Maitland's-Vertebral Manipulation - 7th edition

398 MAITtAND'S VERTEBRAL MANIPULATION Figur~ t2,70 101 lntervellcb\",1 jo,nts. TlO-Sl(rolauonllocalisedman,pulall()/l; (b) close upon hands 2. Standing (and h~ cauld nalstand ~r~ct, in fact h~ Rotatinn tathe ,ight in flexion decreascd the leg had a lumbar kypho~i~) p'ovoKed ~in in hi~ kft leg ~ymptom~, slightly but definildy. (It is very hdpful and he wa~ unable to b~nd backward~ ~cauS(' of from a treatment pointolview to have different incruS('dlegpain respooscswiththediff~'entdireetionsof rotation.) In thi~ man's drcum~tan= it i~ wise, when ron~idenng 3. He had an ips;lateralli~lonfluion.(Item~(2l.nd 131 th~ selection af t~chnique. to choo~~ the relie,ing S('em to indicat~ that h~ ha~ a di5C disord~r, which i~ po'5ilion while performing the relicving direcl,on lor prClVoking po~sible radicula, pain. The affending parI th~ ,otation. of tl>edi5C i~ p'obably medial 10 the nerve root and il~ sle~v~, and will th~,efa,e ~ harder ta help by 5. In the up,ight po'5ition, pclfarming a lateral ~hiftaf pa'i$ive movement technique~.1 Ned f1uion while he his lrunk towards the left de<;'eased his pain; ~hiltto wa~ fie~ed wa~ limited by inc,eased ICjl pain. [There the ,ight slightly incr~ased the ~ymptoms. (Be<;aulC mu~1 ~ a canal component in hi~ disorder.) II did nOI af this pain ,e~ponse. the li~1 mu~t ~ directly relate\\! increase hi~ bad ~in. (The cause of hi~ bacK pain i~ to hi~ disorder.) probably nat cau~ing hi~ leg pain. Twa a~pect~ of th~ one~truclu~pemaps?Thedi~?) 6, Straight kg ,,,is(' on the left wa~ 35', cau~lng po~!~rior leg pain. On the nghrit was 70', and h~ 4. While~till in Iheflued po~ition.rotationtotheleft said it cauS('d an uncomfOllabk tight !celing increased hi~kg ~inbyabout 100 per ,ent plu~tin9Iing,inthekfrfootlawally.(C'05sedSUl

Lumbar Sjlin~ 399 Figur~ 12.71 e.ody chart. Mrl rapon~ - treatm~nt may need to inciuM mobilizing length of the pain rderril down his leg. [This meant th~ fight SlR.) thatthediwrMrcausinghislegpainhadalot~nt component) 7. Testing the pow~rof Ilis call in standing demonstrat~d 50me wea\"ne~ whid1 may halJl: been 10. His leg p;lin ind his back piin could be provoked i neurologieil weakness but mayilwhilJl:beeni ~p;ll\"3tely.{Th;sm~intthitthefewereor!e<!st pain inhibiticm reaetion. twocompoMrll:5toltisdist>nkr.Withth~added informitioninnumber(l)abovl:.hchasatleastlhree 8. Al1~mpting to stand, from sitting only a short tim~ romponenls. Number (4) abovl: makes it 10Uf [haifa minute). h~hid tlad painandiSC'\\'~re romponents.) lumbar kyphosis, which took wm~ 15 ~C(lnds Or more(alongtimdtodissipate.(Becau~the 11. rongling was f~lt eith~r in th~ big toe or th~ lateral kyphosisdevelope-d so quickly. this meant lhat borde, of his foot. (This indicat~d th~ passibihtyof thediwrdercausing his bad pain was very two neM: roo~ being involved. This rould mean thit mobile.) two intervert~bral di= may be involved. or th~ patient may have an anatomically abnormal 9. His leg pain was minimal on first standing but then formation of the nerve roots; sce Figure 8.}.) graduallyincfea~d in intensityandalsointh~

400 MAITLAND'S VERTEBRAL MANIPULATION 12. Ik alw ~ad canal mOVl:m~nt abnormaliti~~ as w~1I a~ FollowingthetechniqYe: int~rv~rtebral joint mov~m~nt abnormaliti~s • Movements had furth~r Impro~d. but MrL'sdiwrderwasollvioYslyatypical.Th~di:;c • SLR was still unchang~d. compon~nt ~~mt'd to bo: causing ~im mo~ disability t~an t~~ radicular as~t, but obviously th~ radieular • Symptomatically, he f~lt mOr~ comfortable and felt he aspect took ~ig~~r p,iority. B~ing atypical m~ans that rouldstandwaig~ter. on~ ~as to bo: rtry quick to notic~ t~~ chang~s in t~e ~xamination signs of th~ separat~ rompon~nts. and to After four such treatm~n1S Mr L was gf~atly improv~d, react with appropriate t~ehnique c~anges butSLR,althoYghimprov~d,wasnowherenearas muc~ imprOlled as were the JOInt mOll~m~nts. Sitting Treatment was also impfnv~d. His calf pow~r was normal. During Because it se~m~d to bo: discog~nic (getting up from this stag~ of tr~atm~nt. a scan revealed post~rior disc SIttIng) wit~ a nerve-root i\"itatinn' protrysions slightly lateral tntl1~ I~ft nf the post~rior longitudinal ligament at bot~ the L4/Sand lS/Sl 1. Th~ ehni\"\" nf t~c~nique would bo: rotation, as t~~ l~v~ls. symptoms and signs are c1urly unilat~ral. Btcaust t~~, ?disco9~nic?, component was improved, 2. Therotationwouldbo:~rformt'dinth~ and also t~e radicular symptoms wer~ I~s [plus calf 'symptom-relicving'positionanddi'ectionto pow~r impro~ment), Ittt SLR was us~d as a teclmique avoidprOllokingpain. and aft~r four treatment sessions oft~is ~is left SLR bccam~ full fang~ and pain fr~~. How~v~r, th~ rig~t SlR J, Thinking a~~ad to furth~r treatment t~c~niques. it still telt tight and did provoke minimalldt I~g symptoms. seem~d possibl~ that th~ canal signs would not It wa~ decided to do rigllt SLR as t~e treatment imprOlle in parallel wit~ the joint signs. and t~at technique. The tightMSS cl~ar~d and r~main~d clur tOf 4 t~erttore SLR str~tcl1ing may bo: r~quir~d lot... hours. Mr Lwas positioned IYIMg on ~IS Ittt sid~ wit~ a SlJpport Thenexttrcatments~ssionconsistednf~rforming (folded tow~1) und~r his iliac cr~st to gain a lat~ral shift SLRoncac~ leg and endin90fft~escssionwithafe~at to t~~ I~ft position (his comfortable sMt position. st~ of the pr~vious positioning and rotation trc~nique.lt wal item (5) abort). H~ was also position~d in a degr~e of d~cid~d to stop tr~atm~nt (ynl~ss h~ had an flexion tn ke~p his lumbar spine away from Ih~ painful ~xac~rbation) ~nd review all as~cts in a mont~ and markt'dly limited ~xt~nsion position. A rotation of thIS thorax toth~right in relation toth~ ~Iviswas Th~ ass~ssm~nt aft~r a monl~ r~~al~d t~at h~ had also adopted, and his right leg was k~pt up on th~ nOI only r~tain~d all of t~e imprOllement from couch to avoid anycanalt~nsioning (whicl1 would treatment but also found h~ could Sil, stand and b~ occur if his,ight I~g we.. altow~d to hang over the much more activ~. H,s movem~nts w~re n,,11 and almost ~dge). Th~ techniqu~ was to 'otate his pelvis to the Idt fru of any discomfort H~ was r~vi~w~d again aft~r (that is, thesamedi'~ctionasthoracie rotation to 2 months and di:;chargt'd. Aspc<.:ts of 'back car~', esproally t~~ right, bYt pcrformt'd from bl:low Ypwa'dsl as a in felation to the 'w~ak link', t~~ capacity for harm to SlJstaincd (sustained becaus~ of th~ lat~nt compon~ntl accumulat~ painlessly and t~e need to bo: awar~ of grade IV. pr~disposing factors (5ff Ap~ndix 4) w~r~ foreiblv ~mphaSlzed • During th~ ~rforming of t~~ tec~nique h~ kit an casing of ~is leg symptoms, whid was a favourabl~ This pr~s<:ntation ~mp~asiz~ thaI t~e manipulali~ indication. physiot~erapistmust und~rstand t~~ pathology t~at mav be involved in suc~ a patient's disord~r. yet s~e m~st tak~ • On r~aSstSSing his movements alter t~e technique, t~e mOSI notic~ of the chang~s in symptoms and signs. ~or joint mov~ments were imprOll~d bYt SLR was example, t~e fact I~at his disord~f may hav~ b~en une~angt'd. p'ogr~ssing towards a n~IV~-root compr~ssion did not pfevent SLR bl:ing used as trealment, because I~~ possibl~ The t~c~niqu~ was r~p~att'd, but more firmly and for neM' condition signs w~r~ imprOlling and the possible a IMg~r sustained ~riod. During th~ ~rforming ot radi\"ular symptoms w~re also improving. Nevcrl~~I~s. t~istccl>niquealltinglingmhistootdisap~ared I~~ first SlR mobilization had tobo: done onlyoncc, and t~at once was a mild str~tc~. T~~ 24-houf as=m~nt indicated that it should b~ continu~d with car~.

Chapter 13 Sacroiliac region: sacroiliac joint, symphysis pubis CHAPTER CONTENTS When applicable tests 404 • Introduction 401 • bamination and treatment techniques 404 ·Subjeetiw:namination Opcning tile anterior and posterior Ar~a50fsymptoms 402 surfaces 404 Ekhaviourofsymptoms 402 Furtllertnts 405 Specia1llutitions 402 Palpation 407 History 402 Treatmenttecllniques 407 • PtlysicalcJ(3mination • Case history 407 Obstrvation 403 • ThesymphVSis pubis 409 Mow:mcnts 403 Treatment 409 INTRODUCTION The sacroiliac joint has a diven;e and extensi\"e innervMion from L2 toS4. This may partly account for In'C8Iity.lhctfucinciMn~ofSicroiliacpainand the inconsistency and variability in suggestro sacro- disorder.; is unknown iliacjoinl pain P.lltemS. The joint also po5sesses a rela- ti,-ely small amount of movement, which is difficult to The sacroiliacjoinl,asa joinl thaI can cause local and measure. This is what makes tC5ling indiscriminate, rcfer,,->dp\"in,h.ashadperiodsoffavourandperiodsof and thcdifferential diagnosis may then ll-ad to a wrong disfavour. There was a lime when all low back IX'in conclusion wa~oonsid ..1'ed to have its origin in the sacroiliac joint. Thc mood changro,and peoptc lhcn considered that Furtherrnore, the iNCCffiiibility of parts of the joints th...!'C was SO little movemcnl in thefoint that it could make manual evalualionofdinieal signs diffieull. 11lc hardly ix\" the sourct.\" of pain. In reality, the lrue;nd· insensitivity ofpassh\"e testing of thc sacroiliac joint, dcnce of $ilcroiliac pain and disorders is unknown. therefore, always leaves the manipulative physiother- apist woodering wl1ether, in factsl1e has located relevant Probably the main n'ason foroonfusion lies in lhe c1inicalsignsthatcorI\\.>spondtoasaeI(liliacdioorder. factthMmanyoflhcphysicaJexaminationtt'Stsused by those who favour the sacroiliac joint in fact move Thcmanipul\"ti~phys4otherapistsl>ouldscckto many otherjointsat lhesame time. cSlablishascricsof~lcv\"nlfindingsthatbuildintoa Cilscimplicatingthesacroiliacjoint

402 MAITlAND'S VERTEBRAL MANIPULATION However, by encountering subtle clinical clues, lhe A true sacroiliac joint strain or sprain is unlikely to pro-- manipulalive physiolrn,rapisl may build a case 10 duce~ymptomsthatcrossthemidline_lfthesacroiliac implicatelhe.>acroiliacjoinI.Mo~oftenthannot,rl'tro­ region is bilaterally painful in the abst.-nce 01 pre!,'IUlocy spectiveasscssmcnl will bc the final dNem,iMnl-and Or infl~mm~tory disease, the symptom~are more likely evenlherlshcisIlL\"'-'erentirdysu\"'lhalrn,rinlerven- to be rde.rt.>d from the spine, Schwart-.t.eretal. (l995) lion has influenced the sacroiliac joint alone. Thcrdor(', found that groin pain wascoosistenlly as.ociated with she should st.'('k to cstablish a seriL'S of relevanl findings sacroiliac disorders identified by anaesthetk block and that build into a casc fmplicating thejoinl- MRI techniques, Howe\\-e., the authors did not specify Although lhestatementthatfolJowsisonlya rela- whether the pain was below, above or in lhegroin live statement and ther('forc hard to evaluate, the Referred pain and as.ociated srmptomsrelated to author's\\'iewisthallhisjointisnollrn,mostcommon sacroiliac joint problems are not always consistent, mL\"Chanical50urceofpain,e\\'en when the pain is in There may be pain and IIchingdowntheinsideoflhe the sacroiliac are.., leg or under lhe teslides in men. The hip joint may 1\",,1 'out of place',and the whole 01 the leg may fl'el heavy_ Mostpaticntswithp<lininthcsac.oiliac3.cadonol Symptoms often overl.lp with those lrom neural havc sacroiliac di'iO.dcrs. Thcp3inis\"suaIlV~fCfrcd tissue, lhe spine and th..' hip fromth.lumbosacralspinc The symphysis pubis normally prcs.enIS with p.1in oracl1ing locallyO\\er the joint with relerral into the groin or down the inside 01 the legs_ Aswciated symp- Most patients with pain in theSolcmiHacjointarea who tomssUCha'iCfl'pitusora fl-elingofthejoinl 'shearing' are sclectiv\"lyreferfed for manipu].,tj,'\"physiother- with walking may be prescnt .. pydo not ha\\'esacroiliacjointdisorders. R.1Iher, their pain is usually ....ferred from the lumbosacral a....a BecauscofthiS,itisessentialtoexaminethisarcaand BEHAVIOUR OF SYMPTOMS bc able to dl\"Clarc it 'clear' before staling that thcpain Loc.,1 sacroiliac slrainsoflen rt.'Sult in difficulties with is probably coming from lhcSolcroiJiacjoint(assuming, wl~ghttransfcrenccinstandingandduringwalking, of course, that the sacroiliac joint t.:.'Sts a....• positive). In somccascs the symphysis pubis should also be exafIlinL'<l II isdiffkoJt to distinguish sacroiliac problems func. as part ofteshngof the pelvic region. The manipulati\\'e tionallyfromthoseofthespinc,hipandnemalstruc- physiollwrapistshouldalsobcawa....·oflherontribution tures, However, there may be consistent clues that that altelL'<I neurodynamics makes to di50rders of the make the manipulative physiotherapist suspect the pelvicn-gion sacroiliacjoinl.Local'jabs'ofpainfelt'inthesacroiliac joinl' with weight t.ansferenceto the offending side, as in walking or S!ll'ping off a kerb,is such adue. SUBJECTIVE EXAMINATION In theaclltesLlge,thepatient 'cannot get away from the pain', This can be very wearing and disabling Sacroiliac disorders presenl most tn-quently in the Night pain and prolongcd morningsliffness may bea st.\"Condand third decades. Pain in the sacroiliac rt'gion red flag sign lor inflammatorydiscasc, l'ati\"nlSwith in the elderly is morelikety 10 originale from a spinal sacroiliac pain on weight bearing will oft....n fle~ their source,orfromapathologicalproc~suchasPaget's hipsorflallentheirbackag.linstawallforrclid, disea:;eor metastases from a prostate cancer. Howevl-r,ifth\"patientromplainsofaverylocalil..ed SPECIAL QUESTIONS dL\"-l',often'sickly'acheinthesacro;liaca~aaccomp.1· oied by 'f.1bs' of pain with certain aeti\\'ities, th<! sacro- \\Vhere p\"lvic symptoms are concerned, it is relevant 10 iliac joint should be one of the structures considered ask about genito-urinary and bowel funclionas well 115 saddle anaesthesia, AREAS OF SYMPTOMS HISTORY Trucsac.oiliKjoint~train50r5prainsaleunlil:.elvto Sacmiliacpainiscommon:duringpregnancy;whenan produ~ symptoms tl\\at cross the midline. The hip may inflammatory disordl'T e~is\"'; as a result of rq>eatcl fccl 'out ofptacc',and thc wholc Icg may feci hcavv \\-igorous sporting activity (such as fast bowling al cricket);andasaresultofowrusestr.,in.Pel\"icpostunl

S;icroi1;acr'\"9ion:sacroil;acjoint.symph~ispubis 403 alignment faults Or disorders clS<'where, such as a stiff anterior superior iliac spines and the greater hip or lumbar spine, may contribute to strain of the trochanter. Any subtle changC5 in the gluteal and sacroiliac joint If the\", has been a history of pelvic abdominal musculatu~ should be noted. Any pelvic trauma, such asfracturl\"ora fallon the base of the spine, tilt or shift may also be contributing factors to a sacro- invoh'ement of the sacroiliac joint should be SU5poxted. iliac or pubic symphysis disorder (Tahir 13.1). PHYSICAL EXAMINATION MOVEMENTS OBSERVATION The sacroiliac joint should be examined functionally along with the lumbar spine and hip. The quality of 'Zoom lens' observation of thl:' pelvic region should pelvic movement compared with spinal or hip move- include oricnl.J.tion of the sacrum about the hori7.0ntal ment may be useful to note. Generally speaking.. there and sagiUal axes, and the sacrum's \",l\"tionship to the is little value in trying to differentiate the sacroiliac lumbar lordosis. Visual differenc,·s may be S('('fI in the joint in functionally demon<traled mowments. Any relative prominence and position of the posterior and attempt ill sacroiliac joint differentiation would be indiscriminatory and invalid Table 13.1 Sacroiliacjoint. Physical examinalion Symphy<is ~bis. l't1y<kal (umination Qbs(\",.tion Observation Gttlingoulofthf;chai•. wiliingnesslomO'o'e.g.it.~Me Gtll;09outofth(chai,.wiliingntsstomO'\\l<:.g.;t.~tu~ FUNCTIONAL DfMONSTRATION/TESTS I, 1hei. dtt'l'\\(mstrat,on of their Fu\"ctional rI'lOVtments FUNCTIONAL DEMONSTRAnON/TESTS .tfectedby th<-irdisordtr. k.~pplicable 2, Diffe,entiation of th<-ir demon,traled Functional I. Th~irdtmon'trationoflhe\" FUrlCtlonal rnov<:mtnts \"\"\"\",mentbl B.iefapp.aisal affttt~d by lheirdiso<!kr. 2. Dif~rl'nliationofthtirdtmon.traledfurICtional Active mOYtml:nts Routinely mo\"\"meM(,1 k. for lumbar spine Bridapp,.isal Asapplicabl. Rexingeachkn«ontoch<:st,nn~nd,\"gand\",ing Acti\"\" mo\"\"mtnls (roo\"\" 10 pain or move to limit) Routinely Isomel,ictests Astor lumba.spin~ Oth-l:rst,uC!ur<:s in 'plan' Pa,s1vemovcments As applicable Folding tach kn« ontoChtsl in ,tanding and lying Roullnely Supine, spr~;Hj .ndcomp,ess ilia. 1S(lml:l<ittests Passiytmovem(nlS rPrOr>e.tSlt05 ~SI-5andonadjacentilium Routinely _Iaterallyonllium Supine k. ~W;'c.bl~ Rot.tion i\" side lying I. Spread and compress i1i~, + angling the\"\" mo\"\"ments. Bilat~rali,,,mdricrontraC!ionofhipabduetorsand 2. <p ASIScaudad +(8) ASIS etph. and yi<:t \"\"rsa. adduetorsln90\"h,pF. 3. F ([l hip (OP) while E iB) hip(OPl.~nd.icc \"\"..... UtN! 4.2hipsabdueted Pal~t;on 5. With2hipsand~n«F'd90·do2hipsHE. k.applicable + ligamtntousthicktning Ch«k ca\"\".cro,ds etc. Lying ~It~rnate sidn. \"\"lYic rotation (top iliumlforward ~nd bac~ward. I\"struetionsto pati(nt. I':Ilp~tion Ch«kc.a\"\"R'CO.dsdc. HIGHLIGHT MAiN FINDINGS WITH ASTERISKS Instructions to pati(nt.

