fl" .. rw of ra'n, ..nd then she must u..c h.cI"
OWn finger or hand ttl take idcntih,thc.reae-.....;t1y
0\'''''
from hi!> §(las 10
2. If a pal..,...l ,nJICiIICS an ..wa across hIS back. the eurru r!>houIJas...,·lsilalineacross)'ourback. or n. ·,,_ il7', If lhep;>tienl u!>cs tus hand or fin 10 demonslrale lhe .. rca, he is in facl ..nswer"'~ It", qu..... uQl"l non-\crb.1l1y - lhe usc of h;>nd mJioling an ,,,,,,,,and lhe finger indlCat"'ga 1",1'. 3. The matchmg of non-\"erbal messages both with
I'erbal n.·spouses and wilh IOllching lhe art!;' strengthens the exaclness of the informalion 4.
0nt' palient may
\l(, able 10 point to ont" precise SpOI ofp"in and another may use his whole hand, while yt't anuthl.·r may onJy be able 10 mdlcate a
larg, V.l~Ut' 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 lallerindicatingdiffercntcauSs (..'hcther understood or not), and Itwre can be p s ~ 1 influencing asp«b.. 1llt P"'J- by KftIr (1967) K still ,aIWlbJ.. in
,iouo;
Danvr
q~ rdoo~ to;o '·~Lar sympto<m, .,.ucb equiN symptolIlS. OSt~
su'Y"'Y,d to lx· normal (remember: 'You can't tell me too much, you can tell me too little; ll't me be th" judge as to its rd"vann") When trauma ofa mOre major dcg,,-'t' (such as that resultingrrom a caraceident)causessymptomS,H is nea.'S5ary to know the following: 1. The degree of thl'trauma-a.>ccrtain the extent of bruising,itscolourandduration.thedamagl·to thevehide 2. Whether the patient was aware that he or his car waS going to be hit-that is. was he able tobe prcpared for the blow Or was it an unguarded blow (the latter always imposing the greater dangl'T)?
Thc main area, of history concern' Thconset and dC\'Clopmcnt of the present episode The pl'l"Sl'nt stage of the disordl'r. The present stability of the disorder. The prcvious history,indudingepisodk de'"elopmentandth"pc>ssibilityofgenctic components The most common spinnl disorders trealL>d by manipulativephysiotherapists,wherethedisorderhasapri_ marilyspontaneous onS('l,are
1
2.
Ligamentous and capsular disorders due to accumulated stress from poor posture. O"l'ruse, misuseorabusc. Ligamentous and capsular disordl-'rs from a minor sprain. Lock"dorblockedioints Disorders of structu,,-'S in thevcrtl-bral canal and inten'ertl-bralforamina M~'Chanicallydisturbedarthritk(-otic)disordcrs.
Discogl'nicdi>onlers. All of mese have ,,-'Cognizable patterns of onset and development. Ligamentousandarthritic(-otk,-osk}disord..rsof the spine have elGlctly the Spa,n. Hewascarriew'thlusbackprl",iousIy, desp,te a life of heavy work on Ius filnIl. A tr,,·w)'eldis;ablinginO<Ji.onljn~t>on.suchilSthat ~,l5lOtl1l1y
un.>ccept.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"fctors are orrutted. Although they "reof rele\ance in treatment, they ha ..... bet."Il om,tted dt.'1iberatelyfor-WPUflX'Sl'oIempha>lZ"'sthcaspoctsth.at .tn!S(I,·ilaltothe~ofthemobili7jngand manil'""
ulilhng tedutiquesto be used durmg treatment. and to the.&Slle5Sl"Ol'nt 01 thetr effect.. An eump}e will make thr po",t oI'pWuung' de.uw, olndtnthas~theword.~JOU't'(ollSthroughoutthis
:::~ to the inert struct\IftS;olfeaed b) J""S6i,'~
A p.llient has pam spl"Ndmg from C6 to T6
~
trally"OO LoteraUy across the nghl po5bmep.lm preildsmtothenght triceps area and down the postenor asfK'd of the forearm to the wri;.t (figu,," 6.14) If the spread of p.lin from joints, muscles or nt'Ol.'-1'OOI lesions is bon... in mmd,iI wIll bt'nccessary tot'Xanunethe followingstructu"."a~being tl\e pos.sible cause, in p.1rtor in full,ofthl'SCsymptoms· I. TllfjQl/llslhallifU>,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 d<J '101 lit ulldtr "'t~l1'~ of p
01 each other's thoughts. Certainly the profcssion;ll bodiescan work towards such an understanding; their acceplan sale. The manipulative physiotherapist can only pro... ide a physical diagnoe;is (which naturally must be limiled by training and ex?"," rienc,,) and a pl\ysical prognoe;is. which are more lun sory mo\'('ments allhe other end. When a lesion occurs in a muscle, passiveioim mov~nt will not be painful unkss It is a movement thai stn-"!coc'S or pinches Ihe muscle. Hov.ever. pain will always be T"t-'Produn-d when fibreo in,-ol"ed in the lesinn are made toconlract strongly. Joint problems are therdore determined by passive mm'ementtcsts, and muscular k.,;ions by isomctric mlL
ments should be taken 10
II\('
hmit of
~
B\ai1lb'"
rangcandral 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 t<s1Sfor 'erti'brobasiLlrmsuffiOrocy. c) Nreads. 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' ld<Jmma~ofsllf(ne<sorpain~nly).
M~mC'nt5thot
the' potiC'nt con ptrf(Nm to
rC'prodUCC' his symptoms - functionol dC'monstflltion lltfon,startJngIMlest.adK-isioron«dl.lobe~
riI.
wII(~d'lelo:st~b"""'ld~tlIk ...
~m't of lI¥a
aIM
lIICn~oIp"n
121
lotIK
or only to ~ beginnIng or
Under the tall.... circumstances, some assessmenl should be madeo(lhe beh.wiourO(lhc pain fusl beyond thaI pomt in Ih('ranl;(' wh('rc Ih.:: pain COmmences or ... hert' the con~lanl pain begins 10 increase. Whenp,,,n is lh"domi""nl f,l(lor in lh"palk>nt's di50rd.,r, lest mo,-.,,,,entsare taken only to Ihe poinl intheran~whcl\'paincomm"nct'S(andjustbeyond \Q~th"p.'II,,",ofincreaseorsprc .. d).Wh~n
,,,tt
This is a fundamental first li...... 0' appl'OKh 10 50rtulg oultheSOW"Cl!(s)ofapalll.'rlt'sprobll'm.ltlSbasicand mandatory 10 the Ihlnld,L'fldeaw>uringlod.,.;idewhalthflt,the p.ltienfsprescnt symptoms should bea~.lfhe has no pain bef"", moving, heshuuld be asked to move in the direction being tl."SK' MOI"'lopuitl~lnthephysicale~;lminationl"blesfur
eachsectionofthespllw,thestatemL>fltismad,,'Moveto pain or move to limit'. This r",f...rs 10 the two mcthods lhal are used when e~aminmg the patient's acti"e
1, Ocrasionail}'itisncen' al\' some propl" who (annot reach their tOl"S normally, including some whoaf'\' unable to~3Ch beyond Ihcir knees. Cervical 'utatlon,;n the prcscnCll of nm,ll'll spondylilic ch.1n);e,isanothermo\'l'T'l'lenIOfwhichpriorlnowledseofrangei3;helpfuI.Stiffn.:ssund"rth~ci,
cumsl.;>nces may not bca prirnary physical sign in thl'palJent'spresentrondition
3_ When fIerionofthe lhorxicand lumbarlipll>eS a~,)rs to be normal, it i3; usriul (parlicuLuly if on conluluedf'l(i1minillionlittlei5foundjtotlpsharply
Followingtheleitforrangeandpain.thepabmt§hou\d (pl'1,)\·idedp.unpenrnts)Il'lO\-~backandforthfromthe
startln8 posibon whIle the physlOtherap~w.~ lor dISturbances of the roormal m)·thm oi lnler\enebral ll'lO\'emenl.Rt"peatedl1lO\-t"ll1l"1'ltsshouldbe.a'OIdedLf a mo,'emcnt is very painful,.as they unjustifl.llbly pm-
\"ol"andinasethepatient'sdiscomfort."fht>e>:pt.'Ti· encedmanipulah\"ephysiothl>rapl!itisableto~the
rhythm of movement during the as.....sment of moveml'nt for range and pain dcscrilx'li in theprt.'u-ding paragraphs. Initially, however, she may re<juil\' the pallent to make many movements. Disturbances uf the normal rhythm of mtcn'l"TteNal l1lO\ement during f\c1lienl ...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.abeI !>a,·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!orabseoceofdonor extensian in which the rnov"""""t is pcrformed"Simllarl~;on the lumbar sptl"ll", the "mount of "'terill ~xion may \.~ry depmding on !he amount of f"k»;ion or e~tmsion In which the lllOI'ementot'lat...,,1 fIe>.JonlSperfornwd Beoc"use oftht.-aboH'. the wmptoms produced by test" IngmOH'f1\''T1I~withrolal1onint'''-·ce,,·icalsp'neilnd
lateralflcxinnlnthelumbarspirlt'mayvaryqu,tecond,·pt'nding on whether the movement is offkoxionorextl'OSion.l.t'ft rutabOn. uy, 01 the CO:'nicill Sp,l'\(' may produce left uprllKllruLu fO§6ll paIn when the rotation IS done on neutral. ThIS paon may be accentuated. oo.."('\cr. w-hen t.... same molL........t is done in .. ~tl'nSion, and eased "ho.'T1don.. ,n flexion. In the lumba. spine, left latl'rlll IlLox'on may produCt' left buttock pIIin wh('1l the movemx1OO to lhe left tIun:I. 6. RotatlOll totlw left first. 1ilte....l flexion second, and f1e'\lOIl thIrd. DlffermtlllO\"('IT'lt'TllSoIthcspine(i.el1exioo\.1ilt..ral l1exiononew,)y,)ndmtilhononeway)cancau§ol'l>Imilar stretchmgorromp"-OSSlngmon'o>ent!;onthot-sidcoithc "'lI.-"I"\'crkin"al JOlnL When flexion is pcrformo.'li in lhe sagiU.:II pl.:lroc, the art1O,L1r surfaces of the zyg.. poph)·sea1 joml $hde on one another, the inferior 3rlieular surface oIlhe ~upcrior vertebrae sliding Cl.j>hal.:ld on the superior articular ~urface of the inferior vcrtd,rae, whi1l' tl,e interbody spa(e is rmmJwed anteriorlyal1d widml-d JXl'>teriorly_ Rotation 10 tho:- left C;m cau...esimiIarmoveOlC1ltonthedght"ygilpoph}'llt'aljoint,asdOl.'S left lateral flexion This causes an opening movement, which is Slmil..r on the right of the intenertebr..l joint. TlIe movement is similar in that it is an opening mov("ment on t...... right, but it is not an identical movement. The fact!; regarding .. ddailcd 3",,1)'sis 01 oombint-d !OOI.·mwntscanberelatedtothep.1lImtswhohaWp.:lm on mm; ement. Some 01 the rombmatlOru; of p.11niul (or pam·free) tnO\"ernents follow rerogniz.lble p;Jtli.-"rf"G. Basicall}'. then! an> two tra:- of tnO\·em m«hanicall) di.sordt-red.1bcy are regul"r "nd lI"n>guLu; the regular patterns are liltL'tdung or comptesl\4ngpant'mS.
~uIJ'~ttetmofIllOYetllellICOl"lb.IIJ!lOIISa~
~trtlct"ngOl~poll1ffilS.TheyproOuce l.Im'~fmcr«menlSltthf..,t~rtdlratjol"U.wl\l1f
prodUCIng
mitar~ptoms
mo\·cments produce the symptoms. 1be te\.'er.;e is the casoe if the symptoms ill\' produced on lIlO\-emenl to the OJ'POI'iteside.whenihepattemlSl5Iretchmgpattem. Ex.o.mple5 of compressIng regular pallert\'!i: I. Right cervical rotanon prodUCl'$ 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" 5
~>CiIJwlth~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('\·
'.a
000l'
musc~.§OO1('musdesk'ndto~suppl>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
...eal reflex is tested by tapping the tricL'P" t"ndon beh"'d tilt' elbow whil" the patiL'fIt's h.and resls on his abdomen and hi' ne,ed dbow is supported in the phYSlOtheraplSl'.5 hand
Nockorl'"ll"Ckpaindisap~arsand,,~bydi5ta1
{rigllft'62Ij,
p'hentsrequlre~lIycarefulrll"UroIogical~
menl and treatmenl must be gL'Tltle 10 al'Did ex.teerbatlOrlifthe]x,stt",almenl~uJtsal'l·tobcgaincd
limb pam. Ho.n~'I""", it ill common 10 h.a"e pahmls ...femod wllh pain In thl>~pincconlinU0U5with I.... pam In the hmb, ,",'luch may or may not ~ worse disgil, The reason fof- tIus may be lhat. .. hile tho> N'f'\"(' rootcaw;es'Ol'l1eofthe1imbpam.~painmaybfo pn!Sl"ntas~~hoidisCk'S and ligaments. Wllh thl.' apophyseal joints, d,sturbt'd by the disc damilge. may alsogi..e rise tl) somel)rlhelocaland~fer~pain.Rcferredpainof
thiskilld indiciltt'S the 1\CLhon of the neun>Iogic.il lesu....... should rea1lZe thaI although 1"Il'f"o .... root signs invoking two roots can be d .... 10 ....... ign p.lthoklgy in the lumbar area. dual root signs are unlikely to have a benign origin in tN:!ccr"ical area.
Dull rOOI sigM in the havl: a btnign origin
~rvK:11 ~I~ I~
unlikely 10
1. "fhefl>O\en'M'fllofthepa,n-sensil"'estructul't!Sin the "f"rtO\'ements Physiologicalspinalmo\"Cmenls Thctcnsion in sofl tis.o>ueand thc 'luality of movement of ll\e inlervl.'Tlcbral joint by palpahon as.se$SinglheOlCCL'SSOrymo\'em:tenSQ.pollic1,longus
Thepati.ntflexeshisrlbowto9:C>fdigitOfUmprolundu,
The patient fl••eshi, elb!lw to 90" and supmates hisfore••m to mid·position.Tn.pnysioth.rapiststabili,.,nisfo,.a,mandcu~s
nisfing."intohispalmSQthaltn.pall.nlincl.ncllingnisfi,t 'Gue.,cs the physioth.rapist's flng..... S~.t.5t5t~. pow.rof~is longfing.rflcxorsby,.,istingt.rm,nalinte,phalangulflnion Intrinsient ...... h.. h.wtndtllW'lhthelnftbtntwh,ltthe ~apphna6oWnWill'd~,..st~lhckntt
wth_I
Table6.10
VERrEBRAl MANIPULATION
(ronto)
............' I
~pa6icioL
AbdIIctofpallimB.
{
~llll''f
··· ··.'.
-- · Wm5CII'paIiciol.
~palitlSL
fbofpokls& Add\lttOfpollicis
Dilp!lf39",Cl,.,S Intrm>sII"
Tnmk
::::.. 11 :.::::::: Ext.,n"lob'.'q . Inlomalobllq . Rtctus.bdorrllnus
RollUon
fltxlOtl
Tra~itbdom,nus
",
::~
1= ,:
ln...-oIiglDngus Ext...-cfi,lIorM
Of'
&_Iuol.longlil.
