Maitland's-Vertebral Manipulation - 7th edition

ProgflO$is 93 • Structur,,1 impairment. but with a possible (or rervicalsourcc\"U1yinpartbeintradi~l.Theperiartic­ probabl~) likdihood of R\"CUrrerlCl'S of subj<.'cti\\'e ulardisorderismorelikelytohal-eafinalpl'Ql;nosisof impairml'nt subje'Ctive impainnl\"'t, when'as the cervical intradiscal would be a subjE-'Cti\"e impairment with the likelihood • lfrestrictedinhisabilitytodoanormalday's of exacerbations. The inten'ertebraldL'lCd\"\"\" nol repair work be.:\"u\".;, of inal'asing hl'adachl' and as completely or as quickly as periarticular ti5sues, and restriction of nl'Ck movements. th\" patient will th\"\"'foretherervi.:aldiscogeOlcsourccisHkelytohaw hal-ea handicap or participation \"-'Siriction. a compromise '\"'-'Suit from tre'atment and thl' like~hood ofrocurrenct'S. As to his future. only the manipulative physiother- apist', e~pcri\"nc\"and the knowledge of others can give Twoexamination t~'Chniques pro\"ide\"aloableinfor- thepossibilitil'S.For\"xampl\",ifth\"prognosisism\"de mation toward< making a fa\"oorable pmg\"....i~· at the end of treatment, it can only oc flXordl'<i that 1. First, if ttl'-' exami\",~tion t~'Chniq\"e of caodal gradl' IV++ comp,,-'ssion appli~'<1 with the- cervical spine there is a possibility that time alone may produce fur- in the position of the appropda\\(> de-gree of ipsilat- ther impwv\"ment and that thl' ,ubjecti\".. impairment eral nexion and rotation bl'romes pain·lree, the may subside. The structur.1 impairment may improve likelihood of \"-'Cur,,,ncCS IS Significantly ,,-'<1un'<1. b«ause the pat;C'nl's body may accommodate for the Recurrences would require a slrongercauS<.', be k'SS restricted mo,'eml'llt as it be<:omes I<\"SS painf~ll S<.'''''''''. and \"\",pond more \",,'dily to treatment Periodic assessment of th\" disorder's components is 2. S,-'Condly, ttl'-' pr<.>gl'lCSis is favourable whcrl the required (one consultation in 3-6months).lfan\"v\"n patient has afull/tamll'S> ranse of cervical ext~-nsion more reliable qualification of the prognosis is \"-'quiR\"d, with over-pre;;;ure. To test lhis properly, the patient the pt'riodic assessments m\"y need to be extended and moves to the Iimil of cervical extetl5ion and isencoor· v.ried oVer a period of 2 y\"ars. TIlis may show a dis- ag<-'<i to gain further extension by the manipulative ability statos changing to an imp.~inn\"ntst'ltus physiottl'-'rapist stroking his fo\",head \",!\",atedly to gain .....·en further active extension, and finally by If there is no imp\"'\"'em\"nt in the symptoms adding qoite firm O\"cr-pl'CS/;ure (cven controlloo although the mOl'eml'nt signs haw significantly staccato nudges) at the limit of the range. If this can imprmu:l,th\"n th\" h\"adach\"s must have a significant beachi\"vl'<i without causing flinching by Ihl'patient. nT\\\"icalcomponlTlt theinte'Pret\"tioncould]x,consid\"redtobeid\"al THORACIC SPINE Becau\".;,a l'l'CUrrcnccisstill possible if the p.>tienfs activ- ities in daily living n'quire neW US<.', ov\"ruse or abuse, Scapular symptoms the prognosis may need to ]x,considered a disability, Whcrl scapular symptoms are of cervical origio, they Upper limb and cervical symptoms will sp\",ad ov<:rth\" scapula Thl'S<! symptoms are much mo\", complex, lx'CauS<' the • To the middle. lower scapular and upp\"r scap,d\", symptoms may hav\" their origin in (possiblyC7) The c\",,'ic,,1 spine. discogenic or posterior joints • To the upper scapuIM{C4) or The neural tissues, intra- or \"xtranellral. with • If theR\" is SOml' middle amt lower >capular radiological Or entrapment componl'T1ts 3. Irritative or comp\",ssi\"e nerv~~root sources, connection, a milder comp\"\"\"nt of o\"\"rflow from Ol-erose, new ose or abu\".;,. C5-C7 4. Thor,lCic outlet problems, etc As to th\"origin of the scapular symptoms, if the'\" is no Wh~T1 pain is n'ferred distally from the spine. care- obvious cen-ical component thl'\" the ,\"\",uree is more fol differentiation of the possible soure~'S is important likely thoracic in origin. On thoracic ,,~amination, the (sapp25J-2S4) manipulati,-e physiotherapist is usually able to '\"\"pro- duU'the~rmploms. It may b<:nea>SSilry for thep\"lpa- If tI\",sourccofthe pain is the postcriorjoints, with no tion t~'Chniqul'S to be used in combined diflXtiotl5 to contribotion from th.· di...:: and pain....nsitive stroctures .ctue\"\" the repnxluction. of the nellral canaL the prognosis is easier to Iorecast I,..lovemcnt and posturai cor,,-'Ction may be u~'<1toease If th~ sout<:~ ;s in th~ tho...cic Sllin~. lilt p'ognosi~ i~ till' symptoms. but it will be onlikely to eliminate ttl'-'m bttW than if th~ soul'Cl' is in th~ c~lVic.1 spln~ compl\"tl'ly. The pain is less debilitating and l'C5tricting lht'reason ]x,hind this statement is that the thoracic origin is more likely to]x, p\"riarticular, when...s the

oflOCbvity~dlS<:Ogl.'fticor\"\"\",ralrefurTal.lftherause responselO\"'-..,t\"\"\"'t,backpalnw'throughing()fSlll~l­ of the !lOI.l!'Cecan bedetennined and chang«! fa,our- ing), and the rrlOft'oI t'-that ane-p\"'St'l\\t, the lTltt\\' ably, prognos.is 's good. Lifestyle changl'!!l may be lilceIythedi:sorderistobed~.A1so,thelTlllA'oI appropriilh'lOprl\"\\'l'fltrecu~ thesepre;mt. thelTlllA'ch.mce therei:sofprogre\"Stllg to If the SQU~d the arm pain is dearly only dISCO- a radirularproblem \"\"th neurological dwlgei \"-\"1\"iring gnuc, w,th I sponlanl'ou!i 0Il:'il.1 such. ha,·tn& p;>intOO ~and(dusingadegroeddi::>abilil} the ~ O\\'l\"r I WftI<md. and being wokm dunng Fromtheprogno5l!lpomtcl,_,theelinici.Jn~ Suncby rught WIth ned: and arm p;>'n. then the prugno- to know: sos15itut>allyuntel...ole Todanfy the progno:l!IIOo it i>- l.~,·igourofthe~tOUSdays'........L ~1Ode!<'munethe~and~tyofthed'5­ 2. The dq;reeofdlSilblhty so Q1...-d. onJer.Thi5lNlybeMlped ..ithkno....Iedgt'c1anyp;>s1 J. 1lll\"pabmt'sgeneraJiltIleclhNlthand\"-elIbeing. tustory_ The result cI treatment and ~ t ismt- <I. A dl!t.aiJed history d p~\"UU!o episodes. 5. If therei:safamilylustoo)nfs\"nilar'-:I< problerns. iallO the fom:N. If it IS impcll;6ible 10 find iI positIOn or 6. Theageofthep;>lienl 7. The behaviour of the Slgr'15 and symptoms in ITIO\\·C'mt'l'It that relit\"\\'e5 the distill s)\"mptoms. then the progna>II' IS poor. More dl.\", rotatioll. .... hich opens, the terms of 5e\\'t'nly and \",Ie of refeTTal. The more distal and \"'-'·'erl',M1d the poorer the resporu;elO joinI01 the alfectedside. and/ortractlonilll'uscful.If treillm<-'flt, the puorer the prognosis.. 8. Any p)KhosocW f<tctorli ('ydlow flags') hindcring thep;>lI' is rontroU.able this ....ay and respondsf.:l'our- the rero'ery to full function. ilbly 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· Tht'T\"l'fol't' low lumb.~r paIn th.~t can 'diablybe diag· mO\\lnI.ThetL'<:hniqueisexpla;nL'<linthischilpter. noso.'<l as bcing disrogcnic wIthout any other associatl'<l Whenth\"neuraltis,;<lesandthethorilciCO<ltletilrc SOUI'U' of symptoms is quite a diUe\",nt problem - it is in,oln>d. th\" prognosis is pooR'T and Il'55 predictable. clear-cut from a di,'gnostic point of view, but nol from 1ft\"\" t\",atml'Tlt prDgl'l'SSO'S favourably such that in thc a prognostic point of ,-iew. Th~ prognostician neecb to Lall\"rstdgl'!!loftrcatm\"ntthepatLentcanbeln~truct~ findanswerslOthefollowingqut'Stions: succes!lfully to do hiso....n stl'l.'lchesdaily,C'illUlingihe 1. Will it bepoe;sible to make the patient imprm-ed S1gru> and symptoms to be retaull'<l for more symptomatic and d,sablllty free? thanN hours, then theprognosisisunprov«l 2. W'ill it be pososible to ITIolIo.e the p;>bent i1Symptomatic, ~'lng thedisc structurally heled LUMBAR SPINE andsbble J. \\\\~t1ltheproblem\"'Or'lm.w,thsymptoms low lumb<ir pain beginning 10 refer into the buttock ore'\"\"\" mtothe II OS common Jo.no,..ledge that q!l'>Odes oIlombar p;>m pos«'riortlugh' \"erriIJ1lOI18 the ~al population ~ Will s)'mptorns spTNd to the loes' ((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 lOilChle\\'mg.xuralep~ changes and suffer an epl50de that starts from a tri,-illl Ma~aprognosisiseasier.... hen't(anbede1er- mcidentare,~d,fr.culttotreats~Jl).'The)· mined,fthtod,scism'·ol,oo. requ' ..... afe\\.·\"·idel)'~g\"\"llel .....atments.U,;ualh- To begin w,th. a dl'taik'<l history of the p;>l1el1t's tow at theend ofthetreatmmt the resutt isonecl anongomg lumNrdison:ler is~tial in formulating_ ~ble dISability. pftW\"J'iJ. It is not uncommon for a peroon 10 be Othcr low lumb.lr pains Cim arisE' from the z)\"8\"f\"J\"\" unawa..... oftheseo.·..rityofthepainuntilthemominl> ph)'l;CaljoinlS,thclig.~'1\\C1'lous,carsularilndmuscuIJl' afterunusual,hcavyorsustainedworkinlumb.1Tn....~­ tissue, and oth\"rconstructional Impairments (indud- ion. It ill fa\"ly safe ground to believe this is theeilse ing those affL,<;ting the pain-sensiti\\'O' StTUcturl!$ in the with a discogenic disorder. \"ertcllralcana1) Discogeniedisorders have many rca\"\"nably d ..<IT Competitive ~lite sports particIpants who hav\" a characteristks(...g. difficulty in putting stockings and genetic tL'Ild..ncy towc,lkl'lt'SS in SOm\"iI,..a ofth\"ir h;i,'\"Ilhoes on when first getting oot of b<.'<l, the Iongcr bodily system a..... Iik..ly to problems achie\"ing a

P'ognosil 95 listing good result from treatment. Their age and the and 50 per cent los.s of sensation on the dorsum of the cause of the signs (misuse, ncw usc, overusc. abu$ej i'5 big toe. Eighteen months later the patient with low also an indication of their problem and its prognosis h,mNlr s)'mptoms only had not had any episodes; the Depending on the history of the changes O\"cr the next other \"\"Iuircd surgery and had a good result 18 months, the prugnusis oc'Comes clearer. BY ACCURATE ASSESSMENT THROUGHOUT An extreme example of the variation concerns two TREATMENT WE CAN Pll0V10E THE OPPORTUNITY patients who started with thesameonsct of low lumlxlT FOR CLARIFYING THE PROGNOSIS pain on the s.1me Wednesday. By Friday one of them WaS symptom f\"-,,,. and the other had pain referred into the big tot', weakness of the extensor hal1ucis longus

Chapter 6 Examination B.(with a contribution by C. Edwards. OAM, BSc(Anatl, BAppSci(Physiol, Grad Dip Manip Th, MMPAA FACP Han DSc (Curtin) (Specialist Manipulative Physiotherapist)) CHAPTER CONTENTS • Physicaluamination Active tests 121 • Subjectiveuamination 98 Auxiliary tests associated with active movement Kind'ofdisorder 96 tests 136 SiUofsymptoms 106 Passivclem 138 Behaviour of symptoms 116 Differcntiationtests 162 Sptcialquestions 118 History 118 • Overview 170 Physical examination (P/E)-vcrtebralfgcncral • Planning 122 format 170 P1anningthesubjectivecxamination 122 Planning the physical examination 122 Intelligent man;pulath'c t~.'tmcnl is based on the starting point to encourage clarity and a systematic apprt-eiation of the history of the pati.mt'lOcomplaint appro.~ch and inlerpreUtionof the examinlltionfmdings. [tis taken for granted that all patienl5 havingcontraindica- Afl~r lh~ SlIbjtttiv~ ~xaminalion, a plan of th~ tionstopassi\\'emobili<:ation treatmentareexc1uded I\"OC.dUf~ of lh~ I'h~cal uamination nnds to ~ by the referring doctor. Ne\"erthelt'Ss, it is the responsi- mad.b<:fo.. itis~rform.d bility of the therapists to recognizl' all danger signals. Inmochanic<l1 probleffiS of spinal joints, thecxamin- Although throughout this book most diagrams show ationisconcentrated on finding which \"I'rtroral levd(s) both ttie patient and th<;, operator as malt'S,it would is responsible for the symptoms, and assessing how complicate thedescripti\\'e text if both pallent and mOVl'TTll'fltofthejointhasba'flaffecled opcrator were rderrro to as 'he'. Soml' rl'.1ders and reviewers have comment(>d On this discl'l'pancy, A pi;,,, th;,t L'flCOUTages a e1e<or ,,,,d methodic;,1 although all of them point out tru.l it isofminorconse- examinationpmgresSl\"!i through the subfective !'<'<:tion quelKe. The word 'she' isdelibcrately chosen in refer- of thl' examination to thl' physical section, with a ring tothe operator in anattempttoemphasizethefact 'planning'stageintl'l\"JXlS'->d between thl'lwo. ll\"ll' plan- that passivl' movement tn'atml'flt tcc:hniqul'S can be ningstageforcesthl'inl'xpcriencedpcrsontordate very gentJe Pl'QC'->dur<-'S and that the additional strength mentally the many facl5 of the patient's story to the a maJemanipuJator may have is not nece$$<iry for the parts that will require examination, These procedures stronger manipulative techniques. One of the writer's art'carriedoutautomaticallybytheexpt'riencedphysio- therapist, but do require adherencl' to such a flexible plan. The inexpcrienc<->d person. however, must havea

98 MAITLAND'S VERTEBRAL MANIPULATION aims is to present the subject of manipulation as One To make it eilsier for the p,iltienl, only one que~tion rL\"quiringskiliralherlhanstrength sI1ould~askedatiitimeanditsl1ould~~rsisto:d wilh,wilhin reason,untilt~e answer is obtain(lj SUBJECTIVE EXAMINATION The subjective examinalion \",lal<'5 10 Ihe palient's The subjectil'c.> examination can be dividL-d mlo file accounlofhiscomplaintand;lspaslhi,tory.Methoos parts of questioning will vary from palienllo pM;enl because allhoughsomepalienlsareexcellenlwilnesses,olhers 1 'Kind'ofdisonk'T frequ\"nlly appear unable to undersland som'>ques- 2. Sill' of symptoms. lions Or are unabll' 10 answer lhem simply. Skill in 3. llehaviourofsymploms. extr'lClinglh\"approprialeinformalion re<juirescare, 4.Spt'Cialqul'Stions. palienceandacrilicalatlilude,lflhl'k'Chniqueisgood, 5. Hislory. much can be gained in addil;on 10 the answers 10 lh\" questions. Thepalient gains confidence in thephysio- Thespt\"CifksubiectmaUerofthl'Sl',foreachsectionof lherapisl, who in lum is abl.. 10 und\"rsland lhe the spine, islistl'<l in Ihl' Tabk'S and discussed in lhe pat;ent'splight. The intluenccs of social and environ· lexlgi\"en in Ihe relevanl chapt\".s on each sect;onof ment'llfaclorsmuslbeapp,,-\"Cialed,andilisn<'CL'SS3ry Ihespine;thegcneralsubrectmatl(>Tisgi,·t'Tlbclow. to remember that Ihiscolours the examiner's thinking as well as the p,1\\ienl's Fromfhe\"eryfirstqueslionasked,regardingwhat Ihe P.1ti<'flt FEELS;s\";s main problem,lhl'examiner Iflheinlerviewmgtectlniqueisgood,mucl\\can~ begins thinking abolll possible hypolhL>s<'S for the dis- order, limited though they may be. The subi<-\"h\"e gaino:d inadditiontothean~wer.;tothequ~tions.. e~amination qU,'Slions lhat follow will be relaled 10 The patient gain~ confidence In the phvsiotherapist, Ihehypothescsandha\"ethreemainarNsoflhollght who in tumi~abletounder.;landthtpatien1's plight 1. The kinds of structllrn involved 2. Clarifying the hypolhesisabout the disorder. Communication is difficull and full of pilfalls, Th.. 3. Thl'disorder'sslage,currcnlslabi/ilyand physiotherapisl may not word thequcstion in a W<1Y Ih<1tdearlycxpl'l\"SSCSwhatshemeanstoask,andthe irritabi!il.~ or Sfi't'rity (TolbIf6.1) wordsuSl-d in the que<;tion may not mean Ihe s.lme 10 Ihe p<11ient as they do 10 the lher<1pist, or the paticnl 'KIND' OF DISORDER maymisunderslandwhatisbcingaskL-d,Hemayhave problemsllmlareimportanllohim,andincorrcclly First question a!isumelhallhequc.>slionisdin..'Clt-daltheSl'(seefigl\"e 3.2). H<'flCC then' are all maMer of difficultit'S 10 spoil The aim of the firsl question (Ql) (Tahle 6.1) is to deter· what is often a~uml'(l wrongly to be a simple process mine Wh\"t the p.1ticnl's main problem is in his Own ofdi.eu,;si<ln. terms. 1t isimporlant thai he should be giw.'l\\ c.>\\'ery opportunily 10 e~prcss his reasons for S<'(>king treat· Tomalo.e it eaSlc.>r for the patient, only one qut'Slion ment.Forexample,withlhefirslquest;onbcing shouldbea~ked ala time,and ilshould bepersislcd wilh,. wilnin reason, until the answc.>r is obtainL'd. The 'As far as YOU are concemcd' ... p.ousc ... (lhis question can bc din..'Cll-d in different ways if it is nol pausc allows him lime 10 realize that the therapist is moarly understood by Ihe patient and it should b<' specifically interCSled in the patient's OWN OPIN· carefully worded loaloidinflul'ncingthc.>answer.lf ION) .. 'whal do YOU f!>(>l' pause 'is YOUR the patient gi\\\"t'Swhal S<'(>ms to be an iru;ongruous MAIN problem?' answer lolheque.,tion,lht>n the fault may lie in lhe way thequeslion waSpul.lliskinctertorephrascor ThetherapistmaychOOSl\"toindudeinlhequL'Stion, explainthequeslion than 10 reslale it,even if it was so 'at this slage?'.lfthe palient is eX<:es5in'ly tal\\(,ll\"'e. simplypulthatthl'errormusthavebrtnlhl\"patilTlt's. this pre--empls him and he has to limit his answer It is essoential loapproachl'ach inlerview wilha degree tobolh the p\"-'Sl'nl lensc and 10 expressing his own of humilily and charity. opinion - NOUODY e1sc's Wording the question in a manner to encourage spontaneous comments will indicate the patient's pri· oriliesin relation 10 why hI' is \"'-'l'king trealment. 'Is the'\" anylhing it prevenlS you from doing?· isa useful

1 -[- - -I - ;; i

100 MAITLAND'S VERTEBRAL MANIPULATION early qu~'Stion. If the art5Wer is 'Yes', the following Commilling the essence of lhe subjective examination brackct of queslions will need to be asked top.lper isa\"aluablelearningexperience in itself. It forc<'ll on\" 10 identify the things that an.·csscntial,and 'Wlwlctoesilprev('l\"lt?' record them. and lea.'e out the less valuable infonna· tiongiven by the patient 'Wlullprrventsit?' Systematicrceordingoftheinformationobta,nro'sa 'Do you ha\"eany TfQClwn from having tried lodoit?' villuabl~ learning expefience, as it nelps to identify the e5Sl'ntial elements,fnr furtnef examination and Wh('l\"l a palil'l\"lt dlX'S not put an emphasis on pain as trealment his mn;\" problem and dearly indicates th\"l it is his activili~'S lhal are restricl~>d, the next question is, 'Do The lh\"rapisl should reassure the patk'l\"lt by \"\"lying. you get much in the way of pain ordis<:omfort?'. 'Don't feel lhat some things are too silly to mention. Your body can lellyou thingsaboul its reaction 10 the Therearemany'kindsofdisorder'(S/'t'below),but disorder that Ican't find ootunlessyoutellme.Youcan·1 the reply to the inilial qUl'Stion is moSI commonly 'I gel tell me too much. bul youean tell me 100 little. Let me be a pain aCl'OSShere',indicaling the area. IVhen this is thejudgeofwhntlnl\"l-'<iloknowandwhatldon't' thercply, it is usually bcsttoclarify lhearea oflhe symplomsbeforeaskingqol'Stiort5aboutthehistoryof The relevance of using asterisks (') or highlighting thedi~rd\"r. may bc appropriately introduced here, as they form an Important CQmponenl of the written record of both the Establish the 'kind'ofdisotdcr: why has the palienl ~ubje<:tj\"e and physical examinations. The asterisks sought treatment orlx'L'Tl referred fortrealm\"nl? II will servc two func!ions. Firsl,lheyidentifythe points to only be n~'C~'Ssary 10 use dire<:t or leading questions to which the lherapist can refer back when making establish lhe 'kind'of disorder if it is not \",vealed assessments for changes to the patil-nt's symploms sponlanl'Ously during the inilial open-ended questions and thedinical findings. This speeds up th\" as..;es.s- mentproc~'Ssandalsomakesitmoreprecise.Se<:ondly, In art5Wer 10 the first question, the pati('l\"lt may it is a good leaching process, keeping the therapist'on respond with the following 'kind' of disorde!\"li her tocs·. so to speak. 10 lalch onto highly infonnative and significanl words, phrases or functions that arise l'ain in the subfe<:live examination. Similarly, it teachl'S lhe Stiffness therapist the significant featuR'Sduring the physical Civingway. loxamination.ltisimportanllhattheaSlerisksbcuscd Instability. al the in$tant of R'COrding lhe feature. not on comple- Weakness. lionoftheexaminationasaretrospecti\\'loexercise,This Lossoffunetion is why Tablr6,1 statl'S 'asterisk as you go along' I'ost-trauma: a) Surgery. Using asterisks in tne reeording of informalion is b) Manipulation underanaesth(\"<i~ essential. This Sl'rvestwo functions: c) Hosp,talil.edtraction. • Itidentifiestnosepointswhicncanb<::usellinlhe The pallern of thinking during the subjccliw examin- re-assessmentof the patient's progress atIon{Tnblr6.J)depktsthequestioningasaninterroga- lion, but it differs from that held in a roort of law • It Sl'rves as iI leaching prOCe5s, to latch onto b«auseitisaninltrrogalionwithempathy.l:leingan in/ormative and signif,cant word, 'interrogation' indicates the depth of questioning required to gain the detaik>d information related to It is important that lhe asl\"risk be used at the instant of bolhfonningan hypothesis and knowing the kind of ll.'Cordingthe informalion. not on complL\"tion of the structures involved. 'With empathy' indicah.'S lh\" examination as a rdrospe<:ti\\'e exercise. This is Wh,lt is depthofqueslioningrequill.>dtoundcrslandhowlhe mmntby'asleriskasyougoalong' disonler feels 10 thepatienl in his terms. Making features fit The sublt<:tivt aamination isan 'interroqation with empathy'. It indicato the oepth of questioning and Ascan be seen in Table 6,1,queslions need tobeasl<ed loaSS<.'Ssiflhefealu~oflhehisloryfilwithlhe tnablothethcrapisttogetanimp~ssionoflhe patient's personal experienCl\"s of their disordcr and tneimpaetitha,ontneirlik