404 MAITLAND'S VERTEBRAL MANIPULATION WHEN APPLICABLE TESTS pl!lvis. Both of her forearms should now be touching each other and be /lat on his lower abdominal wall When pain is ~produced in the sacroiliac joint during To achieve the best mechanical advantage, her sternum vigorous sporting activity, it may be n<.'CeSs,1fY to p\"r- should be dose to her forearms form the movement at spo.'ed as in thro\"'ing a javelin Alternatively, it may be nL'<:essary to rl-1'l'at an aggra- Method vating activity such as ht'l.'1 strike during fast bowling at cricket, Or it may be nL'Cl'SSary to sustain a provok- To produce an opening stress on the anterior surfaceof ing position such as e~tension of the back as in a but- both sacroiliac joints, the physiothcrapi<t use!; her pec- wrflyswimmer. toral musek'S quite g.:.ntly at first but gradually builds up toa firm oscillatory action. which pushl'\"; her hands In such cas<-'S, the speed of the mOVemL\"Ilt, the num- from each other. This pushes the anteriorsu!\",rior iliac ber of repetitions or the sustained time can act as a spines away from each other, which thereby slresses measure of symptom \"-'Production and therefore as a the s,~croiliac joints anteriorly (and compresses them measure for reassessment. posteriorly). NeurodyMmic tL'Sts such as the slump, SLR and For the test to be considered positive. local saCIl)- prone knL'\" bend will also be useful in order to deter- iliac pain should be rl-'Produa-d in rhythm with the mine whether the neural structures arc contributing 10 oscillatory testing movement. !\",lvic symptoms, notably groin pain or buttock pain. Opening posterior surfaces Exclusion of the hip and spine also plays;m integral part of the examination of the pelvic region. Sturting position Of all the physical tests that can be used to implicate The patient lies supine and the physiotherapist stands the sacroiliac joint, only two, if performed properly. by his tight side, asdescr:ibed above. For this t''<:hniquc involve this joint without involving the lower spine she places the palmar surface of her right h.md against (Grieve, 1980). The fir.;1 k\"Jt involv\",\" moving th<' ilia th\"'patienrsleftiliaccrcstlateraJly;and leansacrosshis synchronously so as to produce an opening effect of lowl't abdominal area to enable her to dirL'<:t her right the anterior surface of the two sacroiliac joints and forearm comnally fmm his left towards his right. The then opening the posterior surfaces; the SC«lnd test palmar surface of her Il.'ft hand is placro on the lateral involves direct pressure over the sacrum and adjacent surface of his right iliac crest; this forearm also in the ilium in an endeavour to \"-'Produ'\" the pali.:.nt's coronal plane. Tl>e fingers of both hands should be symptoms pointing anteriorly around the anterior superior iliac spines, and to produce the best movement her sternum EXAMINATION AND TREATMENT _ must lie against his abdomen tomable her elbows to be TECHNIQUES dOM'r to the Iloor than her palms OPENING THE ANTERIOR ANO POSTERIOR Method SURfACES This again n<,,-'CIs strong !,,-'<:Ioral muscle work, but the ~~~:;:~;;~:r surfa~s 05Cillatory movement for stressing the joint po6teriorly (and compressing it anteriorly) isachie\"ed if the lineol The patient IiCll supine. A small pillow under his knees the forearms has an anterior indination will hdp to position th.:. low lumbar spin.:. for most people in a neUlr,,1 position, thus lessening any move- Direct pressure over the sacrum and the ilil/m ml'ntthereasthesacroiliacjointisstrl-'SSLod.11lephys- iotherapist. sl;lnding by the patient's right sideat thigh Storling position level and facing his head, places the palmar surface of her right Mnd against the medial surface of his right Thepati<'Illlies pront'and the physioth<.'tapist places h<'t anterior superior iliac spine. This necessitates her lean- handsCCfltrally at fir.;t owr the upper sacrum.11le hand ing across his pl!lvis SO that sh.:. e,m di,,-'<:t h.:.r right po6ition is the same as that described on page 368 forearm in the coronal plane from his left side to the iliac spine. She places the palmar surface of her left M~thod hand against his left anterior superior iliac spine, directing her l\"ft fOl\"€'arm from right to left across his At fir.;t the oscillatory pressure is applied to the S1 level (Figure 13.1a), but it should be applilod to all

Sacroiliac \",gion: sac,oiliacjoint.,ympllysis pulH. 40S l.e\\e1s unlll ~g the dtStal end of the wcrum spmaI6exionrdatedacb\\·11}·orexlen!iionoithehip.and (Figurrlllb) tilnns the upper penis forwards is commonly -.0- TlwpoontoloontaetlStheneiongated to the poster- iof!IUpl'rior ilIaC 5P'1Ir a\"\",. and the presu~ du-ected ated with sptnaI extensoon ilCh\"ueor Rexion of the hip postero-anteriorl~ (F~1I' l.He). With all of the aoo.~ techni<jues, >a'lUlI; an~ should be U5£'d tocompk-ti;- FURTHER TESTS Ihete'>t5;fOf~mr'eF;gu1l'J3.ldsho...slhepostero- Backward tiltoftht upptrptlvis anterior pri>SOoUIl' Mng dltl'Cled IateraUyonlhe left Stoning position posteriorsup..'Tiorili....,.pine. To leSt the left sacroiliac joint. thl.- fUhenl lies on his Tlw s.lCTOlhac: test sN:luld be performed as part of right Side with his hip!land krwescomfortably f1oro the e\\anuf\\lItion of e\"err patient with back p.:ail\\, less than 90\". The physiotn..rap;\"t stands in fronl of his hip!l,facing hisshould\"\"',and I..ansacross his hip!l to whetht-... then' is any likelihood of the symptoms aris- place the heel of her righl hand ovcr the posterior sur- ingfrom thcsc joints or not. as pain with this mov .... face of his Icft ischial tubt>rosity, with th.. fingers and m\\-ntcanbethefir,t,ignofankylosingspondylitis. fOl'('arm pointing over his hip towards her (ace. She plan~lheheelofherlefthandO\\'erhisan..trioriliac Two furthf,r to$ls th~t ex.lmine the rotary m\"\"\"m\\~1ts spine, with her fing<-'fl:I and fOl\\'arm pointing O\\'ef his ofthepeh'isabouttht·sacrumthroughatransv..r.seaxis peh-istowardsherothcrh.andShethenslrelcheso\\'er should be USl.od WhL~l the SiIoCroiliac joint is thought to be the source of pain. The first test tilts the uppt-\"T pelvis bilckwardsand thcscrond tills it torv.'ardll.1illinglhe uppt-\"T pelv,s bild:wards IS commonly usoci.ltro With

406 MAITlAND'S VERTEBRAL MANIPULATION ~A.. 'i~.~ Figu'etJ.J Sac'oili3Cjoinlm~menl in thedire<:lion of lumba,ulension :~ the patient's hip 10 be able to diK'C1 her forearms Forward tilt of the upper pelvis towards each olher (Figurt 13.1). Starting position Mrthod The patient adopts the same slarting posi!ion, but Ihis By squt'ezing boih anns lowards each other and simul- time the physiotherapist stands in front of the patient's tanoouslydisplacingherpel\\\"istOlhelcfl,thephr-;io- waisl facing towards his hips, and leans forwards therapisl exer15 a rotary strain on the sacroiliac joint by aCWSSlhepatienl 10 place the heel ofh\"r lcft hand pushing the anterior iliac ,pine upwards and back- against Iheposterolateral margin of the iliaccresl. Her wards and the ischialtubcrosity forwards_ Rotary fingers point upwards, continuing around theiliurn. movement in the opposill:! direction is similarly Shecupsthepalmofher right hand ol'er the lcft ischial cffected,Thistcst can be repeated with the Icft hip and tuberosity so that the heel of h\"r hand,pressed into the kneeretainroat9O\"buttherighthipandkrleo:! palient', upperlhigh,reachC5as deeply as possible. straightened out. This has the effect of putting the Her fingers point backwardso\\'er thepatient'sbutlock spine into relatil'ely moreexleosion and hence, as the (Fisure1J.3) upper pel\\'isis tilte<l backwards, there is reJatively les.> flexion strain on the lumbar spinc and themol'ement Mrthod is biast'd more to the rotary slrain on Ihe sacroiliac joint. Using the same altemating presliure method mentioned above, a rotary strain is placro on the sacroiliac joint.

Sacroiliac~gion:\",cro;liacjoint,svmphysispubis Similarly to Ihe backward lilt test, if Ihe lelt leg is CASE HISTORY allowed to straighll.'Tl and Ihe right leg is fully Oexed, this will have the effect of Oexing the lumbar spine and Subjmiw~amin.lion hence, as the upper pel\"is is tilted forwards, there will Two weeks~, 34-~ar-old Mrs P pidr.~d hcr be relatively less eXlension Sirain on the lumbar spine 3-month-oldbaby'iOOOIJtofhis<:Ql.sn~feltasharp, and the mo\"em~'flt is biased more to the rotary sirain de~p, $ickly pain immediat~ly, in th~ aru of h~r Irlt On thesa<:roiJiacjoint posteriorwpcrior iliacspimo, SII~ f~lt astllough 'wmething had slipped out of place: Th~ pain was PALPATION acrompanied bya 'grinding' f~~ling, Sh~ had previously f<:ltthisa~.to'xSO«',withocra$ionaljal>bingp.jns It isyital to palpatc for wft-tissuc changcs around whilst walking, Th~ had started .bout 8 months inlo h~r the5Olcrum.the5<lcroiliacsulcus.andother~levant p~gnancy. sit~aroundthepelyis Shc f<:ltthe sh.rpsickly pam (Figur~ lJ.4), which Sttmedto'xromingthroughjustaoo\"\"hcrgroin, When a sacroiliac joint disorder is suspected, p.1lpation ~yery tim~ sh~ put w~ight on her Idtleg, Sh~ could not around the sacrum and the sacroiliac sulcus, especially for sofHissue changes, is vital. However, because the st.ndwithhcrweightontheleftl~,Sherouldonly sacroiliac joint has effects on tissue around thepclvis 3li a whole, it is important to palpal<' oc·yond the S<lcrum gainrelidfromlhe$icklypambysitlingandpulling and sacroiliac sulcus, Rele\"ant sites for extended pal- her I~ft kn~~ to h~, chest. or by lying on her $ide and pation are: the ,'arious I..yen; of tissue in the bUllock, including the sciatic nerve; the sacrotuberous ligament curlingupinabalI.Whensheaggravat~dth.l\"';nit and the sacrospinousligaml.'Tlt regions; the symphysis pubis and the pubic rami; the anterior superior iliac <:Quid linger for a f~w hours, and her whole leg would spine; and the groin, induding palpation of the f~elhu\"Yandachy. femoral nen'e and lateral cutaneous n~7\\'e of the thigh In this way, tissue chang~~ associated with sacroiliac Apart from. bit of high blood pre$sur~, h~f gcncral joint strain or alignment faults of the p<:!lvis can be health WaS fine, Sh~ was ti~d 'xcausc th. b;li}y wasn't detected, sleeping, Her doctor gavc hcr wme 8rukn, but that only helpcd to usc her pain slightly. Palpation in this region may also have a valuable role to play in reaSS<.'SSm\"nt and retrospective ..ssess- Physicalcumination menl. For cx.1mple, the sacroiliac sulcus may be tend\"r ObseNingMrsPin standin9r....eal~d thatShchada to touch but the lumbar spine isalso stiff and painfuL If lordotic lumbarspincwithiii~ityoflhelower the tenderness in the sulcus is refern.'d from the spin(', \"bdominalsand a pel.is tilted antcnorly. Herhip treatment of the spine should pnxlucea marked reduc- was in slight flexion, and she was only partially weight tion of the t~.\"demess in the sulcus On re-palpation bearing through her Idt I~, A few centimetres of wcight transferenceontotheldtleginc~a,.dherldl_Slded TREATMENT TECHNIQUES pain d~ep to her l PSIS When the test movement gives a positive pain Forwardfluion responst' and adjacent joints are implicated, the tech- Mrs Pwas ablc to forward flex w Ihat her finge\"ips nique that reproduced the pain should be used first. At touchcd her ankles. Al this point.th~ paIn de~pto hcr l the outset it should be pcrform~>d at such a grade th.1l PSIS'xcame 'sore',The addition of hcad and neck flexion only minimal discomfort is produced, The J5S<'ssment 2~ hours later will indicate whether it can be ~r­ d;dnotchangethisso~ncs, formed mort' strongly Or whcth<!r it should be gentler. Extcnsion Wells (1986) also d~'SCrib.-,s a comprehen,ive series Almost imm~diately she was askcd to utend h.r spln~ 5·, of techniqu~'S that may be relevant 10 the treatment of sacroiliac joint and pelvis problems, thepaindccptoherPSISbecames~re, lateralfluion When ask~d to lat~rally f1e~ herspinc to the left, the pain deep to hcrLPSISwasonlyfeltasa discomfort at the cndofthcmov~m.nt.

408 MAITLAND'S VERTEBRAL MANIPULATION [On \"lI..-tting. ~ wa~ no oct\", pain. no c1lX01\"1fort, lMlrltWa-irqlrOdut'\\'durfy,ntlltlllOYl:mmt;tIIt no~...cIgooo:Iq..-lilYoflllOYl:\"'Cf\\LI ao:IcIitianofhipmo:'llia'ro(;1liond..:lnold\\;l~ lMpain. ShImp 'n t~f lJump posIt.OIl, tilt pain d«p to 11ft LPSlSamr Ilia(approxi~tionandSfp.'.tion OIlr\\'l()ffw\"fnllftlfftkn~~2O''Ihortoffun \"Imost ,mmfd,atfly, apprlWmal>on of the: ilia madf htr octfft\\.lOn.Kt~and~fItxionandfd~ p;lindcql to the: LP'SIS worst. d'dnOlthanCJfth's- Rotanonbadlwa,dsofthflfftsidfofthfptlvis st\" Wlltn ptrfo'mfcl. this m~mfnt gaVl: he' the fteling of relief from lhfdefppaon In the LPSIS area. At70'ofLSL.RYlffflthfrp,aindetptothfP'SIS, butlhi~d,d not thangt whtn the anklt waS Palpation dors,flexfdor plantarflufd. L3-5 Wert ~tiff and loxallytfrn.lf' pa,n wn.n poste'n- anterio,andunilalf,alposlf,o-antf,iorpff'SSu'CSWflf HlpF/ADD WhfnlffthipfluiOf1WaSPf'formfdpasslvely It Iocr of fl~l<.IOr1, tllf paIn dffP to IIfr PSIS on

....»croili~ ~gjon: wcroili~c joint, symptlysis pubos 409 ~ppl,~ TM sacroil~ sulcus ~ thirttrW:d ~nd tendoeo' to plITplItr. TM deep plIln ~ ~PrOdUttd by ~ uniL,lnal poslffil-3tltmot pRWl~ on 1M l PSIS. IndNnlmon'SOby~tra_prtSSUn'to ~khont~PSIS. T~\"ml:nt joint. ~ally when ~sht bNnngun one \\es.\"The TM fiBt thrtt t~~tmtnt ~ illYlll'ml mobiliuuon ~anl testing of the symphysas pubts should ind\"\"\" us,ngt~tedln,q~ofpostcnorrotfl,,)noftMu~ plIrtoft~~\"\"sonth(Irlt(p.40SI,iJSthisw~sth( • Spn-ading an apprOlUmal1Of'l of the ilia (p 4lM) m~,n d,=t,on tllit ~I~ 1M s<dcly, 6«p pa,n in th( l • fol'.....rd ..ndb:;ock....rd ro\\.iIti<ln of the upper PSIS Ifea, Ah(f tllft<: tf(alm(nts h(, w~lking w~s still ~s pcl\\~(pp.4OS-4lI7). b<ld,lllhough h(,I(g aching wils,(lju«dlnd wh(n • Suprnc lying on thc«igeof the plinth SO that liMo Igg'lvatcdh(fPilinSl'ttlo:dinminulesfiltneflhilnho)u~ nghtlcg is allowed 10 f..11 into full extension; the Her hip f1uion ~ddUC1ion w~s a li!tl( ~tter, but her left hip is lhen fully Oewd with the righl h,p held ~,nillutens<onwlsunchilnged. infulJexlension. On«lhere ..a<;nolTlOf~improvcmcntus,n!lth~ • Insupinelying,bolhthcpatil'Tlt'shipsand~ bildcOQ.d pdvic .ot~tion ttthnlCl~, ~ 1TIOf~ di=t areOexcd toWOand the hipS a\", aUowoo to fall ledlnlCl~~d\\o§<ontotryto,nfl~th(6«p,sickt'f intohorizontal~Il'1lSion.o..\"Cr~pressurec\"nbc plIin, This IIid bc'Cft 'qwodllttd USIng ~ tr;lOWl:BC ;opplied by pushing outwards on theinsidcsof both1<nt'e;slffiultanl'OUsly_ ptnsu~ontM:PSlS.Ag<adf:IIlWiJSc:lloKninordnto TREATMENT rtSIlttt ~ plI,n, Almost ,m~~ttly, M< U'tMSion .....~i1nd~~abktoputmon'wrightthrough ltftanteriorsuperioriljacspinecaud~. wM< kft q ..tIm walkll'!c._ On Me not VISIt saKI tNt rightantcriorsupcriOfiliacspirl(ttph.alad wllid~~k.. d<oysof~nglbltlOOQlknlolrr.thm Srorringposition M' plI'\" had ~tumnlto Its In·l~ltOll:nllrvd.. This hl~ntdonlfu<tMrthrttOttiJSOOM. Wilh tho> patienl in supine Iymg, the therap1Sl stands onthepatimt'sleft.sidco.fOfUilmpk-.tho>tlC'i.\"lofher Itl~l.edth.;Jt.llthoo.>gh~lief\"iJS~lI'ICJ right hand is placed ag,nllSl the left anb:!nor supcnor obll,ntd by 1~i1\\1ng 1M PSIS Iocll,;, tM<~ was WOII: iliac spUle (ASIS) from above, Her right elbow is ~Ison for h~r symptoms f~lufO,ng. As lh~ lumb<lt ~in( po,nted lowards the pattenl's left shoulder so that tm- was sl,ff, II Wili d(c,d(d 10 mobilizc l34S on th~ Idl direction of mO,'eml'flt of her r'sht hand is caudad on using iI unilat~rall\"\"t~fO-lnte,iof techniquc. Aftc, th,ee the ASIS Sl'ssionsusingthistcchniqu(nerb<lckfcltllotloo~' ~ndh(fspinalut~ns<on hild improvcd.but her The h<.od of her left hand is placoo aga,nst Ill\" p;llndt<:plOlh(PSISr(m~intdthesam(_Onn:tum,n9to underside of the right AS15. ller left elbow points Iocalplllp;ltion~roundlhcPSlS,tMu\"il~I(r;l1 along the femoral Ime so lhat the direction of mo\\c- posWO-lnt~rio<lc<:hniq~\"iJSno\"l\\'IOStp;l'nful menl of her left I1\"nd is cephalad on lhe ASIS. Aftn 11u« KWlIOS of llS<OlJ UIlS ledlrnq~ ~ ~ g\"l1l.hftOQlkJ\"!lilndpain~toIMPSIS tmpro¥ed by SO pnC'Cfl'_ She thm could llOIilltmd fill' 2wn:bd~ to pcrsonill <nsons.lnthatb\"\",Mepll,nllidiC'ltlftlloasloghtacM. atldlhcontv5lgnn:m:;\"n'\"!l~\"'lhh,pfluion add\\lCt1On.'wot~~tmftltsofmobilizingh;pfluion adduct>onsctt1o:dlhclastbotofxlllng. A fI!09r;1mm( of !r;l0WftSI: ~b6ominal ~nd prlvic s!ab,lizlttOOu..mses ..otSllso,m;I,g~lo:diJSp;lrtof~ hotll(progr;lmmc THE SYMPHYSIS PUBIS If the piltil'1l1'S symplOms suggest a symphysis pUbtsdlJiOrder, pain is likely 10 OlXur in thea\"'a of tho>

410 MAITLANO'S VERTEBRAL MANIPULATION Figu~ 13.6 Joint lin( symph\\'Sis pubis. This t<'<Chniqu. can ~ Figu,( 13.7 __ caud3d joint lin( symph\\'Sis pubis. Tni, l<'<Chniqut can ~ m<>difi~ '\" tnat pr(ssu~ is aPllIi~ 10 tnt Lmodifi..a '\" lnal p=sur. i, ap~i..a to tht pubic ramu, on pubi\"amu,ontn(@o,<Dorfromlhtlow.rbordtrOftht jointlintorpubic,amus\\_' .. phalad) tht@JOfonlh(<D Caud ( ....... ) (Figure 13.7) Method Ceph - joint line (_.• ) The movement of th~ symphysis pubis via the A51Ss is produ~ by the therapist using h~r pectoral muscle to simultaneously mo\"e theA51Ss in opposite caudad and cephalad directions (Figure J3.5) Other accessoty movemenrs More localized acCt-\"SSOry movements can be pe'- formed on the symphasis pubis using thumb pressure Joint line (1) Pubicrami(LJ)(Fig\"relJ.6l