OP
ut."""'hal.f:l
Sl,-eiy Ramg M he.Kl me:! neck. Ali an eu.mplfo. a patoenllNl)''''''-egJuleillp''infoo- .. lUcheuminalion findIngS do not clear!) idenbfy the lumba. iipUlf'cw!hr IupolSbrUlgthecausoe_lf~i,~fletionoltheheild andneckwlulfolhepat>enI1J.esSll~reprodUCl"S!hr
gluta.l p.un,.and particularly iflhe .... ~ol mon'menl ,shmltcdbylhPpa",.""Slrictionofmo:n-mw'I'ltofpattl~h.e~ructu"",inlhe,'erteb.aleanali5ider\li
fiedaSthPauseoflheparn.TIu5ll!StlSusOOforlhe thondc and lumbar spines. M.nlmum benSion can be t=rtcdonthecana1strudure1ifthepabcnISlI5s1umped ... ithhitthinonhischesl. To tralforaIlll!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-".tcns1Of\posilionis
maintau'cd, and being sure thai the 5ymptomsall' 5bblcandrom;jstenl.lhephY5iotherapi5'~ins
4. Wilh I"" ....holcspmc milJnt~;ncd in f1e,aon .... ith o\'er-pressure, he isaskcd loe~ll'f1d his left knL"l!8S faraspossible,and ....hilcheisholdingilinlhis posHion lhe ranboc and pam response i5 notlod (f'Kurr6.28)
the Solme o\'cr-pressure 10 thoracic and lumbar f1c~;on whilc ~t the s poltM'flI must be so po5lbonC'd tholt ttwne~.. no "tenll f1c'OOl1 Of rotiItlOf\, dnd so tholt the "PlI1Il'besU\ltsOollUralmKl·flcxion!"'I~~lion (il'_l~ing pronl!or supIne for !he cenical >PlI1Il'). To make the po1lpo1hon l'....mi""tion as ot,o.>cti\e a.!II posSiNe. lhot> exllm",er ~Id make ,t ciNr 10 the piltlent thatshed
sweating ",levant to the 1""1'1 of the
spineund"re"amin.~tionisfoundb}'wipingthehand
just once o,'er a wide area, wilh the main allention oc~"g at the para\'ertd>ral Mc.l. Rele\'ant [indinS' shouJdbnotoo and aSSO!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,nfraISl-gments. • De;pitt'thepn._nceofintervertebraldegl'Tlerati\'echangesduetowearandt....~r,oldtraumaor olddiscaseprocl"SSl"Swhicharenottotaltyinacli"e, some ptmlionJoumalof
PII~rM",py,2B,withkindpl:f",iulo"ofiuthorsind
pubti$he'$.) •
Th~
third group includes prople whose spines show e\'idence of joint changes due to diseasoe proccssortraumaandwhodoha\'esymptoms, for which they may or may not have had adequat~ tr~atment yet who ac"'pt these symptoms as bostmg )'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'rure i$ applied ,n .. «>mbincd p<Jl'ilero~It."";or and medial direction. This di"",tion of mo,-.... menl produCt.'!i" maximum ~I;d"'g of ,n., apophr~al loinl ,mm,'
.I.
pll§ltlOflS thc!ie postero-anlC'riorpn.'SSurescan be per' lonned in.such a way as to prod~ iI rotary rno,,·, llll'I'llor ..... tl"l'alflexionTIlO'l·..mmt
~t~bucsoftM,"I~ctnlmouon
seg"letltsllld"Ilypu-Ofllypololobil'~thtollgh
.... Ofmdoftl~t&mlltt,suffm5.s.lIdspasl'l. 5udlabnoflNll~lfind'll9SranbeclqNct~onii
m,"."~
of ro'$ISlanct' until the end of rangt" is ",adled; that is, then- IS 'Tl!SIStanct' through r~'. When crepitus .. pl'l.'Senl during """ement. ,t will be pamles& If It IS unas.sociated with pr'C§Cf'lmg symptoms and pa,nful ifitis-.ociated. In 'ide;ol' joints, ..'hm the s)'no'I'~1 jotnt surface a ... strongly rompT'l'5.5ed and """'ed, the "",,"emmt will be painltoss {MaitLrnd. l~l.1here;llre cin:umsla",," .. ht-.,., pain is e"p'-..-it--ncN dunng;ll large amplitude 01 lhe rang", and it is 5OfTlt.-times possible to hciKhlen this pai" b} holding the joint surfiKe'S finnly rompft'S5ed while moving the joinl through lhe sam"amphtude of lherang.. Ilffjain1d0e5notrol'C'e5l5arilyca.-pa~,tmilY
wefl. h<Jwt.,,-ft", be
I'I"SJlO"Sibk
for an -.oated ,amI
becorrungpainful.The501Tll('IppIil5tothicl'llM:Ill~ld,agf1lm IMpi,n~ffltby~pil'fntduringp;llpiluon
oft,sSUf;llndmoYl'mfnllsmost,mportant Mo\'ement abnormng\'. 'flu!, may be di!;turbed by such factl:n as mhribc pau.ent when only modent" p~ IS applied to ;II dwIgl-, s~ in suppcor'll...e capsular and ligamen50ft bS6Ue, or is .. ppl>ed to produce mD\-emmt. is alw;II) ·new·. When .. pabent has I1'ferTed palO Uwt IOUSsttuetun'S,orbyproh!ctl\emU5Clespasm. In malunj; detemunatiom, ,t is important to point can be reproduced b)' palpat>on 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 p
(oIl't:>\.ltfO-Jnlenorprnw~onlll(~ptOCtU.
11lIPo.l~Ill-Jnlefiorpr6SU~on~JrlfCVlJrpollJr
td T....nsvtlW pr6SUrt on
F'''I"'' 6.37 I'I»tero-.nlcrio. IlII,cnfsfut
p'''''u~
on lhc spinous
151
1"" IM....I wmttoflh:'fH"""'1'f'll'=
pi"""", (oll»clin~d lo...ardslh~ patoenfs hUd, (llIlntlincd lowarlls Ihc
FOgu~ 6,38 I'ost~ro-Int~"or prffiu~ On mrdilllyto.. anls'h~~inOllSprocrn
th~ Ini~llIr
pilll' lalln,,;nrd
lat~ ... Uy
...:ay rfllm
I~ ~,nous ~5.
(bjlllClinrd
prl",,-ont unly whe" joint mon-ment is stretched to lhe hmit of u.., range; or the upp<Jliile may be the case, lhe joint being too ['i'mful .. \en when it is at rest It may "ary in other ways too; if pain sl.utsl'arly in a rangeol mon"n"",!. il doc"S not alwaya worsen in thesamc pattern when the joint i.\ mmcd further. For example, the pam ~It during mQ,'ement m,,~' be quite moderate until approaching the hm't of the rmge, when it suddenly inc~ tQ berome !it'\....... On the other hand, the patn ma)' irocTlebC.'In inll."OSlt} CUIlSiJ...ably inthP first part ofthi' ll'IO\'t'mI'T\t, and then mamtain a ~y degl'ft' of pain until the hoot of the rmge i'li reached (>n Appondix I). Dlffen>nt pattrn; oi beha\'ioor of pain""lmredifferentrrcatrnentteclutiques. Ph)'SI(';iII~oithel}-peoffl'redbycon~
fibroustisiSuecanalso,al)'('OI'ISiderablyinil$~w bon.:\b·m.ntbdorethel"niloithe~ma)'bl"per
F".,....'6.39T... ~~~.iftslthtspol'lOUSprom.s ,nc1~posll'fO-lntmorty
IOint at f"ull ,,00 the mo\'ements of the jomtlhat are afl«1l.'d, but aoo the manoer in which e.:lCh mO\'l.'fTleTlt isaffoooo
Rrs/KlIIS4'S 10 "" mlJl'l'mn,ls. There are three "anable.; to be consld~,,-od wh~n determining the m.~nncr in which joint mo\'cment is affected: pain, muocle spasm and physical resist,lnCC. It is important 10 I'{ral joint movement Cd" be made by this examination
Eumin.tion
To understand .rld treat joirlt disorders, it is important to be abll.' to rt.-
4. It may be nOr! out
th~ !>Ourc~
Tests may help to
01 th.
d~t~rmin~·
symptoms arise from Ih.
spin~
or a
I'"'nph~raljomt
fourdifferenlbut relatl-dtl'StS. Each test can be performed in isolation, and the finding of any One can be cllf1firmedbyeachoftheth"",remainingl~'Sts.
b,ample
• Which S9inall~1 is th~ $(lurelbld'oc"/"'irrr/'ttU11/lslIrrclumgin Iht:> fully flexrcntiationoftht"contribuling strncturescan lake place. Tht:> trt:>atmenl of MrsC. scfvl"Sasannample.
F"tg....,6.41
Dided"'--.2kpainspreading down and laterally in Ihe left supraspinous fos.s.1 area but nol reachinll thc shoulder nor pro,·o!dnedJ1ger,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$ing positions and thl>n u mg the cenical later..l flexion ttodmique to "-'Produce her ~rm symptoms_ This was ..lsounsuCCC!>l>ful. SO I thench.1ngl'd thi'lll'alml'flI.. ....-rally in the whole of the \lPper limb on thi' same side as the first rib symptoms, bul JIC\'ef on blMh sidcstogo::!her.SOl'al""comnll'l1tl'ntiating rouhne of sorting out the problem indicated that the arm symptoms were !leCQndary, not primary, and that the cervical findings were psomeIric1t'!itS, palpatwn l'XaJlUJ\o100n (It''mperatull'. s"'eallng_, soft tissues, position of ,ertt'br,"" l'AIVMS); PPlVMS C/wt(trS#' notdjor ...lmmJ tt'Sl,
o••,"'''~
+rorrecl/O\"errorr«t deformities and eff«ts
~"Ip"I"
(",,(tWIIIl/ drmon,trtllwn/!cst5 +diffen-'fllial;on
A$ltriskOlS)'l'UgtJ IIl>t'"ditm,t0l"'t~,t
Chapter
7
Principles of techniques
CHAPTER CONTENTS
• A technique is the brainchild of ingenuity • Rhythm 176 Rdcascpain 178 Trcatin9iJOlhrnptSlsometimesfin effucb,'"
w.r
InSId.-the~GVUlOtbe"'-C\.bullht.")'canbe
~_1hI' "ertebralcolumn
issimiL1r. Until this 'fut>I' is Ic.med by "'-'fWt.-d p~, In'alment by tnObIhu· tionwiUnot be fuUydfectwe. With C\ery technique, it is the ph)'~iolht."-"l'i:>l'S body lh.~t must produce lhe mo,"em..,,1 n,,~ phr~'''' tht."-~piSI'5 ltands, Ihumbs or fingers should ",-,,'cr, under ~n)' drcumsl"ng~..
1.1
Cut·....... ,.; ... of. m.nWlI9"""'"
te-anln'puLlh,e ph)-siolherapist'shod, When usm(o; teehr\lqlM."'o buck a!i o;oen'icallak>nl 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 <E'I rate. §OfI"Ie guid,ng figure!leelll reaJIONblrandtherefonoa ....",oIh\'oorlhn-eOlCillatlOnS pK '«Ond is offf'n"d as .. guide v.. rialJt:lm from Ihis m)thm .. ...,dti.cu~ Loler(_p. 176), Thl'impottancr oJ. learning to fcl mm'ement cannot be emphasizrd too much, for without Ihis '(cd' cumilld(lOl1 will be lessinform.. h'·candlrcatmL'fIlt~cf(ecti.-e. Galnjng'f~I'oftht",~rntnttstsstntiatinordtrto
surt'Slolhl-'ertt-'br.w).itis~rytoF"»,tionthe
",,-'Ckin >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'
......
.....
F''t''~1.2(l;"'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>
There are three e~ceptions to this general nIle of p,,-'Ssure-.onbcingfastcrthanprcssure-.off, I
When pain is e~pcricnced as a consequence 01 movern"nt in a rel"aslng dir
TREATING END-OF-RANGE PAIN RELEASE PAIN Pain experi'"Jln..J as a ",suit of this pressu",-offsituation can be ref"rTl"d loas release pain. Thiscan beexpocrienced aethely, as when an arthritic joint is moved to its hmit and then released from the limit. The", arc three aspects 10 this. and th" fin;t iJl\'ol\',-'S lime. The amount of linle that the limit of the mov... menl is sustained will influ"""" the intefl'>'ty of Ihe release pain. Secondly, lhe range of mOvement in the releasing direclion can alter lhe pain response For e"ample, if the neck is turned to Ihe left and the releasing movement involves d,-rolation to neulr"l but without stopping lhe movem"nl is conlinued to inmlve some rotalion, the right pain may be "xperi· ClloCt"d after the Iwutral position has \x-(,n passed. Thirdly, Ihe sfX"-' 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 eeeious patient has faik'fuL The com'erst' is also true. Sometimes, as evidenced by the reviewer. patients may requi"" a balance of both
SUMMARY To Sl.lmmariz.e the need for manipulations as means of quick thrust techniques or manipulations under anaesthesia in dinkal situations, my dinical experience has taught me that whe""as a d''Glde Or SO ago I considered that of the patients who did rcs!X'nd to passive movement m'atmenl 85 per C~'lll only "-'ql.lired mobilil.Mioo and 15 per cenl rt.'quir~'Uft 125idts) I
lawai f1t>:lon or l,ans""rst ""rttbr1llprtssu,t
lon9Jtud;n~l_mtnl
I
T.-.etilln
I Rot",""
uniJl"fflJ1
Bil}tt'fI1J
symptoms
symptoms
f'ost.ro.ant'fio,lc.nlr1llv."tb,al pr."ure
I
Tr~nsvtrst vt"tb,~1 pr=ure
Posl'fo-~nttrio,lc.nlr.>1
••".b,al
pr."ure
I
Tr1Insv.rst ....rt.b.. lp'csw'.12Sldts)
I
I
Posttfo-~nttnor unil~t'r1Il vt".b,~1
Tr1Icti""
prtssu,t Tr.JjOn
I
I
8i1ote'al symptoms
Unilateral sympfCmd~
longiJU(Hn~1
In .~,II '
lca"""llalldilptl!y>nglcduuqua..lti§i1 .....I1Cfof
2. Thell-"COg"itionofthediffen..."t t)"pcsofJX1in,arid
dlfft"renl pallems of bcMviour of thaI palO (Butlcr,lm). Prroictablel'1'5JlOfl5C5.
~
4.Refineml'ntolasscssmcntsIuJJs..~analyIicaJ ~tof~51""q ....htyandbeha,·iourof the pat>enra potin plL.lli the concurrent rcrogmhon of the ncuro-mU!lC\lIoeil<eletoll stNctu1"C5 11I,0hfd are ..reolSolimportotnlgrowth.
~"'w/lcnilndlW1llltlollSCwIlidItcdullquc.how
toodopl!hclccM'CIlICtOthcpilfticulilfSlWill*lof !hcpl!lCf't
'SeIection',tidi!icusliedlnth15cN~.i5d,v>dedinlo
lneul.eTl'dltlQnliofthi5bool< twotilbles ...'ere pro.ided.uguidelinefforthe~tionoftn>atmentteel\
One t.lble liskd a Sf'ql.lt'J"lCe of 5elechon bMcd on ... hen the JX1loml'ssymptoms .. ered.stribuled uniIa~ally or bIlalffally (TRIM 8.1), and the second tlbJe mau.>d 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 ~ dJilgTlO5<Jl and presmll1lg symptoms and tlp.
usefulasanovcfS'mphfi~>dba,isfo.scJcctionult~'Ch·
appcarsin Magarey{19l:I61.
nique!l. TolM'1 down, in writK'" fonn, guidelines for the selection of toninthea"ailablcrangt'olm<J\cmmts inwtuehthct«hnlqucshouldbc~
2. Thefinnnes5orgcnIJcneo;.softlwf1"OO\-rment. 3. ~ .. mplotudc of the f1"OO\·emcnt. .. ThespccdofthcTnO\ement_ 5. The rhythm of the f1"OO\'emcnt, ranging fmrn 'VOtlo>'to'$Uol'CaIo' 6.. Thedcslrt'dpa.'n....sponsc,orabsenct>ol~ dunng the perlomung of the technique
i.
Thelro~thoftlmethemovementshouldbc
conhm.1fti
Q\--er the Iobt 10 or more fears, the s...Us a!i6OClOItcd with theseleclionolridprost'-"55ionoflechniql.lC.'5MVe grown UX'lCurrcntly w,th the growth of Imowlcd~ m a.....lom)". ncuroph)'5iology, biomechanion N"/ttMQltof>tlrltd.a.llIltrlllydlSUi:outtdSV"'p\OIIlS;u"'laltnl\'
dlWhrttd""'l'l.... ifl""'r!Y~lI<wolnprucl UnilltMIIyG~;bultdsym~IOlrttt thtpuslllowanhtht . . oIpa... ,nd moblHlCIl'«'\lrib] Un,I"t~ d.w,bIlttd .,...,pIOms. lOu,tel lilt push i 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 compon
...
lBB
MAiTlAND'S VERTEBRAL MANIPULATION
pi'hents fNql.M'lltl)' hone different polm R'5flO"5'1'S depending on ..·hether the lllO\-ement IS nmcd out fn:,m thetopdown ....rWlorthebottorn upw.. rds,. 'The~b.'~stn>clureliinthe.'m..br
buliystructu'" Fort'Umple"fthepatlC1llhaJpi'lnon the nght side 01 lheno-T12 area, ttus pam may be pro....ked by !;olenl fII."-rion!() the nght, whICh would
.. l~."",l ..ndml1l!n-..rtebr;olfor.min.lc;onMmm·edin ... ther;o ~ or nuda
strctchingfl."cling..orhenwyfl."clililli"PI"',\\"~
tlw poltJcnl in d~l posilioM (for """mple, I)';ng him on ltisleflorrighlsidl',proneorsupi.....);orby pos,lioning the intl"r\'ertebral joints in f1exion,e.ll'I1· sion,lJteral flexion or rotothe'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.'
PATHOLOGICAL DISOROERS AND INJURY The lotallext relating to the sclcction of tcchniqucs is divided into two parts. Thefirsl,which appcars in lhis chapter, is related to patil'Tlts having the palhological disorders and injuries that are common and a,,-'SCl'Tl frequently. The "-'Tllaining parts appcar in thechaptfls dedicated to each individual section of the spine In thischapler, the disorders {both pathological and injury) are related to· I, The commonly seen disc disordt'rs. both Whl'Tl the disccauSl'Ssymptorm;andwhen;lcauses symptoms in conjunction with the pain-Sl'S and for neural anomalies (Angoli, 1976; Fig,," 8.1), each ner...e ha~ specific areaS of symptoms (supp.I08-109;Et:helbcrgand Riishcde, 1952; KconCohen. 1968; Nathan and Feuerstein, 1970; Bernini rIal., 1980). The mam1eT in which the pain disturbs or disrupts the patient's rest and acti,'itics and the mannl-r in which the pain is changed by the physical examination tcst mO\'emenlS also add to lhe inform~tion l"CgplKt'l/\tIw mlt'nertEbral m,c thene ;o.re acmmpanymg changes l/\
tht' zyppoph)'Se'.1J joInb and thesupport:ing "g.omenl· ous structu!'t'S. all 01 whICh can ause pa'n and GIn,. m part. b(' I'l5f'B"'SIblf, for I'('('\lna>t (>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
5ri0cb0noltedmi<jueswdlbed,n"CkdoilU-h>O otlw1-
d ~ onh. but It .IS roecessa'1' 10 menbon ~S1tUo1lKlnSthalal1'notuncornmon.