Examination 101 bcha\\'iour of Ihe symptoms; and also toaS5\"S$ If the behaviour of the symptoms, when related 10 wheth.\". the behaviour of the symptoms fils with a rec· acti\"ities, indicates that exacerb3tions are both easily ognizable syndrome Or pathology. provoked and 13kea long time to subside, the irritabil- ityoflhedisorder is high. This indicates that thephys- Making h:atun:~fit; ieal examination oftt'St mo.'ementsshould only be taken 10 the point of onset of symptoms. Neverthcle5S, • Do the fuwres of the history fit with Ihe curn:nt it may be wise to lake the movement minimally behaviour oflhe symptoms? beyond that point to know whether the further move- menteitherheighlcnsthesc\\\"erityofthesymptomsor • !loeslhebehav;ourofthcsymplomsfilwitha ext\"nds the spread oflhe symptoms. r«Ognizablc S'/ndrome or pathology? Thett'Stmo\\'t'menlsalsoneedtobetakenonlyunlil Stag~, stability and irritability of thc disordcr the onSCI of symptoms if the3ctivity that pro\"okt'S the symptoms has 10 be interrupled bo:ause of the inter>- FromthcmomenloffirslS<'<'ingthcpatient.thetherap- sity of tht' pain. The disorder is not ncci'S&nily higltly ist takes note of ,lny nll,lnces that m,'ygive the first irritable if the symptom. subside immediatt'ly, but dUl'Sas to what Ihe patient is suffering from, anything ::t~~:~\"'::~:icie\"tlyfot'wre 10 require cautIOn with thatmayhelpinknowinglhepatient\"scharacteristi<:s, e1c.Theserondpartofthemeetingrelatestoanything If the patienl\"S'l'f'llptoms a'econ~idered irritable or in the introductory remarks and settling the patient in :.e~re, tIM' physical e.aminalion or test movements comfortandea5inghismentalstatebeforetheconsult~ ~ho\"ld onr,- be taken to the poinl of on:.et of the ation begins. During this phase the therapist may ~ymptom~ not;C<'someciinicalcluestoassisthertomakejudgL~ Hypothcscsrcgardingstructurcslnvolved mentsduringthecoosultalion. 'AsteriskasyougoaIOl1g'hasbeendiscussed(abo\\'t'). The right-hand side of Tablt 6.1 lists the kiods ofstruc- tUfC5theexaminerwouldha\"eiomind andisreallyawayofsayingthattht'examinershould be able 10 pkk up major issues to be llsed forasses5-'- Further the examiner should consider Ihe ways mentofchangt'Softreatmenlandforhighlightingkt'y in which theslrucluR'Sha\\'cbeen used and the differ- issuL'S from the pallt'n!'s or examiner·s point of vit'w; enl injuries which may have consequently occurred they must not be left until the end of the consultation. (Table 6.1) 'A5leri~k a~V'Ou go along· is an es:.ential clement of Added 10 this list are many olher elements (eg. hypothesisgeneration,amlitshooldnolbeldtunlil muscular. postural. biomL'Chanical, ergonomic, pas- Ihe end of the ronsullation ition\"I,clc.}.Thl\"}'arcomilll-d from tne present dis<;us- sion, as tht'yare considt'red to be mainly secondary or Questionsor;l'1\"ltedtothchistoryofthedisord.\".should predisposingsitualions 1o the structures from which beaskL-d so as todet\"rmineth\"sour<:e and th\" slage of the symptoms are arising (see ['art D of Table 6,3) the di><:>rder (t'Specially if information gained relates to Co\"sideralion must also be given to the structures the R-cognizable pathology dlovelopml'Ot). When the that are the SOurce (or th('CilllSC of the sou=) of the stageofthedisorderhasbccnestablished,thecurrcnl stability 01 the disorder should be determined. If there Tablc6.2 Typcsof'useofstructurts' arc wide variations in thescverily of the symptoms. Or andthcdiffcfcntinjuricsclIuscd 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 Go.itsofquestHHlsreleY3nt tOlhe history of the d>SO<-der· Mcthod of injury • What maybe the SOUrce of the di'iOrder? MisuSl' • What isthe~ta9cofthedi'iOrdef? Newu:.e • What isthe~tabilityofthedi'iOrder? Ov.ruse Iflldism-derisronsidcred'unstablc',thenthcphysical 'O\"iS\"US\"l' eXlimination hnto be modified to lIvoid cXlIcerbation

102 MAITLANO'S VERTEBRAL MANIPULATION hblt6.3 P1anningthtphyskaltxamination Thtn_twoll>i\"ki\"'~lIIIr_ _ ' I I a ( a O . T h r f 1 o t \" O f t k i n g l ! l r _ l n ' o f l ! l r d b o R l r r . i I N l d l ! l r l f t O l l l l \" l ! l r JClI/tt\"l'{conlributngfartonl- A. ThrSOOllat.}ofl!lr'YlllfllCl'l$ I ~asll>r~sourtrSflI..,.(IOfIflitIlrptlortlr• ..,...ptomstllat_brr.umt~ Joo\"ts~\",,,,,,,,,,_t.ir~ JDorltstllatlrlcr\",t\"l!lrsymp!Dm;ltlra...a(s) NotII<aIi'u~\"\"'~tstllatrrfrl'''\\JIl!lr\"\"\"\"''''''lIr.....a(s1Musrtr..u,*\"\",,,,,,,..,plCI<rIllllrarntsJ 2 Lislpnts*\"\",wbrlDwlllrk$illllthatshl>oMborchtttrdlwhmapprtlphlltd J Nr~arlySjltcillltstsilldiaml' . __::::::====~ =.~=\"::===-========- Inl'luoerlc%ofSfl'lPl\"\",,'ndpathDlogyonrum'nlItion'ndfirsttrotmrnt lsthepall'lsnnrrlYroINoIlIrlattnt![Yn/N<lI G<>'tth<>(J(GmpJr\"\"wflicht/lr\"\",wrrs\"'r!J0rd. ... LocoIS)'I'IIploms _ i Rtpe't~MOVEMENTrausillgplin-or9Oju.t~Pl ii. SNt,ity of pa;n so ca~ ._.\"_\" __\"_ ,_•••\"\"••,__..._.___ _... . _...._ •••_ .••_ . _••__• iii. Ouf~tlOn botfort pain .ubsidt•. ...__ _..•. b. R.ft'rtd/otllt,srml'r\"\"\" •••_ ....,_.' _ _ Rrpealrd MOVEMENT cau.ing pain. 0' 90 ju.t bryo\"g ,ef...~! of pain .. .. ii. _ _ • . .._._.SNt\"ty\"fpa,nsoe~u~ ,i\" CNr~honbrfo,-t p;insubs-Hks 2. Oot5lhetlltu~oflhedj\"\"'lIrrindiraltta<lI>On'lrt1/lVol ii.i_E\"a'sylt\"hptotwIOlor~ql.y..f.,jonrajcuwt y••_possopdttt>fy:;~:::~============== 1 Nrthm,rryconl1alNticatlOllS'[~~fy C. The ki\"\"ofruminlltion(a<oUripallOllotrlfld'\",,} 1 OOyoull>'.... you ... nrrdl\"br9tnlJtorlllOdrra~fi\",,\"\"lI>yourr:uminlll....,oftM_! 2 OcIyou«Pt'C!ltcoI\"lI'I<Iblrsiogn tcIbrtU\\'orlObrhlrd to find? Whyr J_WtIicIIspr6l'kt~~lIIn \"\",_tojlltl1on'llJ 4Wt1tft .... youplafl~ tprottlluror D. The CAUS£ of thr SOURCE of l!lr S'(Il'IptOl\"\" AHooated ruminatillll l~I~IItIlIOJ~~II'Itdiicalfac1Ol'Slnd\"'9lOthetlUlotoftllesympioms.. WhaII5SOC'OllIN bnors _ lit uamllltd , \"' ..._ ..l>ylhejotnl.lI'IUSde ... lJtIler.tnlClu'r ..... btcomtsymptomatic,<VJ/ot II. .... \"\" thr joint or ml/5dlt di><l<dn may~? I~ poslu~ I'I'IUSdt imblol4or>ce. lllusdt po¥W. obrsoty. Slrffnm. 2 ::c:.'.'':::cl==========-The~.:.~::::n~=hi~JIfO:::~~\".:«~.~\"\"'.~. Eo '~'tmrnt 1 WhlChsho<t-wm orlong-ltrTnlllJal.ofl\",at~t ar~ pu~? 2. Do you ~~pecI to br I't,[;ng pa,n, ,nin,n<:r. weaknnl or instability? 3_ Nt lhe~ 'ny pr\"'Ul\"\"\" 01 <:onlfllind;eatlOn. whlcl1 nred t\" bot rrsPCCI~? ~. In planning the TREATMENT (aftt' th~ ..amin'tlon). w~at ad,iet should Dr includ.d 10 pr~,~nt or ltilen r~eur~netS? \"dIpttdf,omIH\"\"\"\"lISOIh>sI:rltr.'b:IJ\",,\",,,,,,,,.ndll«ord'\"9Guidt(1998j.wilhkioOp'rmiuianofl.lol>dr'dal.Pfn.. Adrl>Odt.

wmi....tion 103 symptoms _ \"\"\"\"rticular. mtr....rtinJ!ar, \"\"\",ral and comforting trlO\\-emcnt is f\"e<jUlred Thfft Ire po&I_ d~ of~hng....hichart'mon'<:omfortab.,.thanothtn.. Tlw site of P-'\"in is alway~ deep ..,atro, and the pibent IS F'tnanicularSfructlJres not able loactoally touch it;hcM·\"'·C1\"\"fthetheraplSt rocl<s the ;Oint back and forth, the p<1lient ;sable to 1'h<.\"SCll1dudctheligaml.'Tltoulercapsuleandtend()ll. id\"nl1fy,tasthesitc,Th.. disorderosuaUyhasadegrw Ligament disorders of relallvely ro::entorigincan of inflammation, although this is IlOl 10 say thaI It h.ls be c~p<.\",tcd to be painful on strekhin8 or !l<\\lK.'C1.ing them. \"They would be \"\"pt.\",u·d. thcn>forl\". to ~l..et adi~a~asilsongtl\\. tIw patieofs functional mo,'erfl<.'nl:!;, although on Slop- Ifthed~er ischrunic.it jscommon for a 100\\ .... I1ll\"l\\tinonedi~tobefreertJunlt:llopposiw,.md pmglhemo.-cll\\Cl11 al'd lhus..-cle.1sing the stn.-'Ich or ITl1O\\~-menlll\\oned,rt'Cboncan produce .. shn]l I\"'tTl sqUl...:oethes)·mptornsOOOJklbeor><peeI.,.jto~ wlulst ~ Tl1O\\·ement in the oppoIilw dln'Ction. though Also II should be po$I>ible to p~ the hg.ament ,n a hurtful,doesnotprod~suchlsh.lrpralllorpn!'·'\"\"t poli,tion where it is P-'\"inIesL The histo<) of the d~ further monment How\",.,., none of thejoint's ffiO\\''''' ord~wouldbee~peeI.,.jlo,ncludcsprains,.stratn\"or ments ..... totally fltt of piliI'. Pmormtng small r.ang\\! mil\\Ol\" trauma, but abuse supe-nmp<l§ed on fat'gucor osc,llatorymo,crnents(whether3(\"{e$SOryorphys,o- othcrpredispos\",g<:ircum5ta~maybethccause logical) in a neutral mid_pos,tionw,lIcrcaleanache Ligamentous di\"\"rders of \"l'TY Qocentongin (I<.'SS wilhlnthejoinl.lflhcmonom\"nliscontinul-'d,thedchc thanawcckl\"'Quldbeex~tl-dtocaw;cstrongo.'Tsymp­ willioc\",aseproportoonallytolheduratlOllofthealcil. roms, and ....ould \"\",trkt functional activilH'\" greatly. !atOf)' mo\\emcnts. Tlw ~ Sl!\\l,\", lhe \"\"In, the mono \"l'hoen!would also beotheroompon<'l'tscontributtng to ~lriclt'd the mmemmls. lne hIStory of the onset 15 the symploms (e.g. mfbmlNllon.- oedema). On the other h..md. chronK ligamentous d ~ \",ll be gradu.o1.and thcp.1l>lml is not Awa... of the <:aUSOl' Susl3inin~Asquee:ungolthrjotntsurUces~ p<lll1fol on strrlchlng and squeezing.. but will w,th- USU.Ill~t>uildsup~nlllC.....seof ymptoms;bulonlyif ~nd more tcnsioo tJun Ihosc of more =rol origin. there ... ~ joint surface component to !he disorda Findingpall1k'!;spo6l110ll5forthe5estruct0Jt51Sre!a· 11\"\"·\"'~-'f\",ifthedisorder;\"chmnic,boththeduratlOll h'·cly easy: the \"\"'\"' N'«'llt theomet of symptoms, the And the5trengthoftherompactingn«d tobeincre\"s.ed more the symploms will be localiz.ro to the injured Itga· Thi$ diffi'rl-ntiation test may need the addition of a menl, the more chroruc the disord ..r,lhe K\",ater the tiny C,lrdinal movemt'nl, or the comparison of pain ~Sibi1ityo(thcn·bemgadl');rccofr..ft'rrl'dsymr· pro,'ol<edbythcc~rdtndlmO\\·\"m,·nlduringsustained toms. With this thought in mind, it is \",-~ry ttl stalc :'Ioqu~~l.ing <:omP-'\"red with the :;quec~ing \",leasc.-d (in th.>t it is not rare for a chrol\\i<: Iigamcntousdl5Order 10 bethe~ofr\\\"fermfs)mpt0m5without~being P-'\"rt or wholly), to pfO\\'lde the answer. S)-mptoms (pitO/dlS<:Offifort)canbeexp«reodtobea'lhrough- ;ony s)\"nptoms al the Slle of the ltg;>nwnl's d\"\",\",,\",,\", rane'f\" probability Anti.inflammatory nwdiattion ColJ\\ be exp«ted to red~ the ..... el. of symptoms when tJ\". Theouterl.......,-,;ofs)·nQ\\wl\"\"nlc~lesbdw\\.. in much !he SI.~ manner .-s descnbed abm'l', Tendons inflammatory component is an \",'1'1'\\ more actJ,·e dIS- GIn besymptomah( and betwi,t' In moch lhesarnewa)' ease PI'QCl'$lS. nus IS not so if the \",nammation is p..... uhga\"\"\"'15,b\"tw;thoned;fkn:on<'e.1fthedi~cris sentonlyasaresponscloamechankalprocess. ~t the tenomuS(;Ular or t..nofX'riost\"al juocltooS, and Inflammation c~n b;\\skally be oneo( two tyfX\"l1l\\,. th\"\", is no i\"namnlatory component in lh\"disorder, firstisa~a rcsultofp....viousinJury(manyyearspn.'vi- th\" slrl-'1ch or squ~...I.\" situation will be Ihe \"'1mI' as ousl)'),whichwill have led toradiologicallyevidt'nt w,th ligaments. TI,.. differenlialtng lcsl behn\",n \"--\"'- OSleO<lrthriti<: chdng<'5. Therecan be long painles6 peri' don and ligaml.... t ....iIl be that an isometri<: !<-YlSion ods.unlil<einaeti\\ .. ostooarthritl{d,seaseorolher .apphed thmuJ;h the tlondon will be painful, compared formsofarthrilt5sucto.f'§ON\\JCorrhcumatoidarth- w,thbcinlr;P-'\"tl\\le!6forligaments. ntIS; these\"\", ra\"\",'fn-... ofdiscomfort. The~ groupofp.atienl:5wdlhawconstlnlp;tInOl'disrom- fort, wtuch has both a l\"'In-through-rangepl'15Ot'Ot.- \\lostinlra ...rticularclpsu .... rd~\"\"'·,.ld,ffer· tion as well ~lncnd-of-rangep-inthatP\"\"·0U5.a markl'dincre\"\"\",;ntheinlcnsityofthesymptorns.1115 entqualttylothclrsymplorru;lothatofperiartlculM slructu~.Th.,.a~mo\",c(>nstanlthantheend-of- th;slaltcraspectlhatisth\"dommantdini<:.alevidl'fl('e range ligamenl disorders, and are usually more d,oblh- diffl.'reTltialingilfrumthelnflammationbccauscofdtS-- lilting. Painless resting positiotlSt'itherdo not e~ist,or l'aS('; til.' latter Iws a mo~ graduAl increa~ in inleNity the\"\"h~\"'lisonlyfn-'l'ofsymptomsforanhouror~. A change of po!lihon is lhen needed, or a period of ofpainasthejoinl!sI1lO\\·l'dlhroughitsrange.There isanotherdiffeMlhatu1gaspecttothisl\"'in~

to movement: the more aelive the pathology, the Whcninlrancur.:lldisordcr~art:'cauS<.-dbytrauma, longer lh\" exacerbation lasts following ('(-'SS,1tion of suchasinamolor\"chic1erear~ndcollision,theydo movement. Thl\"\" is an 'in between' classification of respond top.1ssi,'cmovcmcnt lreatment, although tile inllammation tltat oc<:asionallyconfronts the clinician, lime taken to reach a satisfactory stage i~ m/lrkedly known as 'subclinical arthrltls'. ll>e presentation is longer lhan when the 'joinl' is causing an irritative One of constant aching al thc site of thcjoint in,'olvl-d, S!.1!e.n'e repe\\itivc strain situation is much the \"\"me which increases in ink'llsity wilh activity. Thc physical when it i~ a major conlribulor to the ~ymploms examination reveals through-range pain. yet there are AI this stage of our c1inical and lheoretical know- positions where the symptoms subside considerably. ledge,itis probably advisable to lhlnkol lhepain· Noneofthemedicalt<'$ls,suchasbloodtl'Stsorradio- sensiti\\'e~tructun'Sinthe,'(']'fl-bralcanatinparticular graphy,revealtheaclivilyofdi\"\"a~orpathological the dura, as a subs•.'ction of the llCUI'al phenorru.'TIa. changes. ll>e response to p\"sslve movement tre\"tment Allhough many of lhc physical examination lcstsare asoutliru.-d in this text is not lhe same as is Ihcca\"\" thes.1meforboth.thestruelureandfuoctionofthedura with the mechanical variely ofinflammalion (orarth- aredifferenl.lli~avery lough.~lrong..ligamenlou~-like riti5). Passi,'e movement has no role to play other than tissue. and when the dura itself is the 50Urce of symp- 10 identify thcsilualion as subclinical toms,itisa \"erydifficult~lructureto r<.'Store 10 its full range of painless pa..mve movemenl. However,il is far N~ural more common for it to 00 lm'olved in a p\"llenl\"ssymp- toms on a serondary basi~;thatis.someolllt'rfaultin Onesignificant 5tatement that can be made about neu- the intersegml>nlal mm·eml.,,1 results in irrilation of ral symptoms is that they are different from muscu- the dura and causes it tocontribule. Under these dr- loskeletal symptoms. The symplOTll5 from routine cumstanee.,n:>loringlheinlersegmentalsymptomatic uncomplicated musculoskeletal disorders are ,\"\",1dHy state to normal will effcct an elimination of the dural recognizablc as such,and 'pain' Or 'achc' are the pre- symptomswithoul having to lreat the dura dill'dly. dominant symptoms. Neural disorders, on the other Kef\"rred pain from the dura is w,,11 documented as ltand.althoughtheydoha_epainasapresentingfac· beingnon--segmental(Buller,l99t;CyriaxandCyriax, tor, also have what are commonly considered to be t993),andilsphysicalexamlnation(the'slump'tcst} bizarreorwcird symploms, and the palienls fr<.-quenlly readily implicall'S its invol\\·emenl. have difficulty describing them. When the neural.ys- lem causesp\"in, it is almost cl\"Ttain to include some Di5rog~nic othcrsymploms oflhe bizarre variety·· rarely, ife\"cr, does it prescnt as pain alone. I'atients commonly won- Discogenicdisorde~arelesscommonlythesourceof der if they are being neurotic or hy5terica], or if the srmptoms than was thought to be the case 15-20yCilrs problem is all in Ihe mind. E\\'en the pain can have a ago. How.>ver, they are still relalivelyoommon in lhe weird quality about it and is nol like the usual pain L4/5, LS/Sl and C5/6,C6/7discs, with the lumbar most people talk about; it is ill defined in its area and discsooing more prone to progress to the hemiated ofk\", affects a wholc hand, armOr leg. Other symp- (prolaps<-d) stage than th., cervical d;scs. loms are whole-limb in\\'oh'emcnl, heaviness, a di51al Inlradiscaldisordcrs within an intact outer annulus areaofroldne<•. mentaloonfusionandblurred\\'ision in lhe lower two lumbar levels can usually be readily Frequently a patienl will complain lhatall Ihesymp- recogniZl-dby thehisloryoftheonscloflhesyrnptoms toms are always on one side of the body. and by the beha\\'iourofthe symptoms. The history is Thrcc/!x=elyu~fullexts\",gardingthisgroupof usuallyoneofliflingina position of flcxion plusrola- unusual complaints are those by Breig (1978),Grie\\'e tion. The patient usually feels something h.:Ippen in the (1981) and Butler (1991),and f\\lrtherreadingofthc lowerback,but the pain need not be scvere at that lMlerlwot\"\"tsisstronglyr<.'Comml.\"dl-d time. How\"\"cr, lal\"r the lower back may be uOCOm- The responses 10 trealment of neural disorders by fortableandache,and mo\\'cmenlsmay be restrielL-d pas.o;i\"e mo\\'ement areolten different from the respon,;es by pain. It isquitecommon for the patient not to notice of 'joint\" disorders when the neural disorder is pri- anything significant until thefollowlngmoming when maryrathf!rthanseeondary.Whl.\"lhejoinlslruclurl'S he firsl gl1soul of bed (or is unable 10 do so). l'ilinis are at fault and are irritating the neural structures, considerable, but it is always felt inanarea rather than if the joint component can be cleared. the 5e<:ondary a localil.edspol. The area is usually across the lower neural irritation will improve in paralldwilh thepri- back,anditllmybemorepainfulononcsidelhanlhe mary joint component. However, should the source be olher. This may indicalelhalthedi50rderoflhedisc nerve entrapment, it isoftendlfficult to alter the entrap- intemally is more towards that side of thl'disc; if the mentbyronscrvalivemanagemcnt. damagc iscl.\"lral,lhearea ofp\"in will be felt more

Ct'ntrally. The site 01 the discdiwrder may be in tht' 8 Evidl.'llceofa lumbM kyphosis in the standing nucleuso,the inner annulus, or in bolh position, Ora list to one side (sci.llic scoliosis: Ce'lainly, if the current history is the third episode. Maitland,l96l)onobservationlrombehind.The boIhthcouclcusaod the annulus may be involwd. It list wilt often beconlralateral in Iheca5<' of an isnot until theouterannulusisinvolved,,,-'Sullingin a intradisealdlo;orde'. bulgeofthedi.sc,that there is any referral of symptoms An aftt>r effect is quite rommon, and if present i. to the glul\"\"larea ('the weakened outer annulus' in rOblf6./). II is not until the srmptoms extend into the indicativeofadiS(disorder.Thc'aflerdf~'Ct'meanslhal, thiSh tha, ,he weakened ou'e.aolluluscanberonsid- having performed activities in an unfavourable manner, l'T'I'dtobeinast\"seofprogrcssiogtowardsherniating. the palient may not be aware of ib having any effect, HmuQtrd,prolQrlS<'dand~W'Slrillllarelhestag\"\",when BUT will know all about il by the following morning. lhe area ofp.lin is likclr tobc radicular and include neurol<>glcalchang\"'\" In the cervical spioe. lhe progress is not the same as descrilx-daoovefo.thelumbarspine, In fact. thecer- The blot... dou,al indicators of the intradiscal dis- order will includeonc, wme or all of the following: vicalinter\\\"e.td>raldiscsa,equitedifferenttothosein the lumbar spine (Twomey, 1992), A 'list\" i, nol unoom- mon fo,thehernialL'-d inle,vertmral disc, but lisbare I. Backp.,mwhencoughingand/orsn~\",zing. nearly al.\"ays COlllralaterdl 2. Difficultyin ,ising out ofa slumped sitting The cervical intrddiscaJ diwrder may be more com- poosilion, and in being able to stand erect (or, if it is monthanisg''11erallythought.lx'Causethesymptom- .. tology St-'CTTIS tu fit with Cloward's work (Cloward, bad enough,theinability to stand straight at all) 1959, 1900),es]X'Cially,,~thpain fcltin lheso::apulararea J. Difficulty in geltiog out of lx'l1 in the mornings. (...'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 0.4. Thc inability to fle>. far enough to puton socks (C617 disc), which is more oommon than C6 nerve root imohement(C5/6disc).Rea..\"tin,·~'Stig.,tions(Twomcy stockings. ,md Taylur, 1992}show that lhe cervical discs are signif- 5. Difficulty in bending nver the hand-basin to clean icantlydamagt-dinwhiplashinjuries. l<!e,h,etc Thisscction is an ovcr-simplification,and isintcnded 6.1nnrdertosleep.thepalieotmaroeedtolie only as a guide for the more common presentations. n... supine wHh pillows uoder thekm\"l'S to allow the lumbar spioe to lower to a slightlr fleR-d position reader is refcrrcd to Bogduk(I987) for further debils or. when srmptoms h\"\"e\" one..,.id~-d dominance, he may choose to lie on one side (usually the least painful side) with the lop hip and knet> flexed. or Clarifyingthchypothcscs even ina foe!\"lpositioo. 7, A dishke of standing. or the half-f1e>.oo position This section follows the 'first queslioo' in much the \"doptedatthekilchensink 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\"1f ty,l50,t052-64 with'indpt,missionof aU'hor.ndpubli$l1.rs.l