Chapter 14 Sacrococcygeal and intercoccygeal regions CHAPTER CONTENTS Posttro-ilnt(riore:tntril~alprtlSUl'f: Tr;Ulsve~rocqogcalprtSsult: 412 • Introduction 411 Anttropostmort:0Cc:Y9talpr~rt • Examination 411 • Trtlltmtntl~hniqLles 412 Palpation 411 • Euminationandtrtatmtntttchniques 411 INTRODUCTION J\"'&<'i,e mc.r.\"etm'fll test invol'e5H central politero- anleriorpre6ure. Thi5alWl isquiwrommonlythesiteofpilll.aod it isnol al.. a)1>NSY todetemunl' whether the po1l11 isa wfenro EXAMINATION AND TREATMENT TECHNIQUES ~fromthelumbosacr.tl\"\"\",,orWhetherltis ill local pim from a joint drsorder. Palpabon In e.1her G1>e ... ilJbep;o.infu1.Ifp\"mi$Jm\"'<.'I'lon~I\\\"\"IIlO\\·e­ POSTERO-ANTER10R CENTRAL COCCYGEAL \"\"'-Y1tmthesittmgJlOSltion.adllfeTenl~honlt\"itisw;ed PRESSURE 10 de«,orminei!S:;QUI«!.'The pain...-sponst'whllelllO\\- Starting position tncing pelvis in siltmg in a firm chair is oompaf('d with thcp.1in response with IhCS<lmepeh'icmovcmcntsand in the same chair but with IWO paddt'd blocks. one 1llc pahenl lies prone and the phy~iolher\"pist places undereachi5Chialtubel'05,tylnthi5pa;itionthcrcis\"\" as moch of thc pad of the lip of her lhumb as is pos- Pn'!S5u\".onthecocryx.ln~ofchronKcoccydyn;a, siblco...:r the mid-<OCC}''' (Figwlr U/). where mobilization \"- had bttle eff«t. il is important tof\"lUlmme the!Jump testorSLRas reslricbons in nalr- Mrthod ..I mobihl)\" mltw. OIlWare I'Ndllytm1t3b\"'l.I§ing neural TI.erochruqucistt...SM!W'asNtdcscribc'dw,!h5lmw.r mobi..hubOrl wduuq\"\"\" (BuUer. 1991). tl.'dvuques. but 'I is unportant hI= th.l pain produced by~bone-to-boneconliraisa\\vOded (Figurr /4.1). EXAMINATION Gentle mm-ements shouJd beUSol'd at first.ancI the dt.'VIhofthegradeshooJd beincn.'ascd only if the pain PALPATION ~po-rmilSil Thcimportantpartaboutlhe tech- niquc is that thcgrealcsl usepossibleshould bemadeof: ['alpation is lhe most imporlant parl of 11,., e~amin­ 1. V,'ryingthepoinlofconlacl,e\\'cntotheextentof alion, Alignment of the Sl.ogmen15 i~ the firstl'Sl>t-'fltial. changingbylmmalatime and p.a.... response on palpalory mO\\'ement is lhe5a:· and mnd most import.lnt essential. n,., first palpatory 2. Varying lhe angle 01 lhepres.sure-cephalad. caudad. left. right and romblfldtionsofthcs<-

412 MAITLANO'SVERTEBRALMANIPULATION Figu,e14.1 P!>,te,o••nwiO,c.nlf.lro«:ygnlp,,,,,,,\" Figu.. 14.3 Ant<ropo'it.,ior<-'occvgn1prmu,\" above. II i. \"\"Cl\"\"\",ry with this techn'que to ma\"'lain a \"eryd<'Cp position ofille thumbs if the wholc lateral border of thecoccy~ is to be \"'achl>d. ANTEROPOSTERIOR COCCYGEAL PRESSURE Starting position Again.lh('only change is Ihat of the manipulativ. physiolherapisfs thumbs. n'is time she musl sink her thumbs deeply alongside the coccy~ to reach the anterolateralrrn'rginofthecoccp(figllrr/4.3). Diffen'nliation bel .....\"\"n Ihe manipuLaliq~ physiothcr~ Method apist'slechniquesorenl\"S$andthedisorder'ssorencss should be attempt....:!, Ix\"'au\",-' the pati\"\"! can fre· The tl.'Chniquecan bept'rforrned unilat\"rally, as in qu\"\"'tlypkklhediffen'I'\\Ce.lf!hepatienlbehe\\\"l'silis Figllrr 14.3. which givcslhe di....\"'tionof mm'ement an Ihe thcrapisl\"s thumbs and nOlthedisordcrcausing angled inclin~lion. However, it can also be pt'rformed Ihe soreness, the therapist must change (and keep with each thumb in the same anterolateral point 01 changing) her thumbcontaci until all of Ihe bruising contact. on\" on each side. The Ihumbs then lran.mit feeling has been eradicall>d synchronous pressu....- to the co<:cy~. and a straigh1 anteroposterior movement is achie,·ed. Then' is no TRANSVERSE COCCYGEAL PRESSURE nccd lor lhe anal approach to produce an anteroposter. iormovemenl Starting position TREATMENT TECHNIQUES The only change from the above lechnique is thai Ihe Those e~aminalion tl.'Chniqu~'S that produce lhe P\"-k therapisldi\"\",IS the pad ofm,r thumbs to thepalienfs dictedpaiI\"lro;ponseareuSl.>dast!lclI\\!atmentt<rll- IcltsideaP.d places them on the right-hand side of the niqucs. However, it i~ wise to u'\" the t,odmi'lul'S as coccy~ (F;gllrl' 14.2) grade II or III lechniquesuntil il is known that tl'l'rewill not be any unfavourablereaclton 10 firmerll'Chruques. Mtthod The same silu~lion regard\"'g ront~CI SOrenl\"S$ ~nd v~rying the inclinations applies as in Ihe technique

Chapter 15 Examples of treatment CHAPTER CONTENTS C~rvical joint locking 428 Shootingocdpitalpain 429 • Examination 413 • Lumbar 430 • Treatment 414 • Case histories 414 Low back pain 430 • N~rvt root 414 Acuteback~in 431 L1buttockpain 432 Scverecervicalnervt-rootpain 414 Spondylitic ~pin~ with su~rimpoclStd localiz~d $t'vert>lumbarnerve-rootpain 416 lesion 433 Residual intermittent nerv~-root pain 417 Coccygodynia 434 Chronic lumbar nerve-foot acht> 418 Juv~nil~ disc I~sion 436 Insidious onset of I~g pain 419 eilat~rall~g pain 437 Poorlydefinedlegsymploms 420 • Thoracic 438 • Ccorvical 421 'Glov~'distributionofsymptoms 438 Painsimulatingcafdiacdisease 421 Thoracicbachch~ 440 Painsimulatingsupraspinatustendinitis 422 Traumalicgirdlt>pain 441 Painsimulatingmigrainco 424 Abdominal pain~ and vaguc ~igns 443 Scapularpain 426 Acutetorticollis 427 Th~ approprial~ case h~lo,ies arf: also ref~rrf:d to itcanbeassullledlhatallrcJevantabnormaliliesknown at th~ ~nd of ~adl individually d=ri~d trf:atmcnl a'lhetimeoftrc.. unl'Othavebeenincluded.11>ecase hisloriesha.'ebl'en,;et oul so Ihat lhey can be,....dily l~chn;qu~ usedforquickrefere~.W1'heachhistorylhe,..i.sa The foregoing p;lrt of lhis book has been concerned wilhdcscribing tcchniquesand the prindples of lheir quick !\"C'ference diagum showing the area of pain of application. Now this knowlt'dge must be pul into which the pali\"\"t complained, and a title showing ,he practice. Supervised treatrnl'Tlt of patients is. of coursc, lhelx'Stwa)'lodolh,s,bulselcctedcaschistorieshave particularreaSQnforitsincl~ion. baon givlon in sollle detail as a guide. Th~ will indi- cate the reasons for each slep laken, and lhe resulls EXAMINATION thalfollowt'd The examination deals with lheappropri.:l'easpcctsof In lhecasehislorieslhal follow lherewill beasp<)Cts lhe patient's history and lhe associated signs. and is dividl>dinlothefollowing: oflhce~aminati(n·\"thatha'·e\"otlx\"l'nlllcniioned,bul 1. Brief5tatemL'IltsS<'ttingoutthehistoryoflhe condition as il stood at the time of treatment.

......414 MAITLAND'S VERTEBRAL MANIPULATION 2. The relali.e physical fmdings on eJ(.ilmining the the type of treatment ~rJ' This is 50 becaust' pat.enlatlhefirsl\\,rsil. under one diagl'lll!l'hc iiiif' the patient may ha,-e An)' one of a number of ..-.lated symploms and signs, NdI. TREATMENT of which may indka~ a dlffl'rent approach to IfNt- Nthoughclifgnosisisi\",portant,aoorapprttoatoon mml. Henct.', although diagnos.s i5 important.- II CN of~5Y\"'flt_.nclsOgns~tonVQminatoonis apprecUUon ol the symptoms and signs pre;ent on exammallon is the vital iss...., Thi5 al50 e1iminMLos ~V1tal~ boundaries in our thinking. Stodd.Jrd's Mlrnlilllt!o.tat- Treatment is d\"'ided into the following: \".,thicPtrtcti«(~odda.rd,I969)c\"'arly\"\"\"t05_t­ 1. Ahstolthe~lprinciple!iin\\'oln-dinthe menl..,thedill~, but t~di\\iskJmcanbecan'led manipuLaIi.eln!almfonl e'oeflfurther_ 2. A record of the treatment gin'\" and ib rift-oct, and A5an~ple,lJ1thefirstfo:ou.rCil5ehi:storio!stht the faetOl'SinHlIved inany.lteration, piltientsallhadadiagnoslSol'di!iClesionwithneJ\\~ [t is hoped that the following section \"'ill guide the student through the~arlystagesofmakingdecisions root compression'. Ho\"·l\"\\t\"f, on eL1J1UI'IiIDon thnr on t..... tmenl, and also guide the medic..1 pr..clition...r ~gm; were marWly different, lind eilCh was treated .. m assessing thc treatment results the physiotherapist a different m.. nner,ltl forthe;e A'asonslhatsymp- shouldbolgeltingwhl'npatientsarereferl't.'dfors\\ll'h trealml'\"t, Th<'Sl' cases are ;ntl'rldl'd not as reading toms and ~gm play uo.:h.In Important pdrt, and thrf matcri..Lbutasrdl'n'ncesilndguidesforlh~st\\ldl'l'lt. mustbegi.-enmuchcortldCTillIon. The basis for this book has been to relilte treatm...\"t totheSymptOr1\\$ilnd signs found one\"amination. Thi.' CASE HISTO:;;'::,:\".;:,S _ oonccptlSunK'CeJ'tabletomanymedicalpraclilioners. and it is ft'asonable to consider that manipulatIon I Th~ C3~ histori~s which will tie d~alt will! ar~ list~ In Tabl~ 15.1. shouldnotbeundertaken~.diagnc><;islSpos­ NERVE ROOT sible !iO\\Ol'e'oer, t\"'o 5I\"ls0fOn::umstann\"SlIpph. SoIl'K.'- tl/Tles II is not possible to rnalol a diaK\"OSis, lind SEVERE CERVICAL NERVE-ROOT PAIN rnobthullon CAnnOt be ~mi\"istewd diagno5llCil-lI)'. 5e«Jndly, ..lthoughadia~maybrpossible,th.is bilminiltion dot'S not necessarily gi\\'I'er>(>Ugh indication toguKle History A man aged 41 )·earsde-.eloped aching lJ1 hi!; nsht !iCapuLa in l\\O\\'ember, for no apparent reason. (h'e!\" Tilblc 15.1 c..schisloncsdcilltwith ... Pa,nsNn\"latingcardiKcltwaK .... \"\"~, ~ctMCIi~rootpain .\" Palnw..lilatingloUprllSpniIMt~llJS ~ ,..\" J I p r _ r o o t p a i n Pa,nloU\"\\Ilatjngrn~ ~, ~lntr..... 'II~t~-rootpa.n Chto.\"~lufl'lblf~-root~ '\" Sapuwpain Ifl$ldious onlof:t of kg paIn ..\"\" Acul~ torlleolhs PoortycldiMdtegS'fII'IPtorns .\"'\"\" ~it:aljointlocting lDwbldpa,n Acut~ bKIo: paon ShootinglXClpllalpa,n L1lJ.uttodpain 'G!cN't'distribuhOnofsymptoms SopondyIllIe~'''tw,thloC3hl~k_sion '''\"\"\" Thoraciewekach~ '\" TraurnatlcgmHCpil,n Coccv9OOvnla \"'\". Abdominal pilln andvagu~slgns J~nlleclISC,\",Qn Bil,,~,.II~ pain

E~.mpI6 of lIutment 415 pt'riod of2 weeks, these symptoms subsid<.'d but did l'xamination of the palicnt's\"\"rvical movements there not completely go ~w~y. In J~nu~ry the symptoms waS a m~rk<.'d exacerbation of hi>; symptoms, which ....\"Cum.od. buttht')' scttllod uwr a period uf3 wl\"\"ks. Th~ took 5 minut\", to subside. Moderate weilkn~ of the symptomsrl'Cum-d again in ApriJ and gradually,o\\'er righttricl'J'$wastheonJyddiniteneurologicalchange apt..,.iodoJ4days.sprcadintohisright~rmT.l'l'atment began 3 weeks after the April onsel. When fil\"$tseen, Treatment hewasob\\'iously in distrcss bccausc of pain. The two main areas of pain w.\"\"the right Kapula and right Guiding factors lorearm. Heal'iOcomplained ofa generaJ puffy, numb Il'elingthrough his whole hand (Figu,,\", 15.1) 1. With lheexampleolseverecervical ncn:e-root pain.traet;ollistheolllyformofwnser\\,ati\\,e Physico/findings treatment that should be considered from the physiother,lpisrspoint of view. All cervical and arm mo,'emcnts \"\"ere full range, while ce\".. ieal ,·~tl\",sion.lat\"ral ne~ion to the right and rota· 2. With an Hacernalion so easy to produce,initiat tio\" to thl' right all produaod right Kapular pain. If lrcatmentmustbe\"eryg\"ntl\". thl'Sethrrt·moveml'J1tsw....\"susta;n,odatth\"limitof the range. right fo\",arm symptoms de\\'doped and a 3. Mobiliz.ationofanyformisnotcon~idered !le\".:ral tinglingappcarro in the right hand. Following appropriat\" at this stag\" 4. Thc patielll should be ad\\ i:,cd that h\" may not notice much impro\\'emt'nt in his symptoms for the fil\"$t 7 days. JJcospite this, \"\"t' should be abll' to asst'ssthatpn.:ogressi~forthcoming by the signs 5. Thepatientshouldalsobo.-waml-dofthe possibility of <orne exacerbation following the firsttrcatment. == Firstdoy Very gentle cery;caltr,lCtion in nexion in lying was administeJ'{'d for 15 minut<'S. This treatment was con- tinuL-d daily for 5 days, and o\\'er the last 2 days the durationofeachst\"'tch ....asi\"'reased.Bythelifthda} the patient was having 25 minut<'S' traction. At this stage he was unawarcofany impro\\'ement. although onexarnmation tus extension waS slightly lcss painful in the scapula area and the position required sustain· inglonscrbeforcarm symptoms d\",·doped Sjxfhday By the sixth dayth\"patient was able to say h\" ....as feeling be!ter, and traction \"as then increased to JOminutcs Fig~f~ 15. 1 ~e.. \",,,,kal ne\",e-root pain EI~v~nth day By th.. ele\\'et1th day tht'patient WaS (eeling 70 pcr Cl'J1t bctter, and at this stagl·sustain<.'d extension did not produce any symptoms. On the fiftecnlh day th\" patient was able to say th\" arm was the best it had been, and his rnm'ements were then ,1Jmo;;t symptom f..,... Treatment was dis- continuLod, and he was re'·ie....ed 2 weeks later. His symplorns were then 90 per cent better and we.... not worrying him. Movements we\", painless and thetri- ceps mUKJe power was unchanged

416 MAITlAND'S VERTEBRAL MANIPULATION SEVERE LUMBAR NERVE-ROOT PAIN relievoo of hIs symptoms, the last ,mp1\"O\"emmt in Ius m<nements may ronw.- more rapidly with _~:l:~tion. mobilization. grollu:. rlWl .. 45 )\"Gll\"5 h.:od h.:od .. sudden ~ of 2. If mobllizaOOn ~ 10 be .-d, general rutiltl(lrI would be the treatment of choice because S~\"tllp­ b.Kk polin 6 ..·eeks p\"...,\"iousIy whIle hfbng. o.'ET a toms an> umlateraland theCiilUM' of the}Win 8 J..wl.'Cl period he de\"-eIoped lower leg and foot s)\"lnp- Iiklytobethedisc tOQ\\!i ;md muscle ,,·e.aknes&. He w;as idm,\"ed to hor pltal and p\\\"t'n C<Jn§lMll traction for 12 diI~ He WIIS J. In the presenre of marked neul'lMogK3ldI.Inge thom ~ for roobnumgph)\"siothenopy(ftglll'f' 15.2). treatment must be gentle and caubouS,;md_ ment of the neurok.lg>cal ch.an~ made wily Physico/findmgs Firs/day In forward f\\.exion the p.atient was only able 10 I't'aCh his k.nce>, and al ttus posillon he had polIO only in tllS lumbar 1\"Otill1on. P'l'hl5 rotaa,.,J to right. w;as pn-- b.Kk. Exlcrt§1()I\\ Wd5 full rang.. and p;tmlC58. Lateral forme<I\\'l\"r)'gt'nll)asagrado.-IVFoIlowinglWo~ flCl(1OO lothelclt waslimlled and caused pain in his of this t.,.,hniq....'. the\"--\"\"6ITlen1 wd5 lIS follows. b.KkaI4O\",andaI4S·lhepa;nlOCl'1!..~inhlsback Symptomatically h~~ Iowl'r leg felt better. and his left and ..ppe.. n.odal>lOinhisfoot. His tibialis anterior waS laleral flexion _nwd a little impro\\·oo. Left slratghl l,eXlerl'j()rhallucislongus2,andtoecxtcnsion2+. leg raising wilS un.1I\"'red. Treatment Srcondday GlJidingfactors On a~sm('nl lhe patk'llt's movements were unchanged, bUI he lhou,.;hl his !log might h3,'e been I. Trac1ionwouldprobablybt'lheflrsltrcatm('ntlhat hetll'r al limes. The same l~ochn;que was rcpeak'd, this stlould beconsid..red. HOVl·....·cr, as the patlcnt has lim.. for thR-e tilTl{$. The h.ochniqu('improvoo hisfleJ· had lritClian In hospil..l and been consid('l\"ably ion and 5tr~ighl leg r~iSlng by Scm (2 in), bul his symploms Wl're unchanged.