AdlSCcoinll.lplul1'fornoob-.iousn"erapid,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 ldhere Strai" -This occurs when a faculty Or part of the lx>dyiso\"ertaxed.ttmaybcduetobadposturalpositionsatworkoratrcstaswellastooveruseandabuse in sport or work. rhe sprains referred to arc oot caused by more major trauma. The effects of sprains and Slrains on pcriarticularand ligamentous structures pn.'Sent in onl>oftwo w ays,andonexaminahon w i!1cxhibitthe following' 1. Strctchrcspunsc
all'roducinglocalstretchpulling b)l'rodl.lcingpain 2. CompK'SSrespoOS('-painisprovokedduringtcst mO\'cm,-'Ilts pcrfonned in compressing diK'CIions Both ofthealxJ\'e tend to t>e symptomatic at or near theendofarangeofmovementifchronic.The'stretch' pain and the 'compl"C'SS' re<ponse may, if of recent onset.t"xhibitapain·through-rangephenomenon
Local pain presentatiansofligaments, capsulor andchronicdiscagenicdjsord~rs
In the early stages of OveruSC types of strain, the patient may leel symptoms only intermittently. Under thcsc circumslances. although the stretch or comprcss
196
MAITLAND'S VERTEBRAL MANIPULATION
phenomena will still be evident on ex~min~tion, the test movements th~t will qualify the phenomen~ will need to be combIned mO\'"m"nts, and th"y will ofl"n be associated with lhe functional overused movement that the patient can demonstrate as being the p~inful activ'ity. The symptoms resulting from sprain and strain on th" intra-articular structu",-'S (i.e. of the zygapophyseal joint) are quite different from the above. The symptoms will indude aching and, on examining movements, pain will begin romparati,'ely early in the range and will continue, frequently increasing. until the limit of the rang... is reachl'd. This is th... definition of the phase 'through-range component' as us from other sources. Macnab (1971) reported having made a diagnosis of disc herniation with nerve-root irritation demanding surgic~1 intervention in 842 patients Of these', 68 had negati"e disc findings at surgf.'r)': the nerve-root irritation al'(l5(> from one of fiv'e other sourccs. Although a clinical diagnosis of disc herniation was proven to be wrong in II per cent of cases. Ihis is a very small percentage; howe""r, th" fact is significant. The point being made hcre about diagnosis ~nd its relation to selection 01 manipulatll'e t('Chniques is that, "ven whl"Tl a di~gnosis of 'disc Ill'rniation with nerve-root irritation' is made, it is the presenting symptoms al1d signs. linked with thl' progressi\"t' history of the disorder, that guide the sckction of manipulative tL>I o/lIw aetiology./JlllholiJi{iOO If'Sio,,,anddiscrderedfimdiollsu~liclra,,,''ill''etll(
""tier'!"s disease. This "'JlyCllnble thedu;etlSamcapplil'S to discussion concl.'Trungthe managl'ment(ascomparL-d with the tl'Chniquesthat might beo;elected)ofim;tabilityandhypermobilitydisorders. juveniledi>cprolapses.primarypostero-Iateralprotrusionand spondylolisthl'Sis, The four groups are as follows
Blocking ofjoint movements
11u'firslgroul' IS affocted by the mechanical blocking of interHrtdlral joint mOHmenl. Examples of such ml"Chanical blocking of movement in peripheral joints area tom and displaced ml-dial meniscus in the knee, ora loose body in the knl'e. Mechanical blocking is not uncommon in the cervical and lumbar spines. This group,im·oJvingml'Chanicalblocking.h.lsbeengiven many diagnostic titlL'S. many of which areuna<Xl--plable. Wh"tever the cause of the blocking or locking maybe, the history, symptoms and signs are readily recognizable and spral 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 ,..drni<j"" "",If require dec;ision (T~~I.. 8.3), The aspects arec
I. Mobilizeor m.lrupulate 2. Dift'Cbonof mo\-emft\t
J. Po;.lDon In ...-hldl the dll'Kted l'r"IO'·ftnent ...·ould
"" ...."""""
4. nw.martI1erofthet«hn"lUl'
S. 'JhduraDonoithelMiltment
MOBILIZE OR MANIPULA;,;;',;;,'
_
ucept in the CaSOn of mo....~mmt, porticularly of" mob,llzmg technIque, IS gu,dro by lhe purpa;e of the tt'Chnique 1ll.e foUowing li~t indlc.ttes the factors that may ;nOUt'~lhese1,-ction.
1, SJw"ld IN aim Ix la ",Iferred 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
'*
\\'1ImptmtishJbrnsptdtJllndlltrpmhlmois_titlltrl/fflts ~ltrlrl!l'nn",grorl:>lIp11ut.'lrmtlglr·""''''1Iflr
1. The positinn. in t~a\'ailable range, in whICh the tt'Chnique should be performed should be fn..'(' of discomfort. 2. The Il.'CMique should b.: '-ery comfortable and comforting 3 The amplitude should be as large a>; can be performed provided it i~ froe of any di5d 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 on«p.I90).
'OOniaIpIt'WrlUlIo.f
lloIgnooUCtt\e
HlSfOty.S'f'OIp\OIIIS.Sl9nl
~ is one olher presmtation; the p.ltil'nt experiences his ~in intennlltentl)' as ... sharp ~in.lSSOdon 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-lat!ttriction iscau5l-od byonc
tiO~:~i~~;;/:;:2,~h~~~lo;,~~:1~:-;~~':::d range
parlicuJaraCbraJ joints arc such th"tJateraJ Ilexionand rot"lion can OCfol'l"inthatpartofthespinebctw~",n
C2 and C7, when One is performing rotation right. il may be neccssary .. lso toslretch lhe he"d and neck in thl'di=tion of the coronal plane-that is,strL'Ich the palient's chin towaNs his right shoulder al lhe sbral presSUTdially.
J. In lrcatingpain, lhe techniqucs an' performed genlly, slowJy and smoothly. In lreatingsliffness, the accessory mo\'ementsshould,forpartofthetot.,l trcatmenttime,bep and S111t of pain bmlg produad. II w~ not ruloob) lIwstrmglhofllwresostanef'm.ny ..•..y.I.11. The goal of lIw treatmenl tedulI'!.... 15 to ehmm.. le thai SOl"\'enl)-, quallty and 51le of pam so th.lt II ".annol bel'l'J"'l'duced'~neof ...hathappen5lollw When shfffll'liS and pain are l'<Jually domln..nt, il ,mportant for Ihl' less experit!nced practitioners ah...·aY'" 10 IIm,tlhc initialla:hni,!Ul'S 10 lhose already dl'>Cri!>..'.po..'Cll-dly. II i$ alw.. )'5 assariMed ,,·ith moveml."t. although Ihe m",·eml'flt may besominimallhallhcpaIM.'flli.""ta",,,,,,thalll\Cf\1 has been a mO\'Cml'l11
Selection
The selection of te 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 ""onene
n.e referred pain.l.'\·1"I'I wllh ~ dlSl.1Il dennate;. ..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'J'C scohosi, Withprotcduced. Assessm"nt o'-er 24 hours. or on Ihe day following a furlher b....ntle mobilization in the saml' range. will ell'arly show whL1her the llXhnique should becontinUL-d. Frt.'sary to provoke discomfort "ery gently to producl' an improvement in movements and subst.'mt and is .J.. n!lf"l'Sl"'I ..tthatpomtmtherMlgC.no ......tterhow
= 219
andsigns ..",not-W\-.,re,muchmorecanbedonl'tIwn if the ~ene is tilt- ColSe It should be rernt'mbercd, smtl,ar~-lytheu:duuqul'isJll-"l'furmed.isspa5ffiot holO'I""'-l"I',thatlt1en'lSitlophmumthatcanbeachle\-ed OlOOlher land fmm t1wt de5cribOO ......, Tl!SS, or " IN)' be b«'aUSoeasta.gehasbeenrcached ..'henassessmenl from treatment 5eS6ion to treatment -.ion does not cunfy the effecti",,'rle;6 of the treiltmt'flt techmques. Under ",!her of these CIINI'I\StUIn5, ImiItment mig.hl weUbcdisrontlnuea tcmponrily ..nd .. ~I mad... on 7-14 dOl).,., Drpendlng on whether the SIgns ha,~ further ,mpll)\ement, m-.tmerot mayor maynotneedlobere-instotutl-d There is one fi....1point lhat occurs qUIte commonly and should not be forgoltOn ft rardy dIcMn 111M begtMtng of lruttntnt, and~,nly'_ _ in ~ of a wry Pf,~MjoontOf~~
ItftIOIllCted by muscle spasm. On"ofthccardinalrulesoftrcatmcntofpa~.,ven'O\·e·
mcnt is that a movement must ne\'erbc forcibly thru,t through pTote.:h\c'pasm. Manipulations are usuallj progI'CSS,ons from mobilization. that have i!lCr('ae trauTNItc ~ The!ls
mo'..ement (_ Chapter 8) MCJSI examm.at>ons of ~ (ftV1Ql. thoracic ;on,d lumbar sptnal joints ..re c.uned out U\ the upright po5ihan. Howe'l~ most ire.1tment IKhniques a.., done WIth the pabent prone,suptne or III side 1Y"'@;.Becauw of the a1ten.d ..."'-ght drstribu!JOrl and posibon of c........ structure ..'hen .dopbng the posotions of su~. prone or side l}'ing. there may be lIOl"l"W alterabon II"l the pam response when the wme fflO\·enwnts are compared with those in the upright po!"hOn. It is important.lhef"efore, that if the h.-.:luuquellitObotchosenthat produces partkular symptoms III the upright position. the treatment position adopted must bot adjusted to produce Ihe sam... signs and ->·mptoms. T1Iftl' a",two alll.'mahn'S:
1. Examine far pallems af m(.... elllent in the position in which the treatment is to be carried out
2. Perfo"" the t..,atment in the upright position. SELECTION Of TECHNIQUE There a.., basically two tyre' of pas.!'i'·e mo'-ement tecluUqucs; ph)">iological 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 discontinuedandst
Whtnapplicabltlests 237 Sc:qucncesofcombining movements 239 Vcrtcbrollasilarartcrytcsting 242 Qualified aSSC'SSffitnt 248
INTRODUCTION
For cll3min.ation .md treatment
pU~.lht ~rvical
SllintCOln~subdividefWr; (clol"'r~l....antjointJ.
Behaviour of~I""Ptom~ Gtr>cral 1. Whtn a~ tht¥ prtStnt or wht" do they nugIItlosstf'l>td'lQI""'toryl.
~Ubl~IMSOUftt
4. Whattabll1s.~bto"9Ul.~fortMandothe WO
HISTORY Fo<pancn15w",*" preoenl~5Cd.. beganWlthoul incident, the de-'elopmcnt of the symptoms mU5t be detemtincd in detail from the I1me when they wen> first fell. II is only b) ,,-~attnK thi5 10 any pasl lustory lhatlhelilelyeffccl of treatment Can boodelC'mllnro and the fulure prognosis tshmatW. On the other hand, when a patit'
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.,rvi
Figu,. 10.6
""'vtm~nlC;l1 MId
thonOc spov Ul rotatIOn..
WHEN APPLICABLE TESTS ThtctMCll"qlladranlS'amllltMrc:ombon~ m<M:m~nlS
I,e usdul when trying to reproduct
miM' symptoms origin~ting f.om the cervical sp,ne, 11lemptingtoucludclheccfVitalspineasaso.m:~r
of symptOllli, Of as part of ~1.bI,~mg I faYOllrable trut~ntdin:dion
An auxiliary lest that 11\011 ~icil joint signs when ..etWI lnO\·l':IN'flll:ion held in this rombuwd position, roblion to the righl side i:sadded.
238
MAITLANO'S VERTEBRAL MANIPULATION
Figu," to.8 Upp'" «",i~al f1uion and low~, nntical ~.t.n5io". (al A
~ "I\' many ~olromplicationsfollo\.l.mga-n'iaol manipulabon referTtd to in medw:all'!eraIPntl-1homas and Bergn. 19-17; Sdl"'"rn: and ~.I956;Greenand}o) ... t.I959;Bladinand"~, 1975; KNeg.... and Ol.lension of the head. The "ert
maintained for 10 seconds. Tnesymptomatic responses are SOllght as explained above {Figllrr 10.23). If the te5t:;;are positive in the silting position, there is no need 10 "'pat them in the lying position. However, if this is nol lhecase,lhen the lests must be performed in the lying 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 <JIou\der pain tNt is «'fVica1 in origin. \\n..n.a pahent bas such shoukler pam, 11 an fnoquenltybenoproducedb). !heneuu.I_Eht')1100 Butle!- tu,-" described Some of the tests shaw, by \'irtue of the bma.,->OUr of the poIlIl ""hen <E'\'>CiIIl fOO\-emenl:!;lI~coupled...,ththem.th.otthepilllmts ~Id....
pain must be omic.al in origin A numberof
lIe;bCMIbe
the examination to the areas where discrepancil'S from the normal tmve ~n found. A rea:;.onably accurate determination of the site and type of tissue abnonnality should be made SO lhat a more detailed determination can b,' made later. The most common findings at lhis stage of the examination are: 1. Gt-'Tleral tightness of muscle tissue along almost lhe full length of One side of the cervical spine 2. local areas of lhickening imml'Sknallyit isfclt 10 be in the btera.1 half only, and 'II:ly on one side. The:l«Ond common fonding is marked thinSeduring the rnovemcnt.
Atlanto-axial 0-3
aru"'-'
_
Soft-r~r:hanf}ts
Soft-lissuechanges in tlwCI-21aminar trough an'! less common lhan eIsewherc, although it is not ~ to find thickening ol the soft ~ immediately ad~ centloonesideolthe5plnous~oftlw..,.i5.For
thisfindingtobcp..rtlflenttoapatient'suppercerv~al symplOm!l. firm palp;ltion must provoke deep Ioml or refCfTl"d pain. As ","-'fltioned above, the hardness or spongincss of thesoft fuooluesguides the inlerpn.'13tion oftheoldnl'SSorncwncssofthechangcsandthcircon~uentll'versibility.
l'rominence and Ihickening around the articular pillar of the 0-3 apophyseal !oint is a rommon finding. p.~rticularly in palk'flb suffering from cervical headaches.. It i5 pos.sible 10 diffc....,tiale hetwl'l'll
260
MAITLAND'S VERTEBRAL MANIPULATION
=0 'old'.nd 'new' in relation 10 thesofl hssue(as explained .Ixr.,..j."nd IoreLotethem loostooarthrilk (-u;icjeXOSI05t5. oomparabiJily belw....... the palpation findmgs ..nd the pabenl'~ symptoms isaSSCSSlld by ""Lalmg:
n....
I. 1lw: pa.... ~ whiJt' ..pplymg pressure 2. 1lw: In'ngth of the pressure required 10 pn:l\'ok the potm n.'Sf'Cl"S"'.
3. 1lw: oIdnes or .......- . - of the ti56ue d'Iotnges.
Bony onomo/its Oslt'Oolrthntic(-(J5jcj~oslosesarereadll)·palpable.1
the 0-3 apophyl§O:'al joinl. The... reIe\'anct' 10 a pahmt'lsymplomsis .... part indicated by lhesharp.-01 the margins of the ""ostoses. II lhey are nol shu~ ditl'Cl~'Cl poslel'()-anlenorly over the C3 spinou~ pro1p3tion 01 posterior
int~""jllOlr§'f'3ct
on the spinous pl'Ol:.'tSSeS n~,disadeeplyrellsensation.