106 MAITLANO'S VERTEBRAL MANIPULATION ,.) 'I figu,\" 6.2 DiSC09,oic paio.lol R<'f~f~iJ from post\"olat~fal su,fac, of ~rvical iJiscs.lb) R,f',,~d from ~nt-al disc \",ptufu (R~p<oouccQfromaoward.R.B.lt959)Annalsof$<Jfg.ryt.SO, 1052-&4. w,lh kind p\"'mi\"'on of autnor and publishers.) involved. He,..,. use i.~ made of ex~riencegainL'Cl from suchas.familial(gen('ticpro~fl5ity)b.ckgroundor listening to the storie> of other palients (Table 6.4}. an injury som.. ycars prl'viously. It may thcwfore be ll;e patient's disorders Can becatcgoriu'Cl into two thatth...reisa pattern to the behaviour of the symp- groups: lumsthalthcclinicianrccogniu'S.Shcistheninapos- itionlodin.'Cther 'luL'Sliofl5loc('rtainoth('raspeclsof 1. Thasewhose-symptomshavcdcvc]oped the bchaviour of the symptoms not yct fll\\·('aloo. With gradually without any significant trauma that thisshecanthcnconfirmordL'flythepatlern. they can recall. pTh.clinicianmay,crogniz~a allc\",inth. 2 Thasewhosesymptomshaveonsetfollowing rxamioati\\lflfindings,whichmaylleofnelpin trauma. whether a hea,·y fall. a motor \"ehicle determioing thebcsttre.tmeotstratrgirs. Howc~rr, accident or any other kind of \"\"\"'ere injury, or tn~ .xamin~r's mind n~~ds to be suffici~otly fl.xibl. surgery. to ask othrr questioo, that may fit any othcr typical patterns The first call.-gory of disorders, those of gradual onset,usually fit into a n.-rognizable group of syrnp- toms and examination findings. The patients may have a history which inc1udes'prcdisposing factors',

Eumin~lio\" 107 Table6.4 Clarifying the hypotheses Thc 'trauma situation' is totally diff\"rent, and must Hy!X'thtsiziny«mj«luri\"!l alwaysbeconsidCTL'<l as having more than one com- ponc\"t musing thcpl\"e:S<'nlingsymptoms,1t will lhere- R.coy~izabl. pathology? forenotpresentasa'~\"i/.abl\"syndrome'.and thcrewill not bca 'typkal pattcm' to its presentation, Typit~1 palt.rn~ ...,a-How\"\"\"r, it need not be claSSL'd as 'atypical', The (St\"'lI/sp.. in) soningbchindthisstatcmcntisthatcvenifthetrauma renders the pR'SCntation being not fully compatible with th<, 'lypical p.lltern' group, lhe'l'<'<:ognizablesyn_ drom,,' group or lh\" 'pathology' groups, there may well bcrocognizable parts of the hislory, symptoms and signs. The lherapist has 10 Ill' alert. flexible and open-mind\\'<linh<,r,,-'Cognihonoithesepossibilili~, and \"xtrcmely skilled in searching lhrough her know- ledgcand expcrienceasa 'critkal~f-5<'lf'clinicianto sort this OUI. The skill of 'making f\"atures fit' is import- ani to this sorting out proc\\'!>S,lt maywcll take more th.1n two or threc SL'SSions toenableth<,clinidan to sec whcrc the fealures fil,just as It will take more than H\\I..,.,orfour~sion~forthepatienttounderstand what the clinkian is ('t1deavouring to find out and thence to contrihute10 thcex...rcThl' Problems tnat are tra~matic in on... t us~ally naV<: Ha,ilmo.. th~non.tOmil(m\"\"t7 mm.t!lanon.compon.ntiflllolV<:dilndth.r.fo.. it will b!: much mo.. difficult to r«ogniz. pilttemsof c1iniCill pr.... ntatlon. Thcsl<illof'mil~in9f.atur.,;fil' isimportilnt to th. proc.ss of sorting outdiffe..nt The·Il'.::ogniablepathology'rcfer,,-'<ltoinTable6.4is hypotheses much the same as the 'typical paUem',except that its interpretation is wider in that it COVe1\"5 more than just the behaviour of the symptoms and ex.1minatiOll find- Apatient'sdisordermaywtotally'atypical',andhemay ings. For ...xampl..., it includ\"s sLlch things as the age of bc rdcr,,-od to th\" therapist with th<' n,q\"\",t to sort out the patient the history ofth<, disorder, radiological .my dl1<1ils that wiU help in making a differenlial diaS\"'\" anomalies. gm\"ral h<,alth,etc. An example could be sis,l11is is making the best US<'ofa rnanipulati\"ephysio- diae.'TlOSingankyl06ingspondyl06isinitsearlystages lh\\.,.apistat h\\.,.highest I<'vel. 1lle skills ,,-,,\\uireJ in 'J{a:ognizablepathology'lakeslhequl'SlioningasJ't-'Ct meeting this challenge are CO\\!ered by all of the factors furth...r still. and <lL'ffiands knowk'<lge of p.1thology diSCUS5<'d abo\\'e, in conjunct!on with 1W0othere1emenlS: and related clinical prl'S('ntalion, An example he..., would be tll\" int\"rvNtroral discogcnk disorders, 1. TlI... patient needs 10 undersland his role in the management of his problem, TlIis includes l\"-'COrd- wllich progress through lhe stages from low back pain ingc\\'crychangcin the symptoms in a compara- at tlle bcginning.toradicular p<lin with neurologkal tiveway,pluswhal hcfl'Cls may ha\\'e contributed signs and changes laler. Wilh this as an example,itis to the information in fine detail ('half of I percent easyto~theimportanreofqueslionsrel<llL'(tdire<:tly of zero'), and e\\'en inc10dingitems that he might to th... ·stag... oflhe disorder',plusthe'stabilityof the feel are irrele\\'ant lhus lea\\'ing the therapist to be disorder'althenmewhenlh<,patientisrcferredfor thejudgl', This is just as il should be trealment. If lhesymptoms and signs vary from one day toanoth<,r,then it can bcassuml'd that lhedisord...r 2, Thetherapistmusthavegoodcommunicationand it5<'lf is varying, indk..ting thai there is something asS<'S.Smcnt skills; she must also be very particular unstable ..ooutit. Under such circumstances the treat- about dctails.open-minded,and honest in her own mentmustbegL'nlle,andtheaSSL'SSmentskillsmustbc self-<:ritidsms. She most base wllal she does in the of the I'l'ry highL'St order during a trcatmcntSL'S/;ion ta:hniques on sound reasons, and must pro,-etheir andat\"\"chfollowings<--'Ssion, u5<'indetail

108 MAITLAND'S VERTEBRAL MANIPULATION Tlu'firsl qUl'5liOM J'{'gards the person. We remember and Thearea.depth.natYfe,~haviourandchronologyot may even make wrilten records of anything to be con- symptoms, as well as the \",tation:./lipsMtwecn sidc'K'd during the oonsultation that is going to be symptoma\",as,sIlould~rcrordcdl>l1a'l>odytnart' helpful for the pati...nt. WeK'C<lgnize him as being a human being. a person who hapJX'T15 to have..,me- The area and depth ofrefcrn.>d pain m;.y som'-1imesbe thing wrong with him. Tht\" 'Ql' is discu5S<-'<l on page related to d\"rmatomes, myotomcs and sclerotomt\"'. 98. starting with 'As far as YOU are coocC'Tned'. and areas of paraesthesia oranaesthe!.ia can indicate a pause .. ,etc. particular nerve-root invol,'em\"\"t. Further infonna· tion resarding referred pain is given on pages 188--189. FoIlou~up Qs (clarifying and hypoth,-'Si:t.ing) are of two kinds The pattemsofpain distnbution do not provide the answt\"rs as to the precise structure at faull.and nor is I. Tho!;elltatareneededloachi...vetheamountol th\"\"'totalagreem\"ntonwh~tkindordistributionof in-depthinformationre<1uire<ltoansw'-'rthe p.,inisprodua>dbycachpain'\"SCllsitivestruclurt' pu~o{theque;tion There OJ'{' also discrepandes between the academic findings on research on nonnal structures, and patients' 2. Th~ tllat may lead the t\"xamint\"r along a new descriptions of their symptoms. It is fair to»ay th\"t no path tllat is worth following whilt\" it is p.lticnts po.'Sent with symptoms that can be identified meaningfully in the patient's mind as arising from a single structure; the symptoms always arise from a mixture of SOUrces in combination Hi~t\"ry is introduced at this stage, but Can be deter- Rcaliringthistobeso,thesiteandl>eh;,\"io\\lTofsymp- mined at any stage (this iscontrolk>d mainly by the tomscanprovideanindicationastottlt\"groupsofpain_ patient's line of thought). The.ub;ect is deait with on scnsitivestructure:s that are likely to be involvt>d;al1d pagt'Sllll-l22 thephysicalexamil1ationcanprovideanswt'rSregard_ lOgtheextentoftheim'olvement, It is important to Brltav\",u,ofsymptomsisusuallyintroduc,->dearly d'-1t\"TJTline, in the lumb<lrand «'rvical spint'\" (espe- in the subje.;tive examination. because the answer to dally the lower segments of each). whether there is Ql makes it appropnate, The S.'me applk'S to 'a involvement of the pain'sensitke aspects of the inter- demonstration'. Which may bespontaIl'-'Ously intro- v<.'rtebraldiscsorthenen·e-rootslccvcs, It is essential ducedbythepatientasheexplail1shis'mainproblem'. for the clinidan to have in her personal library tho: U this d\"\"\" not happo.1'l,the procc'dure is to say to him books by Bogduk and Twomey (1991) and Twomey 'Is there anything you can do, or any position you Can and Taylor (1994), Manipulative therapists (medical. putyoursel{into, that will bring on your symptoms?'. paramedicalorlay)cannotdiagno:sethesourceofpain or 'Can you do something here and now which will bymam,al examination. but it is possible to have a bringonyourpain?(assu\"HMg,ofcou~.I!UllpRin,sporl good idea as 10 the inte,,'ertebral level ofpainsensi- ojhisma\"'p,oblml). live structuo.'S involved Aimed Qs help to prove or disprove the hypothesis Oermatomcs Most of the time,questioning will be paralleling the person's line of thought. During thi; time. the exam· TheJ'{'aJ'{'thn.\"C kinds of dermatome charts: inerwill be gaining infonnation regardmg tht\"stroc- tun.'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 1. Th\"\"retical{embryological)represcntation.ascan best\"Cn in many an3lomical texts (Figwre6.4) The first step is to clarify the ~rc~. depth, naturt', behaviour and chronology of the symptoms. and to 2 Ao.'asofpainwhenthenerverootisimplicalt'din recordthemona'bodychart·.Areasofsensorydislurb_ causing the pain (figu1l' 6.5) anee should ~l.., be included, as should brief com- ml'1'ltsregardingareasofmaximumlOtensltyandlype 3. TI>eareasofreferredpainfoundinm05tpati<.'Tlts ofpain (FiguO' 6.3). Refercnce to such a body chart pro- wht.\" they present with nen'e-root involvement vides a quick and dear reminder of this patient's Under these common circumstances, other symptoms pain-sem;itivestructurcs are involved in the pain m<'Chanism {sl1ch as the nerve-root sJ<-,,\"'e, dura and the posterior fibres of annulus fibrosis). These distributions are presented in Figure 66.

bamination 109 cc F'9u~ 6.3 An e.~mpl~ of rerording e.amination findings Thedistributiooof'neural'symptomsorsymptoms byadiscprolapseateith\"rtheL4/50rLS/Slinterver- indicating altered neurudynamics is usually not der- tL>bralspaces. matomal. These are not like point 3 above, and are dis- C\\Issed on pages 113--114 Some authors describe all deeply felt paillaccord- ingto sclerotomes, I-Iowever, patients are able todif- Two nerve roots may be involved in musculoskd- ferentiate beh·.L't'n pain felt deeply in the muscles and related tissues, and pain felt deeply in the oones, joints etal disorders of the lumbmspine. However. thef'O':'Si- and ligaments bilitiesoftwoadjacffitposterolateraldiscprolapses,or of two nerve-root anomalies, renders such a finding Myotomes unJikelyinmu~uloskcletaldisorden;ofthecervicat spine. When attempting to determine which interver- Many p.ltients who have \",ferrL-d pain arc unabie to ddine the margins of their symptoms bel;alJ5(' tebralS£'gmentismvolwdwhenneurotogicalchanges they are deep and vague. Nevertheless, they are able can be attributed toaparlicularnerveroot,lhef'O':'Si- todifferenliate between superficial pain and deeper pain. Myotome charts, as u5ed in thiscontexl, refer bilityofaprefixooorapostfixedplexusmustbetaken into account; it must aiso be remembered that, for example, the fifth lumbar Ilerve root may be implicated

110 MAITLAND'S VERTEBRAL MANIPULATION

...Examination 111 Figu~ 6.6 ~rmatom~ chan baS(jj on arus of ,~ftr\",d pain

112 MAITLAND'S VERTEBRAL MANIPULATION Figu\"'6.7 Mvotomfthart Figure6.6 ScierOl0mcchart to areas of pam (paintal, 1960), not motor supply lhus indicating a possible diagnosis of discogenic dis- (FiglH't6.7). order.c\"entotheextentofindicatinglhestageofpro- gl\\.'Ssion of th\" disorder. The two most commonly Sl:lerotomes founda\",asofsymptomsa..,sh\"wninF(~\"re6.9.The A distinction should be ~nized between two din. kalprcsentationsofpainfeltdl'eply 'in the bone'; one symptoms usually h,we a 'agu{' dislribution, and a\", is deep pain associatl-d wilh the shaft ofth\" bone, and fe1tasadl'Cpgn\"wingacheorpain.The\",,,,,,,·ariations Iheotherisdl'Cpp.linassocialedwithperipheraljoints of the;e two area,. and Figllrr6.lOprovidesa useful (Figurr6.S). guide to the possible variations Thoracic pains Cloward area~ Pain fe1tin the thoracican':'il isworthyofa body chart of its own. be<:aust' itcanoccupyolh\"ra\",as thiln]()(al Cloward,in the ycarssince 1958. hascontribuled sig- spinal pain and refl'rTed nerve root pain. Of particular nificantly 10 the recognition of specifit arcilS of nolein the poslerior Ihoracic area an'thesensory referred pam (Cloward, 1958, 1959, 1960).Thcsignifi· changl'S Ihat can relate to the posterior primary ramus They are aiways near the \"{'rIOOral column. Nerve root canceoflhesea~asliesinlhefactthallhcycomple­ pain spreads downwards from Ihe spine in line with menl the hislory of onset of many patilTlls' symploms,

113 F'tgu.e6.9 Oocogenocpa.... 'd~ml 1101'\\ anII'''''' wrlatt oflowtrC'etYialdil.c IRqlrocl..ced11Ol'\\ Oowa'CI.R.B.II!JS9IA/l'Nlll: oI~,150.1(15,2---64 • • ,llltmd,....._ ofautl'tooattclJl\"blilhm-l lhc rib!; as 11 rcfers,lnmnd lheribcage.I'\"inof~pinai larg<.>, V.l~U<'> ~rea. Being able to point to ~ spol usu- ongin may sprt'ad hom.ontally across the back,and il m;ly be felt 10 pass from theb.ack tI'rougll 10 the chest, ally mWll> that this is th......xaet sil<.> oflht' cau>t' of m \"\"hkh case il IIUllih;l\\e an intradiscal origin. A fur- Iht' f'<~in (ho\"'l\"·er, !iCC point 5 below). therpn.'S<'fllal'onis\"t.e.... ana ....aorpalchofpainma\\ befell anlenorly ,,'thoul any back pain (J\\~utr6,JI) It 5 The queslion should ~ askJ.-d, 'Art' you able to should also be A'ffiCmben.-dthai Io\"'eralxlomll\\alra'\" louch the spot or is it dl.'l.\"p<'r ,nslde than lhal ' ·, The CUI be of Iwo kJnds; thaI arising from the low lumbar ansWl:'r can diffl:'ll'l1hal... betWl'l\"n a dt..·p m~'otome spuw, and lho> groin pam n.-ferrro from an LI ll('f\\'e- and a deep sclemtortl(' The l;>rge. \\agueareas indi- IOOl dl50rder (f(O:lf,.. 6.11) caledisordt'f'Sofolherslructures(5rl'p, 188) V\"'Vfn<·pr«1l1alWn ........ IOmHiullr~_'mpor· 6. I'ain fell in the-' low lumbar SJ'lne may hal e Its on- ~rtrWllII~lJbr.U..,lorJlots/4blishlngtllrJ\"\"O>\"Sllt fl{lhr\"..ht'fl\"<.....\"plOf7fS.~p1O'io1esanin\\'alu­ gin in lhe upper lumbar s.pl..... .obk-' iourxbbOl'l b- the .........inderol thco.umJ\\llIJ()n: ha,.,.7. Palients can mU5CUJo<;.lo.eIetallo.... abdommal I. TlM' n..:Immer must watch how the pallClll \",di- pain ..risingfromalo\\o·lumbard~dlSOf'der cale lho> ..rw of ra'n, ..nd then she must u..c h.cI\" OWn finger or hand ttl take 0\\''''' from hi!> §(las 10 rathn- than from a low IhonOc 1K'r'\\·e-1OOl dtsorder. idcntih,thc.reae-.....;t1y It is nwntlil tornabflSll thtprtClSoe SIte of iN: 2. If a pal..,...l ,nJICiIICS an ..wa across hIS back. the eurru r!>houIJas...,·lsilalineacross)'ourback. pal~t'SsympllNM,asllll5,nfluellCetlte~l>OII or n. ·,,_ il7', If lhep;>tienl u!>cs tus hand or fin 10 demonslrale lhe .. rca, he is in facl ..nswer- of multiple hypotheses.ttcI .,11 be of patamount \"'~ It\", qu.....uQl\"l non-\\crb.1l1y - lhe usc of h;>nd ,\"fl~1I« 011 1M ~milJnck, of tM ~m,nat_ mJioling an ,,,,,,,,and lhe finger indlCat\"'ga 1\",1'. The many paltt'ms of pain lhalan;,rccogruzableindi· 3. The matchmg of non-\\\"erbal messages both with I'erbal n.·spouses and wilh IOllching lhe art!;' calenolonlylht-'prob.lblestruclurealfaull.butalso strengthens the exaclness of the informalion t~inl...n'erlebrall\"I'd lhal is at faull. l'rcci$ion pro- \\id~':'I an inval11abl<.> foundalion for the I\\'malnder of 4. 0nt' palient may \\l(, able 10 point to ont\" precise SpOI ofp\"in and another may use his whole hand, theeHminalion. while yt't anuthl.·r may onJy be able 10 mdlcate a Further ....\\~ding of the t('~lS of Cyria~ and Cyriax (1993), BlltlL-r (1991) and Criel'e (I91l8) \"'ill wid...\" the clinician's mind 10 lake in ref.....red symptoms from t.\"trapmt..\"tneutop.lth,CS, p<.>riphef\"aljoinlS. roeuraldi§Or- <It.,.,;, the autonomic rter\\·ous system and otht\"f!lOUn:t'5

114 MAITlANO'S VERTEBRAL MANIPULATION OJ ~6.10 lMcogtftocp;wlllllldtmdftolrlpost~lml!MlrfKt'ofttr'vicaldi:lc1IIllFkfrmclf..-tttllrJlcliK~ ~~Oowanl,R.al'959IAMolsg/~rprl')',l~\"«>2-.M.withtJftd~of . .thornpubli)hm.J ~1In'many other an'asllnd kinds oi symptoms 4.Differenliotebetweenthe~bIe5OUrcesofthe (nol ~;nllNol pnn:ide infonnation;lS to their §OI.U'Ce, For l'XolImple, patimls may sPNk of numbnc55,)'(\"1 on bizam'syrnptoms. ful\"lhet\"questiorung.ilu;II'feelingofnumbncss'r.lthcr Know all there IS 10 know aboul thoo neural and than .... KIuaI dll1\\inution of sensation. Under thest! mll!iC\\llo5keletl anatomy, and thechanges(nol ~ thoo;orea of thai 5O'<al1ed numbnesll nece!6ilrilypathologicalch.ngeslthataouse symptoms. doesnolfillhepaltemof.lneT\\·erootromp~I\\·eloss oflle\"l5.ltion; no. does it fit.l pdllem ofperipne..al David Bull\". hasSpeeillli7A.'d within thoo field of mU!lCU' ner'\\'e entrapment. A palient may romml.'nt that his loskeletal di50rdel1l to thee\"tent lhal clinkiaru; now whole arm feels hea\\'yo.cold,or thcremay bean area ha\\'e the opportunity to understand other sources of ofhy~iti\\'ityIOlighltouch.AlIofthekcanha'·\" some of the pre\\'iously unclear symptoms, We will a spinal or neural soun:e. The importanl things are to ha\\'eheardand belie\\'l-dthem,notedandasteriskoo the appropriate plDCC$in n.'«lrding them, and e\\'en I. Usten to what the person says. n.'«>gflized them within syndromes. Thearca cOllsiden.xl 2. Belitvehim. musl now include the ne.vous system, both in the J, lWc:ord the in/ormation being provided. title now being changed 10 'the neuromusculoskelebl