wmpltsof IrutfMllt 417 rt'llrddoy thai sht' still had intermittent symp_ in her !eft ..Ibow l'h)'SI<IChPrapy was tned again,. but this 1Ul1e It Thf'p;otll'f\\l\" symplom!landS&gJ\\5wCl'euncl\\anged,SO did not help hers~oms. SMcompLuned ol mtl'f\"- ,Iw\",\"deridaltomakeachangcin\\n'.ltment. Traction mltt.-nt symptoms in the IefI dbow many bmei a d ..y WiI5cho5ft>.and it Wa3idetided to.-intenrullo>l \"ThPydidnotla:sllong ..nd ..erenot ......~,but .. ..,... uoablelracbonmsteadof~tlrioctiQn~~ unplNsanl (FrS\"\" 153) ~ oscillatory m<)\\\"efI>C.'f\"It of the- lumbar rolitli<lni!i did 5ft'mklproduce§Oml'm..ng<;'.Awrightoll2kgw;Qi 19\\enforIOmmu!es,w,tha5-s«ondhoklandnoresl PtI)'5irolfifldings p<riod All c....'.. ial movt'll1t.\"ts.nd ,nrn mo'·emeots Wt're full Follrthdov rangeandpamlt'Ss.E\\'enasust.:\"nedquadrantmon\" ment was pam 1Tt.\"t'. There was marked .. cakn<-'S5 of n ..... pati...nt n.'ported feeling definitely a littlebellcr. SO th... pat;,.\"t'sldtlJiceps,bult\"\"rene~aeti\\llyappean.od thctn.'almentwdS\"-'P\"at~>df() .. \"durah\",,()fI2minutes. normal. On e~amination by \"alpalion, it w~s ca.>ily dcterminl'd that thcrcwasa l0S6ofal least 50 pcrcent mo\\·ernentatthcleftC6/7inlcrv..rtdlraljoinl. Fifrhdoy n...patoentsldlfdta~ttleimproved.andbothne>Oon Trtatmtnt and st..-..,ghtleg ralSUlg had \"\"\"mtamed the- S<m /2·in) GuH1mgfoctors tm~emenl in rang... It was then decided ttYt per- .... Pl'rotabOnrouldbe~IO~IrioctionIO~1i I. As~symptoms..~urn\"'tl'f\"al,the...lectionol krluuqueswouklbebetw·('It'npasten>-antenor 'on>.ttusw'ouIdgainasLightlyqWd.er,mp\"\"\"ftnI'J1I.Thrn-- foIlow'ing a pm.od 01 15mlllutt'S on H-kg tnIoC'- uniLoIfta1~preMUn'androt.otion. bOn. IWoprriodsofrolittion w'ftI'giH·ngently. 2. TradionwouldnotbPlWjulf'l\"d,.noton1y~use Sixlhdoy II hM ........ allnn~ beforr ..·ithout SUCtt5l§ but al\"\" ~USI' tI'It' symptoms are not ...... erI' Thcpaltt'fllrepor1cdfct:hngwc>rSt.'agalll,andhisfle>,- ioIII\\adIOl>tsomeo'whalhad~gained.Jtwasthl'n decided togi .... thetraetion and lea\\'.. outanyotht.... treatment. The traction w ..s gr..dually lncl'l.'ased daily in wt'il;htuntil 25kgwas bt.·,n/:g\"'cnInr15 minutcs Follrtrrnthdoy By thl5sbgethepahent'5symptornsw..reminln\",1, hl5forward fle<ion was 70 pcr cent rerovered and he was able kl reach two-lturds of the way down his5hln. Stra,ghlll'graisingontht,,!eftwa3ikl7r1',andpamles5 On~hi:>mU!<lepower,the\"\"Ift>sor\"\"llocis longus a.nd toI' .....1!enwr.; w~ nomul, and the tibi.Jlis ant.erior\" . . . airno>tfullyn.'CO\\oerrd. RESIOUAllNTERMlTTENT NERVE· ROOT PAIN Figu,. '~l R\"'dual ;\"t.\"MI.nt ........-rool paIn Exllmination History four moolhs previouslr, this woman aged 35y\"a\", hadwhalshesaidhadbccndiagnoso-odasadiscle'lioo wilh \" ...rv{'-rootcompl\"C5l>iOll. She had IrilCtion. which reli<!v~-dhcrsymptOlru5consi.d..rablyi\"thefirstmonlh following this she did not hau~ treatment, but found

3 Mobilizationwouldbo\"quiekerinitsdfeclthan and over the nexl 3 daysincrea,;ed toa oonstanl ache traetio.1, ..ndthe....foreshouldbeallemph.>dfirsl This made sitting difficull and inl\"rfer<-od with his work as a clerk. His osh:opalh had not oc't-'Tl able 10 4 Astht'jointsignswerefoundonlywithp<!lpation, relieve the paio.w he went to his doclor and was it would bcwisctuuscthissignaslhefirsl lreM· referrc-dforphysiotherap)'(Figl\"r15.4) mentmovement Firstdoy Physico/findings Postcro-antenor unilateral vertebral pressu .... on the Flexion was 10 within 23em (9in) of 11-... floor, and leftsideofC6/7wasgiveninthIL't?periodsoflminul\". ,traight l<'gr,lising was Iimiled to ffl'. Other th.ln these TIw only a55<.'Ssment that could be made was thai this two signs, the p.llient's mo\"\"menb were p.linless. He muvement appeaIL'<l lu impmv\" slighlly as t~atm('J11 had slight weaknessofhiscalfand therc was some lin continued. The pMient was warned of possible exacer· ghng in the lateraiborderofthesul\"ofhisfoot,bul no baliunasaIL'Sulloflhefirsllrealmcnt,butwasaskcd sensorychange_Hisreflexeswerenormal 10 note any change in thepauem ofsymptums Treatment Srrondday Guidingfoctors Thep..tie\"t reported that there had been a reductiunof at l\"ast so per c\"nt in the number of times she had had 1. As Ihis is probably a discogenic nef\\e-root symploms_ On ex\"minalion by palpaliun, the move- problem,thechokeoftechniquelicsbctwe<.'n menls seemed to tu.\"e .....Iained Ihe i\"'pro\"ement Ihat rolation and traction. had oc,\",n gained the previous day. The treatme\"t w..s repealed 2. Asthepaticnt'ssymptoms<\\f('notscvcrcand mobilization i5 quicker in its effecl, il would be Thi,ddoy wiSl'rtotryrotationfirsl The p.llienl reporh.'<l having had alm...,,1 nO S)-mptom\" 3 Asthenerverootisinvulved,ilmaybt!necessary but whetl they had COme they Wel\\'as unCl,mfortable at a t<llerstage to make use of straighl leg rai5ing as previously. The treatment was repeated, and the asatechnique. movement was felt to be almOSI nurmal by Ihe end of Ihethird period. It was decidcd tolea\\'e treatment for a week to scc whether furthertreatmcnl was neces- sary.The p<!tient waS advised 10 come for Ircatment if Ihe symploms showed signs of returning On~ w~~k lot!:, As symptoms had gone, the patienl was pleaM.'<l and trcalmenlwa;;disconlUlued CHRONIC LUMBAR NERVE-ROOT ACHE figun. 15.4 Chronic lumba' n~\"'~-'OOI pain Examination History This man aged 35 years had h\"d rccurrentb.1Cksymp- lomsu\\'era perioo of Syears. In lhelasl IS months he had had Wme symploms in hi,lefl l<'g. Previou, bouts had been successfully reliev<-'<I by an osleopath. Two and .. half months ago, while wee<ling in thegard ..n, hcnoticcd minorsymplomsin his buttock and through- out his l<'g_ These de,'e1op<.'<l as Ihe day pmgK\"'<;(.'<!,

Eumples of t~i1trMnt 4::.. Firstdoy inlt>mU!tftl1 at first, but bocameronslanl o\\t''!\" a period of I \"'ccl<. A tingling ~hng. which 1100 ooelopt-d On dek'nmmng lNtW paliml'l symptoms ..·eft no!: in ~lIIler.ol.aspedofthe Io¥.·er leg and foot.l.ilter irritlb~, II \"'as decided to U5of' rotalion quite strongly de\\eloped toanllCheand lIfee1\",&ofnumbneseon~ 'lind lTl .. sust.unedm.annc.'l\",~rotalionwitScklne, dorsum of the foot (Frgllrt 15.5). These sympl~ rotallng the pehis to the nght.llnd Ihi5 WitS susbined ,je,..rioped m'.\". .. penod of 3 \"'eeks. Her doctor pul stl\"OOlgly II WitS repellted four hlTl('S. AI the end ollhe lreal~llhepatienlsaidhiss)·mptomsfell.. lillle her into .. plaster ~ket for 6 ....\"t'ds, but the symptom. easu,''!\", .md strlllghileg rlll~lng hIId impro\"ed by 5nn did not imp\"\"'~ Three ....'Wk:!; lifter ~ plaster\" \"';0; (2inl, ....Iex,on had 1100 impro\\'oo rerTlO\\ed, she waS SoeIlt for a 'Inal of marupullltlon and Ir;>elion'. S«onddoy Physical findings The patienl reponed fl....ling much the Solme, though With forw~rd n\"xion the palient was abk' to rt'ach to his mo'cm~.,,'\" had maintained their 5lightly inc\",\"sed 'Oem (16'n) from the noor With this movement the rang;:,. It Was decided to rcpeattl\\!' rotation. bultoadd leg pain increased, al>d a kiati( \"<:olios;\", which caUS('(! p<)St~n)-anlcr;orcentral \"t'11ebral pressU!\"C. This was a till of the lrunk to the lefl, l:>A;ame e\\ident. The seal- done, and mo' cments ,mP\"\"'ed by a further 5nn. i06'S dISappeared on n.~uming the upright position. Lalffill fIo!xion to the right performed in tnat range Thirddo'l of forwolrd flexion th.JtcauS('d the.coliosis ...as,tr)' 1l'In'rwasll!iJ.ightlessenmgofpatn.llnd therMogeof w.,..limited...nd aUSl'd ~lighl bllek pairL All other spi.....l mo\\t'men15 stili, bul they were 001 OOIKeolbly Il1O\\ erncnts had been mamtlllned. Thr In'II!mnIt ..- pamful FlmI pres5lJ.... O\\er W \"ertriJral roIumnilid not ~led,lIfterwlUd>thepalll'f\\lrt'p(Jrtedthathisalf ca..-;my pUPor mUKle 5pIISlTI. bul then- Wils\" general fell much moft'romfortable f~mg of intervertebral tlghlnes5 III the lumNr \"f',ne Rid-I straight leg raisulg iacUd 20\" of mmemml and Fifthdoy wlllpainfulatthebac.. oflhe..-hoJeJeg.Rcl1excs,s......- .... lion and mus<:1e 1'0..-...... ere.all norm.al. By the fiflh day II ..·as decid~'<l1O add t.;oction. folio...• ing ... hich the parimt fell much betler.1 lis mo'ement.~ Trutm~nt WI'Il' impro\"ing. bUI moll' slowI)'. and it was lhought Guiding foctof5 that th~'S(' should be prog\"-'$SillK marc quickly, ~vtnrhdoy I. Sluw unscts of this typt'are more likely to respond 10 Iro><liOf\\ than to manipulation. B)' Ih,s sl~ge it WilS decided to 19\"1' traction, followed by posli\"l'O'anterior C\\'Tltr~1 '·crt.-br~1 pressu.... lind rotation To ttus wils addro str.lIghtleg rais....g al one ~trong stretdt. Twoda,... Lal...., lhe patient said he con- SIdered ~ WIIS ..1rn<Jei1 ~\"mptom free. His mo\"emcnl$ <eettWd IIlmo&i r>ornW for hIm. lind trealmenl WitS d'!i- conllnued INSIDIOUS ONSET OF LEG PAIN uamin:o\",,;o\"-\" _ History I'or 10 ye~rs a woman ag~'<l 35 years h~d had many Figu\", 15.5 IM;d\"\"'sons.etofl~~ln bolUS ofb~ck p~tn, c\"ch necessitating rest in bL'<l, Th~'Y had all begun suddenly from minor lifting incidents Three months ago she nolic~'<l an ache superficially in t~ lateral aspect of the right thigh. Achin!) wa~

420 MAITLANO'S VERTEBRAL MANIPULATION 2. Agent'Tal limitation of intervertebral moveml.'T1t, Fifth da~ ifiti5oontributingtothc~ymptoms,willbe Forward flexion lacked 2Scm (lOin), ~traighl 1\"lI. raising was full and there was further symptomatic improved by mobilization rathl.'r than by traction improvement 3. ThisJXltientprobablywillbehdpt\"libya As it was felt thai prog...'.SS should have het-'1l oombination of traction and mobilization. 'luicker. mobilizalion was commenced. Rolation with 4. If mobilizatinn wcrcattcmptt\"li,mtation should be lhepatient lying on her ldtside waS given fourtimcs. Following each movement there was an impnwement the first choice. in forward flexion consisting ofa 5-cm (2-in)improv,,\" 5. Astherearenonl.'Urologicalchilngesand~traight ment \"ftl.'r the first \"nd second tim(\"i, 2crn (O.8in) after lhe third and only Icm(O.-lin)afle.thefourth.Slrong lcgraisingisnotmarkedlylimitt\"li,thepos'ibility lraction followed the mobilization of completely relieving symptoms is good Sixthdoy Fif5tdoy The pati,'n! felt much beth.\". H\"r back feU f,..,..r and the It was decid..\".li to institute traction first to as>C5l; its leg ache was almost gone. Forward flexion had main- value before including mobiliLation. Very gentll.' trac- tained its increased range, \"nd the fingertips WI.'Il' tioninsupinewasappliedforlOminutcsWhilethc now 11 cm (3in) from the floor, Straightlcg raising was tractionwasontherewasalCSSl.'ningofpaininthl.'lcg, nonnal and on releasing the traction the symptoms remain..\". li eased. After a 5-minutc rest the patient's straight leg A n:'petition of the rotation increased forwMdflex· raising hadimpro\\'ed by 10\". The patient went home ion to 2cm (O.lIin) fmm the floor, Traction wa~ alw and was asked to rest. repeJled Sl::ronddoy SI::Vf'nth-ninthdays Thep.'ltlent felt that she had improved from thl.'trac- Thl' rouline of the fifth and ,ixth days was repealt\"li. tion. She had r\\Ot had any back discomfort. Forward and by the tenth day thepahent was f...\".C of all symp- fle~ion had impro\"ed by Scm (2in), and straighllcg 10ms, Iler slraightleg raising was normal and forward raising h.ld maintaint'<l the improvement of Hr. flexion was full,withall signs of the sdalic scoliosis gone. Shl.' had loslall tingling;;ensationbylhl.'sewnth rraction was repealed, but as there had been no day. All active and passive movements we~ much troublc with back pain it was done in prone. A strong r....\"\"rlhan when examined On the first day. pull (35 kg) was given for 15 minutes. alld all legl'ilin disappeared.Somepainretumt'<lonrelL\"dSinglhetrac- POORLY DEFINED LEG SYMPTOMS tion, Aftl.'rashort Il.'St, straight leg raising was found lohaveimprovedalilliefuriher. Examination Third day History furtherslil;hl improvement was felt by lhepaticnt. For 2 years a man aged 45 years had notiCl.\"d inlennit- Forward flexion was 32cm (l3in) from the floor (an tl.'nt tingling. which began over the dorsum of the left improvement of 2.scm), and straight lcg'ilising still fo\"tandgraduallyexlendedtothelateralaspectofthe lacked 10° Il'g. thigh and bultock(fiKure 15.6) The same strength of traction was used, and similar Twowt\"Cksagohehad~nhospilalizt\"dforaheart rdit!f of symptoms was experienced. Traction was maintainedfor30minutl'S condilion. and during lhis period Ihesymplomsh.ld worsent\"d untilal the time of treatment he had a con- Fou,thdoy stanl dull ache in thl.' left lateral bUllock. Ihigh and leg with lingling over the dorsum of the foot. In comparison with the first day there had been considerable improvemenl, bul the rate of propt'$'; Physirolfindings appeared 10 have been lesso,·er the last 2 days. For- ward flexion now lacked 31 cm (12in), and straight leg Active mo\\'ements of the spine were full and painless raising lacked S°. with theoCl!ptionofforward flexion, which caused Stronll.e.lraclionj70kg) was lI.iven, and thepalient was then giVl'n a long rest.

E~ampl6 of t~atm~nt 421 a dragging fL\"\"hng posteriorly in the left legwhef1 his ~conddoy fingertips were l3cm (Sin) from the floor. Pass,ve mo\"emenlsofthe lumbar spine showed a marl«.\"lllirni- The palient was still able to touch his tocs,and all limb tationoftheflexion--e~tensionmovementbelw\"\"nthe and bullock pain had gone. Tingling had been inter- fourlhand fifth lumoor\\'ertL'l>rae.Q1herteslsofthe millent and less severe sinc£' the manipulation. The spine,sacroiliacjoints and hips were normal U/Sjoint was SOre from the manipulation The referring physician asled for 2 days of treat- 11le first day's In'atment was repealL'd, and this mL-nt, as the palient was then re\\urn;ng to his home in dearcdlhetinglinginthefooI.Onre-tt'Sting..theU/S the country. mo\\\"ement was greatly impron-d. Tr~atm~rlt The patient wrote 10 days later to say that he had remained symptom free. GuidingfoctoTS CERVICAL 1. The only obj<.'Ctive sign is the U/5 sliffness. 2. These is no muscle sp.1sm protecting mo\\'ement PAIN SIMULATING CARDIAC DISEASE oftheU/Sinterl'ertcbraljoint. Examination 3 As only 2 days of treatment are possibll'.and as History the U/S stiffness (if this is the cauS(' of the symptoms) has probably taken at 1east 2 yeilrs to A mJn Jged 54 yea.\" was treated 7 year;; ago for reach ils pl\"('S('nl stage. it could waste time to M<\"n~i~'s dISease and de.. fncss. Three years IJter he begin \"'ith mobilizing K..:hnique:;. hJd J \\erybad bout of left chest and arm pam, which 4 From the abo\\'e th,,-,<, points it would appear best cameonduringthenight.llelater,,--.::aUcdthathehad to begin with manipulalion ofthc intervcrtebral b<'cn waking wilh a feelingofslightm-.::lslifffleSl;fora fointbetwcenUalldLS fewdaysbt'forethisollSl-'t.Atthatstagehisdoctorcon- sidc,,-'<J lhat a heartcundilion waS the cause of the Firstdoy p<lin,Jndh£'wastrealL'Clforthis. The rotary manipulation localil-ed to the U/S joint Ten days ago he was again w.. kened by leftchL'St was done twice to the right and twice to the left. The and ann pain, and since then the pain had bct:>n range of forward flexion impron'Cl eachlimeunlil the unl>earableat tim\"\" (Figl\"e 15.7). patient waS able to touch his toes without any drag- ging fL\"\"ling in the left leg. The leg ache impro\\'l'd from llisreferringspt-..:ialistsaidtherewaslittlee\"idence the beginning, and the foot tingling had gone after of cardiac disease and, as neck mo\\,ements were four manipulations ,,-'StriclL'd,manipulationandtractionshottldbcgi\\'en asa diagnostic lrial FigUf~ 15.6 Poorly ddinN I~g sympto,'\" wltn good \\1 ::~a:15.7 Sever~ Idt cn\",t and arm pain '1mula\\lng cardiac

422 MAITLANO'S VERTEBRAL MANIPULATION Physico/findings Eighth day NL\"Ck mow~menlS we.... markL-.:lIy rL'StrietL'CI. E~tension By thisstilge,pain had been reduced and all mOVl.'- waS impossible, forward /le~ion, left laleral /luion and m\"nls were IL'SS limilL'CI. Forward ne~ion was p.~inless. leftrotationlack0!d6O\"0ftheirra\"se, alldrishtlaleral and pain was in Ihe same areas-namely thech<-'St and /lexioll alld right rotation \"'e.... limill.'d by approxi. the whole of the arm mately 25°. All of Ih\"5t' movement:;cauSL'CI pain in the arm As symptoms were k'SS severe and forward f1e\"ion \"'3S painless, it wasdccided torommern:emobiliza- RadiologieallylhebodyofC6wasnarrowL'CIverli- tion as w..ll asconlinuing with the Iraction, Ce,\"\"ie\"l cally, alld the.... \",as marked llarro\",illg of the C6j7 rotation to the righlcarriL>doulIhn.'{'lime$rL'Sultedin interbody space with o\\'t'r-ridiog of the apophyseal freedom from the forearm part of the p.ain alld lessen- facets ing of the upper arm pain,l:>ut Ih£>chest pain remained unehangL'CI. Trtatmtnt Th\" thoracic spine belween nand T5 waS tllen Guiding factors mobilized three tim\"\". pushing tl\\e spinous processes from right tol<'ft with lransv..rse ver\\t'bral pres,ure 1. Pain in the left chesl and arm, which may simulate lhisrelievL'CIthccheslpain,butonlyslightlyimproved cardiacdisea>e, can ari>e from T4 or C71evels Iheforearmpain 2 WithsuchscveresymptomsandwithalJ The usual traction wasgi\"en. and this completely movements limitL'CI by a marked inc\",ase in arm relieved Ihcforearm p.ain. pain,lraction would be p....ferabl.. 10 manipulation. Ninth day 3 With marked limit.,lion of movement and with\" TI,e pain had eas<-'CI its usual amount, but mo\\'t'menls def;nil.. P.1infullimilationofforwardn..~ion,lhe had made more progres.s Ihan pre\"iously, As thoracic rL'Sullcanbeexpectedtobeslow soreness had increased from the mobilizing of Tl-S, on\\ytraction was giv\"\" on trusday. 4 Aspainsubsideswithtraetion,andn..xion bewmt'S free, mobilization could be used to Tenth day haslL'J1 the R'Sult. Local lendernL'Ss had improved. so the eighlh day's Firsrday trealmenl was repeated Asextension wasso limiled,cen'imltraclion in fle~ion By the thirteenth day. the alterJlate-day mobilizing (appro~imately 35') was given, which almost com- plos Ihe daily traetion had resultLod in fJ'l'ed.om of movl.'- pletely relieved lhe pain. Treatment romprised two mentandonlyoa:asionalsensaliOl\\5ofacheinthearm. stretches, each of 10 minules'dUTatton. Pain returned un lowering the traction ead! hmO', The patienl was PAIN SIMULATING SUPRASPINATUS TENDINITIS warned of the possible flarl.'-up of symptoms follow- ingthe first lreatment. He wasaltempling to continue Examination hisownclerimlbusinL'Sslhroughoutt\",atment Rt'fereneeofpainfrom th(' v.,rtebral column intojoints Second day is common, and it is sometimes difficult 10 determine Iheorigin of,say, shoulder pain, asdemonstralL'CI in MOVeml'J1ts ,md pain w ..re appro~imaldy Ihe Silme as the example thaI follows. When pain is referred. Ih.. on Ihe fiThI day. Traction wasrepeated,but il was given joinl 5i!,'TlS consist of pain On movement wilhout as a stretch of 15 minutt'!>. Some degree of relil'f restriction. Sometimes Ihere is pain in an associated remamedonreleasingthetraetion. are,'(suchasthescapula)toguidetheexaminer,but IhisisnnlnL'CL'SSiIrilyso.Sometimesthe.... arenovert~~ Third day bral column signs 10 indicaleIhat the shoulder pain aris<-'S in the neck. The only lVay of finding oul is to Pain had eased a little, and rotation ShOWL'CI a liltle lreatthenL'Ckandobscryeth\"5houlderpain.~ impro'·em<·nt. Traclion waS repeaiL'CI. response to trealmenl when Ihencck is the cause is always quick which makes aS5CSSmenl easier. This Fourth~stventhday problem of ,'ertebral causcof periphl'ral joinl pain Marked progressconttnued with this daily traction.