LOWER CERVICAL SPINE ~arenospcciala.spo!CtSlQthepalpationexamin.
ationofthissectionolthespine.
findings are important
How~er,lhecommon
abnof",:_~lit~",--
_
~withthe~ofthespinousproce8lof
C6-7 dcscn~ above. the movemenl a~"ty is that there is a distinct restriction of movement with poslt.'ro"lIlll!rior pl'l'S5ure applied 10 the spillOU!i pr0c:e56 of C6. The pain response associated with this movement (and lhe movement may need to be applied quile firmly) is one 01 deeply felt pain (somcti~ dclcribcd by the patient. a 'nicf, hurt'}. There may a\sQ be a spread of pain inlothellCilpulararea.(lrPlen a bita\lCl"ll spntC 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!iISbral mu~k$ lie within the ('In::le formed by the finger and thumb (ri.~""' 10.511». 0Vl"I"
Mrthod Having bh'!1 up the position prior to lcSIing the rotary movemenl betw,-Ul CI and C2, the physiother.lpist should, w,lII her left hand, perfurm small Ialf!nl flexion movernerrts of the head on the neck through OIpproxima~y '111' (10" 10 eKh side). bps the patiom'shead Iothelcft,tohes)o"ldfueitheSf'U-'s proce!ll'> of 0 mo>'e to the nght. Similarly, lIS • latenlIyfbeshosheadtolherighl,tohewill ftoeIlhesptn"" OU!I......-ofOln(lWlOthelcft. Br_ingtm. movement. tohe shouki s.top OIt the poont where the spinous pl'OC'elB of 0 is in the midhrw. She then rotaleS the paIR'!1I'. head back ;md forth from the cent", 10 the lefl up to the point where the spinous pl'OCeS5 is fell to move. Lamina of 0 on the koft is feillomoverockwardsagainst her thumb, and the right tater'll surface or this spinous proc~'SS moves against the pad of her index finger. On'emcnl asseiK'd. Although the rutation to the right can be asses&'d by mo._ly turning the piltM.. n t's head the other way, it is br more accurate tochangesides 10 repeal the led>nique to the righl
10$.
n.e
(1-2 (roation) ="''''pin(''---
_
Stortingpo5ltJOtl thumbs, ...... ~ the §milll movement between the two bony poonts on each ~ide.
lhepaticnllies.supinew,thhisheade.:tendro b..-y....J the ft>d of the coucf> ;md cradled in the physiothcr;>-pist's righl arm (for rotation 10 the righl). Wilh her Iefl hand,sheclaspslhespinouspl"OCCSSOro III much the same pincer grip as lho>l in Fig..'" J0.5211 (Fig''''' 10.53)
CI-2 (rotation) in sitting SfClrting position
Mrthod
TOl'Xlminc the range of roIiItion 10 the lefl betw~~~, Ihe fin;1 and S 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 (ronl
Postero-anttrior central 'nrltbral pressure as a 'combined'techniqut Thl' following description is pre;.ented as an l'XillJIpJe of postel'&""nterior mO\ement pcrlonned with the Sp"lOIl5 pn:x::ess mobilized WIth the joml m a position of rombined.lateral flexion to thr nght WIth extension.
Srartingposition The patient lies prone and the phys>otherapist pasibons his heiid (and thll5ltw intl'l'\ertebr.alle':l'i to be mobilizcd) in ltw degJft of lateral flexion and exten-Slort reqUI1'l'd. She then pbcn the tip6 01 her thumb pads on the spinous pmcP;6(f.gun" 10.63)
considerable~thll5makingthis\ll'dmtqUrd,fficult IOperfonn.wpalmarsurfllOl'501thepadsoithefin~
M~thod
canbeuscdtoliftWr>eckinloadegreeolflexion.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.<e of pressure required to f('('! mo'·em"n! in the mid-cervical are.' is much less than that n.'Cluimd at either the second or the St-,tTlth cervical v"rtebra. The fin;t cervicill vertebr~ Ciln rarely be> palp~!cd in lhe midline as a bony surface; however, it is possibl" to produce mo,ement by pressure through the o·..erlying
~coutions
Mobilizing in the region of the first Dnd St'COnd cervical vertebral', if Vl'Ty e~ct'Ss,,·e both with regard 10 the length of lime and tm- streng!h of the pressure, can produce a feeling of nausea_ .",..., It'Chnique must never be u!M'dif it causes 19ddllless.
275
216
MAITLAND'S VERTEBRAL MANIPULATION
Figu,e 10.62 Poltero-anmiof ~nt,al ."tcb,al ple'lW'c. [0) p,es~u,. wnile the other tnumb,tabilizc.ill!K"ition
Inc,.a~ed
a,ea 01 thumb contact. (b] U";ng Onc tnumb to tran,mit tne
Poslero-anteriorcentral vertebral pr1'SSureisof most benefit to those patients whose srmptoms of eecvicalorigin.resituat~-deitherinthemidlineordistrib
utedevenlytoeaehsideofthehead,neck,arm,Of" upper trunk This technique is valuable for pati~."ts who have considerable bony degencrativechanges in theeer· viealspine,ic~pech\'eofthean'atowhichthepainof
ct'rvical origin is referred. While carrying out this procedureonth~'SCpatients.however,thedeg,,--eofmO\·e
Figur. 10.63
Post.ro-a"tc~or«nt,al
.... rtcbral pr.lSur. with !K"itionoflate,al
tnepatienf~hcad.ndnedinlhecombi""d ~«iOf1
to tne rigMt with extcn.ion
U5~5
Sueha technique would probabtybe used mainlyasa gr(k.ll is important that the neck and handsmm'e asa single unit. The technique can be made to be of large amplitude by lifting the p"tienl's n('pine shnws marked degenerative radiological changes. liS greatest application is with unilateral symptoms of cervical origin, This is particularlysoifthl!symptomsdonolexlcnd very far from the vertebrae or are ill-defincd in thcirarcaofdistribution when no neurological changcs are evidenl. Whcnlhis technique is used for trcatingpain that is felt unilalerally, it is more likelytoproduceanimpmvemcntifthcdirectiOfloftheprelSureisperfonned from thenon·painful side towards the painful side.
Variations There are Iwo variations of'lransveTSe vertebral pressure'thatcatlbeu~effecti\'Cly.Bothinvolvepr
Pr~routions
Ifa palient feels neck discomfort On the sid ... of the neck to wh.ich the head istumed during or following this t~'Chnique, it will readily disappear in a few min· utes with active neck mOVl.'Tl1ffit5 Although it maySd 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'$01 the day or 1Il cydC50f I hour of traclion followcd byahalf-hourrestrepeatedthroughouttheday. This type of traction;" maiJlly used for patil'1\ls withSfo",bepossibletoadjusllhchal~ l"r, not only lofil th" various shapes of h"ad and jaw bul al;;.o for diffcn'nt 'head-n,"'k' ",lalionships, This is
calion of traction 10 a certain weight, which is held momentarily and then gradually released; this;s follo"':t....ded .and Can bi!come uncomfortable durin~ tn>atmenl Howl"ler, ..'hen !he$Uplnepo5lllon is used for troOdion in f\erion t..... thora6c: spine is not extended. so it thenb«'omes the poslbon olchotnAllOOughthesittingpositioncanbeusedfortr~
tion in fleld the h~ad, in l'\'lation 10 tile n~'Ck, wtll be lifted in the almcnt; It is the5trength and durat,on lhitt is modified by changes in the symptoms, The angll' of the pull musl bl' as near 10 lhCT\('UlraJ position {mId· waybelw~lheintl'r-\'ertcbrtienlswhoha\'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 pt (Figurr 10.80)
Method The physiotherapist hugs the patient"s head firmly in her left arm and lightens her eontact againsl therighl occipilo-atlantal joinl. She then din.'Cts her forearm pointing towards his right eye. Small preparatory oscillatory movements are produced by pushing
C~rvical
59inC
,.,
Figure 10.80
(a) and (bl Occipito-atla"taljoinl. Unilateral post.ro-ant.,ior
though her right h.. oct. along with very tiny mO"crnl'nts of his head with her leI! arm. These movements allow the head 10 be lipped by the right-handed push, but dQ not allow il to move far. The manipulative thrust ;s then executed with a short. very fasl thrusting-IyfX' movement throullh her right hand and through the right ocripilo--allantal joint
This thl'U5\ is countered by a controlling and guiding movemt'lll with her left arm
Upfler cerviCal joints, occiput to C3 (transverse thrust, Iv - . opening 0/1,1/2 or 2/3) Thist<XhniqucR-'Semblesthetram;versethl'U5ldescribed on page 298. but a greater raogt' of extensioo of the he.1d
on thene
Hnd extensio". With the lip ofher right index fingt:r, the ph~iolhcrapislfindsthea/4in.k'lSpinousspaceand
then mo\'es her hand late.ally to bring the anteroL1terai surface of the proximal phalanx of the index fingt'r behind the 0/4 apophyseal joint. She places her finger50n the back of his neck and hcad to provide support, and her thumb lightly on his ~,w. While holding lhisproximal phalanx5talionaryagainst th"articular pillarofC3/4"he06dllatesthehl!adinarotarymo,",-~
ment, starting from the straight head position and grad· uallytumingthehcadfurtheruntilrotalionisfdtbythe phalanx at th"C3/4 joint. She then tightens her righthand gripwiththefinge"'Hnd thumb SO thHt if the head istumedfurth"randth"righthandfoUowsthetum,C3 also follow. the tum. This unifying of the spinc abo"" C3withtheheadisvital(Figun'IO,84)
...
298
MAITLAND'S VERTEBRAL MANIPULATION
Mtfhod The nwupulaliorl cons>5IS of ~ snall....mplitude wrp rotation ot the unit, hNd to 0, with ~ thrust being oened behind the artlcubr plll••r of 0.
lnttMrtt:br"a1 joints 0-7 (laWai flt)lion IV..c")
Starting position The patK"nt liessuptIll' WIth hIS head beyond the end of theooU/;h and thephysiotht-rapist. standing at the head of the rouch, grasps the paliCTIt's chin in her left hand while her left forearm lJ~'S against the left side of the patiCTII'S head. With the palm of the right hilfld at right angles 10 the neck, and the nngers supporting under the hea.d and neck. the patient's head is latently flexed to the nght through a lYw degrees while the ph)'slOtheraptSllJlO\'e5 her body and feel until. is standing by the patient's nght shoulder f.King his hNd. To localize the Je"e1 of the ll'\ilrupulalion, thrph~ lheu.ptSl uses the Iipoflhe right index fingertopilpate forthedesll't'dintl'rSplnOUS~.\"''henthPJe"e1ha.s beenascertained,the~terol.Jteralsurfaet>althPt>.st:
of the proxtmal phalanx of the nght index finger i5 pbc.1'd lIgau>5t 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 rhYSlOtll
Cervical spine
F"+g~~
10.86
InleMrtebral joints. 0-1 (tran5_ent Ih'~~ll_
--(l~nin9)
Intervertebral joints C2-7 (trans'«I"SC thrust dosing the right side Iv ---) As ..... ,th the transH'fSt thrust fOf the uppn cer\,uI jolnts, the t«hruquc can bo.- adapted 10 either opI."l'l fwider) or da5t the jomts. The descriphon of the IKhruquehere IS the samc as that ~ribed on pa~296 ..·lthF'j{Il" 10.81
Mtthod Small or;ollatOl)' thrustinj; mon.·..'I('flt5 an" emplo)'ed by the phn,odlel"o>p1Sl 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$t on the ~ A pahf'l'lt with "iscrral pain .... N'ly
Sftksl}ingdownasa~tiootoadopttogainrclicf
r.lbentswhoNtn·LI1termmentdifficultywithbreathmg are be mon:' I.tkely to /\a"r an inle!""CQStal.. COlitmerteb....1 or intervertebral problem than a pleu....1 dl5Of'der, There.re many manipulators of the \ertebr.l coIumn who confio:: chams
4IT' in close proXImity to thcct~to\"l~rtebnljOlnl5. E'-Ml!i (l997)hassuggesk-d that arthnticCO'-lO\-f'l"IebR.l jointsGn cause m«tr.anac:aJimtationofrhesrmJ»theticchalns. Subtle autCJl'lODticlo}mptoms. t5p«ially in the limbs. may
~toe.~ofsuchmechanic:a1irn\ilhorL
3. \.lobilizationormanipul.1ltionofthelhon.cicspllll' and ribs may be necessilry after thor.oc or open
lnspiralion frequently cause pain,"piral1on does 50 far less commonly, I.nd if • patient am;..·('B lhitt breathtnglS unaffected twshould~;lsled to t.lk.l' in;l deep breath, gradu.lly W'liffmg lI'IOn! and more mto the lungs to PI'O\"l.·the point. This 15 becaw;e, Ii Ius symp!orn§ a~ mild or inlenruttent.. his normal c<pan.siond0e5notn'adtther~oflTlO\·f'I'IlC'I'\tthatpro
,·oLespain. When listenmg to the palJenl's story of his pam problem, one must bear in mind tlv cost/Xhondr.ol articulations and the ""apulolhol'acic mO\P"'.1ll~
Often it is not so ob\"10US that the thorOlCic marbble
he.rtsurgery.[nfact,.traumaIOlhl'ribca~during
8urgerymay well n.'Sult in postoperal1\'emusculoskeletalp.ain.nd$tlffncss.
ASSOCIATED SYMPTOMS
SUBJECTIVE EXAMINATION DisordmofthethoraciC$pinearcoftenaccom~med
Table 11.1 outlines thesubjl."Clivl'exammation for the tooracic spine. One Item thai IS peculiar 10 this area is the cffOO of bn'athing on the patienl's symptoms.
t>y'Y"'ptomso.iginatjngfromthe.~tonDmic
nervous system
Tabltll.1
~spinc.SubJtetivtcumj~tion
"Ki...rofcl'-*r uublishwlty"'l.. nl .... IIt'rn~h>rDr'iOU9h!lrt'allll.cough"'9or~~
~qut50borlS 1,0000l!lt,,"lornl~bIlatr~t,..,...
.... t/lrfrrt.orJl'td~oIga,t[cordli9'lSl.
1Grnrralhrallh'nd~wc'fhtIDst.IMrdirllh~J 1.~rt'«f't)(-~bttnUlb:n1
_~tl.ilblrl!;.trbt,ngl.il~rllfoI,-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;M<jr~ttlotS .... tllpt.ysiologior1'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. Midthoraci
Ata firstconsultation,ifapalient has upper abdomirul pain of skeletal origin itisrommon for all physiological mOVCmLTlts to be pain free even when combined movements and movements und"r romp,,-'SSion are tested. How"vcr, palpation anomalies can always be found.providL'd theexaminiltion ispem:ptively pel'" form
Tho.acicspine
This only indicates rotation of the wrteb.a when it is confirmed by being able to lell that one transverse process is more postcriorly posilioned inromparison withthevertebra'stra""ve~p~ontheopposite
side. That is to say. if the spinous process ofT6 is dis+ placoxl to the right, this displacement only indicates rnlation of the vertebra if the tranS\'erse process of T6 on the left is more prominent (or posteriorly pos. itionoxl) than the transverse process of T6 on thc right This is rarely thccase, and it ill sorprising to find how often a patient's symptoms, when .elated to this malalignment, are found to be on th., same side as that to which the spinous process is deviated When one spinous process is deeply set and the .djacent spinous process above is prominent, pfC55ure o"erthe prominent spinous process usually provokes • superficial sharp pain while pressore over thesorc deeply-setspinousprocted, 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 ~, pbre physiotkerapist take!i the weight of his upper lrunk on her lefl arm. Toll"itflexion,shelowershistrunklTomlheneulral positioountilmQ\·cm..'fllcanbcfdlloMvelakenplaCO' alherr;ghlmiddlefinger;lhepalicntislhenretul'nl' diflllepalienlislleld firmly and i( Ille physiolhcrapisllalcrally fln'-'" her lrunklothelcflasshelowcTSlhelTunkinloflexion.This makeslheretummovemcnloncoflalcrallyflcxingher lrunk to tile righl Talherlhanliflingwithherlcflarm. Theexlension part o(lhc IcSI is carried out in much thes.amcway,e~replthill thcphySiOlhcrapistassisls
extension.lIisimportanttori"l'tlenlberthat,t;';mo"(ment at only 0l'Il' jolI\t that IS bems eQnuned,. and theref~largetrunkrTlO\emml§a"'nollWCf"5Silry;iIl
fact they detract from W6ilJ1\lr\;l1l0r\. T4-11 (lateral flexion)
Srorringposition TlwpatiefltsilSandholdshis~ndsbelund hIS neck or CIU56CS his armsocl'055 hi5chesl whilc the physiothenpis! stands sidMln behind his right side reoctllng WIth her right arm to hold high around and behind his Idt shoulder. She grips his trunl< firmlybetwt.'Cn her right arm and her righl side in her lefl axilla. ThIS high grasp with the right hand is ~CSl>ary for e'lilmlnatlon of the higher le\'c!s;as thcexam;natiorlextCl'ldsbelow1'8,so lhegrasp needs 1o be taken down 10 the lower scapul.lr "rea. She places Ihc hccl of her left ll.and on lherighl 5ideofh;soockaltheleVl'lbcingexamined,sprt"olds hcr fingers for stability,and places the tip of the pad of her flexed middlefinger;n lhe far side of !he Inlerspinousspaccoflhejoinllobct,-'Sted{ fisurrl'.12).
Mrthod T1>cphysiolherapisllalerallyfiexeslhcp.llienl'strunl: lowards herby displacing his lrunk away from 11ft
Th,nonpine
317
physiotherapist, standing in fronl of lhepatient, leans O\·erh'strunklocr.ldlehispelvisbet....t>enherleftside ~nd her left upper arm. 1lUs po6Jtion stabi1u.e5 the patient's pelVIS. The physiothel"apl5t's forearm 15 then inl~W1ththepaberlt'Sspu,.,.andherh.andlNd'aes lh!-k-I"e1wherelTlO\~tislobeeomined_Shtthen
place;. her left hand on hisspUle with the pad of her middle finger f;loCing upwards apUlst the under-surF''9U~
11.12
InttMr1WnlI_~t.
14-11
(I~tt",l«tensjonl
With the heel of her left hand and her COf;IaI margm. andlatl'TaUy6e>anglUsuppertrunkby~herright ~rm.oo
faa'oftheinlerspUlOllssp.oa'lof~'ellhebonymargins
of the ad;acent spinous processes, With her right hand, she grasps as far mlodidlly as possible over the p;ttient's suprascapular area and places her forearm over his stemum or grasps the pat......tselbowo.erhts sternum (Figurt Il.lJ).