Eximinition 115 Fig\"~ 6.11 J'3insoflho'~c;cspinil origin

Figu,e6.12 lowe,abdominalpain,efenelllrom ~~~~g:~ow I\"mba' s~\"ne Or Ibl an II MIVe root system' and in the 'differcntiation ><.'Clion'oflhe phys- BEHAVIOUR OF SYMPTOMS ical e:<aminatioll_ As has bew st,lll,t patients m.lY hayeunusualareasofsymptomsthaldonotfit.lnyof Changl'S in the sile and intellsilyofa patient'ssymp- lhose menlioned on lhe pn.-ccdjng pagcs_ They may loms should be related toactidtiesandpo.;itions,and ha,'ebiLarrcsymplomsthal they du not dass as pain, 10 periods of short TeSI and long Test (Ihe laller being and may nol even mention them unless asked about throl1ghout the night). During the questioning il is lhi'm; or they may 1'01 recOglll/-l' them ,lS bdng relaled e\"SI'ntial to diffl·....·ntiale the bl'haviour of the local pain symptoms until they rcali:l:l' lhat lhebizarresymptoms from that which is rcfer ...>d; the two may be as:;ociated ha'\"edi5.lppeared m parallel with improvement of the or they may beh.we in t0laJlydifferent paltems, tile primary symptoms for which they sought Ireatmenl lallerindicatingdiffercntcauS<.'Softhepains.rigu\", Examples common from lhe cer\"kal/upper lhoracic 6.13 gives a c1earindicalion of the gen...ral questions levds include heaViness of the \",hole arm, g10\\'L~ that should be asked. slOCking paracsthesia, blurR>d vision, head too heavy The beh,wiour of the patient's pain with \"arious to hold up,elc. Butler(1991)rdl'rstoneuropalhicpain, acti\\'itieswiliindicatehowitaffl.'Clshimin,mdgi\\ean saYIng: idea of its se,·erity. Furthermorc, it givL'San indicalion of the le,'elof disability, \",hichcanbeexpressroin TII€ dimu,1 fral\"r~ ... are \"0/ drtlr, Q>ld rir, terms of impairments, dls<~bilihes/activitylimitation. ,ugg\".tirmrolhi\"ko!thellm'tJlJssystrnlwIU'lI and handicaps/paTtidpation reslriClion (1CIDI-I,WI-lO symptMlsIW·lIbilobscl\"eisgood ... syml'loms 1980,I997),Questionsshouldelicitfactsagainstwhich nlllyjumpjromQrfl/I,/lIrca,cen'icQlotlcdlly,dooll> subsequent progreslican beevaillated. For example, a lI.rotller.g/oc'l'-IIQtlda,rotllrt. p.~lientmayS<1ylhatheeanwalkasfaraslhefrontg.,te bt!forehis leg pain becomes S<'wre. This fact is a basis He also refers 10 'Jincs' of pain and 'clumps' of pain for assessing progl'L'Ssif,during treatment, he \",aehL.. 'These~aluresare,'erylooselygroup'--dbylherapists the slage ofbcing able to walk furth\"rthan the front as being neural in origin, and inc1ude neuropathy_ The gate.ThesesubjooiveaSSC5Smentsthenbl'Comeoojec- t\"'obest texts on Ihe SUbjl'Cl are by Butll'T (1991) and tivefacts. G.wve (l988a),both of which are considered rrull1da- An understanding of the c\"uses ,lnd sources of ,I lory knowledge to the Maittand concepl patiL'Ilt'srderrL-dsymplomscan rarely be \",ached ina

uamlnation 117 1.IT<Dlolar'll? bc a\\\"llid<.od. This is later referred toas'irritability',and (qualjyklcal1illl<lrelerl\\ldJ is itemized in th\"·planningsh<.'ct·{Sfl'Ta~le6,J). y~ ~ Toass.ess the irritability ofa disordcr,lhrt'.. aspects of the behavinur of a patient's symptoms most be Does ~WI'J inintensll\\'? I ,'dated toa !X'rtkularfunclionor3ctivity: (quality ~) 1 When dolQJ!l\"'i? 1. Detc,miningtheactivilythatpro'-okesthe 2. OolQJMveso:nee\"\"\"Yday'? pati,mt's!X'inandknowinglhevigourolthat activitY·P<lrlkul,1rlyasitmayrelatelophy~ical ;:==~,;;? cxamination3ndtreatmentmo'-emcnts. (OOISaIIDllvaiollorrestnebng) Slbllongdoesilas1? 2. Knowing thedeg...... and quality of the increased 6,Whatll!ip5loeaseit? symptOI115 caused by Ihat activity. ],lbIlongcanlQJbefree? 3. Knowinghowlongittakl'Sfortheinc....ased syOlploms 10 subside to th\"ir level prior to performing the provoking 3ctivity, ..\\ comp.1ratively minor activity, soch as ironmg for halfanhour,thatcauscsp,linofaseverilylhatfon:es '\"Whal ......8$iworse? '\"00 '/00 me\"\" notl101g th..,patient 10 slop ironing, bot Ihatsobsides in halfan hoorsuch lhatanolher halfhoorof ironing can be car- :-~T~' ~~~roo' ried oot, indicat\"\"minori.ritabilityofthedisorder.Thi5 th..rcforcp<'rmitsafulJexaminalionplussoml'lTt'at- menton the fi,\",l day w;thoot lil<ehhoodofexaccrbation. If. howe,·er. thesymplOI115 did nOl sobsid~ until th.. patienlhad had a full night'ssleep,thedi50rderWoo!d f'i9ur~ 6.13 G.n~ral qu\",tionsfor .srablish,ng b<haviour of becol15idered to be irr;lab!e and thel'xaminationsand ,ymproml t....almrntwnuldhavetobel..lilored,takingcogniZ.1rlcc o(lheirrilJbility,soastoavoidex.acerbation sing!\" consultation: to reach il - ~,..,. - is dilfkull No malter whether th\"paticnt\"s pain iscoru,lanl or intermilleot, prl'S<.'rlt at rest or 011 activity, there will bc enough. Th\".... arc SO many innuetlcing factors. The mo\\'t'ments, positiol15 or ac!i,'iti<'S lhat will aggravale l~,d of proven scientific factors is poor in il5<'lf. for ore\"sclhepain.Thcscpositionsoraclivitiesshouldbe further reading on th~subject. Grieve's text (Gri.,ve, cardolly noted. as they may well guide the choice of i9S8a)wouldbch\"rdtnbelter.Onen'l)tl'alaspecl po>itinns to be adoplL-d or avoided during trealmenl. that can be elicited from th~ patient is 'remembcn.-d Care is required when assessing the elfect of resl on pain. FR'<joently the patient will say the pain is worse p.1in'{or.incompulerlangu<lg~,'programmoopain'), when in bed. when in fact the symptoms may only be andlhisn\",-'<1stobedel~rminOO.Anex,lmpleofthisis worse for thefirsthourorsoasa n.'Sult of thl' day's lhal,lp.'tienlmayha,,~boltockpains..p..adit\\galong the lateral aspect of the thigh and calf,wilh the mosl activilies.On forther qo('Stioning_the pain is foonci to se\"e.... parl beingatth~ lower lhird oflhe lower k-g. bewru,iderably relie,-ed by the rollowingmoming. Uptoac('ftainstageofthesobjectiveexamin~tion,this Howe\"er, !X'in that is worse at night and is severe ..noogh to make the patient get out oflx-d rt'quin-'s may be lhooght 10 be due ro a nerve-mot disorder. However,whenilisdiscoven.odthMlhepatient had a carefol inv<'Stigation because of the possibility of more fractul'<' 20 years ,lgO at lhl'lower third of the Iibia and serious pathology than the mt'Chanica! probll'ms usu- fibula. whkh caused consid..,rable pain. the whol., ally,derr<.odforphysiothcrapy. thinking must now inclod.. lh.., possibility of pro- grammed pain, The resulting effect may be that th., Irritability Can ht: dcfin.d as a lilll••etivity causing a I'xamint'T needs to rethink h..,r prioritit'S abOllt lhe lot of pain thatta~~ a long tim. to ~III •. Som~tim~ soUlU'oflhesyrnploms itisu~fultodcSCfibt:th~symptomsoflh.paticnlas Irritabilityofthedisordtr '~v.r.·ifth.aclivityth.tcau~sth.symptomshas 10~intwupt.db<cau~oflh.'nt.nsityofth.Jl3in. Questions should lx- asked to determil1e how ..asily Alla5p«tsofi\";tabilityand~.ntyr~uircca~. lhepatienl\"ssymptomsa,eag8ra\"alLodby hisactivitit'S ooth in th~ ~rformanc. of ..... mination t.m and in andhowreadiiythesymptomssobside,sothalexacer- th.pr\"9r.ssionoft,.atm.nt bationofsymptomsfrom ..xcessive ..'aminationc\"n

118 MAITLAND'S VERTE8RAL MANIPULATION Great dIfficulty cJln be rncountelYd when endt'a\"our- SJlo-'CiaIOs, roullllt Q,Jand dangL.... Qs are~ special ing to _ the WYfflty of the pootM'Tlt', poo'n, Thr qucstionsth.1tmustbo.'asl«:d,5pl'cialqueslJonstndud.e whole ,ubject of P\"'1n i5 mormously compiC'x (Mclzack the df...,t of prulungt'd rest (~ rught'5 =t in bed a:'l and Wall. 19&&), full ofCU'lSickr.ble known knowloogi' compared ..-ith a holM hour'J ,\",I, thc ftf...,t of adJ,· but 10150 1Ub,ect to many unknown and h)'poIlltsiH'd lties, thedcgroi!ofS)'mpt0nt5~IItltft1dofthcdoymm· ftilturn. r.tients lNydeicribe,ymptoms III manydif- pa..,.jwithonfir>tsctting()Utofbedinthe~ u-e.ft'ft'flt WJl)\" for w>del)' ~ rNSOr\\S, but oItm .ndthcmiddJ..ofthedoy,~ a ~ of uniformity. &i,ing usdul ~p\"'!l'\" RoulW queslion5 rdootc to gt-'f'ICI'al health, \"eight SIOI'dforltltcillUcWlto~,PttJb,ablythemost Ios$. fatigue \\e>'els, homoe and ..,on. r1.'lation§hip5. pn!'- Imporunt fact alwa) 10 N'''' in mind IS tNl JymplOmlo ,iouo; openlions.nd tIl~. med\"'.n.-.. Me.- can ha,'e. ph)'5iologKal bors>s (..'hcther understood Danvr q~ rdoo~ to;o '·~Lar or not), and Itwre can be ps~1 influencing sympto<m, .,.ucb equiN symptolIlS. OSt~ asp«b.. 1llt P\"'J- by KftIr (1967) K still ,aIWlbJ.. in su'Y\"'Y,<\"tc thJItlld~thedlffftmtph~allh~ 01 ~UI driI'rmml'd b)' physiGIl \\('SIS, Too often In thc cImiCilIJituaOon,.P\"'tirnts.\"\" not g\"cn the bo,>ndlt of HISTORY the doubt wlltn thry de§Cribe either unusual or bi7........ !l)'mpt0m5 for which there is no pro, en theoretical A!;c.anbe5eenb)'rea<l\"~lhcTablesforthe5ubj«r,lY knuwledgeas )'1\"1. Treatment dOl!S nQI ~m to h....e an ex.amirultion of the cen'ical, thoracic and lumbar eff«t on them, \"nd unhappy p.>licnb b..'CUffil· taggoo with the label thai their pain is pu~ly ~ychological spines (\"'\" rr DO, JOJ and 339). the history can be Inctaken al an)' stagt' of qUl,>tiooing aM may be Gri!.'ve (1981) and Butler 099l) pro~idc much useful sought in s<--gments during the remainder of the qUL'S-- information aboul Ihe possible reasons for the clinical tioning whenl...'cr 'I 5l'l'ms mOSI appropriate, When typ<'ll of symptoms enCOUnleff'(t and thl')' cerlainly confronll'C! w,th ~ chronic non-episodic disorder, the male k'1'l>e to cllnlcians_ The primary points al this hist\"ryisb..'Sllefltotheendbe<:au~theDreaDnd the stagi'otknowlooge ~ll' that patients should bl:' IIslened behaviour of the symptoms wlll gu,de the question· lOan.d behe\"oo becaU>e(.) their dl.\"SCriptions hclp us ing, enabling the e~amineT to e~clud\" im·lcviUlt infor- to undl'Bt...nd from what they are suffering.. (bl they mation from the p.>til'nt'.s story. Be.:ausc it is usually can show thingli about their per.;onallty. and (c) we p;oin that Cau~ m05t people to s.eek trNlment. the stand ~ better chance of malung an ,mpro\"emenl by ,\"\"ample that folluw.s w,1I be presented in thesequence Matme\", used if the patient', anSWft\" to 1M question is 'I get a ~ t 01 pain moy be _,stN by ~pplymg pamacr056\"\"\"\"'·. IIrelchtooneortwoofthep.1benl'Snorm.tl fOinll .. hile History taling is a skJll tNt \"\"{UJ~ knowledge \"~ldIinglusl'NCbon. We.glunglh!stnfonnatoonagainsl and practice. Macnab' CNpleT' 01 history (Macnilb. both Ius hlsmryand hi5dcscription olwMI hr is uNblf, 1m) ohould M rHd. ~ood and applied by all todobecJltlloroflusplUl ..'ill...u~pin~, lhe finer detaIls n'LlIlU'lg to the p\"\"\"\"1 epi50de 01 the aim of W quesbOrUng i5 10 know 1M fWlimt'1 lympI<Jm5, together w,th thoee 01 any earlier hismry, I)mplOlnfJlnd problmlsilOcompll\"lel,!lNtltltpn),.;o. an pro.dd\" -lP\\en III tht a~oIbeing abJ.. to Ihrraplst an 'Ii,,,' thrm henclf_ It i5 then a n.ltunl maU a ~ d~ - In\\'alu.able information .up II) ask about t'\" onset \"nd hislory 01 tilt present about the sta.~ of the stn.octures at f~ult. ~ before asI<ins about re}e\\-ant p,.,..ioulI hilior)'. It is not enough 10 know thaI a P\"'lient'.s S)mptoms Putbr181us!ory' i1t the end of the Mquef'a fKih~1t'S caml' on 'gradUlllly'./lS it may not Mclear wNt thiI ~ti'eql-leSlioningforwi~pcllCllCoophysio­ 'gradUlllly' mNllS. Ask,. 'do you mNn it UlSIdiously. tMapisL sneakily in\"eig!ed its \"'ay on your. If the ans\"\"er is ·yes·. tilt 'gradual' probabl) me..J~ tNt the patient would N'\"e grOld\"aU)' become 'W~n' of the symptoms SPECIAL aUESTlONS 0\\',,1' 1-4 week5.llenerinfonn.tion is gained b)' offer- ing him two exl\",ffil'S - '\\Vu it gradually O\\l('f a few Thit sectlon OO\\'e.. p;!rtkular questiorul that must be days, or was it 01'1'1' a few weekllr. liked 10 aJ '\" be .ware of any inhL'R'1'lt dangers for II is also nC'Cess,1ty 10 se-parate this kind of 'gradual' rn.tnlpulatlve trealment or factors Ihat may Iimiltreat- from that which c~me on gradually Over One day, ml'1'lt (e.g, vertebrobasilar insufficiency, ostropofOSls, Ask. 'Can you \",-'Call whether it began on ONE day, dC.). Tne questim5 vary for each section of the spine, el'\"n If only I'I'ry mildly, and that the day before .ndared~lnlherelcvantchapte. ., you were perfeclly normll17'. If the answer is 'yes',

EllIminition 119 then., is ~f)- 10 know ,he following- 2, 'Did i, rom\" on latef' during the d.iy?\" - wlUch I, 'Did )'ou w,ken with it?\" - which would indicate \"\"'t..'ouldirw:ii<;.;lte,inthea~oIanytrivillinci­ 1\"\"1 toml.'thing had NppenOO during the d')'(I) before- QuestION should then be pressed to deter- dent or unusll;,oUy hei\\'y or different work. mll'le pr«IlSjXl5lng fKtol'5 such ;,on lInusu;ol xli.· !lOmethong had been gri>du;olly dc\\'riopmg Mymp- itll'S or forgotten Iri.,....lll1Cidents (5tI' T\"tw 6.5,nd tomatk.lolly, md lh.at the d.iy when the symptoms '•.·'eUnllOt) began ..oasjust'the liststnw'. bble 6.5 TakJI'g the ICIi~\",''''-,- _ \",\".\"'...., Howlont Mitt'/OU lIMit? [IftaYPlftdlOfollowupw,th'HowlontTKISn~E1 Howdldth~ ptOtfIt booJt btqin? bllonliMOll1c:omlMnlSl [C'Iinfylollddenor9f8d....1j r l - - - - - . L I - - - - -1 1 Suddtn 1 Gradual Inc:,dtnt 1 I ~ Noinc:id~nt, Whit did rou ~u'dlv not,~fif$11 rl----\"-I- - I rl~--,-I_-I W.ktt>td Du\"\"9 Fromprtd~ from ,n6clcnl[wwrity wilh Im/pm lCtiVitits,tlC. orwlly..,l.altdj I I I PREDISf'OSlNGFAClORS ,,~llop(ISIngKtNtty; ..1_ _ lbJIlt'r-y , \"\"\"~WlU.-lpostu.., ........1 ......... ... Cold, p.oho.oghts 2. Ac1at~KW,tyol\"ltidrn[tock<j=ofd~bII,l'yfotCOll'~hl'ytKrioouslll'dIoIoqyl J. Historyoflocal,.in,historyofrrfnmlpa.\"p,mbjllllinupnntsordown..anl5l 4 ProgfftSCMt ,Mill ptrioct'ti 11M'I1,ngoffoflY'\"IlI0111S ~h ..tory , Fi\",bou,i\"ck\"B: c,u~ Duration TrutrMi'1t 2. Su(ttUiittbouU; Fmlutncy E':i':olc,u:i': AtroYery:\"tt (Ato;t, A,tlc.) J M\\'ditllhiltorvllndlOcio-«OI\\Omid

120 MAiTlAND'S VERTEBRAl MANIPUlATION When a minor incident prccipitates an onset of symp- Thc main area, of history concern' toms On the following day, the foe,\"erity of s)'mptoms. Thconset and dC\\'Clopmcnt of the present episode the deg\"-'C of the incident and thep,llienl's ability or The pl'l\"Sl'nt stage of the disordl'r. inability to continue working provide invaluable The present stability of the disorder. information regarding the dcgree 01 the damage of the The prcvious history,indudingepisodk stmctu\",\" at fault. Similarl)'. the comparison of the de'\"elopmentandth\"pc>ssibilityofgenctic s),mptoms on gelling out of ht--d the morning foJlow- components ing the incidenl. along with the state of the ,ymptoms be/ore going tob,-'d,provides information rdahngto The most common spinnl disorders trealL>d by manipu- theunderl)'ingdeg~ofdisorderofthestructurcon lativephysiotherapists,wherethedisorderhasapri_ which the minor incident has impc>5<\"t itsdfl'C1. Such marilyspontaneous onS('l,are disorders often prog\"-'SS from local pain to include 1 Ligamentous and capsular disorders due to rcfer,,->d pain.Jt is then necessary to know Whl1hl'rthe accumulated stress from poor posture. O\"l'ruse, pain hasspll'ad gradually, or whether it involved misuseorabusc. rl'felTL>d pain from the outset 2. Ligamentous and capsular disordl-'rs from a minor sprain. Symptom~that ha~ de~lo~ 'gradually' need Lock\"dorblockedioints furth~r c1afificatlon Disorders of structu,,-'S in thevcrtl-bral canal and inten'ertl-bralforamina In questioning rcgarding the historyofa patient's M~'Chanicallydisturbedarthritk(-otic)disordcrs. symptoms, it is necessar)' to recogni7.e that the pati..nt Discogl'nicdi>onlers. may havl' two disordl'rs. A new problem may ov\"rlap All of mese have ,,-'Cognizable patterns of onset and with an older, longstanding one, and every effort mu,t development. bemadetodiffl'J'Cntiatl'betweenthecontribution\"ach L i g a m e n t o u s a n d a r t h r i t i c ( - o t k , - o s k } d i s o r d ..r s o f ismakingtothcpatient'sdi,;ability. the spine have elGlctly the S<lme history patterns as peripheral synovial ioints with the same disorders A patient may pr~~nt with ~ymptoms that can com~ Examination of the history of patients with ligament- from two disord~~. E~'Y effort has to ~ maM to ousdisordersmustbcdiJ'l'Ctl.'dtowardsdetermining differentiate ~tw~~n th~ contribution ueh i~ making the parts plaYl'<l by 10thcpati~M'sdis.ability • Stress • Strain • Sprain Sometimes a palient prl\"\"'nts with symptoms that fit .O\"·..ruse thelaterstagl'Sofarecq;ni7.abledisorderwilhoutrcal\" • Misuse izmg he has an associaK-d history. and themanipula- • NewuS(' livephysiother,lpist ma)' ~ogni7.e thai it is qUitl· unusual fora patient to have these as his firsl pll\"SCnt· • Abuse ing symptoms. In thl'SC circumstam:es, the patient • DisuS(' musl be pr=<.<.'d vigurously for previou, symptoms that he may ha'-e had, yet ronsidl'rl>d to lx· normal Arthriticdisorderswillha,\"eaprolongedhistoryofcon- (remember: 'You can't tell me too much, you can tell stant aWarenl'SS of discomfort studded withexaceml- me too little; ll't me be th\" judge as to its rd\"vann\") tions, In some patients thedisotder will bc linkl-d with previoustraum.1 and in others there may bea familial When trauma ofa mOre major dcg,,-'t' (such as that link,but in all there will be through-range pain, and resultingrrom a caraceident)causessymptomS,H is crepilus may be pt't\"!Jel1t. The history ofdiscogl'Tlk dis- nea.'S5ary to know the following: orders, which may or may not involve the \"\",\",'e root and other structures, is detailed onpagl'S 192-1\"4,Thc 1. The degree of thl'trauma-a.>ccrtain the extent of historyofaloch'<ljointis\"eryspl'Cific(srr'pp.2J2-233) bruising,itscolourandduration.thedamagl·to Rder,,-'<l pain has characteristics that can indicate thc thevehide structure from which it is coming (s<¥ pp. 108-109) 2. Whether the patient was aware that he or his car Taking the history of the present episode first pro- waS going to be hit-that is. was he able tobe vides information that enabll'Squestions about the prcpared for the blow Or was it an unguarded blow totalhistorylobcmorcpositivelydi~ted.lfthefirst (the latter always imposing the greater dangl'T)? qOl'Slion is, 'How long h,we you had it?' and the