ExampltSoft.utrntnt 423 is wmmon In the hip and should<T. and Ie5s rommon to lhe righl and V.1t>nS1Orl reproduced thJ:'l right In the elbow or lnee. The following case history is ~uprasplnOUSfos.sapam. \\\\,thdo5erquestiomng..the S'n.,nolSoni'a.lmple pallent recalled the p.lln in this area approl<irnately 2 \"'eeks before his ~Idt'r pam de\\\"eIoped. He abo HistOfY mentiolWlhalml'l.'Cl'lll)WJ'!ihe~ll)wal.ef>ed with a slightly $Ilff neck,. wltidl al\"'ays disaPPNtN A young m<ln aged 25 )'NTS was n-f~ f..,.. ph)'!i1O- lherap)' tfNlment 10 his right shoulder. which h.ad ,,·,thinl-2hoursofgettlngup,Mobilizationofthe~· bl'enp;!il>fulfor2months.CortisoneinjL\"Ct1on5intolhe shoulder 18 da~~ ago had caused a !il\"\\\"ere reaction. icalsptnll'byleflrolalion .. asu!ie'dasallO!5Clllahonfor Imlnuleand,upollfa,ourab!ellS5l'SSm('Tllofprogft'S, Tho! rat'et\\1 said the symptoms had rome on grad- wMrepealed twicornort'. AbductionJw,d then I~t u,.lly, and he krocw of no pre\\'ious history of pain or its painful aK, and cerncal mo\"l'menl\"S Wl're painll\"'ll. inlury.llossymptomsconsistl-d IIf an ache ill the shoul· The static lestofthesuprasplll.1tu~ had al500bt-'roml' dernillighl,alldjabsofl'ainontopoflheshouldcr palllll'5S.Localshould{'l\"lr\\'alml'lllwasdiscontinu<'<!. witl1n,own'erlboflh... arrndurillgtheday(FigurrI5,S) Tw~l(rhday Physico/findings Thepatientrcportedfe..'hngmu<;hbcller,but~,,·kal Tlll're was an arc of p.llll fell 00 top of the shoulder during mid-range abductlon. and a static ronlTolChon rotation to the .i~hl ;,t,1I caw.ed supraspinous fOliSa of the supraspmaluS muscle a150 caU$l'd pam on top of pa\"\" CI'r1'icall'~terWon.mdshoulder abduction ..·eft the shoulder. PolSlSiw mo'''emcots of the acmrniocI.iIvic- sldl pamIess. Rotatlon mobihzatlOrl 10 the lefl \"as ularjomt and glenohumeral joillt ...erepain1es5.All =e::.,':;.n'l'hlYW\"'.andresulledinpainleSlsnecl cen'ical rno\\emenls ...ere full nngt'! and pa~ Thinttnrhday EM'e'J'I for slight tenderness in the ft'S'on of the inser- Pain Md mumed to the top of the 5hoWdcr. and the lion oflhe nghtsupraspmaluS tendon. all tJSSUe!ii felt painful arc of abduction ~ abo murned. Cen'ical rt1IIIlion 10 the nghl agam caU5ed pain III lhe right ~I SUpraspInOUS fossa. Trealment mobilizing the \"\",,'kal spIne with a roIatioolo the left was repeated. alld Trutmtnt resulled in fm'dom from all symploms and sIgns. iodudiogthea.cofpinwithabduClion GUiding (acrors Fo()rt~~nth day Shoulde.treatmenlwilhl'1T1phaslsonthcsupraspina· tus 1<'11don is 10 bc gi\\\"cn byel«trothcr.lpy and de\"p- TrealmL..,lwascanc...11ed as the pallellihad no pain, fnctlonmass.lgetolhel('ndOll and neck and shoulder lIIO\\emeIllS ........ painle!5. firsr-ttnthdays Trutml'ntoffurthl'rdevtlopments DunnglhefirstlOda)'lioflll'alnlClll,I..........eresome There .. asasl.ighlretumolsupra!ip'l\"lOU5fo!;wpam I'Ilghtswhen the shoulder did 001 ache HO'\\{'\\er.lhe 2 w\"\"\"-slat<T, wttich \"'oISCleal'l'd by mobilizing W«'f- arc of pain on abduo;til;>n nmu.rned unchanged. On \\lCIIspin<>b}'rotationtothelriton2ronsecub\\ ... da)\"~. the eit\"\\enth ~<, the S1~ of the pain had dwllged to Tlll' patleOl was later known 10 ha\\e rem.ailll'd S)'mp- the middle of the supraspmous f~. tom free for 4 months. EJ~nthtkJy Jt should not be concluded from this case hlslory thalallshoulderoondllionsth.J.lha<·... aplllfularcof WIlh the p.llll In a 1l(\"\\\\ ~'Iion. C\\\"f'\\'ical fI1()\\emcots mU'o'('ment mwst be trealed by mobilization of the cer- were f\\.'l;\"....'(:ked and were found to be fun, but rotallon vical spine; .ather that such ~ymplomsmay 11;1\\'(' a cet- vkal component. It is Ilsdul to lreal Ihe ceNkal Ftgu•• ts.a SIIouId.,sympIOMSof romponenl first while aSSL'Sslllgch;;mges al theshoul. dl'l\". Should thl'l\"Cbe httll' or no improvl'ment in the ~roic.lo<,gln shoulder eilher al the inllial treallTl<'llt scs.sion or in lhe

424 MAITLAND'S VERTEBRAL MANIPULATION 24-houraS§CS!ilT\\t....t pl\"riod,tll<>n t\",.. tmt'nt must focus 4. The progress should consistQfa lcsscnmg of the onlheshoulder_ se\"\"rity of thc attack$ and an e~I,-'l15'on oftl\\(' pain-fn'C period betwcen attacks. PAIN SIMULATING MIG::;':::\"::;\":..' _ 5. Trcatmenlshouldbeire;tltutedaSli<)()nasanattaek Eli:amination begins, ..'hat\"\\\"\"rthe!lourofdll)· History 6. While treating during an attack, the tn'alment selSionscanbeexpected to be Iongbeause A woman agm 40 )'c.al'S had a 21-)'Nr histor)' of what extrodedfl'$lSshouldbegwenbef\\<,'eenbochmqU('$. thl\" dodor ~ ailed m'granw, During this Ii....... her ~tpcrlOd ..'lthoulpam~becn2)'.e.'S.. lneach 7. The changes lhal can be anticip;lled from thl\" boul of pam the sympk)mS begotn OIl til<> back of thl- \\anouspf'OCt'duresshould betht- ............. ~ ..·ould be neck,. and !hen spread inlO the nghl occipit..l ..\"\", ..nd ..,.pectedwlthother\\\"crtcbr..ll>ynd~, thenm'erthl-head to the right ear and the right frontal area. The pam. which she desc:ri~ as a \\-ici0u5 throb. 8. The fiTSt aim is tu make all cervKallllO\\'ements lasted from 2-8 dars,enforOng bOO rest m we....ly freeofu.epa,nallhenghlofCl ~ to noI\" how stages. Symptom!> of pam were acromp.1lUlld by nau- freedom from this alter5 the p.-lIent', p;lin cycle sea and blumng \\i1SOOO\\. The only prodrome \"'as a ·fffhngofweU-being'(r,~..\"J5_!l) Firsf-thirdday f'tIyskul findings (ot f~ ~nd of on attock) Rotation mobili.t.ations (done only 10 the Iefl) we... gi,·\"\" as genLlir- but wstamed ~ures, M'ioe the HeJldandnec.. fflO\\ ...........b ..·~qulh'full.butf\\o,xion fir<-! day Md four tunes on the S{'('(Jn(I and tturd dirs. and extension ga\\~ ~al dlSCOn\\f()l1 in the right upper ned, a\"\", R'ght lateral fle->:.ion gan~ modetate ThrsproduM;i .. pual clcanng ofthl' pam fell 10 the pain on both sodo's of the ned: .. ttheJe;.-e1ofCI, .. hefNS Il\"ft 1a\\eT'..1 fJeuln hurt only 10 the nghl of Cl. righlofthefustcerviall\\ertd>riJ RotabOn I() the Icl1 \"-as normal. but 10 the rif,ht it caU5ed pam 10 the nghtofCI Fourthdrry Trtatment Thepatientreportedwith ..llofthedlSlurba~tNt acrompany an ..tt..ck,. but she did not N\\!' the US'-Wl Guidingfoctcm throbbingheadp;l\"'- The palfl 10 the nghl ofCI had re-appeared and beroml' more f\\OIIc\\'..ble 1. Whilethepal1enI'SS~-Dlptomsar('<;(:\\-ere,genlle and SU!ibmOO Iracbon in ....\". 'lr..1would po55ibly Gentle trllct10n in neutral was gl\\\"efl for 10 m,nutes, N5ethesymptQn\\5con..idl.'rabl} and ttus eased the feelmg of naUSN and c1e..n.>d her blurred ,'ision. Tbese S)'ml'loms did not Mum on 2. Roblioni5usuallyltM>~p...xedu\",rorhelping relNsingtlwtractiOl\\.Aflera5-mmuten\"$t,thl'tr...:- neck wnditlONo, parhcularly whom they ..re tionwasrepeared. unilaleral FifthfJndsixthda~ 3. Itl'll:'t'dstobeelCpLunedlothepatll'ntthat,ono.:e the pa,n 10 the nght of CI (which c..n be produCf'd The nausea. although It.'$S, wa. still pre;ent, f\\'!uming bytt-<tmgmon.'......\",ts)ha:sbt,enchminat..od, 2 and -I hours ~ti\"ely after thl' fourth and fiftlt Ireatm<!l\\l w,ll only be gl\\il'n dunng attack$, and th.cn!fore the end-result may appeilr slow In dlly'st~atmenls. commg Traction was repealed in two penods (one of figu~ 15,9 Ct....~al\"udac:\"~ 20mlnutcsand the other of 10 minutes) on ea<h d..y, but this only produced a slight impro\\'('1fl..'nt ~~nfhdfJy Vision waS normalar,d nau!>ea WIIS absent, but the paintotherighlofCI was stili in e\\ld('f\\C(' on rotation. espedally if this was done to Ihe right, and tht'rewas slight right fronlal p.lin, Rotation mobili7..ltion to the left was d~ four times asamuchstrongerosciliatorypf'OCt'duTC.This ...'Sultl\"Cl in a dearing of all symptoflls and silo;n.,

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _...;;:''::::m''-'\"'-'::::'::::.'::::'m''\"'-'..:':::\"=---- Eighthdoy thai rot~tion manipulation to the left was the effectIVe treatmentinthiscasc. The p<ltient report~'d k\"\"ling wdl,and the only remain- ings'gn wasp<linlolherighlofCl when thehe~d waS Si)(thond5e~nthdoys put inlO full extcosiOl'l a\"d lhen lalt.'Tally ncx~'d and Transverse manipulation 10 the right was the only rotated to the right. ortechnique used. and by the end this period thO' Kotatio\" mobili7.atio\" to the ld'i was done Iwicc as rreepatienl waS again symptom and sign free. a slro\"g full-rangeprocedurc, allowing a lo-minulc K'St belween. This made the patie\"t f~ of pain on Treatment of further developments-2 t~'Sting. Treatmentoffurtherdevelopments-l The patient remained symptom free for 13 days, indi~ eating further impro\"ement, and then developed The patient ~mained symptom free for 10 days moderate pain in the rightocdpital and adjacent neck (a much longcr period of fll.'l'dom lhan usual},and area with slight right frontal pain. The feehngol nau- then retumed with pain on the right 5ideof the nco:;k S('il waS minimal. The usual ~gn of pain with rotati\"\" radiating ovcr the right side of the head to the frontal tOlhe right was present area, with blurK'd vision and a f\"\"ling of nausea First day On\"xami\"alion,rotationtotherightcau\",-xlp<~inin theright5ideoflhenedaltheCIlewl.TIUspain At this slag'\"roldtJon lett manipulation wilhout tTac- incrca>ed both in intcnsity and area, to a righl hemi- tion was the most effective treatment forthispatienl. cranial pain. iflh~>rolation wasrombin«! with righl and it was known th~1 it could be don\" as a strong lateral flexion and full e~tension (the upper cNvieal proc<.'durewilhsafety.Asna~awasnotexressive, quadrant) long,..,.,ts between rnanipulations Wen' unneccssary. Rot~tion to the left was given four hOles as a very First day slrongand susta;nl'do:scillating movement followed by ~ manipulative flick. The pali{'I1!'snc<:kon the lefl Thepalientwa5giventransve~manipulationtoth\" side was th~'I1 too sore 10 allow further tn'atment right at CI-2 th\"\", limes during a I-hour period, Active rolalion 10 the right wasalmoslpainless,and all which allowed for long periods of res!. Symptoms were nausea and head pain had gone gf'(>atlyea~andmovementsbec,'m<'les5painful. Sf:COmiandthirddays S«:onddoy The patient felt pll'ased that she had nolhad ton'SOrt There was no nausea and only slight frontal pain to drugs. Then' were fewer symptoms. and by the Rotallon to the right slill causro some p<,in 10 th.... third day shl> only h.ld shl;htright frontal pain with rightofCl tl'Slingrotation in the posit;on of righl lateral flexion and \",xlension Maximum·range forced rotation to the lefl was given thrcetimes, with complete relief of symptoms Transverse manipulations lothe right w~ ,,-opeal(.'d. and signs. with5horterrest~betweenastheybecamelessnece<­ Treatmentoffurtherdevelopments-3 ...ry.Bytheendofthetroatmenlonthethirddayshe The patient remain~'d symptom fN.\"\" for a further wasboth5ymptomf\"\"'andsignl\"\",again 3 weeks; she then devt:loped a mild righl fronta\\ pain Aetiverntation to the right was painless,even wh~'I1 Fourth ondfifth doys done in conjunction with right laleral fI\"xion and extension TIl<.'n' Was a mild ov....mighl recurn'I1Ce of ril;hl hemi- cranial ache (not pain), which indic~tlxlth.~t treatment First day should conlinue. There was no n~usea or blurring of vision. During the treatm{'I11 on the fourth and filth Trans,'en;cmanipulahontothcrightwasgi\"entwiee, d••ys, longitudinal movement, rotation tOlhe right followed by a 3O-minute period of K\";l. As the symp- and poste1\"O\"anteriorCf.'ntral vertebral pressure were toms did not return, further manipulation was con- attempted in tum, but as each was used it cauoe<l an sideredunneressary. increasc in symptoms, and rolation tolhe lefl had lobe reinstituted in order tosclile them. II was now known

This lll'alment was given in 1957, and ~he is known 2. As the cervical movO\"JTleTlts a\", 50 hmlted, it 10 h.wl' ,...\"..,ainl'd fll't' from all;Kb unlil her dedth w()tJldbew~rlolrcallhlSan,'afust in 196'> 3. Conditions of sudden onset usually respond more SCAPULAR PAIN rapidly 10 mampulatlon than 10 traction E.uminition 4. Rotation righl would probably M the main H,story ll\"dmiqlll'here Orll' wel'lo.ago. wtull' yawnmgand stft-1dun:g.,a woman Rl5tday ..ged ;j,() )'('ars felt .. Wrp pain m ... the left sc..pulil. Dunng the next 2 hours the ache increa~ slightly Ul Mobilization 01 the cen icill l;f'UW b). rotation 10 the intensll)·...ndspn\"ildm ..... great.....re;olocon.·I\"thl' right .. asS\"l'I'l\\l'r)gl,\"d)fOO'20~fol\"\"\"Ulg k!ft sldo:> 01 the lower neck ilnd the left m,ddll'and this.eer...iGlle>.tensionandn~lbleralfle\\:lOOhad uppl.'f SCilputa. al'l'il (Frg\"\" 15.10). After thai, the in<:Jw'Sed 1»' 20\". The teehniqUOl' ...as repeated. but ;15 :oymploms\"..\",.\"rM'dunaltered. therew;osnopaln()l\"muscll'~,,;lhthe.-:illa!>on Thep.ohent had had a:oimilar<.>p1SOd1' a y\"ar ago. it was done w,lh g\",att>r PWS<;Ull'. follow'ingthR'\" wluch n.\"CO\\'ered wIlhoutlrealment in 4 days. applicalJonsolth,srotahOll.thepatIMthad50per<'l'flt of her range of t\"';temi<l\" and right lateral fle\"ion; full PIlysicolfindings n\"\"ion and left rotahon onl)' lacked 20\". All t~ Th\" symptoms coll5isl<'d of a COll5tanl n3fo;glnll 5<:apu- 1M aeh\", wh,eh wasaggravalCd by movl'm.,nl alld 1\"'1\"- movements still cau!><.'<.! Kapula. pain.1he paIJt'flt was tially rclil'\\'l'd by r<'S1. Trunk and shouldl'rmovl'''ll'nls wal\"l'll'd oftlxo possiblhty of an increase in syn'ptoms were full and paink'SS, bul lhl' rer·.kal movem\"nt>, f o l 1 o w i n g t ....a t m e n l exc'1'l for left lateral flexion and right roIi1tion, Wl'''' all \"eryJimilL'd and eauS<.'d scapular pai\". F\"rw..rd Second day fko\"'lon L.:tcked 50 per cent of its nJO'It.'ITll'rlt, and although il was posl'Iibll' to initia\\o> ...xtl.'rulion, pilln l1\\e\", had bet.>n no increase of s)'mptoms. and the then pre-.'entl'd further mm·ernenl. Rolallon 01 the pl\\tienlfellmuchbl'lterThlorilOgl'ofmo\\'l'menlhad head to the k!ft was hmJted b)' 50 per cent. and paUl R:'mairM'dthesaml'3shadbeenobI3inL'dfollowmgthe pre\\-ented all but theMI fewdegrt'l'5ofrighllatl'ral firsl trealment. The 5<ime mob,hutioo was given. but fIl''QOf'l. (Ttus combmatlon of limited rolillK)ll 10 one it was dOll{' 5e\\'en luncs. 1\"here was no impro\\l'fTIl'Jlt 51deand laleral fle:<ion tolheOf'PO\"l'lIeNde i& unusuaL) withlhel.>:>t t..·oapplicallOO5oflhl' rotalion,butO\\w- W,thallofthesoi'lTIO\\-l\"I1'Il'fllS.painUlthek!ft5GIpula all the mO\\'l'Il1l'l'1ls made further impnn'l\"nll'Jl.l F\\exion was TTIilr~I)' inc...ase.t. 1he ani)' ~ thaI and right lateral flcxion W('ll' full and painless. Rota- could be found was 0'0.... the ~,nous proces.ses !>on 10 the left increas<'d by 1000and now lacked the~ betw~T:!:;lndT4 100ofm01'cmt'nt,,,-hill'nll'llsiooillCTl\"a!ied10\"<md Trratmcnt :nostill lad.re of 1TlO\\l'fTIl'Jll. 80th thesf, mm-emmtl GUldmg(oetors causcdleftscapularpam. I. Scapular pain can be caused by l'Ither a <'l'rncal Thirdday or .. nupperthol\"acic<:Qnditi\",,;Ihl'refQreboth an....sTTlil)'ne<'dlObet ...a t e d . 1he lmpnn\"OO mo'o'fillelll was \"\"\"intained. and it ....... decidedthal.aspmgr1'SlShadbeensJoy.·l'IOOWserood ~\"'\"\"\"W''''\"'''~'\" day. the upper thor.>cic5p1llC should ~mduded in the mobilization. As il was known how' much imprOl'r- ment the rotalion had produced 00 the secood da),. thelhoracicmobllil.ingwasdonefjrsttoilS6l'Si5thecom- paraIJ,'e \\'alUl'S of thoracic and eernca] mobilil.ilhon. Trans,·c~vl'T!l'bralprcssu...::wasdiroctL'dagainslthe righl side of the spinolls proct'OlSl\"li of T:!:---4. Thl' ll'ch- nique was done finnl)' for] minute. The result was full Icftroiationandl'''tcnSiollofthchead,althoughbolh movemcnts stili eallS<.-rl p.1in. Following two further applieation.softranswr~,·crtl>bralpressure,allpain had gone.