PI'e:!l6ll\S oo..-nwanis w,th heT right ~ulLa. She
palpates for the mtefSpinOUS rTOO\'emmt through the ~ofherrruddlefinger,ensuringthatduringthelat
rralfleltionherfingerl1\O\·e!lWlththespine.malntamOOTllaet against the spinous pl'OCe!lSl"5. Ttoe palpating finger fwlslhe spaC(' bclweerllhe spinous pl'l)Ce5Se5open and d06C as the pJHcnt'slrunk is laleraUynexed and relumcd to thc neutral position. Laler,1I neltion in the opposite direction can be palpak'd without a change of posillOn simply by lalerally
mg t!\en
ne..,ngthep.atiml·.trunktheotherway.Hmctacarpophalangeal 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
When the middle and lower thoracic vertebrae are to be mobilized with transverse pre5liures, the patient lies prone with his arms hanging o\"er the sides of the couch or by his sid... to aid relaxation of the vertebral column. The h...ad should be aHowed to rest comfortably by being \luned to one ,ide, preferably towards the side where the ph}'siotherapi.t stands. Howewr, as this head position tends tv produce SOme d"gn."l' of rotation in the upper thoracic "ertebrae, it i5 bell", for the patient to adopt the 'forehead rest' position when these v...rtchrae are to be mobilized in order to eliminate any rotation. Alternatively, some couches
Thoricicspinc
have a hole 10 allow Ihe head to remain ~ntrally placed_ lnsomeeasesil maybeusefultorotateorderotale the spine using Ihe head position to produce the movem""t. If the mobi1i7.alion te 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... aclion of th.. pressure can be inclined a liltl.. mOre towards the f~t as ",en asbeingpo>tero-anteriorlydirected(FigurrjJ.10)
3. For this n.."t technique that mobilizes the first Tib. the patient li..s supine while the physiotherapist.
tobctreak-d,oppliesthep,,-'Ssuretoproducetllo.> osciJlatoryantcropostcriorandcaudadmo\'ernent on all partsoflhe firsl rib thai are palpable (F(g"" 11.11). The symbol for IhislL"Chnique is.J RI Otllfrribs.Alloftheribscanbee~amined throughout their entire length by thumb palpation, including the coslochondraljunctionsandthejunctionwiththrenl ribs. This iSpl'CI of lreatmg costal paUl IS de5cnbed in Pmpllmd M
2. If lht' rib is moved aSa lreatment lechniqul.',il must also creal" some mm'cmenl at the Inler.,.erld>ral
Thoracicspinc:rotiitionto~right(T2-12)
Srorrmgposition "Thepatil.'nl lies supine wilh his al'T1'lll folded iICI'O!llI his chest, resting his hands on the opposite should.:.n (rigu"JI.22). Thl.'physiOlhcr~piststandsonlher;ghlhandsidl'ofthl'p.>ticnl,till;ngholdoflheleftst.ouldcr wilhlhclefthandandthclefliliaccreslwilhlhcrighl hand (F(glln!ll.2J). Th"lrunkisthcn rolled towards lht'lht'rapist so thaI lhc Idt shoulder rom"" off lht' rouch,exposing the thoradcsp;ne,"The righl hand is
.....
325
326
MAITLANO'S VERTEBRAL MANIPULATION
lhen placed so lhal lhe f1ex~..::I interphalangeal joinl of lhethumb is placed oVeTlhetr,Insverseprocessoflhe lhoradc vertebrae to be rotated. allowing lhe fingers to lie across the thoradc spinous process. Theronlact hand isposition~>d 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'OCCSS spine to be tn'atoo. and it;s thl.'ll attached to its fixed point. Aft"'rthis the pch"ic Jxolt is applied andall'aehed to its fixed poinl. The dift-'clionof the pull is th~'I'llongitudinal in the line of the p.alient'~ trunk, but pillows may be n,'eded to adjust thl'
Thofa
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~of5U
spme, the mobilization redl-
ruqll('5describedcanbeperionneda'i"~rapKl
smaJl....mplitudl' thrusts. ~ may be genenl in d~ tribution. CO"ering mon': tlwl one intrn'mmral Jeo.e1 (asm rotary PAs described on p.319),or~canbe performed In a much more Joc.. lized manner so thai the emphasis of the lnO\'emenl IS focusoed, as much as lSpossible,onasingleintcrvertebralle\·el.lhesemorc localized manipulative tL'Chniques are oow described for the thoracic spine.
Intt'~rtt'braljointsC7-T3(latt'ralflt'xjon(r"')
51artingposirion The patient sits w,,11 Wck on a medium-height rouch while the phys>otheraplSt 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 rockinglheneenlliessupirw>"'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.'
manipulation is then carried out by a downward Ihrusl Ihrough his elbows in thedir«lion of his upper arms. This thrust is transmitted 10 the palieol's trunk above the underneath hand. The thrust may be given as Ihe palient fully exhales. Int~rv~rt~bral joints
TJ-10 (longitudinal
movem~nt_.)
Stortingposirion 'The patient sits well back on the couch and grasps his
haods behind his neck, allowing his elbows to drop forwards. The physiotherapist stands behind the patienland thrcads her arms in fronl of his axillae 10 grasp over the dOr5l1m of his wrists. When grasping his wrists, she ,,"courages his elbows to drop forwards while at the same time holding his rib!; firmly from each side with her forearms. She lhen tums her trunk slighlly 10 one side to place her \ower ribs againsl his
331
332
MAITlANO'S VERTEBRAL MANIPULATION
small movement with the therapisl's ribsagainsl the patient'sspine, performed atthesametimeastheliftis cXL'CulL'd through the arms.
Interverttbral joints TJ-l0 (rotation:;) Starting position
Figur~11.31
lal.nd(bllnmvm.braljOint.T:l-lO(PAs!1
spineallhel3tient he,selfnot There was no low lumllir movement at ill, but the ~mill amount of low thoracic exten~ion that she could perform provokcd Whit ,he dcsc,illl'
d~I~rmin~d
uscfully
Yct with aU tile programmes Ihat have bet'n published \andth"reo1remany),non"oftheauthors~mtoreal· i~~ thai ~ patient who fet"ls pain as a very localilecl spot, for example betw
~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 e<juina inml'emenl ( p 18) N..turally. such a p.1tJent ....ouId n<JIbe ..d em.-d for man,puLtti,elre..lmen!. but there is lho! po&:>ibilJly that tho! first signs of 1I\\'ohement ma\' n<JI become l'\'Jodlont unhl ..ker the doctor·s referral and before lho! man,pulah\e ph,-".;o. lher.lpLSl·S fu5t consultation
HISTORY
tom!i~ammgfrornthebaclg
--
l){/>tfJO LUMBAR FLEXION Examinationoflumbarfl~ioncanincludc'
• Forward flexion (FF} wilh ovcr-p'~ssure and relurn to tl1~ upright position • CI~aring I~SI of lumbar ~xlension fromfull flexion atspecd • CI~aringlestofsuSlaincdovtr-pr=rcinfl~xion, fluionrotationtl1cnrapidlyintofullcxl~nsion
• Forwardn~xionwilhtt:rvi",lfluionaddcd • Forw.rd flc,ion with rot_lion to the I~ft _nd rigl1t add~d
• Halfflcxionplusrolalionlcft_ndright • Fluion from b~low upwards • Flcxionwithanyprot~ti\ICdcfo,mityeountcrro
Forward flexi"n is a very important mo""ment in ~ lumbar spine, and shouldb'-'examinl'd in depth and with intimacy. Smooth, even unrolling from above downwards occurs during Ihf! normal mO\'f!ment R{'(o'"eryfrom flexion to the standing position should also ~ a smooth mo'"ement. I !owf!ver, a palicnt may hal'e what appears to!>c a normal mO\'ementduring flexion but dilficulty in dropping ill10 thc normal lum" be5 from this po$Ili! Roution
r;g~t
lumbafspin(
If lhere is any sign ofa protectivedefonnity (em,. nrouslymllt>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 til
does not mention the arc of list that can occur during forward flexion. lllis may be seen aSa deviation of the patient'sthora~toonesideduringlhemiddlethirdof
the flexion movement, orallematively the patient's
pelvis may displace backwards on the opposite side Nor does heml.'lltion thaI these lists may be p"-'Sent only on extension. In addilion they may be present in conjunction with a protective spasm of either the flexor or extensor mu»eles.or the flexor Or exlt-nsor spasm can also be present wilhout any list. Wht'n spasm is present in the extensor muscles. response to treatmenl is slow whether this spasm is bilateral. Caus.ingamarked lordosis localized to two vertebrae. Or unilaleral. Movement in thelumbarspinein particuLarhasone fascinating feature: its movements can produce entirdy different pain responses depending upon whether the movement is perfonned from the lop downwards or from the bottom upwards. All of the basic lumbar ph)'5iologiml movements tesled in the standing posilion Can be perfonned by the patient from abo"e downwards (whkh is what most ...xaminers would dO,and becontt-nt with tn., pain response answers obtained) and also from below llpwards. F'I?"res 124-127 explain the example,; Rotation from below upwards is of particular \'alue whenlhelowert\\'ointerverlebraldiscsare5uSpafspin. 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"
.,oioureto,sa\',ilshifttothe righi, she Mands b\' his left SMH-, rlaong hIs left l"1booo bet...emher uppersmnum-~,on, E for exlension, I.F kfl, LF ® for lall'ral nexiontolheright,lnt
1.1ll'Tally n~"'estothe left and thephysi()!hcrapist pulls
Wil~;~~~~'7~'1~~dF':a[ribo~'C;,!:~~~ physiother. al"~t us/.s the whole of her left arm and hand to twi'St w thoracic and JumoorspmeinlowTOtaled posItion. An'rystmnggraspofthep;llJmt' pri'lliisneedC'd;ingincreased,theflexionhasa loose feel about it and thus becomes "aludefultoassesslemperalureaftertreatment.espeocially when it is lhoughl possible that a disorder may have becndisturbcdunfavourablybytreatment
Softtissur,bonvtissur and position Alilumb3rint~~inousspacl5shouldbl:'palpat~d d~pIy,
3sshould pr0tt5Sd in Chapter 6, it iSlledbythepatient.Animport
ant example of this istheexaminationofa patient who hened by using all Ihe fingers of both hands (f'gu", /2,30). TlUs t('n!S a ... described indetitil be\o.... It must be A'ITM'fl\ben-d that the exammmg mo,'ements .. re usuall)' performed at a slower speed than when they all' oS(>(! as t..... lment Ie.:;hnKjI)('5. Also, the examinallOl'l mO\'ement should be taken 10 Ihl'endofthca\·ail..blerangeandtta"flm-er-pressure IIpphedsollstollsso:.-ssth.. end·ft'l'lofthemo'em......1.
Tll-Sl(latC'ralflcxion)
Starting position The patient lies on his right side with his hips and ktl(.'l$f1e",ed to allow his lomb.uspin.. to lie rela~ed
Lumbar spine
... • ~
Ngu,e 12.23
.... 't",""','
¥"
~,'Y •
~l .fl
Rot(1)+Lf(D
midway t:K,t>\'en flo;,xion and i:'xtension. Jf the patio;,nt has unusually largi:' hip6(omp.1rW with the size of the thorax, a pillow should be plaero under the lumb lumbar spine from t:K,low upwards by rocking his pelvis. She lips his pelvis (ephalad on tho;, left by pulling with her right forcarm, and rcturns it by pushing against hio> thigh with m., righl side. An 05dJlatory movement produced in this way rocks thcpt'lvis,with theundersido;, hip and femur acting as the pivot. Th" movement is easy to produc:e afldeasytopalpal"(l-"igure12.J2}. To test lateralflo;,xion totho;,oppositesideth"pati"nt shouldbt-askedtoturnover. Tll-Sl(rotation)
Starting position Method \\'ith the physiotherapist grasping the patienl"spelvis and upp"r thigh with her right fon-arm and hl'l" right
This starting position is similar to that dl'SCribed for lateral flexion, but it is neo;essary IOl'nsurc that lh" patient's top knl"C will slide fn"Cly forwards o\,o;,r the
361
MAITLANO'S VERTEBRAL MANIPULATION
undffnealh knec-_lhe,*,~'pi5llNns~tJy pat>ent. pbocing her left ~arm along his back to palpat" tJy in\Jt'n.pinOuS spact' from Wldemcath. ... hilst t»'isnng her tnmk sbghdy to face hrs hips. She holds m-er Ius left hlp ..ith her right hlInd, her fmg,," spreadmRoutbetundhistrochanterand thc heel 01 her hand antenOr to the trochanter. Her nght foreann hokba .... ghis left femur (figuR"ll.JJ)
Mtfhod Wh,l" the phys,otherapist slab,hrei the patil",rs thora~ with her larm. Rotationintheopf'Ol§l~dil't'ctloncanbele5ted
..·,th-
out dwmging the palJo!nt 10 the other side Ho,..I'\·~ uniformity of 'feel' is best achic\ed by "-'P"'aling the techniqueontheolherside
Ttl-51 (f1uion/tKttnsio,,'J
_
Storfing position TIle p.:ihent 11l~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:
Mf:thod Whcn the leg is used as a levcr, care is needed in taking up thc slack because of thc movcment that takes place at the hip joint. VI/ith the right thumb against the
be
5Omewhe,... in the middle of the vertebra. This would be quite wrong, the centre is 50mewhere belween the under-surface of the treatment couch and the noor. Imagine the rotation gradc III (figurt' 12.44) being per_ formed - as the patlenfs left iliac crest is rollt'd forwards. the right iliac c«-'St's contact with the couch ~ at first, the lateral or post..roJateral margin. and at the end of th" movement the contact point has m""ed IO""ard towards the anterior superior iliac SpiOO1 Therefore, tf>e cent,... of the arc of the arcle described by the left iliac eft'S! must be below the top of the treat· mentcouch. It may be mort' easily understood if an analogy with theold-stylcwagoo whffl is used (figuTl' /2.42). Imagine that the rim of the whC'C1 represents the crest of the ilia (plus the 5aCnlrn and alxlomill.ll wall). Although the lombar vertd>rae arc nca«-'l" to the back than theabdominal wall. the analogy is just as perlinent if thchubo;>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 brlno.'t'wllhhcrlcfthand.She supports his nght leg In appro'ornately 90" knee and hipflexion{frgurrIH5)
Method With her trunk and nghlarm. the ph~ap;"tsU bilizesthcpal1enl'SlrunkwhllerotoltinghJspeh'isfor"'-ards on the nght 5ldl- through t~ medium of his
RotatIOn 15 one of the most Ulieful procedures in treat-
ms p.unful rond,hons anstllg from the lumbar spine
It 15 most ,-.. Iu.abW- ..'...... used for symptoms thai .. re unilateral in ttw1r distribution, whether they are re:l'erredtotheJegorlocalizedlOthclumbalr .. realn eumpae. where the symptomsarecentr;ol but theSlgr<S aR'wulat\'filLthe;eSlgnscanbl'taken as thcgulde to the painful on,lndlatmlflwonlrft,frurn bflowupwards";Ill.m.tnllUllSiin f + [email protected]
Jess 10 strmgthen the5tr.ligllt leg raising strm:h. figoI", 12.51 ~1.)1
llotabOnwllllstra.,11q
380
MAITLANO'S VERTE8RAl MANIPULATION
M~thod
The physl()l:ho"raplSt pr2
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'<erhis knl't.'S and her right hand posihonoo approxillliltely over his thoracolumbar spine. Her legs are positioned in walk-standing. She crouches forward towards his fcet(figun'12.55) M~thod Thetechniqueha~fourphases,thefirsttwoofwhKh
are identical. For the first phase, the patient takes his hands off his knees and gently stretches his hands towards or beyond his toes and th~"Il returns to the hands on kn"l'S f'O"ition. The second phaseinvol'1':I repeating this gentle stretch and return. During both these movemcnts the physiotherapist follows his two gentle stretches, maintaining light pressure with hef right hand against his thoracolumbar spine while fol· lowing his trunk movement with her trunk flexion. The third phase is the actual mobiliz.1tion, which is an exaggeration of the first two phases. tn this third phase the pon:thinl,tartinoJ
pos\enng her nght pdns agairn.thisWCTUm Prttauf;Ot1S Thclastlvo-OlN'thodsllrE'notusedinthepl'CSmC('ofa hcrniahngdlX. Fkuon is not a tedtniquetou§cunlil others IhiIt ef'kct rl\O\'cmcntal theinler..-crtcbral/Oinl ha,'e been Ined WIthout Sll~ When It IS first used It should be performed gently soth.al ,ts df
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'~handsworl<simllltanl'OUsly,thl'
right hand lifting and rolHng its crest anteriorly and to the right while the left hand encourag~>s 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,and thepatienl. to assist relaxation. With thcsc two factors in mind. the following method is gi,-en as a basis for traction therapy.