..... polx'nl ...... rtihis ....,werbysay,ngTw<-\"l)'years ..go. y'oungc..lfinlOlusstatlOllw-agon,ag;;amwi!hllQsignof I .. ', ~ should be gently inlcrNpk'd by saymg. '~o, b;;acktroubJoo,Then. .. wctl. I.Ilcr, he reached for the l'm\\iOlT\\', whall mNJT isoo.., long h\"ue you had itttus IUlIlO\\IS cup of lea. The ,nddml of the cup of IN llDWr, After y'ou ha,e determined whm, the \"\"\"t becomes much more ;;aaeplable when il i§ seen <I5·the quelitKTnSdeh.-nninehowitbegan ..nd whatCilusedll. last straw' Palx'nts w,lI often say 'It began suddmly', w'lUch 10 tIll\"mampulati,e physiotherapist may \"\"\",n ..1 a p\"r· A.WtIg iboul 'jndlSflO5Ul9 helots' ,n 1M hIStory of;l lJCul.lr'~tantbutlothepalil'nt\"\"'Yml'anO\\·e.r. pot~nt'sprobl~rnis~ntlal,as'laldl;in prnod of 2 or more day'S. A gradu.ll 005<.'1 usually uNk~tand,ngtIl<o futures of;l plt~(s probI~\"\" rne;lnsanins,d,ousonset(dISCuS6eC!abon'),bulwMI· \",·t.'I\"lerlll5 lnepatil.,,1 uses,lhcy must be clarified. If ;lndgu'dcsint'utrn~nlprogr~onarodinlh~choic:l:' 1!>e()nS(:t was gr,1dual. delermitll.'whl'I\"'-.,. thepatil.'l1t of prop/lyl\"CIk:musu,cs knowsany~\".onwhyit,houIJha,·ello-1!un-wh.'lhe fir..! felt tl\",1 made him aware somelhillg w\"s wrong Eath qUl'Stion that is ask,-d must b,d towMds InS('arc\"illgforl\"ecau~ofap.ll'cnl'sepisod\",itis being able 10 makl· a diagnosis, Thcrt!fore, Ihe dean.·r necl\",sary to know how IIx, symptoms first apP\"'!red ,,,,,sonstherl<'lurelnee~aminerhasofll'ochiSlorypauemsof ..00 IIll.\" 10 be able 10 find .... tisfaclory that thC' d,ffen.\"'1 dlWrders, the It\\Of\"C inform\"uon can be \",,,,romp\"rablc.Such m.>teh\"'g 15 equally Important gw>ed by- asking lhe righl queslions 10 st\"\"'gthC'n lhe whetherlhep\"tienl~.. ~uralbacl<.>che...n,llCI· JUdgemenl n-sarding the d....gnoslS. dentofdlSCdarnage.oran~rbalionof;lll.·.rthntoe' ~p\"lienlSw·hohadaninc1denlth.oluusedthe d,,;order_ <hsordcrwdlfilinlooneoflhraoGlll'gone5; II is ~~.f)' <;omrt,mes 10 be prepared 10 probe \",,,-'OSi,d}', \",en O!endlflS the probing O\\TI' a penod 1. ~whohadafallorU1Jur')' of the fir..t two roosullahO'ti, 10 make the fNlu~ of 2. ~ who had .. mmor or In', ....1,oddenl bul tho.' \"'>tury fil the fe.. turl'S of the p.abent's complamt. lIOb«d\"ItJtoelseunlilthelll':<t~\",g Bul'fit',!heymusl Dl>l~\",g into the p.ast hlSlory is essenh.. I, p\"rtlCU' 3. n.o..e who mo\"fcly Iwisled or bent. f,,11 sudden larir in n.~auon 10 lheor,g,nal onsrt. if the progn'S/iof piI'n. and were unable to retum 10 lhenonnal pl»'hon thrdi!lOrder is 10 be und('fSlood. The garrulous pihl.'l1l can make this pro<:eS.S irksome for thef>O\\'ice, \"'ho Ilis 'cry important 10 beable to MAKE FEATURES RT. musII..arn what can bcd,.cardl'lfoT ignort'd from a For Hample, a v\"ry fil45-year-old fMmcr, while silo 2o.ycarhistory.HowcV<'r,aftcrsortingoulth\"origin,,1 tingallhebl'\\'alfasttable,hada,uddeno~tofdis· unsct, the illlerwnillg yCMS can becovcrcd by such ablingpam w!l<..\"h\" reachl'd across the t.lble 10 tJ.kea qUl-'stionsa, cup of h'a from his wife. An, mo' ..nwnt provoked Howlongha\\\"l'}'O\\Irpalll·fn.\",inlervalsbcen?' _·en>pa,n. Hewascarrie<l to bed and thedoclor was C\\lIlUded It\"hadne\"erhadlroubk>w'thlusbackprl\"- 'Ilow many times h<>\\'C you had trouble?' ,iousIy, desp,te a life of heavy work on Ius filnIl. A tr,,·w)'eldis;ablinginO<Ji.onljn~t>on.suchilSthat 'liasthefrequcncyofcplSOdeschar\\b't'do\\'t'fW ~,l5lOtl1l1y un.>ccept.lble as il sunds -Ihe-re laslroup~of)ears?' hasto~.reasonforthe<;pmelOrNCtSO''ioIcniI.ylO '1Int'y'oubeoenronfinedIOOOdbecauseof,P' such .. lri\",01 \"'enl. lbe ......son h.os lobe \",!her thai '\\\\'halhasc\"US<'dthe~es?' ~l5a~patholog)-pl'l.\"'>mI,nthesp,Ol',or '\\\\'hal kind or I ..... tmcnb ha\"e helped you best th,;,1~m\"'lha\"ebeenf;ICIOfSpresentthalpredis­ sof\"r?' ~lOlhr&pillt\"'ginngw.y' C~ngthepredispl»lIlgf.octor<,elell\\('lll:ll \\\",Ih the prl\".lerll hlSlory ,I lSes\"enllal 10 know till\" mU!>1 be sought which, \",hen;added together. atl'rom· Pn'.lg~ of the symploms from the lime of on5Ct k' potiblew-,Ihh,sn'achingfurtht'cupofl\"adisabling lhe present moment, ilS w\",n \"5 kllO\\\\\",ng theeffl'C1 him so. Inl\"reslingly, 2 \"'l\"\"ks prior In II'oc cup of lea of ilny Iwatment Ih\"t mil) have hem lIlShtuled. Qut-.... tneidcnl, while oul on Ihe farm the f,umer's small c.le Imns regarding mroical history and socio--<.>conom\" had'puncturc.l-la\"ingnojack,thefMm\"rliftedth\" history ~hould also ~ asked. Table 6.6 prol'idl'S' comer of the car at the appropriate mommt while hi, 'l\"kk rcf\"\",tlOI for thegcncr,,1 poinlsme-ntioned;5pt' son changl..:! lhe \",\"'-\"\"I. There was no sign of back cifichistorics\",iJlbed,scusst.-dlat\"rinlhefl\"Il'\\, trouble CIne week later, he had 10 drag and Iifl a 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 t --.....,...I.....\" sa)'\" in an rndea,·our to 'male f..alu\",\", fit' \"\"tmllofpauhiW;wy Pltttrnofpretllth<5tOty Having \"5bblished the lund of dJ5Qrd...., the patlcm SU9tofclMlOtr 01 questiorung can be directed along one 01 threo> paths. Subiutyafd~ Thethll'epalhs5U~lftlabo>ea~ PLANNING 1. History 2. Area of sympt0m5 PLANNING THE SUBJECTIVE EXAMINATION 3. Ileha..iourofsymptoms. The t\"blt.,; on pages 99, 119, 230 and 339 list aU the If !he palienl has an k\\llConset, oris in~·..... pam. subject matt,:,. ,..,IBloo 10 Ih,:, qut.,;tions a,ked of the then !he history probabl)' COl\"'\" fiN!. Howen'r, if the pall,:,nl at an initial (onsultalion, As mtmtiQflt'd \"arlit'r, di;order is chronic then it is poo:;sibk> that the beha\\\"- the sequence of introducing th.. history eilll be varit>d iour of the symptoms, (loflC\\' the theraplSl has a generll t05uit lhe circumstances. Asone gainse~pt'rit'1lCl\"both by the process of examining \".,.ery palient in detail anti ideaoftheareaoltheprob~,shouldbefolao..ed also in communication skilb, the paltetn of asking the \",,\"l \"The third p<:JS»lbihty i~ that the pat,enl may !la\\·t cndlVid~1questlQnS to reach a diagrlOl>i~ can be var;t'<l an arca of ref<--rrN pain intoa limb. Ind because itm.ay to a very Wide degm-. For the beginner, It is euential be neces6arv to derid\", whether thIS \",fettal is radicu- thai uriati0n5 in ~ sequ\"\"\",.. of a king questions lar or not, Itmay be Ilt'Ct'SS;Iry to den\"\" d&lrly lhe a..,a should be made only asconfiderv;(' in Ille '<lills ma~ of symptoms b\\,fo... going inlOl'illler the hislory or thoi' ilpmsible It 15\"Ita1thatatnoita~..tIould thephys~ therap~ IosehE'l\"tnmol~t. ftM\"once the tram 01 ho;ha\\'ioUI of the symptoms. thought is lost, _tW quest>oN can ''ef}' NStly br Which\",verare.l is chosen nrst, the final goal is to forgotten. T...l.V 6.6: shows the pLannt\"S for the wb;ect- we e:ummallon. In pLanmn& ~ !lUb,et\"lh\"E' examin- arrive ill an informalive diagllllSis (Tahir 6_7). To pl~n atIOn. the first potnllo make ~ 0115 otJeieo'alion of the subjecti\"e ex~min~tion the phy~iotherapistshould aU aspects of the pabenl'S mm'ementsllnd Iltlludes. be thinking along the folloWing lines: \"'eU ll$ the small nuallC'e'i 01 beha.'iour while being ushen'd mlo lhe place wheft> the consultatlon will be I. Thoughts ~hould be aligcu.-d WIth the doctor's earned QUI The s«ond stage consISts of the inlroduc- thoughts on the diagllOliis. tory qunhOll5 m lhe consultation. The first pointed ~tion, directly a»QCialed with the ll'J<ilmiNltion. is 2. Thoughls should be \",lolled to the observation of At Ihl5 particular stage. \"'hat do you consider is your the patient when beIng ushe~ into the room. mam problem?'. Followmgon from the lloswer to this queslion, the plan is 10 establish the 'kind of disorder' 3. Thoughts should 100 be ..,lated to the kind of of which the patient complains. (This is relatoo to all of disonl.... from which the patll\"Tlt may be lhe itl'ms in Tabl(66) ~ering. During the qut\"Stioning, it is very imporl1lnl to be PLANNING THE PHYSICAL EXAMINATION sufficiently alert 10 pick up key words and statements that n.'quinl 'automalic immediate-response follow·up Aftt\"T the 5Ub;Kti,'e I\"l(,)mll1,a11OIl has been rompletN questions', while endeavouring to parallel questions the manipulati,e ph)'SlolltheraplSt should ha\\e a dNr mind as to where 10 go in .-dation to (a) the dia~ subjecti\\-e flnc!lngs, (b) the ph)'Sical e\"\"mination. mel (e) makIng trNtmmt progt'105l5, Issessments and an estimation of end-results (Tabk 6.8) When planmng lhe phys.ioolexamination the ph)\"§io. therapist should ha\\'e throe dlShncl thoughts In mInd 1. What stnxlufCll must be l\">.ammed 10 derermu.... the source. Or !lOUn:e5, of the patient's symploms! (S/'JI'Tahk6.8,partA) 2. A\", there any limitations to the extent of the exam· inalion imposed by the palhology, irritability or severity of Ihe disorder, other disorders such a5 structural damage or lh,;: behaviour of the symp- toms? (5\"1' TaN, 6,8, p..rt B)

Tablt6.7 ChartdtmonSlratingttlationshipsandcont~fof throrttical and dinitill mowltdgt with ftlattd hypothon [H. = history; Sy - symptoms; S - Signs) lMroR£TlCALlOtOWL.EDGE Q.JNICAl~TION Ana'-Y.~ - - - _ Hr;Sr;s. ~;f'tthoIo9y. Fare;and~ I '\"\"\"\"\"\" TESTINGOfHYPOlMESlS j Befortthcptrysootlltrapists~rtsthcp/lysial ,·l\"Ttftlralrolumn frequenlly n.>fa\" pain to the abdomen and lhorax. OinKal inH'§ltgahon hits shown llut the D3_!JO\"Ilflltt'dUra.~n«obl0~1d<:1I InlJenclVN...1 disc L~ upable of GilUSUlg 1oc31 ill'd plIninlllllldofwtUdlWIICIUf!5~lIftCkto~ rekm.-d pain ..\"ithoul any 5lgn of herniation or nenf' and~MtCtstomm.idu, ..hcthc1t!ltn:~ root COIl'IpASSion (Oow...rd, 1959). It \"'ouk! ,...,... that \"\"\"~t_to tttt o:xto:nt of the tumUIlItJ(Wl impo:Md th,sJ'ilin;\" lle\\'eI'\"more pl'OnOLlflCec:l in the distal 5O.'g' rnt'nt of • dennalOrJle. Howr.w. when herniat,on of b¥plthology.irTillbihtyor~ntyofthedOOrdcr.or dl!l(\" m.berial com~a ntn·f'root the patn is com- monly fell more sev.......1y in 1I dil;tal an.-a such as the othct~loUdIassUIICtUfllcb~Fu~. ~lIftCkto~Ilypotht5nlboutthcpoW~ clllforforearm.Sympl0ffi5ClInbereferredinIoSUper· ellIStS of thc oisonkr and faetor1contributing to the ficial a\"'a5, wlUch may become hypcraesthetJ,c (Glover, lIevf;lopmt:..tofthtd~t. 19('(1); into u,.., muscles, maling them lendcr; or 10 joints, which may then Iht'TTlsclves become painful on Havinbmad~decisionsreg.lrdinNthCS('IWOa:;p\"\"'b, mowmenl(Brain, 1957). the therapISt should beabl... tOcotnmlt her thoughlS The plan can be ronsldert'd in four SL~ticm~, which n-gardmg u,.., kmd of l'xamlllali\"n proct'dures she are menlioned below, and tho.-y must be lhought of as should usc(~ Tabk6.8, part C) lhe next Slep is to having two gools. T\"blt 6.8 shows thaI lhe physical consider the remaining physic.ll ('>O)min.ation from exam;n.ationhasn\\'OdlSllnctgoal§' ild,ff('retllpou1tof,teW. I. PART ONE is mt,reIy reliltf'd to detemumng the 3. \\\\-'h,1I other asP\"'Cb of ph}\"$iC.l1 eummation.. dis- structures that art' the source{s) of the symptomJ tlnC'l from di!nming the soum.- of the s~-mptoms, and 10 finding IYM)n'rr>ent d,rections that a~ ilbnor- shouldbE-lookrdiitasbe\"'gtheplll§6ible~ mal and nl'td to bE- i1ddres6ed in treatment. why the ~ of the symptortlS becamfo sympto- 2- I'ART m'o is d,l\"f<1t'd kM·...rds ~numng ......tic?{ TIlbk6.8.partD) thef~thata~theunderlyingcaUS0!5ofthe ChnicaI t'Vic\\en('e ill'd experimenlill work ....,·.. shown slnlcturesbecorrung the soun:e of the p.-r>lIng that pam from a muscle lesion is localized tolheslleof dISOrder. lht les.on. although it spreads inafN as the interu;ity Parts 0fM' and two a~ not synonymous. PI.fI IWO ltlCf('ase5. Lesions of synovial joints and the support- Invol,esa diffenml liflL'ofthinking to Part one-why Ulgilll'rtstructures,ontheOlherhand,canalsocausc should thepaflicular~lnKtun.·shavereachedastage pain ,.,;,f..rred for some dislance from theJO,nl. Syn- ofcllusingsympIOmS?l'aflOTlCisa ...lenllessexamin- ovial joint k-siolt,'i can sometimes be rt'Spon~ible for ation 10 find the structurt'S from which lhe symp- referred pain without any pain in lhe ~iOTl of the toms are coming. They arequilediffcft'Tlt and mUll' be joint. For example, it is well known thaltheoslt\"O- dearly seen as SL'P\"rale piltts of the eumination. 1l'Iey arthritic h,p can CaUSC knee pain, and lesioos of the must NOT be run logether and thought to be thello1IDe.

124 MAITLAND'S VERTEBRAL MANIPULATION Table 6.8 Planning the physical examination A.. Tile sour«soflhesym~lom. 1 N~me ~s tile llO'\"bl< sou,«. of.ny pan of the pati.nt', sym~tom, every joint.nd muscle which must be •••min.d Joints which lie under Joints which rd., symptoms Mus<:I<:3 wh,.h lie unde' the sym~tom.tic \"'.~ Into the .\"'~ the sym~tomati. 'rea 2. U'tjoin\".t>oo;•• nd befow tile lesion which s/lould be checl;ed. 3. A\",th.\",anyspeci.lt<:3tsindl••teci? I.j n.u,olO<jic.I ... min.ti<>n {b) othCf-spttif'y Are you going tot..tfor .. rtebralart.ryi\"\"\"ffici.ncy? YeslNo Are you going to 1<:31 for cord ,ign.? VeslNo B. Influenceolsymptom•• ndp.thologyoncx.min.tion.ndfi..tt..,.t.... nl Ispain·J.eve\"'\"? V.s/No \",'Iat.nt'? YeslNo 2. Doe. the \",bjecti\"\".xamin.t,on sugg...,t.n ••sily i\"itabl. disorder? local,ymptoms YeslNo. Rek\".dlother symptom, YeslNO Give th. example on which the .n,wers .re based I.) local symptoms Ponc<1 R.pe.l.dm......m.nt •• usingpain Part (ii) Sew;'ityofp.insoc.used .... Port (iiil Dur.tionbdorepainsubsid<:3 . (b) R.f.\"ed/olllersymptoms Part(il R.po.t.dm\"\"\"....ntc.usingpain_.. .... Port (ii) Sotv<rily of pain \"' •• used _._ _ .. Pon(iii) Ourationbefore pain \",bsides_ J. Doesth.'n.ture'oflh.di\",rduindi •• tec.ulion? Yes/No (i] pathology/injury_specif.,-._ (ii) e.'ytol)fllVOl<ee.acertlationoracute.pisod __ _ . (iii) personalil.,. _ .._. .. _ .._ _. 4 Are the,e anycont'~irH!ic.t'ons? VeslNo . \".,,,--- -- - __ The kindof ....min.Hon 00 vou think \\'OIl will need to be g.ntl. 0' mod.rately fi,m wilh \\'Ou' examInation of m......menlS? Oovou.xpec1.'comparabl\"\"gnllobeeasy 0' tobehard}tofind? Wh.tmovcm.ntsdoVOUup«ttobe'compar.ble'? WhichteslPH:w:.du,eSwiIIJ'Ouc.r\"lt>Ut! Wh\"\" do\"\"\", pI.n to porform \",..\"\"sm.nt ~rocedu,...,? Assoc:i.tedexamination Pt-ClVOCItive'n.uro/musculo/\",.lct.l/m.dkal'fac:lo.. l..dingtothec.u,.oflhesymploms. Wh.t.ssoci.tcdfactonmu,tbecx.mincd la) a, \",.\",ns why th.joint, mu\",l. or oth., structure hils bttome symptomatic .ndlo, Ib) Wh.,. the joInt 0' mu\",l. di\"'rd., m.y 'c<:ur? {•.g. poslu'., muscl. imbalance. muscl. ~w.\" obesity, \"iffn...\", h'fllC,mobility, In'l.bility, ddormity in pro.im~1 0' di,tal joint, etc.) 2 The dfttt oflhe di\",rder On joint slability? E. Treatment I Which ,lIort-te,m.nd Iong-te,m goal, of tre.tm.nt.re pUr'iucd? 2 00 vou e.pect to be tre.t,ng p.in. ,...,ist.n«. w.akn.\" or inst.b,lity? 3 AIe th.\", any precautions or contraindications whidl need to be r'sp«leci? In planning th. TREATMENT (.ft.. the examination) what .dvice 5hould be inclvded .nd/or m~aSU... would you u\"\" to pr. . .n t o r l . . . . , n r e < : \\ l t f e n. . .

~arcfQUrSl\"Chol\\Sth.atneedtobeconside\"..d i n otber\"Uied f.>ctors are orrutted. Although they \"reof the planning of the phy.'iicaJ examination: rele\\ance in treatment, they ha ..... bet.\"Il om,tted dt.'1ib- eratelyfor-WPUflX'Sl'oIempha>lZ\"'sthcaspoctsth.at t. \\\\,th thl- thorough ~no... ledge of the patlCm!i of .tn!S(I,·ilaltothe~ofthemobili7jnganmd anil'\"\" pam from dlSOfders affecting muscles, dl5C5, srn- ulilhng tedutiquesto be used durmg treatment. and to onalJOUllS, 'neural'.nd nerve rooIS,itlS possible the.&Slle5Sl\"Ol'nt 01 thetr effect.. IQll5lthC'JOInl:J,nt'O·e,and muscl.e.'i that must be eumint'dM;J'O!i5ibleousesofpaln: An eump}e will make thr po\",t oI'pWuung' de.uw, a) Tlw JOInlS tNt Ii<.' under the.oN 01 pOI\"'. b) Tlw jotnts that do noIlie under thr.oN of pOI,n olndtnthas~theword.~JOU't'(ollSthroughoutthis ootc.n ...>. f.... p\",ntntothe ........ cl The neural elements. :::~ to the inert struct\\IftS;olfeaed b) J\"\"S6i,'~ d) T1>emuscksthotllieunderthe.re.ofp.l\"'- A p.llient has pam spl\"Ndmg from C6 to T6 ~ l. Tlwsemndp.lrltocons,d.... 1Stheeff«tolthep.ltn trally\"OO LoteraUy across the nghl po5bm<r thoracic onthep.ltlC'Tlt. .....11 from the top of the 5hou1der to the inferior angleofthescapulil.T1>ep.lm preildsmtothenght ). Tlw,h,,\"d ,,>(hcate< the kind of examination (for triceps area and down the postenor asfK'd of the e-\"ample. the e.\\K'nt and strength of test mo,·t.. forearm to the wri;.t (figu,,\" 6.14) If the spread of m.....ts) \"\"luirYd p.lin from joints, muscles or nt'Ol.'-1'OOI lesions is bon... in mmd,iI wIll bt'nccessary tot'Xanunethe 4. The last a~p<\"C' deals with e\"\"min.,tion of lhe followingstructu\".\"a~being tl\\e pos.sible cause, in underlying abnorm••hties to as<:ertaill the rt.'ilSO\"S p.1rtor in full,ofthl'SCsymptoms· thaI may hil,·e IJ«on p\"'(lospos;ng I,KtOn. to Ihe on\".,l 01 the patient's pain, or lhill may, i(uncnr- I. TllfjQl/llslhallifU>,drrll'e'lF/'lI<>!Il/l\"': r'l'Ct.>d>I\"ildto ....\"C'Urren~ Ct>--T6 a) Kightcosto\"\"rtd,.\"ljoontsTl-T6 T<ZbIr6.8showsan\".\\ampleola'l'lanningthe-Exam- b) Intercostal mo...·m\"nt betWl'(\"l\\ the first and ination's,,\"-·t sixth ribs on the righl cl Sc.:lpulothorack movement on the right InUlt'd'SoC'U\"\"ionth.1tfollows,aspectsolexamlnahon IriIItmgt0t.\"\"\"'-'I'alhe\"lth.posture,musclebalall('('.nd

d) Righi glenohumeral joinl and rotator cuff 01 each other's thoughts. Certainly the profcssion;ll c) Righi elbow bodiescan work towards such an understanding; their f) Righlwrisl acceplan<:e is on a cOl'sen~us basis. However, the person-to-person basis is the key to the oc'St and moe;t 2. The jomts that d<J '101 lit ulldtr \"'t~l1'~ of p<litl but c~1I succ~'S6ful \"\",ult, and il is towards this end that each ro/rl\"'i'lintQIf!ea'l'll(OIherjoinlSncOOtobeinc:luded mllsl worl for the patienl'> sale. The manipulative toallow for a pre- ~ P\"SI-fix<'d plexus and forerro~ physiotherapist can only pro... ide a physical diagnoe;is ofinlL-rpretalion of pain areas): (which naturally must be limiled by training and ex?\",\" al C4-C6 rienc,,) and a pl\\ysical prognoe;is. which are more lun<:- bl T6-T8, including the costm'ertebral joints and tiorull and mowment-related compa...d with the other inlerroostalmov~'m~\"'t. professionals; this must always be T('l1WmbeK'CI 3 n\"\"\"\"ra!jsupp<>rIi,.. ,tml£lllsllwtcanl1'feri'ltolh, The purposes 01 the ph~'Siotherapist's physical exam;\" symplomaticarrtl(s): nalioo are first, toinl<'rp\"-\" the palienl'sronc<'pl:o/hiol a) C3-C9 Mlirulations dis.1bility into I~TmS of m~, joints and \"\"rveli caus- b) l1>e first and second ribs ing their symptorns; and recondly todct<.ormine physical c) Entrapmenlandlraction faclors thai may h.1\\'e pt'I'disposed the p..lient to the oru;ctoflhediso\"ier. II is pIlffiible, by tesls using isomeI- 4 Therrll'scl(6 t!l~llie undtrlll(a'roofpaitl ric resist«! rontractioo and passive m\",'em~\"'I>l.kld,fk.,... a) El\"\"alorsand retractors of scapula enliate between pa'\" from mll.<;cles and pain from joinls b) Extmsors of dbow c) Extensors of wrisl and fingers ltisalsonecessarylOm..1kcanaS6CSSmentofaclivemove- rnents to indicall'thefunclional limits caUS«l by the con- Experienced physiotherapists will e_amine some of dition and klshow the paN....!'S willingness kl mo\\'('. lhe slructureo!i§ted only briefly, beeau\"\" the I\\istory and behaviour of the pain make it dear that th<.>5e When the inert strucluresof a joint are painful, pas- strucl:ures are unlil...ly to be causing pain. Howe\"cr, sive movement of Ihat joint will be painful at some \"Ieh examination sholild ne...er be compt.;,\\('iy onutlOO point in the range. To <.\"licit th... pain it may be n<!fi'S- on lhe assumption Ihal the slruclure is rIOt contributing :;<Iry to mO\"e Ihe joint while hoiding the loml surfaces 10 lhe pain compressedatoneendofthepoe;sibililies,totC:'1tac~ sory mo\\'('ments allhe other end. When a lesion occurs PHYSICAL EXAMINATION in a muscle, passiveioim mov~ntwill not be painful unkss It is a movement thai stn-\"!coc'S or pinches Ihe Th...\", aT(' larg... diff~.,.,1'l«'S in the b.1Clground to the muscle. Hov.ever. pain will always be T\"t-'Produn-d thinling of orthopaedic sUl};eons, orthopaedic phys- when fibreo in,-ol\"ed in the lesinn are made toconlract icians, manipulalI'e therapists and the palient, and strongly. Joint problems are therdore determined by never the quartet shall men. However. Ihere is no rea- passive mm'ementtcsts, and muscular k.,;ions by iso- ~ why they can't wod<, thinl and discuS/! as a team mctric mlL<;c]e cOlltraclion tesls, wh'ch T\"t-'CIuce joint It is easy to set' the orthopaedic surgeon and the phys- movements to\" minimum. ician being abl\" kl understand e\"\"h oll>l-.. 's lhollght processes; il is easy 10 see th... manipulati...... therapist The isomelric tests do I'Ot always pro,-ide dear and thepati....,t being able tosee ...ach otlwr's thought answers, becauw an isometric tesl necessarily results proc<!SS<!5. However, bringing the former two and the in compr,,\",ion of the joint ,urfaces. Similarly, isomet- lallN Iwo thought prtxX>SSeS logcth~.. is not e35Y. Il can ric k'Sts in Ihe lumb.u and cervical areas always pro- be \"\"hieved, but it net.'CIs to be based 00 a pen;or!al duC(' considerable inten'.....td\"al movem,... t. Under undel'5tanding of each other rather than a professional these circumstances, the isometric tesl may cause pain (lfl('.1Oeir fr~mes of refero.\"na! are gre~tlydiflen-'f1t,It is oc'CaUS<! thejoinl ismoving, Therefore, it may be ne<:es- RQl \"\"'5OMbie for a member 01 an orchestra, or a sary to test the muscle isometrically in diffen-'Ot pas- soloist, to ha...e the same thought pn:>cl.'5Se> as a con- ilion~ of the joint range, and to mmp\"'\" t~ d...STt.'C of ductor or the composer, butlhal does not pre\"ent the rain produn-d by a \"-,,,i,tOO active mO\"\"\"\"-'Tlt wilh team of all four w\"rling logether 10 produce ~ good thaI of a pa~sive movement \"'\"lilt. 1l>eir Irames of relerence are not the same. nle Examining a joint does not doffeT('ntiale bet\"\"..,n pain caUS<!d by the intervertebral disc, the apophyseal humility and f<!Cognized acceplanc<! thalth\"one can joints, capsuil.,; Or their ligam,·nts, It dOl'!i, however, establish w,lh the other, again On a pt-'rSOnal basis,;s rewal a disturbance of mo~~\"\"~.,,t.ltshould be remem- the ley 10 opening the door 10 a wider understandins bered that coru;ideration of movement mu,t n01 be limik-d to Ihat of the disc and apophyseal joints, The spinal cord and its in\\'eslmenlS and the \"\",rve roots