Fourthdoy quickly Or easily as would SOme patients with symptoms and signs of this type Th~ pati~nt could feel pain only tn th~ I~ft scapular 3. If manipulation is given it should be don\" gently, aff!a on full ~xteflsion of Ih~ h~ad or full rolation to the being guidl'CI by thl' patient's comfort. Ie!t. For the fioal tff!alment, the patient was given trans- 4. The best result ,,·ill possibly be obtained by doing ver-;.e '-ertebral prcssuff!againslthespinousprocesses a small amount of mobilizing 10 prodUC<.' an increase of TI--4 followed by rolation 10 th~ fIght for th~ cer- in range of m\",·emenl, follmn'CI by gentle tracllon vleal spine. All movements were painless following Ihe to maintain the impm,·ernenl while allowing mobiliUliOf'. No further treatment was required, as Ihe soreness 10 subside. Mort:' mobilizing could then p.1tient was frt.>e of symploms and sigos On the follow- follow. This cycle should be repmted until the ingday. maximum progress hasbecn gained.lhe last part of Ihe treatmenl would need to be a period of Iradion. ACUTE TORTICOLLIS 5. As the )Xlti\"nl is I.loable to ext\"nd his ne.:k. the traction will ot.'Cd to begivl'll in flexion. This also Examination applies to the mobili7... lion used 6. Following treatment, the paH('nt will need to rest History w'th pillows supporting th\" neck 7. If th.'re is marked impro\\\"('ment during treatment A boy aged 16 yl\"ilr5 waS wakcned two nights ago al on e.\"h of Ih(' first 2 days but with ao overnighl 3am by pain in thc righl sidc of his nl'Ck. He had nevCr deterioration. a soft (ollar may be required to help had aoy troubl\" with his nl'Ck previously, and had not maintain the progl'\\.'SS. Under these circumstances, bl..,n carrying oul any unusual work during the few the collar ,hould nol be needl'CI for many days days immedialely prior 10 the incident; nor had he 8. As symptoms a\", right-sidl'CI, lhe ideal technique IJ<,en unw~1I (Fig\"\" 15,11) will 1>0.. rotalion to th\" lefl; how.·\"\",\" as the\", is defonnity. care will be n\",-'CIl'CIlO ensu.., that a Physical findings physiological rotary movemenl is produced 11lI' head and nl'Ck we\", held in a posilion of approxi· Fif5tday mately 35° of left lateral lIexiOf' and slight forward lIexion. n,., patienl So1id thai u..,re had bl'l.'O no impro\"l~ A rotation mob,1I7.ahon to the left was given first. ThiS m\",,1 following one day of complete \"'51 in b\"d. waS done wilh the neck comfortably flexed. The tola- tion was taken gl\"Tltly to Ihe limit of the range allowlod His acli\\\"~ rang~ of lI~xion was full, but ga\"\" some by the pain and spasm. 00('(' the limit was reached a right middle neck pain. Both extension and righl lat gentle OSCillation waS carried out. attempting all the eral lIexion wen;. gNSsly limited by the pain. Rotation tim\" to incrt:'a.., the spasm-f!\\.\", range. This was con- to Iheleft and right gav\" pain. btl! with rotation 10 the tinued for approximately 1 min\"te, As there was quite I\"ft Ihe ranS\" was full. whil\" to th\" right it was moder· a marked improvement from this one mobili2illion, il atclyrestrkted was decided to gi\\\"(' traction in flexion while lying This was donc for 15 minutes. By doing this, the fol· Treatment lowing mobilizations would possibly be moreeffe.:live and of less discomfort to the patient than if more mobil· Guiding foctors ;7~ltion was don~ at th~ beginning. 1. As thl're is some flexion de!ormity of the neck, 1'01l0wing the 15 minutes' Iraction the angle of the rt$ult is likely 10 be slower than if only lateral deformily was reduced, but there was still markl'CI fl\",k,n det\"o\"\"ity were preset1t limitation of right lateral fkxion. \"\"tension waS grcatly improved. Rotation mobilizing 10 the left W\"S repeated 2 If a day of A.'St has nol made any difference, the three times, producing further improvement. During p,llient is uI,likely to respond to treattll('nt as the mobilizing, the rolatioo was easier to produce and the muscle spasm was much less. Tracti\"\" was repeated w\"\"The range of lateral flexion w\"s then.50 per cent of normal, and extension 75 per cent of norm..l, but each mm-ement still caused right n,,,,k pain. Some indication of the deformity was still present, but Ihe p\"tienl was able to adopt the normal head position

428 MAITLANO'S VERTEBRAL MANIPULATION without pain. Rotation was K'P\"atlxl thrL\"\" times. It Third day waspossibletodothismuchmorestronglyatthisstage Traction was repealed. TIll're was no deformity, and only right neck pain with full right lateral flexion and full right rotation. Following this, terminal extension caused pain. right lateral flexion was 75 per ccnt of full rilnge, and The patient was manipulated twice with rotation Ihe deformity was almost gone. Rotation mobilization without traction to the left, after which the movements 10 the left was repealed twice more, and traction well'painless. reapplied. Movements were then full but were per· formed cautiOllSly, and thedeformilyhad gone CERVICAL JOINT LOCKING The patient was ashod to K\"St, using adequate neck Examination support. As he had bcenusinga rubbcr pillow, its dis- History advafltage was explained; Ix-ing rubber it has the K-n· d.\",cy to maintain its shape, and during sleep this will A girl ag~>d 15 years had, while playing bilskl.'tba.ll. ll'Sult in a constant nudging againstth., relax~-d \",-ock. suddenly tuml-d hl.'r head to the left, and it had Although this may seem trivial, itissuffidenttoirri become stuck in thispooition. She felt pain on the right tate an easily disturbed neck.Togi\"etreatment~·very side of hl.'r neck. She had had no prcvious neck il5Sistance, the patient was shown how to make an injury Or symptoms. and was not otherwise unhealthy ordinary flock or feather pillow inlO a bUllt'rfly shape (Figure 15.11). byshakingthestuffingtotheendsandtyingthecentre isthmus lightly with ribbon. He was ask~od 10 lie with Physica/findings the isthmus under his neck for support, leaving the l1te patil.'fll was unabte toextl.'l,d her head or laterally wings to stabiliU! the head. Then, whether he lies on flex Or rotate it to the right. Examination by passive his bilck or side, he has adl.\"<juatesupport for the neck intervertebral movement showed the C2/3 joint to be and the head. lfnecCSS<lry, a soxondsmall pillow can fixed. be used temporarily under tm., 'butterfly' pillow to give thl.\"amount offll.\"xion n~'Cd~>d to relie\"e the pain. S«ondday Treatment The deformity was almost gone, and exteru;ion was Guiding factors full butcausecl slight right ned, pain at the limit of its mOVCr1lent. Right lateral flexion waS limited by 1 As iloc<:urredea,ily,it maydeareasily. approximatc!y25percentofitsmovernenI.Rotahonto 2. c..-ntlelongitudi\"\"lmovementandrotation thelcft was full and painless,but to the right there was pain at the limit of the range. TIlere had been more should be tried first progK'SSthan was anticipated (SI'l'Treatment, (1) and 3.lfmobilizationdocsnothelp,alo(alized (2),p.427),and therefore more could be done without causing the patient discomfort. manipul<ltionshould beu5l.'d to open the C2!3 joint on the right Rotation left was repeated as a strongoscillaling 4 Complete restoration of range shoutd be achieved pfOC<.'durc. This made right lateral flexion almQl;t full on the first day, although the movement may still range after three mobili7.alions. but furthl'r repetition \"'~~ of the rotation did not produce much further increase Extension was now (ull and painless, as was rotation First day lcft. Both lateral flexion right and rotation rightcauso.>d terminal pain. Treatment was changed to mobilizing Longitudinal movement was tri~od without succes6. with lcftlatCTal flexion, and afterbl!ing carried out ){ota!ion to the left was tried next, and this produced twice it produced ~light impro\\'l.'ml.'Tl1. As thl.' patient's slightimpro\\'emenl. RepcatingthemO\\'ernent did I\\Ot neck waS sore from thestrongl.'rprocedures, he was help further. A localized diagonal Ihrust was u>ed given supine traction in f1l.'~ion next, tipping the patient's head to the left. patiently coaxing thc position to relil.\":e sp.lsm first.Oncmanipu- Following this, there was no deformity and only lation completely restored movement. The test for p.>in with rotation to the right. One strong rotation was range by passi\\'e intervertebral mO\\'ement was made then given, but this time to the right. Assessment was following the manipulation, toensull' that range was made difficult by sorencss from the rnobilizalion, but rt.'Stored. Heat and massage we~ then gh'en to relieve the patient was told that he \"'-'lod not rest at home.

SN:Ondday central vertebral pressurc is usually bcst for evenlydistribul,'<lsymptoms. Movement was normal, but sorene§!j was still p~nt 5. If traction is to be used. Iraction in neutral would l'dlliative treatm\"nt wa,gi\\'en, but furthermanipula- be preferred to traction in O.\".-ion, as lhecondition tionwasconside,,-'<luru~ry. is pmbably arising from the uppcr e<;'rvical spin<' 6. AslhepatientcanonlyaUendforln-atmentfor SHOOTING OCCIPITAL PAIN two oortliCWtin'days at a time. it will be re<lSOllllbk togivealongtTe<ltmentontheseronddaydespile uamination soreness if progress is being achieved,as the patient will ha\\'ea week before/urther trcatment History can be given Amanaged 36 yean bent over a handbasin 5 weeks First day ago. and sustained a sharp pain across tiw mxk at the le\\·elofCI. Following this, h\" was unable to mo,'\" his TraClion in neulral was applied gently at first, but as head without pain this produced no improvement in the pain felt with mowments while it wason, it WaJ; gradually increased Hecompldlned of 'shooting' pains across his upper until a firm traction was applied for 10 m;nut~'S. After neckatthele'-elofCl when tuming his head,and an the traction there wasa feeJingofbumingsuboccipi- ache which ,pread downwards in lhe midline from Cl tally and a lcelingolgencral loosening of the \",-d,but toTl(Figurd5.12) there was no impruvl.'nl<'nt in the sharp p;lins.lt s<-\"\"med pointiess rontllluing with tra-ction, as there had been Ph~jCllJfjndings noquickp~ress. Nl'CkOe~ioncau5edapulling/eelinginlheareao/the Wilh the p;lti~\"'t lying. longitudinal mowm<--nt as uppercervical~pine,bulwaS full range if carried out an oscillatory procedure was appli<.'<l. After 20 s<-'Conds cautiously. Exl~\",sionand lateral Oe~ion we\", painless of this, rotation to the left was improv~'<l, but other Rolationtoeach side WaS full range and cau5ed mod- mon,ments remained unchang<-'<l. This waS repeated erale pain in lhesub-«cipilal area,butall movements lwice more without further change had 10 be done slowly. Quick mO\\'emenls in Oexion or rolationproducrosharpsubocdpil<l\\pain As right rotalion now caused more pain than left rotation. it wosdecided to use left rolation as the next The referring doctor asked for treatmenl by traction mobilizatiun. This was done fir:;tly as an oscillating and manipulation, to be aUemplL'<l in lhal order. prorr'<lure,thenasa manipulation without traction. As this did not produce any improvement, the same order Treatment wastri~'<l with rotatiOflto the right, but this also did not produce any impmveme\"l. No further trealmtmt Guiding factors was gi\"en that day, and the patient was warned of :=:::.~~ exacerbation of symptoms following the 1. AJ;thesymptomsarepredominantlysharppairu; with mov\"ments, an ineffeclive proccdureshould S~condday be changed quickly for another. Tne p.ltient reported a bad night With a 101 of shooting 2. Suddenonsel:s wHh immediate limitations that do pains, but th~ symptoms had subsided to their usual notbox-omeprogress;vdywo\"\",,overthe le\"eltoday. following 2or3daysaremore Iikdy to be help<.'<l by mobilizatiOfl than by traction. As traction and rotation hlld faik'<l,postero--ant\"rior centraJ \"ertebrol pressure was used next, localizing it 3 Upp\"rcervicalmnditionsareusuallymore to Cl and C2 and commen.cing gently. for approxi- difficull to hclp than rnid-C<'rvical conditions mately 15 seconds. There was an immediate improve- ment in the f.-...edom of rotary movements following 4 Rotationisusuallythernostefflrtiveproc~'<lure this technique fortheccrvicalspine,althoughpost\"ro-anterior This mobilization was continued, as it was produ· ~:,~ .\",',\"\"\"-',','\"'\"'\"'..'''=,o;..,~'\" cingast<-'adyimpro\\'emenlin thef.-...edom from pain \\ withmovcments.llo:ausethepatientrouldnotcome in again for a w<-\"\"k, the technique was carried out

430 MAiTlAND'S VERTEBRAL MANIPULATION 12 times with gradually incn;asing pre:;su,..,. The p.ltiL-nt The ache waS relieved by short rests, but a full was again warned of the possibility of a temporary night's rest in bed CilU\">L-d stiffnl,.\"Sl; of the lower back. nare-up of his symptoms. This stiffnL'SS re,ldily dis,lppeared on moving about, but the backache became much worse by the l>Jld of the Third day (1 wrrk latrr) day. Sitting increased the patient's backache, and she alway,; eXp\"rienCl-d difficulty rising from a chair. Thirty minutes aftL'\" the last treatment the patient had Sneezing causN considerable back pain vomited and had a lot of shooting subocripit\"l pain, but by the following day he fell marh>d.ly improved, Physicol findings and had been alm~t free of pain ever since. Currently his symptoms \"'ere 'a feeling of limitation to turning With forward nexion the patient's lower lumbar spine the head but no real jabs of pain'. was lordosed, and she was only able to reach her knees before pain preventl)d further movement. Backward The same postero-anterior central \"ertebral pres- bending was limitl-d, and lateral nexion to the right Sure was us<--d for a further five timL'S. This made rota- was more limitl-d and more painful than to the left. tion p<linlessand ullll.'Strkted Rotation and straight leg rai~ing were normal. T1le lumbar spine was sener<lll)· tender in the area of pain Fourth day (following doy) (L4~SI). R\"diologically the body of L4 was alm~t sit- ting on 1.5, and they were fUSl-d on the left. The lum- bcept for a slight pain on full, 'lukk, active rot,ltion, bosacral disc sp<lce was extl\"l'mely n,lfroW, and this the p.ltient fl'lt normal. The\", was nO recurrence of was narrower to th/! left. This created a scoli05is con- vomiting. The treatment gi\\'en on the third day was vex to the right from L4 to 51, and there was a com- repeated, resulting in full, free rolation. pensating 5<:OI;05is about L4 convex to the left together with a slight amount of rotation.Pass\",e intervl'rtebral T1le poltient wrote I week later stating that he had movements of the lower spine could not bead\"'luatdy l05t all his symptoms tL~ted for range, lx'Cause of pain lUM8AR Treatment LOW 8ACK PAl N Guiding factors Examination 1. Painful mOl'ements, wh.m associated with marked radiological degenerative changes, areoftt>Jl help«! History by gentle oscillating mobili~ation, particularly postero-anteriorcentral\"ertt'bral pressUl\"l' A WOm.,n aged 43 yeaTS was limited in the amount of hou5Cworkshe oould do be<;au>oe of back.lche and pain 2. Even though the symptoms are bilateral, the pain with movement of the back. Since the ag.. of20 she had felt with lateral flexion is worse when done to the had bouts of back pain, usually following heavy work. right. It may therefore be better to use a rotation mobilization using the right side as thl' dominantly She had had her present bout for 2 weeks, during painful side which time it had not improved (Fig\"re 15.1J). 3. Symptoms thai have a gradual onset u.ually rl'Spond bett\", to traction than to manipulation Fig\".., 15.13 low bad p;lin with mark.d rnIi\"logical Firs/day d.g.n.lat;v<changes Poslero-anterior central vertebral po..'SSUl\"l' was chOSl'n, and was done for a jX!riod of 20 seconds as a very gentle oscillating procedure over L4 and 1.5. Forward ne~ion be<;ame more limited, and the patient was only able to reach to SOcm (20in) from Ihe floor Mobilization waS thLTI changL-d to a gt>Jltle oscillat- ing rotation, with the patient lying on her left ,ide. As this produced improvement in the range of fo,....'ard

ElImplnoftnoatment 431 f1\"xion, il wa~ repeat~.,j th\",'(' linll~. Forward f1t'xion A;C;U;TE;B;A=CK:;PA;l N.:;:~:::..._----- impl'Q\\OO 'o.'lOem (Ilin) from tht'floor Thepatit'nt ...aswamt'do(apossibleexacerbation. Examination ~condday History The pal......1 ll.\"pOt1oo feelmg eaSIer fl)l' a while after During the last 5 rears a heav), nun aged 62 ye.rs had treatmenl, but by the time she reached home lhe had throe compar.bn,ly mlll()l\" bouts o( back pam, symptoms Wt'I\"C ,.et'}' ~.nd she had. b.ld rughl On each 01 sudden onset from lriflmg lnodents. I hs pIT'- \"\"\",mmatlon, (or....rd fle.xion w.s still JOcm (l2in) sent bool.commenced with a slight backache followH~ from the floor The amount oItreltment\"~possibly weedmg In the g.Jrdm 1 week al;O- The pam imprt)\\ed, thecaUSf'oItheaacerb;ltiotl,ralherthant]'l('tech- but was awa,·ated by an 8-hour drin' in hi~ c.r roque used, 50 rolahon was \"-'Jl'Nted thn-r 1'mt5 with 3 lbys ago. Gr.ldu.all) the 5)·mptom~ became more thepahenllpngonhcrJe(tSl<ie, Tom::lucethe pos&I- \".,.-.......00 changed in n.1Ilu .... from an ache IQI sharp bihty 01. fum- eueemahOl\\, II was dended to stop at threo> t1ll'Ieo. Forward nexlOl'l \"as impron'd b\\ only pain \",th IJlO'\\-cmmt, which\",·entua.Uypn.. ~~ walk- 5ern(2m). ing. A(lt'!\" 2 lbys in bed without any unplU\\·emmtln Thirdday hIS s)·mptoms-. !us doctor \"\"l.~,od marnpu\"\"\"on. At t~ tilN'oftreatmenl, tht-pallenl \"tim bed un.1lbloe to The p.o.hent ~ed anoIher~ night. Forward flex· IJlO'\\~be<:a.-ofjabsolpaminthecent .... oIthelov.'er ion rema,ned 25cm (IOin)fmm lhefloor. Tr«tion,,·~ b..c:k(Foglln'15.14). ronstdered to ~ the l\\e'>;l 5tep. 8ecaU5C' m(I'\\'ernmt \"as requi\"\"'\" it was dcridN to use ,ntermittent uri- Physico/findings able traction,..and 12~ wasgl\\en for IOmmutes WIth a 5-seoond 'hold' penod \",nd no 'rest' penod. At II\"tilm~ibleto\"\"\"mlOelTlOft'thanstralghlleg this low weIght she f,,11 ~ic\\ed of pIIlO, bul said thai if II Mdbeenan\\ stronger,t\"'ouldhaH·!;.\"enlwr ~ \"Pft'adiI\\g and comprl'Mlllg the i1ioa. and OI!(~ bad. pam. fkraDrI.-as the pabmt wiIl5 unIIbleto mQ\\'e. StriIlght leg ne.mg '\" as almost full on both SKk..., but rI'IOre hack On ~ng the tr..nion thew was moderat,. back p.o.in was produced with r.lising the righl IegtNn \",th 5Ol'l'fle55.Aflt'!\"ashortn5Lthep.o.tll'ntl1'JXllil!dfftlmg r\"'l.SUtgtheJe(tJ'lerionof the ned.. \" 'ththedunonthe better than before the traction. Forward f\\e>.1(>0 was chet produced slight b;>ck pam. and the QCfOiIIol( ,oint test ,,·asnegali\\e nottcstedbe<:aUS('ttusm(l\\eml'nt\",oIten~lIff~fora Tr~atml\"nt short J>l'f'Od immedLal,.ly followl~ h\"achan. GUldingfocror.> Fourthday 1. wminahOn is tooluruiOO tohcconch.1Sl'e,bul at The patient (elt g~tly imrnl\\'l-d, and forward fk:ooo least thesrrnptOlruj ..... Iocalt:«'<! totheb«k.nd \"'as now 20cm (8in) from lhe floor Tr..nion was sh\"a,ght Ioeg r.lising is good repealed. 2. ~faet.thalthere<ponst\"tostraightk'gr,lISing \"anes SlIghtly whom romp.lring the left leg with the nght Icg may call for.umlater.ll tcc:hntque when the pallenl is mo.... mobile Fifrh-ninthdoys Figur.15.14 Acut.b.c1:painronfin,ngpatl.nt.obed Then> was steady and marked progre;s from day to da)',and tr.lclion was able to be slightly inc....ased in pressuro each day until On the OInlh day she fdt no b a c k d i > r o m f o r t w 1l h 3 Q k g o f t r n e t i o n . T h t ' d u r i l t l l m o f trachondidnote~ct't'd15mlnut(,; After the fifth traCllon (on the ninth day),nll movements wert' full and p.linless nctively, and the patlcnlhad bco:>n able 10 carry out houscworkwlthout dIscomfort