Starting position A belt is firmly fixe
the patienl'ships and kncestobe flexed, The position of choice is the one lhat places the intervert~-bral joint midway between flexion and extension to permit the greaK'Stlonb";tudinalmovemcnt By means of straps, the thoracic belt is lhcn attachl)(! to some fixe
The traction is then applied from either the head end or the foot end of the apparatus. or from both ends, but care must be taken to diminate friction between thcpatientand the couch if a roll-top traction CQuch is not being used. The physiotherapist does this by raising and lowering the paticnl's thorax and pelvis alternatcly to cnsure that the stretch is being applil)(! between the belts and that it is not lost in frktion betweenthepaticnl'sbodyandtheoouch Although a friction-frceoouch is not essential,it is such a tremendous advantage that if it is possible to make up a simple one cheaply thet'ffort is more than rewarded. M05t palient rolHop couches consist ofa fixed thoracicscctionand a roHing lumbar section. but this arrangem~'Jlt has little to recommend il. An efficient friction-f,,-'C couch has both "'-'Ctionson rollers. llisaISOl!S5Sibl"'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"O<SI of m;I!ena1 for coo\"erlLng a norm.:ll trealmenlc"""h,nloasbbk>andeffKioenlfriction-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 l
'0'
o o
",~~~L_J
,., Figure t2.67 Exampll'Sofa moMiling coucil. (01 Floor plan Ib) Rotation. (c! Exten,ion. (d) Lateral fI~xion"lcl Rotation
2
taken. the patient will almost certainly suffer a markl'd exacerbation of symptoms. The symptoms may be ",lie'"OO minimally by 13 kg of traction. and under these circumstanCl'S the
Lumba'ipIM
Sl.......gth mav be incTe-.d 10 "rPro~lmal\>ly 20kg UJd the dur.. tion can be 10 mmutes. HO>on 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) localist<j manil'ulation. (0) Distal ~nd raised lbjProximalend,aist<j
Lumlm~pine
behind the patient's left hip. This position lea,'es both h.lnds free to add to the rotation at the intervertebral joint. The left thumb presses downwards against the left side of the spinous process of the upfX'r "L.,-jL'bra, and the right middle finger (usually the strongest) pulls upwards against the right side of the spinous process of the lower vert"inand hack ~tiffne~ and the ~tlffn~~ would last for a few hau~(Unusualforanan-inflammalory
musculoskeletald,wrder,j Coughing caused ooth bad pdin and left ealf pain Hewasusingindomelhaein\lndocid)~uppositories
CASE HISTORIES E~en though there are case hi~torie~ at the end of the book. it seem~ uloeful to indude he~ an example of how the manipulati~ physiotherapist thin~ h~r way through a i>"t,ent'~ d,fficultyand atypical spinal problem. This particular example demon~trate~ how to link the th~ry with the dimcal pr=ntation. II al!.O demomtrat(S the differentcomponentsapatient'~problemmay have, and how one com~nenl may improwo and anolher not. Thi~ palienn diSQrder demonwates how the Iherapi~1 mUSI
every night, and he feit that the~e were esloential to I~loen Ille level of his pain. {~fl1ap~ tl1i~ mean~ there must llean inflammatory component.] 4. BendingCilus.eilhimloeverebackandlegpain,ooll1of whicl1 ea~eedi5C i~ p'obably medial 10 the nerve root and il~ sle~v~, and will th~,efa,e ~ harder ta help by pa'i$ive movement technique~.1 Ned f1uion while he wa~ fie~ed wa~ limited by inc,eased ICjl pain. [There mu~1 ~ a canal component in hi~ disorder.) II did nOI increase hi~ bad ~in. (The cause of hi~ bacK pain i~ probably nat cau~ing hi~ leg pain. Twa a~pect~ of th~ one~truclu~pemaps?Thedi~?)
4.
While~till
increased
in Iheflued
po~ition.rotationtotheleft
hi~kg ~inbyabout
100 per ,ent
Rotatinn tathe ,ight in flexion decreascd the leg ~ymptom~, slightly but definildy. (It is very hdpful from a treatment pointolview to have different respooscswiththediff~'entdireetionsof rotation.) In thi~ man's drcum~tan= it i~ wise, when ron~idenng th~ selection af t~chnique. to choo~~ the relie,ing po'5ilion while performing the relicving direcl,on lor th~ ,otation. 5. In the up,ight po'5ition, pclfarming a lateral ~hiftaf his lrunk towards the left de
informitioninnumber(l)abovl:.hchasatleastlhree romponenls. Number (4) abovl: makes it 10Uf romponents.) 11. rongling was f~lt eith~r in th~ big toe or th~ lateral borde, of his foot. (This indicat~d th~ passibihtyof two neM: roo~ being involved. This rould mean thit two intervert~bral di= may be involved. or th~ patient may have an anatomically abnormal formation of the nerve roots; sce Figure 8.}.)
399
400
MAITLAND'S VERTEBRAL MANIPULATION
12. Ik alw
~ad
canal
mOVl:m~nt abnormaliti~~ as w~1I a~
int~rv~rtebral joint mov~m~nt abnormaliti~s
to bo: causing ~im mo~ disability t~an t~~ radicular as~t, but obviously th~ radieular aspect took ~ig~~r p,iority. B~ing atypical m~ans that on~ ~as to bo: rtry quick to notic~ t~~ chang~s in t~e ~xamination signs of th~ separat~ rompon~nts. and to react with appropriate t~ehnique c~anges
Th~ ehni"" nf t~c~nique would bo: rotation, as symptoms and signs are c1urly unilat~ral. Therotationwouldbo:~rformt'dinth~
gf~atly improv~d,
l~v~ls.
Thenexttrcatments~ssionconsistednf~rforming
Mr Lwas positioned IYIMg on ~IS Ittt sid~ wit~ a SlJpport (folded tow~1) und~r his iliac cr~st to gain a lat~ral shift to t~~ I~ft position (his comfortable sMt position. st~ item (5) abort). H~ was also position~d in a degr~e of flexion tn ke~p his lumbar spine away from Ih~ painful and markt'dly limited ~xt~nsion position. A rotation of thIS thorax toth~right in relation toth~ ~Iviswas also adopted, and his right leg was k~pt up on th~ couch to avoid anycanalt~nsioning (whicl1 would occur if his,ight I~g we.. altow~d to hang over the ~dge). Th~ techniqu~ was to 'otate his pelvis to the Idt (that is, thesamedi'~ctionasthoracie rotation to t~~ right, bYt pcrformt'd from bl:low Ypwa'dsl as a SlJstaincd (sustained becaus~ of th~ lat~nt compon~ntl grade IV. During th~ ~rforming of t~~ tec~nique h~ kit an casing of ~is leg symptoms, whid was a favourabl~ indication.
t~istccl>niquealltinglingmhistootdisap~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. Aspcdp"in,h.ashadperiodsoffavourandperiodsof disfavour. There was a lime when all low back IX'in wa~oonsid ..1'ed to have its origin in the sacroiliac joint.
Thc mood changro,and peoptc lhcn considered that th... !'C was SO little movemcnl in thefoint that it could hardly ix" the sourct." of pain. In reality, the lrue;nd· dcnce of $ilcroiliac pain and disorders is unknown. Probably the main n'ason foroonfusion lies in lhe factthMmanyoflhcphysicaJexaminationtt'Stsused by those who favour the sacroiliac joint in fact move many otherjointsat lhesame time.
When applicable tests 404 • bamination and treatment techniques Opcning tile anterior and posterior surfaces 404 Furtllertnts 405 Palpation 407 Treatmenttecllniques 407 • Case history 407 • ThesymphVSis pubis 409 Treatment 409
404
The sacroiliac joint has a diven;e and extensi"e innervMion from L2 toS4. This may partly account for the inconsistency and variability in suggestro sacroiliacjoinl pain P.lltemS. The joint also po5sesses a relati,-ely small amount of movement, which is difficult to measure. This is what makes tC5ling indiscriminate, and thcdifferential diagnosis may then ll-ad to a wrong conclusion Furtherrnore, the iNCCffiiibility of parts of the joints make manual evalualionofdinieal signs diffieull. 11lc insensitivity ofpassh"e testing of thc sacroiliac joint, therefore, always leaves the manipulative physiotherapist woodering wl1ether, in factsl1e has located relevant c1inicalsignsthatcorI\.>spondtoasaeI(liliacdioorder.
Thcmanipul"ti~phys4otherapistsl>ouldscckto
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.., Mostpaticntswithp
SPECIAL QUESTIONS \Vhere p"lvic symptoms are concerned, it is relevant 10 ask about genito-urinary and bowel funclionas well 115 saddle anaesthesia,
HISTORY Sacmiliacpainiscommon:duringpregnancy;whenan inflammatory disordl'T e~is"'; as a result of rq>eatcl \-igorous sporting activity (such as fast bowling al cricket);andasaresultofowrusestr.,in.Pel"icpostunl
S;icroi1;acr'"9ion:sacroil;acjoint.symph~ispubis
alignment faults Or disorders clS
mo""meM(,1 Bridapp,.isal Acti"" mo""mtnls (roo"" 10 pain or move to limit) Routinely
Astor
lumba.spin~
As applicable Folding tach kn« ontoChtsl in ,tanding and lying 1S(lml:la'lUlI; an~ should be U5£'d tocompk-ti;Ihete'>t5;fOf~mr'eF;gu1l'J3.ldsho ...slheposteroanterior pri>SOoUIl' Mng dltl'Cled IateraUyonlhe left posteriorsup..'Tiorili....,.pine. Tlw s.lCTOlhac: test sN:luld be performed as part of the e\anuf\lItion of e"err patient with back p.:ail\, whetht-... then' is any likelihood of the symptoms arisingfrom thcsc joints or not. as pain with this mov .... m\-ntcanbethefir,t,ignofankylosingspondylitis. Two furthf,r to$ls th~t ex.lmine the rotary m"""m\~1ts ofthepeh'isabouttht·sacrumthroughatransv..r.seaxis should be USl.od WhL~l the SiIoCroiliac joint is thought to be the source of pain. The first test tilts the uppt-"T pelvis bilckwardsand thcscrond tills it torv.'ardll.1illinglhe uppt-"T pelv,s bild:wards IS commonly usoci.ltro With
spmaI6exionrdatedacb\·11}·orexlen!iionoithehip.and tilnns the upper penis forwards is commonly -.0ated with sptnaI extensoon ilCh"ueor Rexion of the hip
FURTHER TESTS Backward tiltoftht upptrptlvis
Stoning position To leSt the left sacroiliac joint. thl.- fUhenl lies on his right Side with his hip!land krwescomfortably f1oro less than 90". The physiotn..rap;"t stands in fronl of his hip!l,facing hisshould""',and I..ansacross his hip!l to place the heel of her righl hand ovcr the posterior surface of his Icft ischial tubt>rosity, with th.. fingers and fOl'('arm pointing over his hip towards her (ace. She plan~lheheelofherlefthandO\'erhisant .. rioriliac spine, with her fing
Extcnsion Almost imm~diately she was askcd to utend h.r spln~ 5·, thepaindccptoherPSISbecames~re,
lateralfluion When ask~d to lat~rally f1e~ herspinc to the left, the pain deep to hcrLPSISwasonlyfeltasa discomfort at the cndofthcmov~m.nt.
408
MAITLAND'S VERTEBRAL MANIPULATION
[On "lI..-tting. ~ wa~ no oct", pain. no c1lX01"1fort, no~...cIgooo:Iq..-lilYoflllOYl:"'Cf\LI
lMlrltWa-irqlrOdut'\'durfy,ntlltlllOYl:mmt;tIIt ao:IcIitianofhipmo:'llia'ro(;1liond..:lnold\;l~
lMpain. ShImp 'n t~f lJump posIt.OIl, tilt pain d«p to 11ft LPSlSamr OIlr\'l()ffw"fnllftlfftkn~~2O''Ihortoffun octfft\.lOn.Kt~and~fItxionandfd~
d'dnOlthanCJfth's-
st" At70'ofLSL.RYlffflthfrp,aindetptothfP'SIS, butlhi~d,d not thangt whtn the anklt waS dors,flexfdor plantarflufd.
HlpF/ADD WhfnlffthipfluiOf1WaSPf'formfdpasslvely It Iocr of fl~l
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 ht-'fltial. and p.a.... response on palpalory mO\'ement is lhe5a:· and mnd most import.lnt essential. n,., first palpatory
Mrthod TI.erochruqucistt...SM!W'asNtdcscribc'dw,!h5lmw.r tl.'dvuques. but 'I is unportant hI= th.l pain produced by~bone-to-boneconliraisa\vOded (Figurr /4.1). Gentle mm-ements shouJd beUSol'd at first.ancI the dt.'VIhofthegradeshooJd beincn.'ascd only if the pain ~po-rmilSil Thcimportantpartaboutlhe techniquc is that thcgrealcsl usepossibleshould bemadeof: 1. V,'ryingthepoinlofconlacl,e\'cntotheextentof
changingbylmmalatime 2. Varying lhe angle 01 lhepres.sure-cephalad. caudad. left. right and romblfldtionsofthcsd
The tl.'Chniquecan bept'rforrned unilat"rally, as in Figllrr 14.3. which givcslhe di...." 'tionof mm'ement an angled inclin~lion. However, it can also be pt'rformed with each thumb in the same anterolateral point 01 contact. on" on each side. The Ihumbs then lran.mit synchronous pressu....- to the codast!lclI\!atmenttdinlothefollowing: 1. Brief5tatemL'IltsSlOinhisfoot. His tibialis anterior waS l,eXlerl'j()rhallucislongus2,andtoecxtcnsion2+. Treatment
GlJidingfactors I. Trac1ionwouldprobablybt'lheflrsltrcatm('ntlhat stlould beconsid.. red. HOVl·....·cr, as the patlcnt has had lritClian In hospil.. l and been consid('l"ably
relievoo of hIs symptoms, the last ,mp1"O"emmt in Ius m.and it Wa3idetided to.-intenrullo>l uoablelracbonmsteadof~tlrioctiQn~~ ~
oscillatory mdf()
mltt.-nt symptoms in the IefI dbow many bmei a d .. y "ThPydidnotla:sllong ..nd ..erenot ......~,but .. ..,... unplNsanl (FrS"" 153)
.. "durah",,()fI2minutes.
th... pat;,."t'sldtlJiceps,bult""rene~aeti\llyappean.od
normal. On
e~amination
by "alpalion, it
w~s
ca.>ily
dcterminl'd that thcrcwasa l0S6ofal least 50 pcrcent mo\·ernentatthcleftC6/7inlcrv..rtdlraljoinl.
Fifrhdoy n...patoentsldlfdta~ttleimproved.andbothne>Oon
Trtatmtnt
and st..-..,ghtleg ralSUlg had """mtamed the- S<m /2·in) tm~emenl in rang... It was then decided ttYt per-
GuH1mgfoctors
.... Pl'rotabOnrouldbe~IO~IrioctionIO~1i
I. As~symptoms.. ~urn"'tl'f"al,the...lectionol
ttusw'ouIdgainasLightlyqWd.er,mp"""ftnI'J1I.Thrn-foIlow'ing a pm.od 01 15mlllutt'S on H-kg tnIoC'bOn. IWoprriodsofrolittion w'ftI'giH·ngently.
2.
krluuqueswouklbebetw·('It'npasten>-antenor
'on>.