ElIi1mination 121 w;lhlhcir~I....... cs mUSI be abl\" 10 1JlO\\'\" f\"\"\"ly in tlw stiffrleS»;\"mon·UJ1portantlhanp.1l1l,thele;tlTlO\\·e- ,-ertebr~l can.~1 and int..nt'1\"I~r:a1 forami..... T~ts for ments should be taken 10 II\\(' hmit of ~ B\\ai1lb'\" \"\"\" ..........101 t~ ~lructun'S must also be part of the rangcand<ifnereloSary,o'er-rl\\SSu~fOl')applied ph)·5iothl'r:aplSl'sph)·sical_~_. Mon' to li\",it - gentk-or firm O',ff-pn'§l;Ure must be The l.'ummahon of the Inten~td>ral qmenl can appliedtoalltestlnO\\~tsinQr<i('rtoddt'-mune: bed\"'ldedmlothe'oIlowtngseq~ • Theend..of-range'f~I'oltht'll'lO\\ement 1. ActI'l.'teSt!i • ll\\rsymptomrespon5t'totheOP a)Acbu' lJlO\\\"t'mef\\ts - 1l'lO\\'l\"lTOeIlts wludl lhe Mono' hi pain - when the pat......1 ha~ the ..... '-'\"\"\" of p.1lll.'nlcan perform Iort\"produao M pam (srr pp_1V-1331 pams<the~rTIO\\t'l11t'nltestsshouldbcper­ - ph\"~KHogicallnO\\'ements - combml.'d 1l'lO\\'l.'lTll.'f\\!S. formed in .......tral ph)\"5ioIogical po5IllOI\"IS that are fu~· supponed. as freed dtSC()mfort as ...-;bk-and a,-oid- b)Au~d\",I\"\\' rests oAS§OCiatt'd with acti,·.. 0\\0\\ .... IIlg compression of joint surface, It ;Illso means that rm'llt 1615, 'or \"umplt' joint rompress)Ofl teSts tt. acces-sor)' ll'lO\\'ement should only be talcn 10 the and t<s1Sfor 'erti'brobasiLlrmsuffiOrocy. POl1lt inlht'rangt>w....... lhepall1 is first felt (orwhe!'e c) N<'UrologlCal l.'ununahon, which forms \"n II is fir.;,1 fell 10 incrt\".JSe). When th,sassessmenl has essent\",1 part of the ..\"ammation of thc nl.'ur:al ekm.::nts been made, the movement ~hould bc taken fraction- ally beyond this poml to a~ how quickly the pain IncrN5eSOr how quickly il \"f>reads. 2. PaSSI'-l.'t<'Sts Amm ..ment \",\"\"\"t bcclasso:.'(l (()T r(·corded) as nor- a) Mo\\\".::mentofthep.~in-s.::nsiti,·eslruetu\"-'S;nlh,, lIlal unless the ranh't' h pain frce both il(;li\\\"Cly and pas- ,'.::rt.::bralc.1nalandinter\\\"\"rtebralfor\"m\"n'lIld ~i,ely; ,IS well, \"\"er-prt'SSurc (01') applioo at the limil neur,llli\"k.-dmo\\\"ements of rang\" should nol cause pain Olh('r Ihan normal b)l'hysiologicalspinalmo\\\"(·m.-nls. responses. Rl'Cordinga rangc of ncxion as bcing nor- c) l'alpatlon,iru;ludingace\"\"SQrymovcm.::nts. mal would be 'F,I,I'wh\"l't' the first hek (,I) refers 10 d)Pa';\"1\\'l.'rangeofphysiologic..lmo,<('mentofsin- ranl;\", and the second tick l't'fcrs to pam \"-'Sponses. gl('mt('I\"\\-.::rti'bral;OInl:s. d Oif(crcntiatlont.::sts. Amwe\"\"\"leinl\\llltJc,tiasloe'dasnormalonlessthe ACTIVE TESTS \",ngc is Pilin-frccxtivclyi1nd pa~ and w,th ~ add'tionofpaSSNewef-ptnSolI~lttlle~ml!oflhe follow,ng the sut>,octl\\\"n.amination and planning. a adivcrilngc.ThcrttOnl'ngoflroormal_mcntin d«i5lonn..\"..·cbtobemade .... Io .. ~thelt\"lllnO\\.... ~la!,ontojt5ri1~q....htyMldsympton:l~is rnml5 01 the phrso.:al e-..ammahon 5houId be taken 10 r«ornrncrllkdas,l,l ~hrrutoithea'''iIableranp''(InO\\·''lOhmlll.or . .- h e t h e r I ~ s h o u l d b e t a k e n o n l v l o t h a l f ' O ' n t l n t h c fMISl' .. hen pam comlllt'lllCeS or stam 10 'rlCre;llSl' M~mC'nt5thot the' potiC'nt con ptrf(Nm to ld<Jmma~ofsllf(ne<sorpain~nly). riI.lltfon,startJngIMlest.adK-isioron«dl.lobe~ ,,,ttrC'prodUCC' his symptoms - functionol dC'monstflltion wII(~d'lelo:st~b\"\"\"'ld~tlI.k.. lotIK This is a fundamental first li...... 0' appl'OKh 10 50rtulg ~m't of lI¥a aIM or only to ~ beginnIng or oultheSOW\"Cl!(s)ofapalll.'rlt'sprobll'm.ltlSbasicand mandatory 10 the Ihlnl<log proces;. inmh'ed in the lIICn~oIp\"n 'Mall'and COIla.'1lt', and cannot be t\"mphasi.ted enough It should b«orne embedded in a thera\"\",--rs mind Under the tall.... circumstances, some assessmenl should and become a natural proce.~ (~pp 86--87, 99, 236, be madeo(lhe beh.wiourO(lhc pain fusl beyond thaI 307 and 343-3-W). pomt in Ih('ranl;(' wh('rc Ih.:: pain COmmences or ... hert' The patient should be askoo to dl'n\\0n5trall' any the con~lanl pain begins 10 increase. actJViti\"\"lhat l'('produce his ,ymploms.1lll'physio- Whenp,,,n is lh\"domi\"\"nl f,l(lor in lh\"palk>nt's thcrapistshould th('n analyse thc mo\\\"ementoompon- ('ntthalisrelat<'dtothesymploms di50rd.,r, lest mo,-.,,,,entsare taken only to Ihe poinl intheran~whcl\\'paincomm\"nct'S(andjustbeyond Anexarnplemayhelpinond\"rst.mdlOstheanalys- \\Q~th\"p.'II,,\",ofincreaseorspr..cd).Wh~n ing process. Agolfl'1' is able 10 causc the pain by going

128 MAITlAND'S VERTEBRAL MANIPULATION through his golf swing. On asking him to \",!\",a! th\", mowments.lfthesewrityorirritabilityofth,'patimt's swing, but 1o slop at Iheslag\", wh\",,,, h\", f....els th\", pain, symplomsor the natu'eofth.. disordercau,ing them he may have to swing many limes bcl\"ore he is d\"arly (Sl'I' Planning Sheet, Table 6.8) al\"<' such that caulion awareofthcpart that pro\\'ol<es his p.:iin. Inlhis<':<.:Jmple, should be ex\"rdsed when examining mov\"menls. the th\"solfer is abl\" to say that it is during his follow· patien!should,asafirststep,heaskcdlomon·to!he Ihrough. The ther\"pist then watch\"\" th\" pat;\"nt's point whel\"<' the symptom, commence, or (Ommence spine (\"t th\" site of hb symptoms) while the swing is to increase, then immed;al\"lyslopand return to the \",!\"'ah.>d,L'fldeaw>uringlod.,.;idewhalth<'directioos upright position ofmovementareatlhemom<'l1tofpain,Sh\"decidesii isacombinatiooofthoracicrotationleft,movingin!o M\"t'\" t\" li\",i' ~ On the oth\"r hand, if Ihe sevt'rity or extl.'T\\Sion and lateral nexion to the right. To test th\" irritability oflhe pati<'l1t's syn'ploms or the oature of \"alidlty of th<' thinking, th<'golfer puts himself into th\" the disorder causing them ind;cat<'SIIM! movements position, wh,-\"\",,upon she supports him and appliL'S can be takL>fl to the limit of th\"rang\"and stretched, manual over-pl\\.'SSure in the dil\\.'Ctionsshe fL'Cls arc at thcn this is in /act wha! is done for each direction 0/ fault. An increasc in the pain with onc or morc of the movement. Whether movem<'l1ts are tLostL>d to pain or dil\\.'Ctionswili prove or disprove her thinking, If there tothelimit,theyshOlddbothbetaken,asa~ond is no increase with any of Ih<' dil\\.'Ctions, she starts Ihe measure, beyond the point so as to assess the beha,-· whul\" prlXl..'SS agaio until shefindswhatsheislooking iouro/ th\"\"\" srmptom..~ with th\" further movement furandprovcsit. llcfuretesting nlUv,,\",L>flt,the p.ltienfsprescnt Aoemonstrationofin:tetivitythitprovokesthe symptoms should bea~.lfhe has no pain bef\"\", pit,eot'ssymptoms is of help in anilysing the moving, heshuuld be asked to move in the direction components at faylt and finoing tlKaooormal being tl.\"SK'<l until pain is felt.lf he has some pain ~ment dire<:tions, which will b<\" addr<'S~ in present be/ure moving.. I\\e should be asked !o move until the pain begins to inCl\"<:<l!i<'. MeaSl1rement of the treatmcnt.Furt~rmo'e,tll,sactivitycanbcuscdasa rang\" should be made, noting the area in which p.:iin is cau...,.j by the mm·emL'flt. If th\"pa\", is not S<'v\"re, nor of control paramctcr in 'eassessments of treitment. The a kind that must notbeaggravatL'<1,thep.ltient should bea,ked tomm-e further into the range, reporting any lattcrisespc:eiallyimportan~asthcmO'iement incl\"<:asein the scverityof pain or any aherahon in its distribution, so that these\"crit}' and the beha,-iourof demonstraledisa'cfle<:tionoflhepalient's thc pain with thc furthcr movement can be determined. pcrc<:pt'onofhisnormilaetiv,t'csrathc'thanthc pc:rc<:ption of Ihc physiothcrapist's. as is the casc When no l\\.ostrictions \"'-....'<1 to be placed on the whenshc isks him to pcrfo,m anatomically oriented examination of mov..mL\"TlIS, th\" patient should be t<'Slslil:e flexion or side f1cxion encouraged to mOvC to th\" limito/the rang\" and the physiotherapist ,hould thL\"Tl apply cuntrollL'<1 O\\·e.. Ph'(5io/ogicolmovC'mC'nts pn.':SSllrc to delermin\"th\" '.,nd·fL'C1' of the movement and any chang,· in the quality of the symptoms. This When a joint is found to cauSl.· pain, a card'ul asSl.':Ss- over-pressure isL'SS'-'fltial if,un examin<ltiort,a moW~ mffi! ofacti\"e and passin> movemeots should be m\"nt appears to be full range and painless, It is incor- mad.... The active mOVL'IJlents should be kostL'<1 firs! \"-'Cltorecord thcmovl'meotasbeingoormal unJess bo>causc the paticnt will pcrform thL'SC within his own firm Pl\\.'SSll'\" producing small oscillatory mOVemL\"Tl!S limits of pain, and lhcreforesafdy; thcassessment of canbeappliL'<1pain!<.os.lyatthelimitoftheraoge.Care thcse mO\"cmCTIts will indicatc th., sevcrity of thc dis- is \"\"1uil\\.>d when applyingthisover-pressuretoC<!rtain abi!ityand guidc thc.,xamincr in how much passi,'c movcmcnts.W;thC<!rvicalext<'l1sion,wh\"therthcp,,-'S- handling th\", joint will tolc,a\\<', Active movements of sure is applied by lifting under the chin or by pressing the thoracic and lumbar spine are l<'Slro while stand- against the fon'head,caT'<'should beexcrcisOO top.... 'ng.,e~O'pj fo,rotation,which should sometimcsalso V(\"]1t the mO\"L'nwnt being merely one of traction or bclesloo whilcsit\\ing. Sitting is also tn... position most rompression suitable/ort<'Stingcervical mo,'em\"nts, beocauscthc trunk is more stable. There arc thl'{'{' points to bl.' mentionL'<1 in rel\"tion to t<'Sting acti\"e movements; points !hat apply when a MOI\"'lopuitl~lnthephysicale~;lminationl\"blesfur movemenl re\"\"als littl\" in th\" way of pain eachsectionofthespllw,thestatemL>fltismad,,'Moveto pain or move to limit'. This r\",f...rs 10 the two mcthods 1, Ocrasionail}'itisnc<:essaryforapatienttop<.,.form lhal are used when e~aminmg the patient's acti\"e a test mov ...menl quickly if pain is not provok,'<1 by Ih.. /ull-range movement perfOm1L'<1 at the uS\"'ll

wm;lIitloll 129 speed_Forexample,a patJent may say that tuming eachspmOuSpl'OC@S5dltum,ei.lhi!rwiththeref\\ex hIS head i3; painful )'e\\. on ecarnmalion of 1JlO\\e- ham......... or with the fingemps.AjoirolcauslIIS pam ments at the usual spe«l. the ll'lO\\-emmt is normal is found to respond palnfully to this tap-1Il'Sl. andO\\'ff-p~<;M\\beappliedatthelimilofthe r;mge ..-,!hout paln. Howe\"'\"ff,ifhe isOl5led to tum Followingtheleitforrangeandpain.thepabmt§hou\\d hIS head wrply,thepaln may be reprodoced_ (pl'1,)\\·idedp.unpenrnts)Il'lO\\-~backandforthfromthe 2. If a pat......t sa)\", forwam f\\c..ion of the lumbarlipi\"\", startln8 posibon whIle the physlOtherap~w.~ lor is not '-cry painful, yet the mon'menl is limited, ,t dISturbances of the roormal m)·thm oi lnler\\enebral IS lIS wdlto find out how far I>e could bend bclOK' ll'lO\\'emenl.Rt\"peatedl1lO\\-t\"ll1l\"1'ltsshouldbe.a'OIdedLf hIs symptoms began. l1>en' al\\' some propl\" who a mo,'emcnt is very painful,.as they unjustifl.llbly pm- \\\"ol\"andin<n>asethepatient'sdiscomfort.\"fht>e>:pt.'Ti· (annot reach their tOl\"S normally, including some whoaf'\\' unable to~3Ch beyond Ihcir knees. Cervical encedmanipulah\\\"ephysiothl>rapl!itisableto~the rhythm of movement during the as.....sment of move- 'utatlon,;n the prcscnCll of nm,ll'll spondylilic ml'nt for range and pain dcscrilx'li in theprt.'u-ding ch.1n);e,isanothermo\\'l'T'l'lenIOfwhichpriorlnowl- edseofrangei3;helpfuI.Stiffn.:ssund\"rth~ci,­ paragraphs. Initially, however, she may re<juil\\' the pallent to make many movements. cumsl.;>nces may not bca prirnary physical sign in Disturbances uf the normal rhythm of mtcn'l\"Tte- thl'palJent'spresentrondition Nal l1lO\\ement during f\\c1<.ion and lateral f\\enon of 3_ When fIerionofthe lhorxicand lumbarlipll>eS Ihclumbarand thorilcic\"PlnCSan.-re<>ddy!iee1t from a~,)rs to be normal, it i3; usriul (parlicuLuly if on betund (figumlf.JSand 6.16). Abnonnaliliei in trunk conluluedf'l(i1minillionlittlei5foundjtotlpsharply r1)I.ahon.are much _ dIffICUlt to lll>ti<:e, To WItch Figurt 6.15 (01 arid lb!, The patlenl, w~tn e.... mint<l, 'pp\"lred to bend equaHy to earn side. In t~e Iwo figurt'S t~e\", is I d,ffel'l'~ In tne 'pptar,nct of tnt lum!»r spm. wni(~ looks lik., limItatIOn of mO'Vemenl w~en t~. spine i,l.ttrally fkxt<lIO lhe left. Wnen .\"'1t~t patitnt I.lerally f1ext<l conlin\"l)U~ from one ,ide to l~e ot~er it w', to itt Inat wil~ mO'Vl:mtnllO t~e left. l~e .cellon of I~t SIMt belw«n Lt and L3 I'l'm.int<l Slf.ig~L This 1tiffnC11 had t~e Qmt 'ppearance ~ w<lIIld be ittn when bending. Pit« of \"\"lit~ Ihal had an inell 0< IWO of cement sorntw\"ert ... it~in it1ltngth ~'e w~ no such sIIffnC1S W'lh later,l flexion of tilt to !hc\"ght

130 MAITLAND'S VERTE8RAl MANtPULATiON Flgu,06.16 T\"ilfigu\"'lho..... Ii\"'i~~\"\"'nlh.rang.cf fcrw.\"gfloxlonlll\",,,lnotl5oftMlhorKic\\pino.llol,,,..n .ppr~lI\\lOtoly TS.rId T8 forw.rd \"won ~ ...... ~\"\"lod. w~o,.\" bot....nT10...cllltM,.\",..,.,.\"t.ppUISIO.lossofdOlj.... Iho _ ......I.b<wo TS. bolow II arid borwom T8 anoI no 'PPO'\" tobc: \"\"'m.1 Inh\"J\\ erk'bral n'l(Wl'mnlt dunng luml-at \"\"It'nSICln, the ph~\"Siotherapi.st.!hepolJo'nl Giln be \"'Sled to rotate 1m phY!lilOthetaptSl mol. .-.J to ~ brillnd lhe p.>lienl peh\"is to the left. \\1O\"\"'g;om1S In the Slme din.'ction ...hile 5upponing his ......u1df.>r,; to p\"\" ef\\1 h>s O'·crbaJ· yet doong ,I in dllferml .....)'Satl produce qu,tediffer· annng (F~\". 6.1;\"). U the pos.tl>on oIleStlng lumbar enlp;Un~...ndshouldbein\\·esbg.abe<l I'>.!mwon ~ perlonned as.now.. In r,p'\" 618, ou·..· MomnO'tltl from lho 'top clown' may bo COl\"lpllml rrelOU.... COIn be em~ ..' Slnsk' wgmmti. Tl>e \",jm/tlOYOmonts from lho 'bouom up',;as thoyan p n x l \" , , \" q u I I . d i f f. . O'tItpllin~ Wduuq~ J\"O' odes !he eununor .. lit> ..ny dltferences mend·fuel'......t 'l:ymptom ~ It should 0150 be rem...\",bcn.'d thaltt'Stllll; a mo,· ...mcnl in 0 weigl1tb..arinij !\"\",ili\"n m\"~' provoke a diffe\"'nl u.:.t ..tl~\",at'plIlnf\"llulOlba<~1 pain response when comp.'''ng it with th... \",me move- menl perform....1in the nun,w~;ljhtbe~ringposition 11I8\\I prlMdotho eumo\".,. witll a....,. d,ff...oncos in ·.....,.fttl' arid ~plom fospotlso!> An sp\",,,1 n\\O\\\"f'rnenls can be tesl('(! by moving l.\"Ithe. the up!\"..... 'rill\\.· on the Io..er .pine. or the 10.......pme Undl.'T Ih..• UppeT spine. In facl, Ihese Iwo mod..'!! can be oombll\\ed; for e.ampk the sl,mding I\"'ti('flt Can be ..s~('d to tolale 10 the nllht a. far ;\" fXl!I\"lble, and Ihcn. whIle his tho.a~ is held In thIS pooillon by the

'\"..... Com~~ f~oftesl ~mmts ill wright Tht> ,mportallC't' 01 watching the I'l\"p'eillt'd lTIO\\\"e- ~a\"''9positionswithnOl'l-w(lghtb<':a\"ng men! lies in the fact thai if il mo,-ement is 1~led only 10 positions flOtt' tnc r,lngl'al which pain begins. only l\"\"gross All CW\\-ical mo...emenl~ shoukt be watched car\"'ulJ~ ftlm, tt.. froflt beoc....- 09(h can ...... ~l useful infonna- movement of the \\·...rtebral «Ilumn 15 aSSI-'Ssed and tioln IFigurt 6.19), but the rootour of the oeck ..-Iwn insufficienlaocOl.mtislakenofwh.1l;sh.'ppeningdt fullyflc>,edisbesl~frombehmdorab<:nclbo> p&lient may rotate his fwd, with more ne>:.ion \"I\",,, the~·l'lofindi,iduaIM\"glll{'f\\15 turnmg to one side than to th... other, po!>S,bly indical- in!) .. p\"infuillosion in Ihe middl... or uppeTcervical DollOtonly~thc'}IVSS~bofthc are;!. A,w abnormal mon.'me\"l folmd on cl«lminalion 5fIIIlillcolul\"lnlnclthc~mnlflgofthc\\Yll'PtOlll must be p~1 each lime the lJloQ'.~1 is \"'Jl<.'lb..>d ~lC,bo.rtill1oothtqualityoftlM'~tsatt~ forittobe)udgcd5i~n1flCilnt. ~ of the indIVIdual ~rinl H1,l_nts ProtfCti!vdq,m'l/ly_ An abnormal rhythm of rTIOH'mcnl IT\\ilybepfl''S{'l\\lbcc..us.eof3pillnfulk-sion.OfIIm3Y~ du@,oanabnorm.:lhtysuch;os.;omtsliffness,wluchis

132 MAITlAND'S VERTEBRAL MANIPULATION Figu\", 6.19 10) and Ill!, Th= two fi~u,.. may ap~a\".t first balan\"\". to -;now a no,mal ,\"n~. of lat.,al fl(.;o\" to each ~de_ 111.,. is. hOW~'f.' diffc\",,,,,. in l~ .. n~'5 of lat...1fl.xion to ••ch 5iM takill<j pl.,. aoo... the mid·c<Nic.II ....I. Th. =triction i, sIlown byth.lac'<ofcurwofth.'ightn.ck,ontou'.OO•• lh.mid-c.,..,ic.ll....cldu,ingl.t.r.lfI.xiontoth.l.ft(a)wh.nromparc<lwith t~ I.ft n.ck contour durill<j movem.nt to th. ri~ht (1Il_ Tni5 limit.tion is Usi., to 5« wh.n th. patl.nt rc~.tedty mo... h.. nm inthispl..... Th.th... pi't'houldl>b5clVCth.movcm.ntfrom ...nt'.I\"fmmdorsaI painless. If it iscauS«l bya painful lesion, pain wiH be should tlotbccallcda'sci,ltk'6«>!josis,TI1cdcarcst provolwd by preventing the abnormality occurring method is to name it as an ipsilateral or runtralateral during the movement; i/H iscauS«l by joint stiffness. list, depending on Ihe relationship of the list of the lherewill be no pain response. Fore><ample, if a palient patient's thorax or head tothesideofthepajn_An ipsi- who has a painful neck flexes his neck more when lateral list isa lateral displacement of the f'dticnt'. tuming his head to the left than to thl-right, the phys· thorax of head towards the pAinful side,atld aoontra- iotherapist should SUPPOft his h\"ad and n~'Ck to P\"-~ lateral !ist js when thedjsplacement is away from the vent the flexion ooxurring during rotation toth\" le/t side of the pain. The rdationship of the list to the side rf there is no pain response during this test,theabnor· of the pain is important. but e\"en more important is mality is unrelated to the k>sion causing thepaticn!'s what happens to the list during rno,ernent; somctirn~'S pain. If the pUicnt'~ pain is reproduced by this test, it wjll straighten Ollt, and at other limes it will incre\"se thisisanexampleofa'protectivedcformity'. and further movement will lx- impossible. A pati~-nt who\"., Jist increases with further movement will =pond Co\".ct.nyd....jation of. mlW.m.nt tod.tcrmin. if less easily to conservati,'e trc\"tment than will the it indlC.tc:sa p'Olccl1vcd.formity patient whosc !ist decreas<-'S or disappears. Two common examples of static prok'Ctive ddormity Whene\\'era deformity of the se<:tion of spine under aresciaticscoliosisandwryn\"\"k.l'assiv\"cotre<:tionof examjnationisevjdenl,wh\"th\"rasast.>ticprotl'Ct;-'e thesedeformitjes will also cause pajn_ Most of the type of deformity or as an abnormal movement, it may d~-scripti\\'e titles for tI\\es(, abnonnalities are open to be tested by countering the abnormality so that its sig- misinterpretation. For example, a so-<;allcd sdatk6«>li- nificanc\"in rclationtothcpali~-nt'soomplaintcanbe osjs commonly occurs when a patient has no s.ciatjc d~1\"nnin~'<l.The degtL'Cof reproduction of the patIent's pain but only back pain. Underth~'SCcirromstanc~'S,il paincauscdbyoounteringthedeformityistheimport- ant \"s,,-'Ssment, but an auempt should be made to relate the deformity to prc,-ious history. The \",me protecli\"cdeformity m,'y ha\\'cbccn present during