432 MAITLAND'S VERTEBRAL MANIPULATION Firsrday Rotation, which was repealed twice, elimlnal.-d lhe scoliosis and partly imprc....ed the range of forward The only \"---chniqUl\" p<l$$,bl... wllh ~uch an immobil., fl\"\"ion. This technique was repe~led twie<' mo~, but patient. and possibly tt.., Ix.,.;! cnokt' in ,'iew of the did not produce any change, nalu.... of tlle patient's symptoms, is loogJtudinaJ mO\\'e- men!. The movement wa~ dolw I;t\"l'ltly but .sharply as longitudinal mo,'emenl using the kicling \"Ction of t:I\\re(o lugs USIngbotn legs. It causW lNrlcd pain...acn the patient's right leg was uS«! fourtllnC$. \\\\~theach lime at tlle sik' of his sym~oms FoIlo><o'ing this, the of the first th\"\", thcrewasan;ncrt'aSl.\"in It.., rani;e of pam with I'K'l:k f\\e:rion W.lS le5s. Thc lugs w.,..., repeated, fl)f\"Wdrd /leJcion until II became almost full. but the fourth did ~ produce any further impro'~'ment ~ andneck~](ionthenbecamepainIes5.Straighl1eg pabent was ~ to mo.'... about normaU, ralSUlg was then normal on the left, and allhoogl> full Fourth day range on the right, il ShU prodUCl'd SQme back pain, Thepalienl \"'asst1l1 unwdJingtotrytomO\\~onb«l,11 There was no scoliosIS. and only slight Iim'tation of fono....rd f1eXlOll. The patlent ....1d he fell alrnait I\"\"was then dl'Clded to give tlle Ionglludinal mO\\emenl ~L usrng right Iegonlr nus was done m thes.une Rotation was \"'P\"ated t..icPand follo\",·ed b) two wayasthetwo-k);ll'CnniqUl\",as,t,,'asob\\iousthal tlw pootient would ~ be able to kicL This procedure applications of Iongltudinal mo'..ement USIng the \"\"lISdCJnl>n.\"v:l.\". wun n.'o lugsNdl hme, Right slr..ig!>t patient's right leg Forward fk>x1OO \"'lIS thtn full range k); raising was then normal. The pahent '\" as S\"en andpainJess. adeo;jU.tlt' warrung tNt some ...uct\"rb.ttlOll nuglll OCOJr dunng the nt'l<t foew hours. Forward fJc'lOO renWned normal, an.! treatment was discontinued. \"\"\"\"ddey There was m)\" 01 s1igllt flalY'-UP of sympt0m5, o1nd the II BUTTOCK PAIN patient .. ;osablelo ....lkaboutbulunab... tobend,lk Examination hadJostmostofhis'catching'paLn.One>-.1mm••tionhl.' hado1shghtProt«llH'sroIio5ts.w,ththedispLloomlent HistOfy of his shoulders betng to his Ieftside ForwardftM.ioo w;os'·eryhm,t«I,and thlScau5e<!cmtral pain .II tIv A managed S5)~arsgradU.tllyd\",elopl-dright but· lewlofL5,R1ghtlater..lflexton was'-\"r)'hnut«land lock pain mer a pmod of S d.J,)\"S while engaged 00 pamrul, but Iotlv\\eft ,t was fuU and pa,n1es6. Back\"'ard hea,'Y shm·... work 6 moothsago, He \"'a ablt'lOron- bmding. straighlleg rous.ng and nt'(\"k fIco'lm wen' all tim.., work. and although the aching did not become ~I any ..vrselldldnotimpro_eAftt\"l'alongperiodof ul\\SUC«'5I>ful treatment m,'oIv,ng .. h.at he called Theproh'ct1,e5OOliOlJI~resu1t1ng ma bIt loth<! left 'adJustmmts', he went to hislO(\"al dO(\"tor After .. \"\"l\"l'k and lheurul.ueralstra'ghlk-gr.. taingofthep.....'ious of bed rest faik-d 10 help him, Ius doctor suggested a day sugscstal a unilak'r.ll problem (predominantly further trial of manipulation (Fix\"\" 1515) nght-sidal), \"\"en though sympt0m5 were emtra!. Rotation mobilizing W,Q gl\\en wlih the patil'lll lying on hIS left ide, Aft..'1' two rolalions,lhe protect· i'·e5OOl10l'ii~Nd 8\"ne and lateral fbIon right was full and painl . Forward f1aion had Improved. but was still limit~-d and painful Rotallon was n'))Cated n.'ice without any further impro\"'lnlCl't, It was sugg~.,.;t~-d that the paht'nl should rest for an oour,aftl'T which hc \"\"ould walkabQut as much aSpolislbk provided that thcsymptorl\\$wercnotaggravaled Thirddoy Th.,re was nO exac~'rb~lion, and Ih\" p,1tlent had been n,,,reup most of th\" day, w.,rc also fewer symptoms The scoliOSis had returned, bol right later~l fl\"~i,,n was fuU and painless. Forward fl\"\"ioo was shll limited. figu\"'15.15 llbunod:p;lln

hamples of treatment 433 PhY5icolfindjngs L2. I'ostero-anterior central vertebral pressure was given firmly, attempting to give the maximum pres- The patienl's symptoms consisted of a <:onstant ache sure possible without causing muscle spasm. One fell superficially in the right \\'ppt\"r gluteal a~a_ TIle minute was spel\\t mobilizing the al'\\'a at this pressure ache did nOI SL'Cm to vary much wilh moderate activ- The pro<:L'<lurC cauSL'<l nO change in thl' p.1tient's ity or rest. With Ihe exception of extension (which symptoms or signs. This technique Wil-S repeall'<ltwice \"'produced the bullock p.lin) his spinal movem~onts more. because it was felt that the muscle spasm wa' wen' painless. although all movements were stiff. His lessening. By the end of the treatment, the ao;:he in the thoracolumb,,. area was kyphOS<.-d. but the patient buttock had l'ascd by SO pt\"r cent. said that it had always been SQ. There was no tender- 11~'SS in the bullOCk Or spine, bul with firm pJ'l:.'SSure Second day over the spinous processes of Ll and L2, a deeply situ- ated prot('<:ti,'e muscle spasm CQuld be fclt. With the Although the\",wilS lilllecha~.the patiL'Iltconsiden.'d application of this prt>Ssun', it was possible 10 I~l a he could feel some improvem,,\"t for the firsltime in limitation 01 movement in this postero-al1terior din'C- 6 months. This indicated that treatment was probably tion when compared with the areas alxl\\'e and below bcil1g din'ClL-d at the rightl~'\\'e1 Postero-anterior C*'ntral this It\",·e!. By questioning the palient, it was noted that \",'rtl'bral pressure was repeall'd, but tnis technique his treatment by adjustments had consist~-d of rotation was interspersed with traru,versc '..ertebral pressure of the iumbJr spine, pressure over the lower lumbr pushing the spinou~ Pf{)(;\\'SSeS from left to right. n..., spine, and a whip-cracking action of the back pro- n'Sult following four applications of each technique was duced by using the p,'tient's leg as the handle of the a further noticeable improvement in symptoms. whip while the patiLont waS lying prone. Third-sixth doys Treatment The SC(;()nd day's t\",atment was repeated during these Guiding factors 4 days_ Symptoms gradually lCS5ened day by day, until by the sixth day postero-anterior mOVl'm,\"'t felt nor- 1 When a patient has been unsuccessfully treated mal and it was fre<: of muscle spasm. elsewhere by manipulation, more difficulty can be eX~led in alleviating Ihe symptoms. It may lx-that if traction had been incorporated into the treatm~'llt routine on the third day. the totalttwt- 2 The whip-cracking and pressure of the previous ment time might ha\"e bc<:,n shorten~'<l by 1 or pt\"rhaps treatment would have Ix\",n eff(,<:tive only on the 2 days_ However, it seemed unwise to change from lowl'r lumb.u spine. Rotation is mor., valuabl., for mea5un'S that were obviously proving successful t\",ating th., lower lumbar 5pin<' than the upp<'r lumbar spine SPONDYliTIC SPINE WITH SUPERIMPOSED LOCALIZED LESION 3. In vicw of the d\"\"p spasm in the uppt'r lumbar aT('aandth.,limitationofposter<ranterior Examination mO\\'effiL'Tlt, it wuuld be better to diK'Ct mobilization at this lenl using postern-anlerior History cL\"'tral \\'er\\('bralpreso>un' An elderly man developed sharp pain in his left groin 4. It is possible for buttock p.1in 10 ariS<' from the and quadriceps a,-,:,a following re.t in bed for a kidney upper lumbar spine. infection. He complainL'<l of a constant dull ache with in\\('rmillL\"'tsharppains(Figun-/5.16) S. As rotation did not help in thl' patient's earli,'r tl'\\'atment, it would be beller to begin with Physicol findings postl'ro-anterior central vertebral pressure or tran5,.eT'Se vertebral pn':SSure. Radiologically, the patient had mark,\"<l spondylitic changes throughout his lumbar spine. Examination of 6. ll<'<:aU5l' the symptoms developed slowly and did his lumb\", movements revealed that extension and not n..pond tu adjustments. it may be beller to left lateral nexion were both markedly limitL'<l, causing begin treatment with traction pain in the left thigh. All other mOVl'mffits were pain f\"-,,,. l'alpalion in the L2(3area revealed thattransVl'r5e First day With the presence of muscle spasm and the likelihood of the symptoms having lin uppt'T lumbar origin. it was decided to begin by mobilizing betw(..,n Tl2 lind

434 MAITLANO'S VERTEBRAL MANIPULATION after the transv~rsc prcssUf\"-'S. The traction used was gentle and fora shorl time; 12kgwasgivenforJOmin- utes. wilh 3-second hold periods and no rcst fX'riod Fourrhday Thereappeart.'d lobea gradual but ,low impro\\'cment in the range of extension and left lateral nexion, so lhe treatmcnlwascontinuL'dandpostero-anleriorqonlr,,1 vcrtebral pressure was addcd Sixth day A further technique, that of lumbar rotation, pelvis to the right, wasaddcd Subsequent days This trealment was conlinu~d daily for 3 wttks, at the cnd of which tillle the patient said he had had no pain in hisleglorlheprt·vious3dilysilndhildbct>nableto play 18 holes of golf without trouble. Treatment was discontinued. COCCYGOOYNIA pressu!'t' at this joint. pushing towards thc right, rcpro- Examination duccdhisrightquadriqopspain History Treatment Six month$ ago, after an unusually long rideona Guiding factors bicycle which had a wide \"\"at, a wOman ag~'d34 year; developed pain in the fl'gion of the roccyx. This pain I. Ancld~rlyp.lticntwithalotofspondylitic graduallyinc\"'il,*od until it reach~'dastilgewhenshe changc.havingasufX'rimf'O\"t.'dlocaliz~'djoint was unable to sit Ihrough a full cinema programme lesion, is likeJy to b<'vcry diffi<:ult to help The area ach~'d foratleilst an houraher prolonged sit- ting, but provided she did not silagain she would 2. LocalizedlllooHiziJ'gtechniquesaremorclikeJyto remainsymplomf\"-\",, b<'helpful than general k'Chni'lue'> Since Ihe age of 16 ycars she had had minor low 3. Traction.ifitistobeused,wi1lne~dtob<'oftht' backache foHowing gardening Or heavy housework intermittent variabk tyfX'rather than the constant but this symptom had not ahert'd during the I\"st 'ype 6month$(Fig\"\", 15.17) 4. It is likdy that all suitable technique'> will need to The refcrring doctor fclt thai thc patient's sym~ beusedinconccrt. toms might be from her lower back rather than of local coccygcaiorigin,and requ~'St~'datrial\"fmanipulati\"e Firsrday trcatmentdimctcd to lhe b.lCk. to aid in assessing the SOutcc of thc symptoms. rransverse presl\\u!'t' towards the left at the L2!3 It\"'el and above and below this joint waSfX'rform~'dthree Physico/findings times. There was an improvement in eXlension and left lat~.,.al noiun, but the movement wasstiJI \"ery painful All mo\\\"cmL'Ilts of the lumbar spine were fuJi and pain- less, but the patient was able to elicit pain in thcroccyx Seconddoy by sitling on a hard scat and leilningback 10\". Iloththe coccyx and lumbosacral joint were tcnder on pressuTl'. Thcre was no unfavourable reaction from the first trealment,soinlermitlentvariablctractionwasadd~'d

Exampl~s of I,~atment 435 oc'Cn maintalned,itwasdecided to repeal thcposlero- anteriorccntral \\\"crIebral pn\"SSun'. Afll'r the firsl three limes there was an impron,'ment of 5° wilh the sitting lest,bullherewasnofurlherprogressaflerlhefourlh Figu\"'15.11 Coccygoo.,.nia Third day Treatment There was a marked increase in lower backdiscomfort. bol noimpTO\\\"ement in theabilily to sit for prolonged Guiding factors periods. Coccygeal pain wascausro by 15° of le.ming b.1ckwards in silling. This was alm051 back 10 the ori- 1 During eilch treillmenl period, the only guides to ginal rang ROlalionwilhlhl.'palienl lying on h...rlcft proglGS are t<>ndemess to pressure and the side was th nexl mobilizalion ch~. ntis side was piltirnfsabilily to lean b<lckwards while sitting on a chosen merclybecaoseonlyonesid....hould be used hardsca!. Ol,oneday. Foorapplicationsproduredan improvc- menloflO\"(lo25°)inlhesittingIL'S1 2. As lhesymptomsa\", not unilaterally distributed, the fin.1 choke for mobilizing should be Fourth day poslero-.~nleriurccntralverlroral pressure As no 'mpm'·...menl could be ~ported and the sitting 3. AstendemessiSOIlCnflheguides,ilmightbc better to begin trealmenlwilh rotalionloa\\'oid \\('sthadmaintainedilsrangeof25°fromthep~vious the possibilily of causlng back soreness, which day,lh... rotation waS applied wilh Ihepatient lying on oouldmakeildifficullforlhepatienttoa5.~ h...rrightsid.... Aflerlhreeapplicalionsoflhistech- coccygealsort'''t'SS niquethe~wasafortherincreaseofIO\"(lo35°)inlhe 4 IfrolalionisusroaSlhefirstmobilizatioll,ilmay siliingtesl,bul a fourth use of Ihe rolationdid not pro- benecessMy lopedorm il 10 one side only alone duceanyfurlherimprovemenl treatmenl,andlhcnassesslhepatlent\"sabilitylo Sil during the following 24 homs. Fifth day First day All low bao;k discomfort had gone, and the patient nOliced that the coccygeal achc had taken longer than Treatme\"t by mobilizing with poslero-anteriorcenlral usual to corne on with sitting. On ...xaminalion, the I...n· verlebral pressure was givl.'n first as a gentle oscillal- demcsso\\·erth... coccyxwasapprnximalelylhe...ame, ing procedure from L3to L5. Although Ihere WaS some but the sillingand leaning back tC51had mainlainroits lendernesl; o\\'er 1..5, lhere waS no musch\" spilsm. On range of 35\". Rolation with Ihe palient \\ying on her reassessing the palienl\"s ability losil and lean back- righl side WaS rcpcat...d lhn'Ctimt'S,afterwhichshl.\" wards,thepainwasstiliproduccdafler\\O\"ofmo\\'c- could .it and lean backwards without f......ling any mel'!. The procedore waS n-pealed Iwice more. after dis.::omfort. There waS also noticeably IcssCO('(\"ygeal whichthedegreeofleaningbackward.hadincreased tendl'Olt'SS to 20\". A further mobiliution was gi\\\"l'n. but this did T\\()tproduceanyfurtherincre3seandsnlhelreatment Sixth day was stopped. The paticnlconsidewd lhat her ability 105it wilhoul Second day pain had improved to80perc...nlofnormal. Thercwas very lilll... tendemt'Sson palpalion,botat the Iimil of The palit>flt had not notked any improvement, bul il leaningbackwardsin.il.lingihepatienl<:ouldf......lcoc- now rcquin-d wo of leaning bilckwards to prodoce lhe cygeal discomfort. The rotalion was \",\"pealed four coco;yge31 pain while silling. As Ihis impro\"emenl had limes, aft...r which the sitting It.,,1 was normal and t...n· dl·ml'Sshadgon.... ltwasdccidedlodiscontinul.\"trcat- menl for 1 w...... k to assess Pt\"Ol;rcss, and suggL'Sled Ihat th... patient should rctum l.\"arlil.\"r if th... symploms bccameworsc

436 MAITLANO'S VERTEBRAL MANIPULATION Onrwrrk/otu was also limit..>d to 40\", but all other movements were full range and paink'SS. Thc\", we\", no neurological TIlere were only odd times when pain was present. chanl)es andthepatienthad~ntothednematwiceduring Treatment this time. 0., ex,'mination, the sitting test was normal Guidingfactof!i and palpation was painless. The rotation mobili7~ltion wasrcpeatedfourtimes,andtreatmentdiscontinued JUVENILE DISC LESION 1. Heingyoung.thispatit'f'Ltwillbeslowinhis rc;ponsetotreatment Examination 2. lk'Causethediagn06isisadisclt\",ion,rotation History and traction are probably the two most importanttcchniques Following a bo.1tingacddenta youth aged 19 years developed pain in his right buttock,extending into the J. Thl'tcchniqu<'SwiliprobablY'H.-'CdtobeuSt!d hamstring area. He had no previous history of back quite firmly. injury. Although symptoms were not St.',·c\"', th~j' were prewnting him from his normal work and he could 4. Treatment will prob~bly efk'Ct an impro'·emcnt not rest properly at night (figurt' 15,18). in symptoms without maklng as much improvement in the sib\"\"\" Fif!itdoy Physico/findings ROliltion of the pclvis to the left was pcrform~>d four limes, and although this did not.>eem to make much Onstandingthepati~-nthadacontralateraltilt,which diffe\",nec to his mo\\'ements. the patient was able to increased with the limited range of forward fJ\".ion he saythatruslegkltffC'Cr. had. He was unable to reach beyond his knce5,but the Hmitationwasduemoretolightncs:sthantoafceling Secandday of pain in his buttock or ltog. Right straight leg raising The patient had retained the fn'e fceling in his leg for 4 hours, but it then retum..>d to the previous stilte, The treatment was repeated,and postcro-anteriorccntral \"crtcbral prcs:sure waS add~>d. The treatment again producedaffC'Cingofhislcg Thirddoy The patient retained the fre<' (l'Cling in his !log for longcr, although by the third day his symptoms Wt're much as they had been. T~atn1Cnt was repeated, and traction was added. This again produced frt.'Cdom. which was maintain~>d for a similar period Subsrqurntdays Thesamelrcatmentofrotiltion,~ntralpressurt'Sand traction w,'s repeated (or the next 5 days, during which lime the symptoms bI.'Came much easil'r. The fn.'Cdom was retained from treatment to treatment, and the scoliosis w~s rt.>dUCl>d by 50 per cent. Slr~ighl leg raising and forward flexion wercl'SSCntiallythe same, except that the pain felt ilt the limit of the ranges waS d~'Cidedly less. Trcatment was discon· tinued. and the patient was rcviewed 1 month laler, At lhis stage, his symptoms had remained n>Ii~'\\\"l'd and his movclllCllls wcreapproximately thcsamc, On review 12 months later his scoJic.;is had gone, and his straight