Sixlhdoy
uniLoIfta1~preMUn'androt.otion. TradionwouldnotbPlWjulf'l"d,.noton1y~use
II hM ........ allnn~ beforr ..·ithout SUCtt5l§ but al"" ~USI' tI'It' symptoms are not ...... erI'
Thcpaltt'fllrepor1cdfct:hngwc>rSt.'agalll,andhisfle>,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 reli
and over the nexl 3 daysincrea,;ed toa oonstanl ache This made sitting difficull and inl"rfer As symptoms had gone, the patienl was pleaM.' figun. 15.4
Chronic lumba'
n~"'~-'OOI
pain
Eumples of t~i1trMnt
Firstdoy On dek'nmmng lNtW paliml'l symptoms ..·eft no!: irritlb~, II "'as decided to U5of' rotalion quite strongly 'lind lTl .. sust.unedm.annc.'l",~rotalionwitScklne, rotallng the pehis to the nght.llnd Ihi5 WitS susbined stl"OOlgly II WitS repellted four hlTl('S. AI the end ollhe lreal~llhepatienlsaidhiss)·mptomsfell .. lillle easu,''!", .md strlllghileg rlll~lng hIId impro"ed by 5nn (2inl, ....Iex,on had 1100 impro\'oo
S«onddoy
Physical findings
The patienl reponed fl....ling much the Solme, though
his mo'cm~.,,'" had maintained their 5lightly inc","sed rang;:,. It Was decided to rcpeattl\!' rotation. bultoadd pthepalll'f\lrt'p(Jrtedthathisalf
fell much moft'romfortable
Fifthdoy By the fiflh day II ..·as decid~'mU!tftl1 at first, but bocameronslanl o\t''!" a period of I "'cclornW for hIm. lind trealmenl WitS d'!iconllnued WilS
INSIDIOUS ONSET OF LEG PAIN uamin:o",,;o"-"
_
History I'or 10 ye~rs a woman ag~'n unl>earableat tim"" (Figl"e 15.7). llisreferringspt-..:ialistsaidtherewaslittlee"idence of cardiac disease and, as neck mo\,ements were ,,-'StriclL'd,manipulationandtractionshottldbcgi\'en asa diagnostic lrial
\1
::~a:15.7
Sever~
Idt cn",t and arm pain '1mula\lng cardiac
421
422
MAITLANO'S VERTEBRAL MANIPULATION
Physico/findings
Eighth day
NL"Ck mow~menlS we.... markL-.:lIy rL'StrietL'CI. E~tension waS impossible, forward /le~ion, left laleral /luion and leftrotationlack0!d6O"0ftheirra"se, alldri shtlaleral /lexioll alld right rotation "'e.... limill.'d by approxi. mately 25°. All of Ih"5t' movement:;cauSL'CI pain in the arm RadiologieallylhebodyofC6wasnarrowL'CIverlically, alld the.... ",as marked llarro",illg of the C6j7 interbody space with o\'t'r-ridiog of the apophyseal facets
By thisstilge,pain had been reduced and all mOVl.'m"nls were IL'SS limilL'CI. Forward ne~ion was p.~inless. and pain was in Ihe same areas-namely thechut Ih£>chest pain remained unehangL'CI. Th" thoracic spine belween nand T5 waS tllen mobilized three tim"". pushing tl\e spinous processes from right tol. 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'·em Tlll're was an arc of p.llll fell 00 top of the shoulder during mid-range abductlon. and a static ronlTolChon of the supraspmaluS muscle a150 caU$l'd pam on top of the shoulder. PolSlSiw mo'''emcots of the acmrniocI.iIvicularjomt and glenohumeral joillt ...erepain1es5.All cen'ical rno\emenls ...ere full nngt'! and pa~ EM'e'J'I for slight tenderness in the ft'S'on of the inserlion oflhe nghtsupraspmaluS tendon. all tJSSUe!ii felt ~I
Trutmtnt GUiding (acrors
Shoulde.treatmenlwilhl'1T1phaslsonthcsupraspina· tus 1 4. The progress should consistQfa lcsscnmg of the se""rity of thc attack$ and an e~I,-'l15'on oftl\(' pain-fn'C period betwcen attacks. 5. Trcatmenlshouldbeire;tltutedaSliatlyea~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~betweenastheybecamelessnece
SCAPULAR PAIN
E.uminition H,story Orll' wel'lo.ago. wtull' yawnmgand stft-1dun:g.,a woman ..ged ;j,() )'('ars felt .. Wrp pain m ... the left sc..pulil. Dunng the next 2 hours the ache increa~ slightly Ul intensll)·...ndspn"ildm ..... great..... re;olocon.·I"thl' k!ft sldo:> 01 the lower neck ilnd the left m,ddll'and uppl.'f SCilputa. al'l'il (Frg"" 15.10). After thai, the :oymploms"..",."rM'dunaltered. Thep.ohent had had a:oimilarp1SOd1' a y"ar ago. wluch n."CO\'ered wIlhoutlrealment in 4 days.
PIlysicolfindings Th" symptoms coll5islr 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 increase of symploms and sigos On the followingday.
ACUTE TORTICOLLIS Examination History A boy aged 16 yl"ilr5 waS wakcned two nights ago al
3am by pain in thc righl sidc of his nl'Ck. He had nevCr had aoy troubl" with his nl'Ck previously, and had not bl..,n carrying oul any unusual work during the few days immedialely prior 10 the incident; nor had he IJ0.. rotalion to th" lefl; how.·""," as the", is defonnity. care will be n",-'CIl'CIlO ensu.., that a physiological rotary movemenl is produced Fif5tday
A rotation mob,1I7.ahon to the left was given first. ThiS waS done wilh the neck comfortably flexed. The tolation was taken gl"Tltly to Ihe limit of the range allowlod by the pain and spasm. 00('(' the limit was reached a gentle OSCillation waS carried out. attempting all the tim" to incrt:'a.., the spasm-f!\.", range. This was continued for approximately 1 min"te, As there was quite a marked improvement from this one mobili2illion, il was decided to gi\"(' traction in flexion while lying This was donc for 15 minutes. By doing this, the fol· lowing mobilizations would possibly be moreeffe.:live and of less discomfort to the patient than if more mobil· ;7~ltion was don~ at th~ beginning. 1'01l0wing the 15 minutes' Iraction the angle of deformily was reduced, but there was still markl'CI limitation of right lateral fkxion. ""tension waS grcatly improved. Rotation mobilizing 10 the left W"S repeated three times, producing further improvement. During the mobilizing, the rolatioo was easier to produce and the muscle spasm was much less. Tracti"" was repeated The range of lateral flexion w"s then.50 per cent of normal, and extension 75 per cent of norm..l, but each mm-ement still caused right n,,,,k pain. Some indication of the deformity was still present, but Ihe p"tienl was able to adopt the normal head position
w""
428
MAITLANO'S VERTEBRAL MANIPULATION
without pain. Rotation was K'P"atlxl thrL"" times. It waspossibletodothismuchmorestronglyatthisstage Traction was repealed. Following this, terminal extension caused pain. right lateral flexion was 75 per ccnt of full rilnge, and Ihe deformity was almost gone. Rotation mobilization 10 the left was repealed twice more, and traction reapplied. Movements were then full but were per· formed cautiOllSly, and thedeformilyhad gone The patient was ashod to K"St, using adequate neck support. As he had bcenusinga rubbcr pillow, its disadvafltage was explained; Ix-ing rubber it has the K-n· d.",cy to maintain its shape, and during sleep this will ll'Sult in a constant nudging againstth., relax~-d ",-ock. Although this may seem trivial, itissuffidenttoirri tate an easily disturbed neck.Togi"etreatment~·very il5Sistance, the patient was shown how to make an ordinary flock or feather pillow inlO a bUllt'rfly shape byshakingthestuffingtotheendsandtyingthecentre isthmus lightly with ribbon. He was ask~od 10 lie with the isthmus under his neck for support, leaving the wings to stabiliU! the head. Then, whether he lies on his bilck or side, he has adl."<juatesupport for the neck and the head. lfnecCSSed next, tipping the patient's head to the left. patiently coaxing thc position to relil.":e sp.lsm first.Oncmanipulation completely restored movement. The test for range by passi\'e intervertebral mO\'ement was made following the manipulation, toensull' that range was rt.'Stored. Heat and massage we~ then gh'en to relieve
SN:Ondday Movement was normal, but sorene§!j was still p~nt l'dlliative treatm"nt wa,gi\'en, but furthermanipulationwasconside,,-'Jl help«! by gentle oscillating mobili~ation, particularly postero-anteriorcentral"ertt'bral pressUl"l'
2. Even though the symptoms are bilateral, the pain felt with lateral flexion is worse when done to the right. It may therefore be better to use a rotation mobilization using the right side as thl' dominantly painful side 3. Symptoms thai have a gradual onset u.ually rl'Spond bett", to traction than to manipulation
Firs/day
Fig".., 15.13
low bad p;lin with mark.d rnIi"logical
d.g.n.lat;v;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 thlScau5e
Theproh'ct1,e5OOliOlJI~resu1t1ng ma bIt loth
II BUTTOCK PAIN Examination
HistOfy A managed S5)~arsgradU.tllyd",elopl-dright but· lock pain mer a pmod of S d.J,)"S while engaged 00 hea,'Y shm·... work 6 moothsago, He "'a ablt'lOrontim.., work. and although the aching did not become any ..vrselldldnotimpro_eAftt"l'alongperiodof ul\SUC«'5I>ful 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 will need to beusedinconccrt.
Firsrday rransverse presl\u!'t' towards the left at the L2!3 It"'el and above and below this joint waSfX'rform~'dthree times. There was an improvement in eXlension and left lat~.,.al noiun, but the movement wasstiJI "ery painful
Seconddoy Thcre was no unfavourable reaction from the first trealment,soinlermitlentvariablctractionwasadd~'d
Examination
History Six month$ ago, after an unusually long rideona bicycle which had a wide ""at, a wOman ag~'d34 year; developed pain in the fl'gion of the roccyx. This pain graduallyinc"'il,*od until it reach~'dastilgewhenshe was unable to sit Ihrough a full cinema programme The area ach~'d foratleilst an houraher prolonged sitting, but provided she did not silagain she would remainsymplomf"-",, Since Ihe age of 16 ycars she had had minor low backache foHowing gardening Or heavy housework but this symptom had not ahert'd during the I"st 6month$(Fig"", 15.17) The refcrring doctor fclt thai thc patient's sym~ toms might be from her lower back rather than of local coccygcaiorigin,and requ~'St~'datrial"fmanipulati"e trcatmentdimctcd to lhe b.lCk. to aid in assessing the SOutcc of thc symptoms.
Physico/findings All mo\"cmL'Ilts of the lumbar spine were fuJi and painless, but the patient was able to elicit pain in thcroccyx by sitling on a hard scat and leilningback 10". Iloththe coccyx and lumbosacral joint were tcnder on pressuTl'.
Exampl~s of I,~atment
435
oc'Cn maintalned,itwasdecided to repeal thcposleroanteriorccntral \"crIebral pn"SSun'. Afll'r the firsl three limes there was an impron,'ment of 5° wilh the sitting lest,bullherewasnofurlherprogressaflerlhefourlh
Third day
Figu"'15.11
Coccygoo.,.nia
Treatment
Guiding factors 1
During eilch treillmenl period, the only guides to proglGS are tndemess to pressure and the piltirnfsabilily to lean bflt had not notked any improvement, bul il now rcquin-d wo of leaning bilckwards to prodoce lhe coco;yge31 pain while silling. As Ihis impro"emenl had
Fifth day All low bao;k discomfort had gone, and the patient nOliced that the coccygeal achc had taken longer than usual to corne on with sitting. On ... xaminalion, the I...n· demcsso\·erth... coccyxwasapprnximalelylhe...ame, but the sillingand leaning back tC51had mainlainroits range of 35". Rolation with Ihe palient \ying on her righl side WaS rcpcat...d lhn'Ctimt'S,afterwhichshl." could .it and lean backwards without f......ling any dis.::omfort. There waS also noticeably IcssCO('("ygeal tendl'Olt'SS
Sixth day The paticnlconsidewd lhat her ability 105it wilhoul pain had improved to80perc...nlofnormal. Thercwas very lilll... tendemt'Sson palpalion,botat the Iimil of leaningbackwardsin.il.lingihepatienld four limes, and although this did not.>eem to make much diffe",nec to his mo\'ements. the patient was able to saythatruslegkltffC'Cr. Secandday The patient had retained the fn'e fceling in his leg for 4 hours, but it then retum..>d to the previous stilte, The treatment was repeated,and postcro-anteriorccntral "crtcbral prcs:sure waS add~>d. The treatment again producedaffC'Cingofhislcg Thirddoy The patient retained the fred for a similar period Subsrqurntdays Thesamelrcatmentofrotiltion,~ntralpressurt'Sand
traction w,'s repeated (or the next 5 days, during which lime the symptoms bI.'Came much easil'r. The fn.'Cdom was retained from treatment to treatment, and the scoliosis w~s rt.>dUCl>d by 50 per cent. Slr~ighl leg raising and forward flexion wercl'SSCntiallythe same, except that the pain felt ilt the limit of the ranges waS d~'Cidedly less. Trcatment was discon· tinued. and the patient was rcviewed 1 month laler, At lhis stage, his symptoms had remained n>Ii~'\"l'd and his movclllCllls wcreapproximately thcsamc, On review 12 months later his scoJic.;is had gone, and his straight
Examplel;oflrUlm~nl
leg ralsmg and forward flexion had both impro' ~>d by JO per Cl'nl bul "'I'll' not ocormaL HOWI'\'er, al Ihis rangelhe) we". pam free.
2. The palit'lll has had lraction admmosle..,.j on a COll'5lantbasiswithouts~;thereforefurthcr
traction isunlikcly IoSUCCt.W 3, The techniques thllt can be used ,n quick S~IOO 1og.'ec....aron
BILATERAL lEG PAIN II il; periectly ob...ous that oat aU pahents wiU fl'5PO"d 10 !n'alJnl.>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:bralpressure because the symptoms are distributw unilaterally. 4. If nonc of thcabo\'e techniqu~>s relieve the symplOms.mobili7.ationoflheTSa",ashouldbe includro. It must be N.'ITICtnbered that the autonomicncr\'esupply for thearm ariSs from as 10wasTS.
First day Traction in flexion was appliw with firm pll-'SSure (approximalely 15kg) for 10 minutes. As there were no symptoms pl'{'SCnt in Ihe hand at the time of t",atmenl, Ihe Prl->SSUTe of the traclioncould not begaugw to suit the symptoms. On ",leasing the Iraction. neck flexion had impro\'ed a lillIe but hand tingling could still be produced by the palient combing her hair. Aftcr applyingtraction in flexion for a further 15 minutes,neck movementsandhandtinglingwereunchangro S~condday
The patient felt that there rna)' ha\ebeen a~lightless ening of the intensity of Ih", hand symptoms, but the discomfort felt with combing her hair was unchallgoo. Neck flexion had maintaill~'d the slight improvemcIlt fromthepreviousday.TractioninfleJsdidnotproducel'11oughchangetowarrant
continuing wilh them. II waS therefore dec:ided to mobilize the midlhoradc spine before allempting cer\·icallateralflexion. Postero-anlerior central \'ertooral pRossure was appliw from T) to T7, al a pre$l;urc that did nQ\ causc pain in the patient's elbow. The osciJIating was continued for 1.5 minCites. I'ollowing this trcatm~'llt,n~'Ck flexion was full and painle$l;and the hair-
Firstdoy Postde g...... W'r than nght sode) .. tthefiflhthoriOlX~·t'l8«auwofehestp"'i bn.alhing ..'as dUficult roughtng ".lIS Impo!i!'iiblt' nd the man wn unable to hft Ius lefl.:lnn .. bo\'e tus~. He had two """,.., blocks, but thee ga,e only tempor-"1) rcltd"(fWU"'15.12)
441
442
MAiTlAND'S VERTEBRAL MANIPULATION
Physico/findings
5~ronddoy
The trunk was held rigid a. if to a"oid all movement, as movements of the head cau,.,d che5t p.~in. On Ihe Idt sidcof llwtrunk, theconst:ml p.~in radiated thmughout th"fifth thOLlcic level from the vertebra around the thoracic cage to the sternum, The rigM-sided p.~in. which was mild and intermittent, would subside with rest. Trunk rotation to the lefl ca ..."..'d pain throughO\lt the "rca, hut partic ...larly posteriorly on Ihe left afler l()" of mOVeml'lll. Rotation to the right cau,;ed pain after oW', With lateral (Jexion of Ihe trunk, pain wa. produced at the ]",ginning of the mOVeml'llt to the len and after 2Q" of the movement to the right. Trunk (Jexion (o... ld be performed more Jl:>adily than other rnov.... menls, bllt il .Iill had to be done slowly, Without any obvious movements of the trunk, 50 per cent of head and neo;k extension caused the thoraciC pain. Cervical rotation to the left. which laCked 20" movCTl",nt, also caused Ihoracic pain, T"ndernc'SS Will; most rnarkc' res ... 1t was an il1crease in lrunk rotation 10 the lefltom'.
Treatment Guidingfactor5 1, As symplOms are ,.,"ere and movements groSSly limiled, mobilj,:ing will need to be don....xt....-mely gcntiy. 2, Traction may be made diffiellil by th.. patil'll!'s inability to lie on his back withoul pain, but perhaps ilcould be donesiUing 3, Although symploms and SIgns ha\'e a unilall'ral dominance.postem-anleriorcentral"ertebral pl'C$sure will probably be Ihe best procedure becao>e 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 bed to p~. "!'here may be faclors such as rheumatoid arthritis. which will hmillhe strength represented by R, to being moderately gentle, 1'lMTt.fore, as with 1'2.0 Rl nl'l'l1s 10 be quahfled. 'The qualification Ol.'COs to be of two kinds if it is gentle (e.g. Rl (IV-, RA)), the first indicating its strength and the 5oCCOr\d IndlCallng Ihe ",ason whr the move~1 is stopped even though the sln.'l\gth is weak. When R~ is a strong resislance (e.g. Rj (IV++j), its strenglh only nt"'cenR, andL,andlhelinedepictingthebehaviour of the resistance is drawn on the diagram (Figure Al.19). As Wilh pain, rcsistanct' can vary in itsbchal" iour, and eX,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
Figo•• A1.25
.
1" Figor. A 1.24
Spasm
-
tn~t (Ion
1IOll,mll rang. of mov.m.nl
Mo,j,fi~_...... td,agram
0,
Figu ... Al.26 joinl
F.. m.olmo••m.ntd,agramfOfnypermobil.