Eumination 133 ~to\\IS epi§Ode .and IN)\" R(>I !>a,·c completely initially in directions that fltht-r open or dose one!iide l'f'ro'cred; the sogmncaJ'l«' of a cutTl\"flt prokd1\\!' of the in\",\",ertebral ~ L By per{omung them in dcfomuty ...ould thcnbeko5&. Foreumple.ifll p;ltienl po\"\"\"'this ..·ay. ill of p;lmful \"\",,\"erroents may be on ~tanding is §t'eIl to howea lumbar kypl'oo8.i~,_of found. En\"n if II pattern is not found, the mo'\\-emenlS Ius deformity rna)' be of alongsl:and'ng natul\\'. partic- should be combined in an effort to find .. combmahon ularly if previous l'plloOdt'S of back patn han! been 01 that ~l;\"\"·es or increasl'$the patient's sympt~ That ~lmiL>r severity A~ such dclormity doc.! not usually is, if a patient f!e,.e h15 trunk 10 lhe point where he rompleldy disappear, at least 50 per CO!nt of hi,. prt'Sent feels pain in his lumbar sacral area, then the e.... miner lumbar kyphosis is likely to be unrelatl..:1 tn his present should, in this position of flexion, assist the patient to pain. Anoth('r common (')(;Imple of 'old· mi~l'(\\ with 0('>( laterally to the lefl and then 10 the riFJIt. On pct- 'new' is an an: of list that is visible during forward f1e~­ forming this mO\\cm,>n\" if pain is pro\"okcd wilh lat- lOll of tm-lumbar spine 11le;e are rarely if l,,\\·l'l\" totally eral flexion to tm- I<'lt, she- shoukI t'-\"\" add rotation of \"hml....ted by treatmlonL tho.' trunk 10 the left ..nd then to IIw- righl in this posi- Thm. is much )\"t'ltobe expl.un<'d about the protect- hon of combined flexion .....th lateral f1nl<JIl to the left. \"\",, lISts, but there are more reasons than Just for the llus IS only' one ~t' of combining ffiO\\·emenls, pro«:'ClJon of a p.unful I\"OOt or its duraJ in\\!~tmenL but II doesp,e an ide.. of how the moo.'m'lmt.s an be lherr must abo. on some oroasions. be a m«hanic:al combined to find thr Inh>nnabon being soughL dlSturN.na, .and thIS disturbana is somt'\\lmcs irtt- Combining \"\"\"l-men'\" I) dISCUSSed '\" each chapter of ,\"ersible{M.. itland,I96I). tlw:dlff{'f\"{'f\\tlC\\~ofthe-.pine Arm p\"IR. When t..... origin 01 a patIent's arm pain is in dm'bt, it molY be n«es6ary to try tn reprodure the pain by c\"rvical mowments. It is unwise and unnl'C<\"S' Combin..ti~s of ttlt mOVl:mcnts arc pcrformctl to sary to do this with .evere nerve-root pain. If the nor· finll I combination that rei;e\\lcsor incru5esa mal t<'Sts of C('..\"ical mo,\"ement do not \"\"produce th\" patient's symptoms pain. rot.. tion and I.:It...al O('\"ion (especially towards the pamful side) and ('>(t,;,nsion are three movements !hJ,lshould betcstcd In II special ......) Tho.-m-..d should MOloTmenl potterns be mo'\\ed to the lim\" ofttw ra~or to the poml where ~begms.lflhen>l'Mp\"inorthcp'llnisrerton1yin ~\"D.C Ed.....rds,OAM. BSc(An.all. BAppSci(l'h)\"'sKll. the ned.,.gende pressure should be IIpplM'd. U'lCIl'a..ing Grad DIp Marup Ttl. \\.!!-1PAA, FACI~ Hun D5c the mO\\ement lind holding it for 10 ~ to '\\re if (Curtln) (Specialist Marnpulal,,-e 1'h)...lOlheraplSll pilUl spre.Jds mto the rciern-d an-a c.kcdSlUnollly rriem.-d pain \"\"\"y not be felt wluk-the ro\"Itinn is being Tho.- movements of tm- \\'f.'rtebral coIumn .. re complete held, but m.:ly occur when tn.. mml'Tllent IS \",le..SI!d. and as yel not fully undeT\"itood. The drhculalIQnS are A smlllar t('St Ciln be pl'rfomlt.'d in Ihl' lumbar spine. such th.1t e,lCh \\'~rt,>br..1 ~ment, .... hom mo,·ed, us'\"g the mo\\'ement~ 01 lat\"r~l f1('x;on towMds the \"woh\"~'S the mowment of three dlff('rcnt jomts; two side of the pain (ombil1('(\\ with extension. There is one ~ygapophy.,.,aljoint~ and the dis<:. In the cervical spine fUrlher test that can be applK-d to the ce\"\"ical ~pine to the UllCO,ertebralloints of Lus<:hka also playa pari, dl-t~'fmine whet .....r a relel\"ll'd pain is inte\"'cril'bral in .... hile in the- thoracic spine the mon.'\"\",nts are compli- origin. It invoh·cs arriVing romp~Kln to the crown cated further by artlCulallOllS of the ri~. A) ...eIl as the 01 the hc.ct ...-hile theCft\\ iGIl spine is slightly lalel\"ally wpe of the ar!iorul..hOO5, the amount ..nd type of fIeo;«d tov.·anbthe pamfulsideand mirumallyCJ<l~. mo\\l'mmt that IS p<Mble at each IC\\cl 15 oIffCCU'd b\\ The compl\"\\\"<\"oion J>ould be ..pphed s\"\"\"ly lind only the soft tis,sue strue1ure> between the bonv articut..- II'K'n\".lWdto.strongerprt'56\",\"\"ifthe~~~ loons and tm- MrucIUR'S \"·lthIn tilof' rwuroll foramlOoi not pollnful. Reproduction of the refern-d pain indi- and vcrtebr..lca....l cat~ WI It IS of Cft\\u;;;l1 ongm. Similar oomPre$5l.on \\I\",-ements of IIlof' \\\"l'r\"-'br..1column do not occur m tests can be apphed to the thorilCic and lumbar spines. isolation. bul rlltner in .. combined m.lnner Some but thcy r..\",ly \"-'J'rodure \",fcm.-d pam. aspects of this ha\\ealrl'ildy been m'\"15tlfjak'd{Farfan. 1975; Rolander. 1966; Troup\" 0/.• 1968; Loebl, 1973) Combined movements Grefll·rson and Lucas (1967) found that a~ial rolation in the lumbar spine was to the left wh<-'\" the-50b;c<:1 bent Thoe rombming of routine physiologicill movements 10 10 the left. and to 11.1' nsht wlwn bl'nding 10 the right. form test mowments makes up a large pMI of In.. text Intert.'Shnglr. they fuund thaI in Ofl('su~1 the l\"C\\\"_ oIt1usbook.ln !t'T'mSofex.amination. they.lrecombined ....:IS Ilw:case. Stoddard (I959).slak'd that the dJrection

~ MAITLAND'S VERTEBRAL MANIPULATION of rotllion during lateral f1eli\"ion in the lumbar and Wm'\"ln9 rotary and lateril flu,on ~_\"ts \"I thoracicspi.... 'anesd~mgonwlwlhe.-tl1elateral varying poSitioo§offlexi()l1 and cxlension nelps 10 CSlabli~th<typc:ofmoYtmenl~ltefnprncnt nl!X\":misp\"'rform<'dwllhlhewhole.p,\",,inne~ionor extCfl~iOf\\. HesuggcstcJ lhat rot\"t;on is to thc\"\"me ~Ide ;as Jolteral f1c>;ion when the ll'lO\\'cmenl of lalet'ill flexion is performed in 1\\e.oQn,. but to the oppos!te ~,,·hcnperforml'd,\"r<Ien5IOn.k.apandji{l97.a). '-\"'(\".:er, Stilted that ronlraLucral rotahon ocrurs in Cornbuung lllOIemenb gi\\O-\"S an mchation of the \"~y COl'lJunction w,th lateral f1Eo>.ion, but he did not men- SIgns and symptoms change when the same Il'1O\\(\"- lion an)\" \\'ariaiJOO when the mw.emcnl i~ perforrnt.>d in mentisdoneinfk\"'lOnorext~'f\\S,onFore...mrle,tht' extension or f1cxion amount of rotahon that ,s possibl.. bo:twccn C2 and C3 rersonallaboraloryob'ier\\alionsonunp~r...cd will \\arydl'pt'ndlngonthe amount of f1l'X>onor exten- ]umb.:lrspi.... sp«imens(which ... en.o ...'mI,)\\·cdwithin sian in which the rnov\"\"\"\"\"t is pcrformed\"Simllarl~;on 24 hool'!iol dealh;lnd then frmen} would seem Ioindi- the lumbar sptl\"ll\", the \"mount of \"'terill ~xion may all' lnal the dlJ1lCtion of rotation IS lJl the OP~l!E' \\.~ry depmding on !he amount of f\"k»;ion or e~tmsion dir«tJOntoWlwhidllhcspinelS lar....;ollyflexed In which the lllOI'ementot'lat...,,1 fIe>.JonlSperfornwd l\"II1?rdlcssof whethef the spme IS In flexion, l'xlffiSlOO Beoc\"use oftht.-aboH'. the wmptoms produced by test\" or fIl.'Ulral.l11ere doe.; appe.>r to ~ some ,arianon. \"\"\"\" IngmOH'f1\\''T1I~withrolal1onint'''-·ce,,·icalsp'neilnd L\"\\\"cr,dependmgontheprtSt.'OCt!orabseoceofd<-'I;<-'1l.-'ra- lateralflcxinnlnthelumbarspirlt'mayvaryqu,tecon- tin' changes within the ~yg.~poph~i11 joint or disc ~id\".\"bly, d,·pt'nding on whether the movement is T!wreappear.; to be little disput.. \"\" to the dlrcction doneinthl'~medl'gn.... offkoxionorextl'OSion.l.t'ft oIrQl.:ltioninthe«'nicalspi_(O-e7).Thish.!sbc'l'n rutabOn. uy, 01 the CO:'nicill Sp,l'\\(' may produce left in,·~tigJtedby 5e''e'ralauthor.; {Lpclll969; Kapandji. uprllKllruLu fO§6ll paIn when the rotation IS done on 197.t;Parle,1975;Mesdagh.I976;I'ennmg..I978),1hc neutral. ThIS paon may be accentuated. oo..\"('\\cr. w-hen dir«t>on of rotation appean. to bl-tlw-sarne regard\"\"\"'\" t.... same molL........t is done in ..~tl'nSion, and eased of whether the mo'ement of lateral fle,ion I~ dooc In \"ho.'T1don.. ,n flexion. In the lumba. spine, left latl'rlll flexion or ...xlImsion,ln,'est,gMions.;o far appear to IlLox'on may produCt' left buttock pIIin wh('1l the move- ~howthatthecomblnatlonoflaterdlnexionand rota- m<'11t is don., In neutral; hown..r. the pain may bo: hon is alwil)'S to the ume side. and b relat<-od to the acet-'T1tuated w\"'--\", \\h(' mo\\'ement is done in e\"t<-'nSion eff..'Ci on the molemenl by the zygoororhy..,/ll JOUlIs. and eased when done in flexion Hmu·...·ft. ;fimenlKJncd pm-iousI,.1he m\",)/,·--.loI 1hc 1llOI~15 dt.-ocribed abo\\-e in\"ohe the com- \"'0!hesollti~,muscle.ligJmmlsand..tructureswithin bimng of lllOIemt'T1ts. How....... the combining tlw-c..nal and foramIna all play Il p.:lrt in the h'peof of !hI\"('(' It\\O\\emenlS may al:'iO be performed Fa<- mo, ...mentposs,bleateachk...'~. example. lateral fil'x,onand rotahoncanbo:dolll'l'1th<--r Ilo...:au.., of the oombination of m\"\"emenb that in flexion 0' in extl'nslon. Th<-'Se mo\"ements can bo: OCCurs,n thc ....rt..bralrolumn. the <-?o:amindtion nf the performed Inanysectionof\\h('ipine./I'~I',llIlloml1­ p;:ltiL'T1t'S l1\\O\\...ments can (and sometimes mu~t) be iulhJJlthtMJuffl«u!pt'iformiflStht....,.......,.,/1lMlJalso n;panded to tnCOrp<l<'ale the:o;e principles. In otheI- w wntd Inti prodlKl' dlflt-rmt '¥'fptunwl/£ m;pon~ ...ortis. there ano limes ....·hen to ncamil\"ll\" the ~ic This is bo.ouuse ...hich\"'....... ~ement is pt'rlormed mO'remelts of fkx>or\" ex~ IIlIt'ra1 flexion and first ma}'rl'd~thea\\3i1ab1l'rangeoftht'.serond roIahon is iNldeqwole. and other ll'\\OI'cments combin- lI'IO\\'ement,and obviously the ,,\"ailable '''nge of the ing tht'se baSIC mol-'ements must be examined, $om!\" third mo,ement. WlK'T1 using thc!.t' combmahons of a'P'-'Ct~ofthiiha\".. alreadybccndcscrib<-od (Edwards, m\"'·ements as examining movenlents. care must bo: 1m. 19lIO)_ The s)'mptOlll5 and sigm that are pro-- takL'T1 to ensure that each position ismainl.:lint.'<l while d~ by aaminmg rot.uy or lat<-'I\"al ne\"ion mOl'eo performing the next 1I'IO\\'l'ment It should also be ml'l1to> performed whik-Ihe spll\"ll\" is maontainO'd in the understood that in tlw- «'Onl ~il\"ll\". the fle,,1Oll com· rll\"UlT.&IpllSltKll'ltnmationtootherll'lO\\emerlts«nbl- ponent 01 the lI'IO\\etnent. when performed on left rota- qUIte dlffcnmt from lhe stgns \"nd symptoms produced hon''''''lUl~thencckandheadlObl-~edrroorein ,,11m the same lI'IO\\emerlls are performed with the relation to theshouldcr towards which theIWc\\., ..nd spllle In f1CJ<ion orextens,on, Testing movements while h\"ad aretumro, ••,ther than appMx,malLngthe chtn the Spine is maintamed in f1\"xion or extl'nsion causes towards thecll<-'St. as is the CdS(' in flexion of the cervi- symptoms to be acrentuat,od Or rl'duced, and may cal spllll' wh..\" jX\"rformcd in ttl\\' anatomical position. chang.. the symptoms from ~ of locill spinal p;:lin An id..i1 of the possible \\ariations ofseqUl'l\\Cl' ean be tothooeofrefftncdpam. seen in !he eumples of lateral flexion and rotation to

mminJtion 135 theldtfortho,oCl.·r\\'Kal~pine: mo\\·cments produce the symptoms. 1be te\\.'er.;e is the casoe if the symptoms ill\\' produced on lIlO\\-emenl to the I. Fk~1OO first. lateral flexion to the left second. ':lOd OJ'POI'iteside.whenihepattemlSl5Iretchmgpattem. rotdllonlothot-lL'l'tthini. Ex.o.mple5 of compressIng regular pallert\\'!i: 2. FlexlOOfil'5t.rotatlOOtotheleftsecund,liltl,.'I';ll flexion 10 tht-Ieft thini. I. Right cervical rotanon prodUCl'$ nghl supr.t5C.Ipu- 1ilr pain. and this palO ~ made \"'·orse when the 3......teralfle>.iontotheleftfir.;l,f1exion!l«OOd, ..nd same tnO\\-ement IS done III (\"dens>on .:md ~ rotahonlothol>leftth,ni. when done in fIe\"ion. ~......Icr.u fIexIOO 10 the left fir.>!. rotation tolhot-Ieft <erond.andfll\"'(lOI\\tIun:I. 2. Cl'r..ial .....tension prodUCl'!i right ~urrascapular pain, and tim pam is lMde Worst' ... hen right roQ. 5. RotatIon lolhot-Iefl fir.;t.f1exion!ile'rond.liltl,.'I';ll lion l'iaddcd tothe~tensoonandmade ... orsestill f'k>x1OO to lhe left tIun:I. when right lateral flexion is ~Jed. 6. RotatlOll totlw left first. 1ilte....l flexion second, 3. Righllaleral ne\"ion m the lumbar spine produc:o::s and f1e'\\lOIl thIrd. right bUllock pall\\,. whkh is molde worse when tJus mo..-ement is don<' in eo.tenslOl\\ and cuOO. when DlffermtlllO\\\"('IT'lt'TllSoIthcspine(i.el1exioo\\.1ilt..ral done in fle:uon l1exiononew,)y,)ndmtilhononeway)cancau§ol'l>Imilar stretchmgorromp\"-OSSlngmon'o>ent!;onthot-sidcoithc ExamplC!iof stretchin\" ...gul;tr pilllcms' \"'lI.-\"I\"\\'crkin\"al JOlnL When flexion is pcrformo.'li in lhe sagiU.:II pl.:lroc, the art1O,L1r surfaces of the zyg.. poph)·- I, Rjghtlateralflexionlllthe~n'icalspineproduccs sea1 joml $hde on one another, the inferior 3rlieular sur- Icft suprascapular paIn; thIs paIn is accentuated If face oIlhe ~upcrior vertebrae sliding Cl.j>hal.:ld on the the s.lmc mo....ment is performl'd in flexion and superior articular ~urface of the inferior vcrtd,rae, l',lsed whenperformL-d in extension. whi1l' tl,e interbody spa(e is rmmJwed anteriorlyal1d widml-d JXl'>teriorly_ Rotation 10 tho:- left C;m cau...esimi- 2, Fle,don ofthl'Ct'rvical spine produCl.'S left supra- IarmoveOlC1ltonthedght\"ygilpoph}'llt'aljoint,asdOl.'S S<:ilpu1.:Jr pain.. ilnd this I\",in is marle worse when left lateral flexion This causes an opening movement, rightlilll'ral flexion is ilddcd ilnd worse still when which is Slmil..r on the right of the intenertebr..l joint. right rotation is addl-d TlIe movement is similar in that it is an opening mov(\"- ment on t...... right, but it is not an identical movement. 3. Rightlilterill flexion of the lumbar spine product'5 The fact!; regarding .. ddailcd 3\",,1)'sis 01 oombint-d left buttock J\"'in, and this pilin is acrentuatcd !OOI.·mwntscanberelatedtothep.1lImtswhohaWp.:lm on mm; ement. Some 01 the rombmatlOru; of p.11niul (or when tlw movement of nght lateral flexion is per- pam·free) tnO\\\"ernents follow rerogniz.lble p;Jtli.-\"rf\"G. easroformed in flexion and Basicall}'. then! an> two tra:- of tnO\\·em<:n1 patlerns wlwn right laterlll fkox- that can be found on exilmining p.lher'lls' mo,-emenb that an> m«hanicall) di.sordt-red.1bcy are regul\"r \"nd ionisperfomwdlOe~tCllSion. lI\"n>guLu; the regular patterns are liltL'tdung or com- ptesl\\4ngpant'mS. \"There atr\" many patterns other lhan the ~imp1eSln!ldl­ 109 and compre56ing ones dcscribed abO'.-e_ These 00 ~uIJ'~ttetmofIllOYetllellICOl\"lb.IIJ!lOIISa~ doub1 ...1ilte 10 biomechartical components, of whidt ~trtlct\"ngOl~poll1ffilS.TheyproOuce much still has 10 be ~tood_ lne IIlfl~ of the l.Im'~fmcr«menlSltthf..,t~rtdlratjol\"U.wl\\l1f changinginstilnla~axlSofro(ationlSooeofthe prodUCIng mitar~ptoms many rnnfusrng elements. RrgjJ'Drpatt~m5 'I1>et'e;s a further component to patterns of \"\"\".... ment. So far, for thot- sake of maktng the sub,ed SImple ThL'Sl' al\\' p-'1ttems in which movements produce simi- lOunderstmd.on1)'physoolog.lCaltnO\\\"i\"TIlentsha,... ~ Iarmo..ementsat the iot\"rvertebral joints while pro- mentioned. Ho\\-O{j·''''''. IN.\". an> pattem5 01 m,,. .ement!; dudng Ih\" 5<101\" symptoms, although IhL'S<! symp!(>ms thai include ~' ml»·ements with ph)\"5iok>gica1 may differ ill qU.:Ility or ~verjty_lfthe symptoms arc on thesa.me sIde to which the movement isdi.-..ck.-d,the \"\"\"\"ements_ Twoex-ample5of reguL:tr patterns an'\": paltem is a comp\"\"\"''''g paltem-Ihat is,compl1\"$Sing 1. rain and restriction of lTIO\\'ement on \"\"tension of the lower cervical spine OIDtched by similarpdin .:Indreslrictionw;thpostl'ro-:mteriorpressull'over thespinousprocessofC5. 2. l'ainandrestrictionofmo\\-emenlonexll't\\S;onand onrightlaler,ll flexion of thc lowl'rcervical spine matchl-d by comparable findings on postero- anterior pressure on the artIcular pillar of C5/6 at theinte ...·ertebralle\\el.

136 MAITLAND'S VERTEBRAl MANIPUlATION 0tI\\cf comb,ned ~t- milV indudecomblning n,., m..ny examples of irregular pilttems,;md comb\",- ations of painful mOHo'ment. frequently ;ndic..te that ~>CiIJwlth~lJIO\\/'W\\(n~ there is more than one romponcr>t to the diSoOl'der - for Notlt: T1lIt ,mportaOClt of palpation ~ beItn l:'11\\phiI- ~mple. the zygapophysNl joint. the mterbod.y joint nussu.ed throughout this booL and the \"..\",,1 and for..m,,,,,1 s~ Gt>net-..lh', bemg so, palpalOl'y traumatic mJurM.5 - \".g, Whlpbsh - and other trau- matic G1~ of p.1m do not hi,e regular JYttO.'mS III ~m'Ntion t«hniqlle!i must be included ,n e\\\"ery mo\\'emenL \"klntraumatl'U'd zrgoopopnywal ..nd mtel\"- body joint disord('f5 trod 10 han' regut.r JYt!enlS 01 rombmed mo,emmt test tlwl P\"\"\"~ or reprodU(t5 lnO\\\"ement,bt>caUSt't\"\"\"\"\",,·l.'mentsotf\\erion,exlo.'n- sioon.latel\"aJ f\\elIionilnd rolationlu,... simi!.J,effl'ctson pain, It.,.betfocthepalpation to bltJKIdcd at themd- thejolOts. ~tlOll of thlt rombuled ph)'5iOlogx:oll mo\\emenb, For adetailed descriptionofBnan Edwolf\"ds' OrIgmal .... ther Ih.in sandwidung it between phys>oklgKal \"'ork (1992) in thl!l alN of rornt>lnN mon'ulmls, his book Milo\"'\" ofCombrni'd Mowmtnt~ must be reJKI. T1lIt mo\\\"t'mCflb. bookaJwronl;linsdet<>,bon the!iclcction oftechnoques in treatmenl manag<'fllCnl Palpiltory alIm'/IiI!JOtI t<\"dlnique5 muU M included in o:¥trYCOrr'IbofNld-.nmtto:st I~l!/o,potterns of movement AUXILIARY TESTS ASSOCIATED WITH _ ~M;:.EN:;;T...;T:;:ES:;;TS;,.... All palterns that a~ not regul..r f..n into the c..tcgory Th<5l.' te5ts are the perforrJUlnce of movem......ts with of im.'gular palterns. With irregular patt\"ms, there is not the SoOlmeronformity as described above. Stl'l..tching lhe toint sU1fact'Srompl't3sed together. Other tests such and rompl'l.'S!Iing movl:'11\\enls do not follow any rccog- a) th~ for ,'erlcbro!lasilor Insufflci~nq' and nelll'O- nil..,ble palll'm. There apiX'a,,; 10 be no corr;:,latlon in logica! integrity rome undl!r this heading, The5\\, 1.....1s the e.umln;ltion findings oolai\"ed whl.·n combining are described in the differ......t spinal chapters as th\"y moV~\"lTlmls that either comp~ or stft'lch. 1llere is a random reproduction of symptoms, dC!Spllc the combin- ing of m()\\'emcnlS that ha,~ simila, mechanical efll:xts. Neurological uaminati:::\"'--- _ Imgu!ar piltle<ns of ~(nt combl/lilloom do not 1l>t're IS a diffcrm.c<-' bet\\\\'t'm neurological s.gm ..nd loIlowanvtKOgNnblltpill1ltmofslJlttd'ungor ncuroIog>cal dw\"S\"'S; 'clunges' a.... objl'ctive phrsic..1 ~inthltinlnvml.'br.lljoinb defidenc'ies, when-as ',igns' are subjltcti\"e abnormal- Ihes that can be dek'mlined on ph)'»Ka1 examination E.umpl-.s of un>guLu patll.'rm of movements. BUT ;on, dependent upon the pabl.'nt'5 statements and CAN be unreliable_ A loe6of!ieflSItlOll along the t.ll.'f\"al I, Risht rotabOn ofthPcenil;.;al \"Pine {a compressing border of the foot is iI ...... rolog>cal change \"'hen, on \\lSt mo\\\"emcnt) prOOunos right supritXilput.r pain. _ _- lion.thepat\"'\"tdoesnotflmch.ifthe~m­ and ttus pam IS fl'IOlde wone ..-hm right rolatlOll ,s ;..... gi....'5i1 shil.rppbwlth;opomtedobjec't{suchilSa performed m ne.oc.. (a stmdUng lOO\\emeflt) and pin 01' nL'ed1e).espIlOoll1y If t.....pb produces detectable inderttabOn.IIl)W('\\·<1I\". If thepatlent says ..... cilnnOl r-J filSl\"d .. hen thP mo\\ement is perlorTned m alm- $iOn (a~romp...wnglnO\\-err>ent). a light wiping WIth a t\\SSUl' on his srmptomatic foot. ilS compared with the same dcgret'of .. iping on hIS sound 2. Righi \"teI\"al fieri<., of the lumbar sp\"\"'\" (i1 rom- Prelalllf; mo·..ement) produa.'5 right buttock pain. foot. then il is a subJect;,,, findmg; being depmdent and this pam ,s accentuated when the same mo\\'e- upon the palienl'.suy-so. ,tIS not an ob;ecli\"e fondmg. ment IS done in flexion (a slmching. not 01 rom- Newrtheless, il can be Kn'J'1..ble to I..... e~ammer Ii the pressmg mo\"ement) and eased when dOOl' in diminished .5t.,-\";,,tlOn fealuJl'fi fit \"-,th other cbnical cxtroslon (a compressing mo,·em\"nt). examlnationfeatul'l'S J. Left lateral flexion In the lumbar spin.:! (a stretch\"'g The physiotherapist must reporl to the doctor an) mow.'fTll'nt) produces a right bUllock pilin, and this !\",in IS made worse when the saml! mo\\'~m~nl is deterioration in neurological changt'S lhat m..y occur don.:! In eXk'TlSion (a compressing mO\\'em~~ll) aJ1d duriJ1g lreatmen\\' This means that the physiotherapist eased when lhe mo\\'ement of laleral flexion isdoJ1e must examine lor and ~pI'aloolyas.ses.s possible neuro- m flexion (a stretching mon...........t) logical chaJ1gl.'S at the commencement o( each treal- mcnt5C5:510n.

Rtftrrtdpain although each nt'f\\'e mot supplies more lhan 000l' Rdtrn.-d palO h.anng Its ongIllS 10 IN, nen·e mot or musc~.§OO1('musdesk'ndto~suppl>edbyp.....aonu­ R.IOI:Iets is eaill'd radil;u....r pain; ~ pain from .....ntly one mot. l1le root 01' I\"l'.IOb quoted are tt.- other structures IS simply refC\"rT'l'd palO and IS not thm found to \"\"\"e grea~ clinol si~ (Flguft' '.aaoolCU....rpalll. that refem.'d painaon~ 6,20). While the pabml lief supme. W JlO'\"'f 01 the It isa well-pnnen appropriate ann mu>C\\es can be ~ quickh' In aotlSl'd by compresslon of the nen..., mot (Smyth and lhe order sho...n in Tabk6.'.liowe'I'er, ...hen aSllt'SSmg Wnght.I958)and byotheTsoctionsoftheintcnerte- neurologicalmusc......·eaknes5.lhetestsm~:vneoed10 bral.;egment(Feinstcinrta/.• 1954). It maybe diffICult beextendedronsiderablylO~inthee>.tentof 10 describe prccisely Ih... diffl'R\"nC't' hefween a nen'.... ...eal<rtes5 and nerve in,'oIl'ement. T\"bk 6.10 lislS ttlc root pain and a refl'Tl\"l'd pain from olher strueturt$. muscleso(lhe upper and lower limb, shoWing the Nen'....root pain can f,,-,<!u\"ntly be identified by its ner\\'l'-root origin forlhe motor supply and the related char,'etl.'r; it isnol just an aehe,but ~ P~In,oftcn scwn' pcripheraillerl'esupply. Thesc\\'erllyollhl.'painfrt..'qucnllyshuwsinapaticnI'S The relalionship of sen.<ory disturbance to nerve lilCial e~p .....\",~ion or in his dl..'SCrJplion of the pain, root im'olvementis simphfil'd by remcmoc'Tinglhat or in the way ht>huldsthe limb, It is typically a ,\"ery the thumb and indes finger are supplil'd by C6; the unplt'asant sicwung pam. and is most frequently indt·x, middle and ring fing~ by C7;and the ring and greah.'St mthedislal p;!rt of the dermatoll1l\". l1le pain hlllefingCl'!\\byCllOl\"nmol<lmesofCSandTireamto 15 not nt'«'SSanly repmdUCl'd by normal mo'.-\"menl !he wnst on the ....k'r.ll and med.al aspects respect- ItStS,butllfrequnltl)·mcreasestlfttr .. particularfrlO\\\"e- iwly, In the foot. the dorsomediaI asped of the fOOl to mefllhasm... performed_ l1len...errod p.Jlncan. hov>-- the big toe is supplied byU; the~mofthefoot ~\"ft. ~mes bfo reprodUCl'd If Cfttam mo',rmenl§ O\\·ert.... lopof~thelOl'Slotheb.allofthefootbyL5; &r1'held ..t the lirml of the ani1.ablr range fur_ and thelater.ll asp«Iofthel'ootand theli~lwbySI wconds (St'l' p. ID). Referred pam from other!iOtlm'S (.F.gllft' 6.4). does not beha' m thi5w..y Thebocepsandtric'q:lS~lUTthenwnrefleses f,;otallnen· motpainisSC\\'L'ft'.butwhenilis,the in the arm. test«! to elicli disturbances caused by p'hentsrequlre~lIycarefulrll\"UroIogical~ net'V('-mot compressIOn, although this test can be menl and treatmenl must be gL'Tltle 10 al'Did ex.teerba- extended 10 the supinalor. finger flexors and dcltold, tlOrlifthe]x,stt\",almenl~uJtsal'l·tobcgaincd To lestlhe bifi'P\" reflex, thepa.tient's slightly flexed To rdt.. III th\", many dIagrams of dcrmatomes .- arm mus<:le must be fully supported and complctcly confusing unll\"S~ it is understood how differcnl strue- rl.'lilxed. Th\" Ihumb. placed firmly Ovcr the biceps tul'l'S refer pain. If thc ncr\"e l'lI\"t is tlwsourct'ofth\" t..ndon at thc elbow. is thcn tapped ...ith the pcr' palJt'nt'ssymptoms,th\"ya\",fl'l'<ju\"nlly f\"ltonly in II\\(, cussion hammcr. Th.. triceP'> reflex is tested by tap- dislill p.:art 01 the d..rmatome, This esplains the ty~ of ping the tricL'P\" t\"ndon beh\"'d tilt' elbow whil\" the chartssuppliedbyCyrias{l975)ChnicalexamplesaT\\' patiL'fIt's h.and resls on his abdomen and hi' ne,ed pahenlswho!;epainslartsdlsIilJly.orpaloents ..·1\\ose dbow is supported in the phYSlOtheraplSl'.5 hand Nockorl'\"ll\"Ckpaindisap~arsand,,~bydi5ta1 {rigllft'62Ij, limb pam. Ho.n~'I\"\"\", it ill common 10 h.a\"e pahmls TQ~tho>kneejerk... ilhthepatiently\"'g5Uptne. ...femod wllh pain In thl>~pincconlinU0U5with I.... thephY\"lothe.-aplSlmU5t$hghtlyflexthepabenl·S~ pam In the hmb, ,\",'luch may or may not ~ worse dis- toappmxim.1tely3O\" ..nd ensure that the quadriceps 1$ gil, The reason fof- tIus may be lhat. .. hile tho> N'f'\\\"(' relaxed before lapplrlg t.... palellar tendon. When the rootcaw;es'Ol'l1eofthe1imbpam.~painmaybfo response is \"'Nk, some remfom\"l\"l'lml may be gamed pn!Sl\"ntas~~hoidis<:pathology(C1..o.ard,I959). by asLng the patient 10 gnp his hands; together in a ~ d\\SIC may in tum belmtalmg other pain~,Ii'... rnonko!y-gripand pull Strongly. \"ructul'\\\"',nthe'·ertebraICill\"laI.suchasthenC.Ye-rooI If the ankle jeri: istcsted while the pabent lie prone, ~,,.ordura(CyriaxandCyri;lx,1993).Supportile the distil end of his hbl.!l should besuppol'1ed to flex mle>Ck'S and ligaments. Wllh thl.' apophyseal joints, his knee loappro\"malely 30\" l1letl'f\"ldo-AdullC'5is d,sturbt'd by the disc damilge. may alsogi..e rise tl) th...n tapped. This renex acti\\ity IS increascd when the somel)rlhelocaland~fer~pain.Rcferredpainof patlcnlknecls ..reclonfullysupportedlo...erlcgswilh thiskilld indiciltt'S the 1\\CL<d forchart5showingpain his k-ct ol'cr the edge of thc rouch. IocJIlYJndthroughoutth.. 1imb. Normality of rl.'ncx ach\\'ity is not romplt'le withOlJI Muscle weaknes:;; re:lulling from nerv.... root com- applying .....'pt'dled Iilpping,al least six repetitions. to p\"\"\"\"onis be-taSSl.'S»t'dby isom\"tnc(slatic)lests.aod aSSL'SIiany degree o(fallgue,nthe brisknessoflhe

138 MAITLANO'S VERTEBRAL MANIPULATION .=........=.~.... ---:}~= n TIiI::IIlI C7TJlC8(II IIIu caE..-~ ....... \"'- U_~- jer1<\\l4ToI»li$lnteriaf L5E.-I\\IIU::iI~ ... .........\"\"...... .......-II''S2F1101~ Il'Spon~ Rl.'pehhon is as importJnl in the tesl of n'f1ex PASSIVE TESTS aeti~'ity as 'I is in the test 01 neurologically affectoo muso:Wpo.......... There In' many p;assin' UlO\\'ementtests thaI form part of the \"\"\",minalKll\\. IJ'lCludtng: FINlly,nl resullofourtnlerpreti>hon of the neun>- Iogic.il lesu....... should rea1lZe thaI although 1\"Il'f\"o .... 1. \"fhefl>O\\en'M'fllofthepa,n-sensil\"'estructul't!Sin root signs invoking two roots can be d .... 10 .......ign the \"f\"rt<-obral canal and InIt'O'ertebral foramen and p.lthoklgy in the lumbar area. dual root signs are neural linkoo fI>O\\'ements unlikely to have a benign origin in tN:!ccr\"ical area. Physiologicalspinalmo\\\"Cmenls Thctcnsion in sofl tis.o>ueand thc 'luality of Dull rOOI sigM in the ~rvK:11 ~I~ I~ unlikely 10 movement of ll\\e inlervl.'Tlcbral joint by palpahon havl: a btnign origin as.se$SinglheOlCCL'SSOrymo\\'em<-'fIts. 4. The paMi\"c rang<' qf ph}'Siologicai fI>O\\'cnlent of stngJeintervml'braljolnls.

TlIble 6.9 Assessment of arm and leg muscles with isometric tests Nerve 'oct and.eflexes fluionof rn,adon uppt. Thrpati.nlaU.mptstofinhi,rn,adonnisuppt,nrek.gainsttn. rItd\"wuscap,tis.nterio. resi,la\"\"\" .pplied b'I the physiot~erapiSl's hand under the chin .nd on th.forrrn,.d. ute\"\",onofhudonuppt' rItd\"wusc.pitisposte,io, Wni!r the patienlatt.mpts to extend hi'hrad on hi,neck th. majo.and minllf with physiothrrapistrrsiststile movrmenlby holding theoccipulin obliquus capitis SIIpt'io' on. h.nd and th. dlin in theoth••. .laterlll flexion. SUllene The pati.nt alt.mpts 10 flex nis h••d and neck lat.,allywhil. th• ~\" physiotne'.pist ....iSIS the rnovem.nt bypl.cing on. h.ndon tile ,hould.randth.oth.ronth.s:ome ..<kofthepati.nt'shead lIitdling \",apula. trllpt,iu, andf.ce and lev.to'\",apula Th.physiotn.r1lpi,t.ppliesrni,tancrO¥rrth.acromioclavicula, joint a,•• whilr the patient rndeavourslo.lrvatr hi'shouldrr girdle Abductionofarm, deltoid CS8icrpsjrr' Thop.tirnthold.hi,.rmabductrd4S0f.omhi\"id••ndtn. physioln.rapi.t.pplies ....ist.\"\"\"totllrlal..ala.pt<:lofth.a'm Elbowflexion,bi<:eps \"8icrpsand iult.bovo t~e elbow, Elbow extension. t,ittps br1lcnior1ldiali,jrrh The patient holds ni\"upinated fu...,m f1rx.dat the elboow to btrnsionof tnumb, 9O',Resistancrisapplirdagain5ttneanterio,surf.crofthe e>:tenSQ.pollic1,longus \"T,icrpsi\"r' forra.m ju,t above the wrist IMef\\lhal.nge.tfle.,on, Tho patient holds hiselboow f1e.ed to9<r and resistance is appiird fle>:C>fdigitOfUmprolundu, ag.instlhrdorsumofthrforrarmju'tabovrth.wri,t Intrinsi<:actionoflhrf,ngr\" Thepati.ntflexeshisrlbowto9<randsupinateshilfo,.a.mto mid-posi,ion.nd holdshi,ex,.nded thumb away from tn. palm pointing towa,dshis facr. Resistancr isdirttted against tllr tllumbnailtow ••d,tnelittl.fing••. 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 Tn. patient fl••cshil.lboow lo9O', ••t.nds his wrist, rxt.nd5 nis fingers at th. intrrpnalang••1joints and f1r..slh.m II trn, m.t.ca,pophalangraljoint,.Th.pnysioth.r1lp'.tatt.mpllto separate hisfing w~ile the patient squeezes his ••t.ndrd finge... togrln.r,H.th.n pa••t.snisf,ng.rsandsh.att.mptslo squeeuth.mtogethe,. Moto,supplv intrn,legi,te,t.dstanding,supin.andpron.lying STANDING Th. patient Iland50n on. leg rising on to nis too:s and low.,ing while tnr pnysioth.rapist holds nis hands 10 maintain b.alancr. (rontinucol

140 MAlTLANO'S VERTEBRAL MANiPULATION \"\"'''Thop;lt..m:holIbMIluftl\"'plNllnftaI9O\".m;,,~f>CO. Tabl~ 6.9 (C'OfItd] ~jw3bavclhckntt .-...-...,...- - - - - _ Thr~tlIfnob,~_\"\"\"'lhcp;lt\"mfs -\" ... !own llugIItoplKt'l\\(I' loIndorllhcoppclSlt~\\tl>g~_WIl.;e1hc p;Itleftlhokls\"\"\"'jwWlOtloflfttfullyc.<t~1KJ!I't*'. LSI.ndSt) $, .....reistlnttisapplin.insttllofnlttloflhc\"';.ast~1hc \"\"kl~ j~rk n..p;ltlmlhollhh.. fOO1 ... don<,,\",,-\"\"i~w~\"'w ~appronf't'\\is\"\"\"\".M1t1w:~.al,,,,~ oflhc~~rodoft\"\"r\"'I\"\"ttatI<Yl Ilog (eM: ~..ttftlion. c.<t~fI5OI Thop;lt,enlholdshisfoollndtondotsOfk\"l!dwhi~rtSistanceis ~lIuc~longus pl~aga;nsttfl~na,loflh~b,gtllt- Toec.<t~_o:t~nso< ho' ' 'The p;lt;~1It his foot Ind ton lIoIslno:ed whilsl ~li~ is d,gltOrumlongus Ipplied aq.,nst the dolSll surfac:~ of III toes. EVf~on.ptron~uslongus andbrtYis T~e patient is a\\.hd to ke~~ ~is n~~1s 1000\"her and hold the wlo of his feet twimd Iwa1 from eacn Olr.er. Th~ physioth~rl~ilt applies rnist3n~ ag3inst the I\"~rli bord~rs of 1M f~l. pu5lling lr.emtow3nb.lCtlo!her, Tr.e p;lti~nt ~ his ton CIvef th~ pads of tile p/l'tSiOtherapisj'. fingers.Shere5i.bh~KtIOnOf\"\"',. . h'llon>rWl\"nally. Thrpatlmlhollk\"\"kMeflo:edI09O\"wholf:the~ appIr.~bo:hi\"\"lhcpa\\lf:nt'shttL Thrpat>ent ...... h.. h.wtndtllW'lhthelnftbtntwh,ltthe ~apphna6oWnWill'd~,..st~lhckntt wth_I<and_P\"!l\"I16the,...ttal MISS 1'IIoed'<IIIy with the oIhnllafldlO~fi.......u.. \" ' - ,OTHER HEl/flOl.OGlCAl. TESf5, 1.1labtnY:1;2C1oeus M~m~nl of pain-sensittv~ structures in Ih~ of the structures in lheca\",,1 or foramen. l1>e tests thai vert~bral canal and int~rv~rt~bral foram~n. and can be applicd lomo\\etheSlructun\"Sinthe\\·t'l\"t~tlral neurallink~d movemenU canal withoul aisomo>'jng the inler....ertebral joinlS art' fcwin numbcr. To be able to flex lhespine fully and louch the tot'S lWJuirt'S f\"-,,, mo,\"ement of lhe spinal ron.!. lum- Straighllegraisi\"glC!;ISlhcfrccmo,\"cmentoflhe bosacralne\"·erootsandlheirin\\\"(·stml'nls.lfforw\",d low lumbar and s.1cral nerl'e roots and their sk'Cvt's flexion i~ ....\"Stricted. it may be lhal the intL'I'\\'erlcbral within lhe,\"ertebralcallal and mle,,'ertebral foramen. joinlsal\\'slifforitmaybethatthcrt'islosso(mO\"emenl Although Slraighllcgraism!i n:stricted t04O\",a\" be

Tablt6.10 NtNt-rOOI origin for mOlor supply (M) and relaltd ptripht.al ne Ntsupply(P) R~i'~tory Oi~pIlr~gm Ned Shonfie.OC'l Long fie.\"\" fkJcion Ste.no.m~~loid Shone\"ensol\"\\ Longe.tensol\"\\ T\"P<:liU~J ~~;c lk>wer L.... tor + rhomboid~ \" \"\" Se,.. tus .. nte,io. .\",. I3elno-h\"me,~1 \"\"\" e.t rot Inr\",spin~tus AOdLKIion f S u p \" , s p j n ..lus 1~Itoidl ~t 1fCO~-brll.hi\"hS f'ec.M~jora... Int(,n~..1rot~tion. ( ~i:ernSUbsc..pul.. Idd\\ll:t,on ~r\\d rere:s m..jor ...tenswn , '·'\"' 'Lati\"imusoof'i ,MC+R \"\"'\"E.tension ,\"e Tri«ps \"\" Rulon IB.arnioradialis Supination Bi\"\"ps Supin~tor I'fOn31orlercS Pronatorqu.drlllUS e.tenSOI\"\\.arplrlld. j ul.c..,piuln is flexo' c...pi di_3Ii~ fie.. o:arpluln3ns PlIlm..rislongus ~e~:;o~~~~i~i~ Fle\"pl'Ofundus Lat ( Fle.. profundus Mr<!. Lumbncolsl.2 lumb.icoIS3.4 Opponens + fie.. V \"bductordig.min. { lloI\"\\;ol,ntcm\\.5t' P;olm~rinte~i

142 MAmA~D'S VERrEBRAl MANIPULATION Table6.10 (ronto) ............'Wm5CII'paIiciol. ······.'. I~pa6icioL AbdIIctofpallimB. --{ ~palitlSL fbofpokls& Add\\lttOfpollicis ~llll''f Dilp!lf39\",Cl,.,S Intrm>sII\" Tnmk ::::.. 11 :.::::::: RollUon Ext.,n\"lob'.'q . Inlomalobllq . fltxlOtl Rtctus.bdorrllnus \", Tra~itbdom,nus ::~ 1= , ~~ { :=.s~:.;\";~ : ~ l<t.1Iot- {ExrtmalllUtorI ~-II;;; {::::':~ E>n...-oIiglDngus OP Of' Ext...-cfi,lIorM OP Of' &_Iuol.longlil. ~p ut.\"\"\"'hal.f:l<toM ~ fI'\\,nu, fklJOl' { ~~::: : : : : ~1~:,,·miUS 1 IE\"WQn ~::~~t%:~ b<Nt.

_. -TAA 6,10 loonld) \\......,FIoor\"'11ongIIJ t.ffiIiIlplI~tltl'S Lltmdpllntlrl. C Cimlmn.. \"NO; OP ~ o..p ~II \"\"Nt: ~ - \"\"mor.1 ..\"\",,10 Ido\"or ~luto.I ......; '\" - Mtd'l~ nON<; MC \"'u.....lDtuun.ous neNt; 0 Obturator \"tNt; R- 1\\a(j,.t\"N<: S xiatic n,NO; SO - S<>prrio' glutoal ntNC; Sl' y SuprrflC<11 pr'OI'Ital n~; T lib'll neNt;Th Thor.....:U_Uln.' ...... indlc~tl\"eof nCI\"\\'c-root restriction from herniated dis<: ofp.ossi'·e knee flexion ...hi~lhcpan..nIJiepronean simlLlny ~il5'8'1of ~tncbonof mO\\\"l\"Olmt 01 ooeol material (Charnley, 1951). pam at fuJI rJ.nge can indi' the nerve roots of W Iwnboor plexus, ...hile am' \"'Pro- ca'\" Wmf' ;nlerferen~ with the p,lrnles6 mo.'crnent of ductionofpain\",lhanalmostfuUriI~oIrno\\·_t !hestructun':$ in the canal or foramen. Gross limitation ......y indialle mild in~ and should be not«! foe' wceI\"ul.nd Uppe!\" thoracic CMliII5,if6exJon of tIw head and nock PI'O\\'<!ke pillO in W I'11'Ct 5ltbng f'Cl'lhon. adding peI\"j( fIeJoon and 1W1l~r stumprng WIll ll'lO\\'e the canal $lrUCtUre5caudaUy ,,'ithout alter- mg the \"\"rvical and upper thoracic inter.·ertebr.1 IYlat'onshipli Care is reqUIred when testing slraighl leg raisms, b«.u~ minimal restriction may be missed if the test is not done correctly or if it is not repeated two or Ihn.\", times rn quick sucC\\5Sion while watching ca,\"\"lully for any abnormality of pelvic movement or d;lfcn.~ in K'f\\Sion when rompan.>d with movement of the other leg, When raising the leg, the knee must not be allowed 10 bend and the pelvIS must not be.lIowed 10 rise fl'Oll'l the examm.!Ion couch or hitch towards lhe 5houIder on the side bang leSted. The Irs being tested should be held in I sl'ght dC'S\"\", 01 hip adducllon\" keeptng the medl<11 rNlleolus shghtly lateral to t~ nvdl<1n 5;1IgJlbi pillne. while LIter.' rotation ~t the hip mUSl~p\"\"..ented.ltisJl'OMlblelO~theten5101\"l on ~ low.,.. lumbar .00 ~II ner\\'e roots, their rootlets (Ma<nab, unpubhshed obSO'!!'nl:iCln5) ~nd their !01l.'C\\'es when tesllng slrlLgllI leg raismg by paSlSl'ely dO!\"slflelOllg the patIent's fool whIle hoIdmg his leg II the limit of straighl leg raising, The t\"\"'5ion may be further increased by fully f1cl<ing his heAd and neo;:k while in the straight leg r,lising and ankle dorsiflcxion positinn Anothl\"r aspe<:t relcvant to the slraighl It'g rai_lIlg ~t is that, as there i5 an increase in intradi~al p...\"... sure when the patient sits or ,tands compared wilh