M01Itmtnt
in tN- exammation of joint m",·emenl.1l>e following demonstrat how the diagram is formulated. When
di~!Ir~m
thtory
~nd
compiling I
m~mtnt
diagram
\Jl'SI1ngtheO/4JOUltbypostero-anterior~re(ltl
ident,flCSwher-e thatp06,hon ism relation to the roormal range, and I'l'COl'ds ,t on the baSo!' line of the mo,·... mentdiagram aspomt L(frg,,"A.U8)
thespinousproceso;ofC3{forexample),theroulineis ~fol"'"
STEPJ. L- WHAT
STEPI,P,
Forthth}-pomobiIejomt.thenexl$tepi510~~
GentW, tnCn.'ilSUlg pre!i5Ure is applied wry ~Iowly to tN-sptnous pl'OCe55 of am a pll5tero-antenord,n'C* tIon.UMlthepatientisOblo:.edto~wlwnhefinit
feris pam. This point in the range is noted, and the plW~lOI:heraput then rele.-s 5Qme of the pressure from the SP'oou~ prtX.'e!lS and performs small 05Ci1L1· lory mm'ements. Agam s/l@asksthepatient if he ~ls any pam. If he does not, theos
watch;Ilg lhepat;ent'shandsand face and also by askinghim, how the pain bchav,-'Sbetween 1"'lIld l'lor belweel1 PI and I". In f'lct, it i5 beltcr 10 think of pain betw..... nl'landL,bcSCntatioo ofpain, ....-si5\· ancc must be conside",d. This is achieved by receding further back in lhe range than 1'1,whcre, with carefully applied and carefully ft'lt oscill31ory movt'ml'11ts, the prescnceorothcrw;,..,ofany ...." 'i.tanceisa5 graph between thejoonl5 R, and R:(FiS"'",AI.J4).1115 a!§o.--rytoqwlifyorddinl>R:-
and compil,ng a
~m~nt
diagram
451
lm"ards A if i' is NSy 10 pI'O"oke. and towards B if it is d,fficult 10 pro\·o!o:e. "The strenglh of the spasm SO fI"O"okecwhl'ntheelements of the mm'ement di.agram OC'CUpy only a '-ery small perrenlage of the full range, the '-'is of the lTI(I\1"Il'IIl'I'Itcbagramneedsmodt6cltiDn. This is adur\w bybreahng the base lineas in figolrrAJ..36. lheCl!ntre 5«bOllcanthenbeidenhfiedton"prt'!iefllanyiength. in an) part of the mimmal full ... nge. When the examINlhon findingsareonlytobefound in the last, say, S' ofafullrange,poinlAintherangeischangedandthc IineAI:l is suitably identified itS in figu,..Al.J7.l1us example demonstrates that from A to B is S', and A to 1/4is2,andsoon
.
.
~J
f;'urcAl.J6
MD,lLfi~dl;ogfll"'t-loIl'r ....
EXAMPLE - RANGE LIMITED BY SO PER CENT Markal stilfnes& WIth L IS a Luge dlS~ before B l"I«"!i5itale5 a modified form,ol of the Q>O\emenl diagr-MJl. lhe examplo!o will bot" restricted Jo.ne,fo f1ex1Cll\. i condit;.;., of 10ng standIng following i fraetu~ The first element IS R and the d1Sta~ bet,,:em R1 and L IS only 12·. I'aln is" plO\'olcd only by sln.'1eninll; (F'K..... AI.J8).lJthe Q>O\-emenl dIagram ..·eredra"n on an unmodified format, ,t would be as in Fig'lI'rl\l.j9 It isdcar lhatlhediagram in Figurrl\IJ9 wastes con,iderabledlagram sp.lCe. and 'l is difticult to inh'rpre!. \'lith the same joint movcmenl findings represenled on the modjfi~'l1 form"l of the movement diagram. it becumL'S clearer and much more useful The modified format of the ba5l' li~ of the dLilgram (Figu,., 1\1.38) Il'quirell only two extra measurements 10 be stated: I.
-
Knowing tNt R, to L eq~ls 12" male! II ea>;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"
mOl'lmlrnl. The goal is a 'compromise goal', which infel1l that Ihe range of movement will bc rcslored to what it was before it became symptomatic. and Ihe ~I ml'lOms will hal'e either 1x'C1I clun.-d or restored to whalthepalienthadconsidel\.-dlobehi~normal
Such c,rcumstances occur 50 ofll'll that lhey are ..·orth}ofdesc'riplionin\(·rmsofthemol'l"1TK'fl1 diagram. The exampk" be of an e1detiy man ..'ho has IiQUghl lrNtment becau.... he 15 havmg increasmg disromfor1 in the righl mid<en'ical arell, which he 1\OotIaS ..·,thtum,nghi,headlolhPnghLpartKularly ..'hen trying to n:'\erse Iu5car Prior 10 SoCeking lrNtmenl hP bel..... ed he rouJd tum his head equa.lly 10 left and ngllL and the lnO\'emenlS ........ pa.rue....Asi:s50oftCTI theas;Khb,lldsplJ"lOUSproce.s ofCS(FiK"rrAJ,lj
When the .... gittal po6k'fO-dfromlhCSlandardlwobifidproge
P,
.,~5
8 L
',gu", AJ.3 '>agitUlI postero-.nte,iorrnOliemenl,oont.ct point On lawai side ofltft bifld 5piMu,proesoonl.ctingeachofC5'st>ifld'P'",""SPfoec1l emphasil.ed in IhiS ~>dHion. 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 ",Iatelf means nothing mo", than thaI there are groups of prople who have symptoms from many joints. One rheumatologist ",fers to these people as ha\'ing 'acute joint awarenl'Sll' The first groupconsisls ofpalienls who seek treat· ment lor pain in, say, their lower cervical area. The symptoms are usually locally situated. though they may spl'l'adaround the immediate area. Whrnthcscpaticnts gain impro\'ement from the initial mobilizalion treatments, they comment about pain in the mid-thoracic arca.1f this area i~ treated as well, and it improves. the p,llients then comment about symptoms in the 10werlumbara",a.Thcsepatient~arene\'ertotaHyl...,.,
~Iit'll'patitntswhosaythatthtifneckpain~ganas ar=ltof~lecpinginadraught
Not all peopll." tTcating musculoskeletal disorders are prepared to take much noticc ofa patient who says that hi, nL'Ck o.back disorder is aggravated or provoked by sitting or lying in a draughl. Some patients will even say that thl."}" are affected by the rold air from an air conditioner. Most clinicians have hcard a patient S.en:is•.' S th.,n of the ultrasound. The d>oiccf(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'
For the lumbar spu'M', I~ are two othrr factors in relation toexen:ise: the USI.' of ~1Qn "",erUses ascornpared w,th extension cxerru.l"'i; and e~ertising the interwgmcntal muscles as cornpan.>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 hnulf>g subclinlGll acl1'''' p~ may prohibll an I'J(cr-
cisl' programme, At Ie.ost " .. !>hould be a,,'are NI ~ ~ can be harmful. "nd!heu" mtroduction shoWd lhereforebe progress..... illnd CilnofuJ1\' monitcnd lbr question is often asled. should e.....-cJ!ICS ... ,,~tensione'.en:lSeS beeaUSIes. inlrad~ .. l rJl."osun· dOC'> 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 <x:rvlCoil d,sorders in which their pillow is a source of irritation and of continuing symptoms or 1'('('Um."I1Ct.'5. In r";,lt,on to the pillow. the two most import.lnt a5pt'Ctsa~' 1.ltssizereL1II'·.. lOthepoal.......I·.\>pot;!on> 2. Its contenl relallve to the imtabilJI\ of the palient·sd,sorder. The pillo,,' heighl !ihould i>Upport the head and the ned, full,. ..nd in a neutral po6lhon. The content of the ptllo\O' should be sud! NI. If a hollow is made in the pillow a fl$l.Of1CO' the fISt is ....moHod thehollow should rcmdIn. lbr quiclcr the hollow disllppears. bec.lIuseof the nalu.... of its 'i'nng) conlenl.the worse il; ils effect on a n«l. thai is easil) dislurbed I'ahents should ~ sJ«>p bccauw In thlS position the cen·i£.aI mlerH·rtl'bral points are pul on full streich in one d,nx:!ion.
",th
rrone.
BEDS
UndL'T normal c;rcumsunces. til.:: ral11r s)mptorns. Although there are some p.oh,-'l'tts ... "o a", more comforbblc in the prone position. till' majonl) havcgreatdi[ficultyintummgon".,ftheyha,eb..'en aslet>pin lheproncpositl00
DRAUGHTS This has been discusst.-d ab!we. bUI lhe poInt is an important a)·shalea·...eallink·.('\·enifitisasymr tomilrir_lt should be pOInted out that if the chain (the ~rUle) ISgJlentoomuch ...orklodo.itwilJbcthewNlltnl (the intenmebroll joint) thaI breolks denvn fir.l
infn-quently. the spinal sliffl'l('55 and oldung continues after the\'irus has resol\"ed.l1>e5(>s;gns and symptomsCiln mImIC Mll'p\'Klde,and may respond 10 manual trNtmenl. Pat>ents shoukl aoo be told that their weak link j,. lnO'A'~tod.tm.ltgebytheth ...... ",·.",tsli.~ted aoo..·e .II lime when they are O'-ertm~d. genenoUI unwcllor UIlod.er physacal or mental st~
NEVER CLEARED Molny pat>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 in~K in .... or~ Wllh Dr Tom Ahem is !us USl' of mobIlv.ong (nwupulalmg) ~ The changes rt'Sulllng from the rna"'pula,,,,,, harpm as quickly and drama,i(ally .loS they do ....hen 1n.'.1"ng !he same ,ariety of disord~'f"!> in humans. Ahem is In the pr is II\Qn' Il'la\ed and Il1OIl' stable. Ahem ch~ to repeal the procedure after an inwnal at 10-12 ....f'I'l.s.but It rnaybepossibletoproducea:!-Spercml
faH)lJrabledJffenonceb) treab.nghor.;,o""no1shol1;>r periodoftunelllt'reha\ebeennohannfuleff«tsby In-ahnKhor
at>so~byth~horn Manysuggclmiqu"S u>ed to attempt to resto.., the mobility of a joint .. nd neurologic..l complex. It was a form ofach,·t' motion therapy, i.t'. where motioo was initialed by and was und"r the control of lhc therapis\. Slow mo"enwnts we", perform,.,j with direction, amplitude and pressures being selected by tnc therapist. ~au~ the therapist was al aU tim"" in control of thl'SC movements, inappropriate forces w,ore not applied. Movements could be maintainl.,j at the end of the av.. Uable range of movement for extended p
mel1!Sw",""p06sibl"inct:rvicalandlumbarregiort!l. lWo major contradictiOrt!l wilh this form of therapy were those common to most forms of spinal t~rapy,
480
MAITLANO'S VERTEBRAl MANIPUlATION
The5C wen.' vertebral fractuIl-'S, particularly in caScMJ,".t>cf/N AIOt""....
AL."'-lII.A L(l97"),"""",",.wu~UII
lb><JdM""'cfN~.12.1"
Ll1ITIbfoe;,oc,aknllnrichund;hn,UinrdorlkdrutWlg ,.,..",.",....... ~.211.211-228. A1tu."" T J.(I'l'n1 P"",of!ip"",Irip\(P"iOI.Catn., IX, 6-17
Bo.'lUlL...... (t'1iBI·Thrl......... ?yg.aporh'-'jolnIS.Theit ....Ion"andchnical ..~""""-I.. ~cf
~_TJ(I'l'M1CenI.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 tiSllu
A",,,,,,.,,
,.,..nw1.AlD.R.(l970).IlJiJ..--IcM"""'I.p74 London,CoU,... rOOt.l",,6ool<s-
M"""e.l,( I97I I,""SalhedIKe,plorati"n.Ananaly.bof rh" .... u>elof""',..,·erootin\'ol"~mL."linb8pati""t •. lo~"'.lofiJc>"'."J la"'tS~rg"y.SJ"'.891-903.
M...u."•. 1 (1977) Bacb. G. D. (19itI». Apf'lOlaon 01 manipulation. 1~7
MMTI........ G.O,{I978'\.Acu.. Ioc....... oflt-.. .......·>is ... ,th.di.1g"",,,",,,b~by.,,n,I..\'cl lumo..rspinalbloc1<pruct...Ju..., 8th B...."'.IC""/rrrnuof MPMProanl",,~.pp.55-61
I'IlILU.... D. R. and ·!\i.alpIo-o:Ul __ ~
ofEh-..yBnl'oIr/oJtl.... #{IUIrtI~.:z:s-'Q3-~U
\t...m...'-P.G.O.{l990).I'mf4mtI"'~/aI"",.3rdodn-.
pp
1~S--I56.london:SuttJc-tworthf.
MAC.U:n.\t_E.(I'IlI6)Tlwlinttt'\'.>tmenl~.11\
ModmI Mm"",T1tm>p¥t!{I'" VtrttforolCol"mn (e. (;n,,,,,. ed.).pp 661-672. Edinburgh Chu.dllllUvingslOl'll' MCCt.Ll.l.W.,PAn.,WM.ndO'llIlJE'.J,P.(I979l.lnduu'
McKThzo;.lt A. (19811, TIlt L~mNr ~I'"'''' Mrrl....it'" D1a,\~""''' .fIII Thmlp1l. New ZNl.1nd Spi.... ll'ublicalions. MJUNX. R.• nd W",u.P (1984), ThrCillfU",lI"crfp.",
H.>rrnonds..-orth~jn800l.$.
RaA/.IIo."l.U8J8j lttt'W tnl«rtotF.. fOr '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",CI",I.. ~ RJJJfrlLa,.rrerysrnd_olWelIenburg;an." :~;t('h,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/IMpc
nd!he
... _PmiciJ-l_
~_tt/I~.AIr..I
&w-JrmttfttrFitWTnah. e-r.a,WHO W_,A.(l995).H'~poo.I'""",pu"'n,..,lIwn~
.....·iewolpotenb.ll ....... rophlooolop;al~ AUtr""'71srnIpIf.I(SI,Il-I6. """,,",Il.(I976).n..lumb.uspww.-fb«Lp.>Jt\.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
,,,,.rmcnl,,,,,,mpl,, 427---128 Ae1io1ogy defined 197 Aftcreff""t defmedlOS 'A[tludJtwol....,._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 "'lOnw
C_"......~_,_
.,..,..·oc.-l'f'...... 2U,24.'!i
Ihonacspuw 311 Consull.>_
irutwl«lnibalconoullWono
Ccnttaond"",-.m·225
......
hYf'"'l"OWdy22..... ns n&ab\loty224 ",
WJ}'no!Cl,ause.m _ _ L"mba,opinr;ThnnmlNlIOn 11-12.1~ 1is1eJlm&1ll-1I,IS thoofy,anclchninllknowledge 8.
pI'l,1Iiologico1
.,;,sumlf\g34 mLSOnterp""mg31-33 ",-....bcotundq-.nns 33-34
IfUtW~2-16
p"tp.ot>on2S+-256 .......... ;ory~ ;;:.~.. (PAl\lMs)
W<do.ng~1O,1~15
C1inicaJhps
it'w_~R....-_""""""'"
§l"-'Clfkity~
l.... t"""'I_SUtr:M><j......,tt"'~t"......,t. Tn·.t""",t_ ,·"rbal26 ·u.nijd..rivat"""'l"",ard\'31 ".,rbatim ..xampleo J4 35
Com"......
,~:-.ylcsbng
.,..
.....
,;1umrh"'l 2~
c;;'':'~~~~:'~I'oW;~okillo
~91-92
~prubWtno6--l.1~
"'It..........-tdlralmom"8
I3J
..IN!dqucstlOnSl08 """"~ C_m..niocali.., ..nun Iollooo.tJpq_l08 "'-ry.WUIf"OI"i-.dsogm 2~ _ ImlN!d...... ~
......."_~_2JO,236--m ~1...-.......
281-28-1
~-. ~t1, ...
........;,.]~)
~Itototoon("
~~lIIrwd'lIOdvUqut'rJ6-U1
,·nttt>r.o1~278
n>ooth,-ruod281 fInJ di""¥nkdi",,roen 216 Itt olso dc-/onnity
"rot""I,,·..
o.r~21
490
INDEX
Dermot"""", siteofsymptoms iClS-I09,IW,lll Di,'gnosis age of palitecti",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-65-66 wcathcr~15
~411-412
~centraI,~
,,--
slump_l«-l~
cen'icloISf'1l"C!27S-Vl>
'ltn>5N~nisonsl40-I""
l'.thoIop\
""",icalSf'inem a and C2 in 3QdcglW tot.lion
2n-278
orill,n/or(I') 14/_143
Ph~~:~::=;:'~~~:
IUmN'spine 370--3'1
1~t;:::~IcSPI""321-J23
mIfIe>:"",e>.btnSiiliulionunde. &"""'II,,·,k 478
rKB(p....... Iulo!lI!bl:nd) 312
doctoo,"'oItnd~,
"...,.,.".
............
~iar:poin402
cbn>calappbc...... 0 1 ~ 1Nllun&91~
diasn
pain
~rmplornbl'haviour
In
l'roI.pooedd,,,,,Ill5 Prone knebr.lmo......rnenlS) CI·2(roI.non)
~~hnoque3li4. s1ump_367-36lI 1!>or'Ioc'lp,... 3IHI7
""-101\)264-265 Ol~li"n) 31' (l~t..,..1
Tn-51 fIe,ion/eJo.l''1'I5ioo362-.J68 lalcrill/lexlon36l)-.J(,1
rot"ion36l-J62
R2·12jit>l'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 Subje
s«.J..,Rt."",ru. '''''''rru.'Tlt;>s"-",,,"en' 2t~, 215,2t6 T""hniqu.,,; applisive range m physiological movem",,~ofsingl.. inverlabraljoints ..... under I'PIVMs(passi"e physiokJgicalinti.""'·crtebr,,1 moveffil.'rlI5) physic.lexamin.'tion 30&-318.307 appr.,is.ol308 function.ldemonstration! diff"r.;ntiation306.J07,308 observ,llion306 palpation 312-313 pao;si"caraldis -,'"
Vertebrl>a8i1ar ar"'ryk:Sting242-248 miti.lqUCShUning246-248 v..orte/>roba:;il.r insuffiCl