Examplel;oflrUlm~nl leg ralsmg and forward flexion had both impro' ~>d by 2. The palit'lll has had lraction admmosle..,.j on a JO per Cl'nl bul \"'I'll' not ocormaL HOWI'\\'er, al Ihis COll'5lantbasiswithouts~;thereforefurthcr traction isunlikcly IoSUCCt.W rangelhe) we\". pam free. 3, The techniques thllt can be used ,n quick BILATERAL lEG PAIN S~IOO 1og.'ec....ar<UIlIlfonnat>on for the lurnbarspineart'rotatioo,Cl'nlralpressure, II il; periectly ob...ous that oat aU pahents wiU fl'5PO\"d traetion and, J'O'!\"'ibl)·, strlllght Ics rlllSlng. 10 !n'alJnl.>fl1 by mobiliz.otion or marupulabon. How- 4. Plltients\"'ithbtlate1\"ll1Irgs)'mplorm;art'al\"II\\'s \"\"\"'\"\",1\"\\........'hentreatmenl il;~ful.uIIisadm....- sI<r>o. to ~ to Irt'lltment and dIfficult 10 help IS/o>r'ed In a methodial and ~''e IniUUIeI' (h., 5. As this pahent has a Jot of pam ~ ,,'P11 n marked hmllalionof mO....·.N·nl,Cart' ,,'iIl be~' A'5U11 can be 50 conelus!\"f' as to be of adunbge to the with techniques 10 11\\'00 ~ucerNtion. rri.,..m,g dOdor Frtquently it ..,CJb,,'ious thai a pallenl 6. VeryCilrt'fuI~lwlllnecdtobemadelO be sureof therifect of treatment asquldly as rtqUIre5 surgery and would oat ~ 10 ronsern- po&5iblc. Il\"e ......,.~ure. Although this is SQ, the W\"Of\"<~ed 7. If rotat>on is 10 be used, then the It&! side is the dominant side from the point of \\ It'W of both ocrurs sufflCM.'nlly ollen 10 justify a lrial of m;l.rupub· signs and symptoms llOl'l, because the number of treatments rtqUI!'ed to First day ..rL>ach a oonclus,,'f' f\"CSull is usually few. Rotation to the righl was administ~..,.j first asa grade I ~:t:~, ati\"\",\",---- _ mOV'-\"JTlenl. However, this irrit<ll'-od the symptoms while it was bemg done, and produ,,-'d no improve-- A woman ag_>d 27 years had a S-year history of troubl~ ment in straighl leg raising or other sig~. 1llc same with her lower back and intermittenl symploms radio mo.-emenl was then alll'mpled U a \"cry glmlle grade aling into the buttocks and hamslring area. The unset IV. lc...~ pain was prm·olu.'d during thIS tc<:hnique. On e~amlnation,thepalicnt'sforward f1e)<JCJl'l had impn....ed had beo>n insidious. with periods of back pain during the fir;t 18 months before pain spread into her leg. She had been abk: 10 CQnlinue with her domestic \",ork throughoullhis time Two weeks prior 10 admissIOn to hospital she had ool'n cleaning f1oor·\"\"'el curboard~, and after worl<tng In (h., bt\",t position for half an hour W.15 un.:lbk: to stTaighlm up. She W.15 admitit'd to hospital and pUI on constant lumbar tradlOll. After 11 days. thmo had been 00 impTOl\\.·t\"ml'f\"It In her symp- loms or her Signs Cf\"X\"'\" 15.19). Pftyskolfindlngs On examll'\\lbOn, the pal>Cnt wasonly ab.... 10 I'NCh her M>cesinflexlOOand ........·as unablf'1o flex Ialerall) 10 thclcftat IIll. Rl,;htl.l!l'1'al Bexionwas appro-..imalely 50 per cml of fuU rangt'. and she only had IOOofe\"'tt.'Il· 5ion.. Straight leg ralSmgon the left wasJO\",.md on the right .. a~ 45 , ~k»'emcnl produced by presliure O'·l'r the fourth ..nd fifth lumb.lr spinous pl\"lX.'t'!i/;('! was limited by 5OpI!l\"Cl'lli in all directions, and at thIS pollli \"M strongly prot{'Cted by muscle spasm. There were ooneuroklgicalchanges. Treiltment Fi9Uf~ 15.19 Bil~t~,alleg p,l,n Guiding factors I. Symploms Ill\\' likdy to be discogenic in origin; therefore lhe lreatment t\"\"hniqUI'S mOSI likely to .ucO-.'l'd are rotatIon and traction.

438 MAITlANO'S VERTEBRAL MANIPULATION Scm (2 In), and her Icfll~ler... l ne:<ion ~howed tiM' fll'lit joint can alw...ys be found when symptorT15 arise from it. w_slgnsoffTlO\\'cment.'Thetechniq\"\"\"M...\".,atl'Cl,bul wmination did not pmdlK.'f' ... nyfurther impID'Iemenl. 'Thepalletlt commented that the-symptorns in her back w..~ much History A ....oman aged 042 \\ ....rs compLuned of intermittent 'pms and N\"l.-'dk5' In\\'Ohmg the- who/lt of the rixht S\\'m~orn.lIK ...ll\" the patient had \"\"\"'\" much wor;,>. hand. \"TheS)\"TIlJ'tomsaf'P\"'ln'datloNstfi\\etimesdur- How......... itw;lSheorb.xkthatwa.s ...orse.andnothtr ingaday.1astingf(l(\"aslon:gasant-u-eadltlJnl'. \"'s ~'·mploms On CXMI\\in.otion, her fleo;ion and left T1'IerewerenoS}'mptomsatnight,Shehadhadthele \"tefal f\\c).ion had malntamed their progR'M. 'The !IolITll' 1'Ot.1l>Oll was attempted ...gain,. but museit' spa~ s)mpton\\S to. lesser deg:roe durmg the' last 2 )'raN, was present. pl'C\"'entmg as good mo\\ement a~ rouki beKhM\"\\'edpl't'\\iousl} On ft\"-('umlNltlon, her lnO\\'e- buttheyhadl1'Ce<ltlYI~inin~ityanddur­ mcntshad not Impro\\'ed further, It ...asdecidcd todls- alion. As far as she knew, there \"'<L~ no injuT)' or stram ronlinuewlthtNlrot...non. ...ndtoattempll'Ot.1lionon th.atcouldha\\~ca~theonset2yt'al'liagoorthe­ the othe-r Side 11\"5 could be done a little k\"!i6c;l5il)' lTlOr1' recent increase of S\"mploms \"\"dn........ was an area of twine K'TISlt\"'ity in the- mid- than to the nght, and the tl'dmique did not prodlK.'f' !horacicarea, which ...... had for \"\",ny)\"t'al'!l any imprm'cm\"nt In mo\\'ements.lhc p~lientthcn lay pron.. andpostl'f'{)-anteriorccntr~l\\\"ertebr\"lp=.urc Without ch.1nge. Although hard rubbing of this area was attempted. but this mo\\\"ement was found to be eilSl-'Cl thesem;iti\\·i1y,sheoould not tolerate soft rubbing WOl\"Sl'th,lnlll1 thcdayofth... initial{'~amination. Fol- (Figu,..151Q). low;ngilsust'a~averygl-ntl\"'l>radcltcchnique,move­ m ...nt,;we~r('d~andfoundtobcunchan8ed,. Treatml!nt by traCllOl! alld mobilization was n'qUl'Sted Physico/findings Thmjdoy Forw\"rd fle:o.ion WJS the <Jnly rer\\'ical mo\\'emenlthJt w~s pamful. This mm\"ment lacked .w per cent of Its Thepatit'nt again reported feehngwOfS('inherbilck. range, and caused sharp palll along tI\\(-' anterior\"spect \\lo\\,ert\\<.'I1tshad notch.1nged from thosl-...:h'('\\·loJ fol- of the- right arm from the- shoulder 10 the wrist. Trunk loWing the first day's twahnent. Attempted rotahOO and upper Iunb mo\\'emmts ....ere hill and pautJess. andpos«'fO-anteriorcentral\\,ertebr,l1p\"\",\",\"'''',~ T1'Ierew,\"\" no Icndemes.s in thc:renical spilw. but TS both~difficultto.-:hie..·ettusda\\th.moothe5CC· ....,/;S elCtremely It-'nder and pressu............... caused pam III ond day. It W'l\"I'l'Wd rarny ob,'ious tNt then' wa.s no the- n-gionofthe rightf'lboloo \"T1'oe pat>mt ...·as able to point in contmulng treatment hI<ther. pnxluce tingling in the hand by prig through the A mp:lognm rn__1ftl. a n>aWoI\\elumbowcr,,1 cen- ~of cornbingher hair. and thesymptomcoukl be tral protrusion, and derom~swgt\"T)' produad relie\\ed by shaking lief hand \\'I&Of'oush rriicfrisvmptoms THORACIC 1\\ 'GLOVE' DISTRIBUTION OF SYMPTOMS figyn.15.20 'Glove'dlll\"butHlnofsymjltomi Then }nJrorn<.\" ~ commonly .....fern.>d to This dot'S MlrncanthatT4/Sisthejointal...·a)'!lin\\oh·oo It may A.ofer to 1'3-7 - but It does imply symptom!i of an ill ..,Il.nnt.'dnatu.... probablyha\\·ingthcir ....fcn.-'OCCda the autOl1omlc nervous system It can Ix' appliL'Cl to symptoms in the arm or head. Symptoms a\", dull m nature. and co\\'er the whllie of thl' head or hand or arm. TI,e following example is one where symptoms were fdtlocally at theT4le\"el.llowcver, this i~ not essenlial,allhoughsl!;,lSalthcappruprialelhoriICic

still bring about a tingling, it was less inlense. The Guidingfarrors patient was only able to tolerate 3 minutes of this trac- tion the first time and 2 minutl:.>S the second, because of 1. Asthereha~notlx'eTlasuddenortraumahc pain in the mid·thorackarea. Following the second origintoaccountforth~'S('symplOms.traction traction, her neck flexion was 5° less than previously may be the tedmique to try first andthehair-comblngte,twa,unchangw. 2. Trachon in flexion should be used before traction in neutraL as the symptoms could hardlybeof Fourth day up!X'r cervical origin 3. Of the n,obili7.ing techniques, rotation of the The patient reported fcclingaboutthesameasshewas cervical spine should be used before before treatment, and on examination there sccmw to postero-anteriorcentralvertL>bralpressure havebccn no progres:;. Treatment waschang(od from because the symptoms are distributw unilaterally. traction to mobili?.alion. and thefirsttp<:h\"iqueuscd was cervical rotation to the left. Remembering that the 4. If nonc of thcabo\\'e techniqu~>s relieve the patient had been given strong traction without any ill symplOms.mobili7.ationoflheTSa\",ashouldbe effecls, lhe mobilizing wassustainw for I minute includro. It must be N.'ITICtnbered that the Following this, the hair-combing tcst was unchanged autonomicncr\\'esupply for thearm ariS<.>s from as and ne<:k flexion had improyro by Ill\". The rotation 10wasTS. First day wasrepeatroevenmorcstrongly,butthisdidnotprQ<- duct' any change in symptoms or signs. As no head- Traction in flexion was appliw with firm pll-'SSure way was Ix';ng made. the T\\{\"xt mobilization given was (approximalely 15kg) for 10 minutes. As there were no astronglyappliroposlero-antcriorcentralverlL>bral symptoms pl'{'SCnt in Ihe hand at the time of t\",atmenl, pressure, alternating thn'e times with transverse verle- Ihe Prl->SSUTe of the traclioncould not begaugw to suit the symptoms. On \",leasing the Iraction. neck flexion braJ prCS/;ure dinoctro againsl the left side of the spin- had impro\\'ed a lillIe but hand tingling could still be ous PT'OC\\'SSt'S between C4 and Tl. However, th~'Se produced by the palient combing her hair. Aftcr apply- te<Jmiqu~>sdidnotproducel'11oughchangetowarrant ingtraction in flexion for a further 15 minutes,neck continuing wilh them. II waS therefore dec:ided to movementsandhandtinglingwereunchangro mobilize the midlhoradc spine before allempting cer- \\·icallateralflexion. Postero-anlerior central \\'ertooral pRossure was appliw from T) to T7, al a pre$l;urc that S~condday did nQ\\ causc pain in the patient's elbow. The osciJIat- ing was continued for 1.5 minCites. I'ollowing this The patient felt that there rna)' ha\\ebeen a~lightless­ trcatm~'llt,n~'Ck flexion was full and painle$l;and the ening of the intensity of Ih\", hand symptoms, but the hair-<:ombing test had improvw by approximately discomfort felt with combing her hair was unchallgoo. 50 p\"r cenl. While the mobilizing was being repeatw, Neck flexion had maintaill~'d the slight improvemcIlt it was found that the pressure could be markL'dly fromthepreviousday.TractioninfleJ<ionwasrepeal~'d, incrcascd without causing local painorreferre<l pain. but this time it was carned out much more strongly By the thirdapplicalionofthemobiliLation,thepatiem (25kg)be<:ausetherehad~nlilllechange,favour\"ble was unable to induce the hand tingling by combing orotherwise,fromtheprevioustraction.ltwasgivcn her hair. for periods of 20 minutes and 15 minutl>S. Following Ihe tn,atment, neck flexion had increased byafurtlwr 5° (making a total imprm'ement of approximately 10\"), Fifth-sevrnthdays butthehair-<:ombingt~\"itwasstillunchanged There was a markro reduction in severity and dur- Third day ation of symptoms following Ihe fourth day's tR'at- ment, and neck flexion had remained full in ils range Neck flexion had maintained ilsslight improvement, allhoughitstillcausroanteriorarmpain.ThepostcrQ<- but there had bc<>nno further improvement in the anterior ccnlral vertebral pressure was repealw hand symptoms. To enable Ihe traction to be given between 1'3 and 17 without producing any elbow pain. mOre strongly. it waschangw to traction in neutral and again made the palient fll-'C of symptoms and and appliwataprl-'SSurelhatalmostliftro the patient signs. After treatment on the sixth day the patient from the chair. WhiJein this position she allempted Ihe remained symptom free, but as T5 was still tender the hair-combing tcst and found that although she could mobilizingwasrepealedonthescventhday.

440 MAITLAND'S VERTEBRAL MANIPULATION Treatment of further developments firm pl\"('Ssure was applioo over this area of the spine, strong muscular contr.lClion came into play to prevent One month lat('r Ih('TC was a mild ,,-\"Currence of symp- inten;ertebralmcwemenl. toms. which was diminatoo by 2 days of mobili7.ing the mid-thoracic a['('a. Treatment Thiscase hi~tOlY has OC\"'-'\" indud('d to show that th(' Guiding factors tht'Tapist must bl' awal\"(' that atypical symptoms can and do occur, and that on(' must bl' I'('ady to tl'('atlh(' 1. Mobilizatiun will nt\"'-od to be kept within the limits Il'SS obvious areas som('timl'S of the spa,;m. THORACIC BACKACHE 2. Symptoms are e\"enly distributoo but th\".,;, is Icft-sidLod pain with rotatioll 10 I~ft or right, which Examination may therefo .... \"\"'lui .... a uniiater~ltt\"Chniqut·. History 3. Th\" thoracic spin\" ,,-'Sponds best 10 pustero-anteriorcenlral vertebral presS\\ln' first A woman aged 31 years first 110ticoo thoracic bac!«lche and transverse \",rtebral p\"-':5sure towarns lhe 4 years ago. It came on following heavy work of an p.1inful side (left side in this case) next unusual nature, and took 2 wreks to subside. After this allack she had similar achl'S following any particularly 4. With this patient thNc are th~ things to heavy work, even though there was ne\\'er any incid('nt eliminak;theache, the stiffness on rising.. and the of sudden pain with this work. The ache would sub- tenderness with limitation of moveme\"t between side in 2 wtocks. Mol\"(' recently the ache had !x'rome T4 and 1'1'>. The tenderness and mowment will be continuous, but it was ~Ilways further aggravated by helped by mobilization. but the ache alld stiffI\\CSl; heavy work. On waking each morning thel\"(' was a may ,,-,<!uire traction markoo feeling of stiffnl'Ss in this area of the thoracic spine (Figurf 15.21), but the sliffn('Ss would di5ilppcM 5. As mobilization is quicker in its efft\"Ct, it should be after she had ococn up and about for 30 minutes uscdfirst Physical findings Firstdoy Symptoms wt're evenly dislributoo to each side of the Post<'ro-antelior central \"ertebr~1 pl\"('Ssure was given spine. l1>e1'(' weI'(' few positive ~igns. Trunk rotation to first over the spinous proct'SS('S from TJ down to 1'8 each side was limited by 20-25·, and each movement There was marktod It'Tldemt'S/; between 1'4 and To, caused paio 2.5cm (1 in) to the left of the 1'8/9 aIm. ne<:es/ii!<,ting a g<'f1tler pressure. 1l\\(' oscillating was When the intervertebral joints were tl'Stoo passively, done steadily, taking approximately 1.5 minutes tocover thl're was a limitation of rotation bl'tween T4 and T5 th\", area. The spasm did not pro\\'(' to be any obstacle, alld between T5 and To. Thel'(' was very markoo ten- as localizLod tendemt'SS prevented the depth of os<:illa- derness to pressure Over the spinous processes of T4. lion that would have caused the muscle spasm. ThC!I(' T5and To, and toa lesser extent over TJ and 17. When was an inc ....ase of 10\" in the rotation to each side fol- lowing this proc:edure, and pain was stillll'ft-sidoo. This gently oscillating mobilization was .,;,peated another three limes. Rotation, which improvoo but was not yet fuJI range, caused a feeling of general thor- acic soreness rather than a lcft-sidoo pain. After a short \"-':5t, the patient thought the ache was less than bl'fore the treatment Adequate warning of a poso;ible increase of symp- toms was given, and the patil'Jlt was askoo tu refrain from ;Iny work that she knew would aggravate her symptoms Fig~~ t5.2t Thoracicbo<:kach. Second day The ache and the stiffness On rising were unchangt-d The a'lltre of the patient's back was sore (pl\"('Sum- ably from the mobilization). and rotation to the left

Eumpln of t~atment 441 produced Ieft-sided ~In but now lackLod only 15 of its lhe passivt' r..ng.. of Int..r...·rtt'br..1 rotation was fullrangl' found 10 have imprmro and 10 be almost normal. As 11les.:lJl1('postl'fiHlnkYIora\"ntTaln'l1t'bralpn'Ol- !iOlTl{' IitnJtalion I'('ma,ncd, It w.as decided that the Sun' was (;i'en. but it was done more finnly. E,'1'll mobilizatIOns should be nepe;oled, H~ th,s fl1O\\'emenl thouShtheilre<l\"'ollS5QI\\\",itwilljpossibletoi~ not imprm-ed. 'I would ha,·., been IlII'05Sllry to mamp- the pl'eS6UI'(' 10 the II'-.'cl of the mU5de spasm, Thi~ \"'as uLJI.,theeinten·erII'b....ljotnts. rl\"pNtt'd four tllnes, still mamtaining !he 05CiILuing ~ osciltatmg t~hniqUd of lhe thud day's lrut- and tillmg 1.5 minule$ 10 complete NCh lime, TllI' ment \"'l\"l1' l'l\"pl'..ted.11>e'f'f' \"'.lIS no mUJiCIt' spasm ..od range oflnO'\"ftllmt was then full ..nd ,,\",inless, but the ,~liltleSDr8>l'S5-FolIowingthis.lhepatien.t.·itS spil'lf'~t'ery5Ql\\\" p,'en traction in two periods bstlf1g 15 rrunUte:§ and IoN,·.,It \"':IS d@(idt'd 10 10 nunule:s. The ....git'of pull on. thecet'Vical haIler ...;as tn'..tment frw 4S hour.; to ..llowthe5Ol'l.\"l'Ol.'S5IOSubsid., ..ndlhllSmake-. approximately D' from the honzontlll ..nd although ment mon' informat...., thI' pattenl had not had any low bioI:k p.-rn. the fIt=d h,pand knee position w'\".-doptro. rhirdday Dunng the d ..y following t\",atment the pilhcnt's b.Kk Fifrhday wasSQ.....,butshert'pOl1t'dthattheaochew..s~SI'\\-'I'1'l1. Stiffncsson risIng had .....mainal unchangLod. Rotat,on In the morning the piltientl'l'pQ1'l\\'d fwling very much was now only slightly hmited, bUI still caused lefl· bellt'•. Th,'''''' was no <teke, and almOl'lt no shffness on sidropain, Thc..... waslcsst~'f'Idcmt'SSlhanatthebl'gin· rismg. Rotation was nQrmal both activdy and on pas- ningofll'('allTllml,and the..... was now nomuscll'spasm si,·d}testinglhemm'cmenlatlht'intt'r'erlebraljoinl. ['ostero-anterior ct.'TltraJ \"crtebral pn.'!iSurc was Nomoo,lizalionwasgiven,buttractiollwasl'l'f!t'atoo .....pcaledgcntlyasaoontinuousoscilialionfourhml'S, foranothertwopetiodsoflSmlnulL'Sandl0minules and was interspersed with trans\"crse,'crtebral pTl'S- su ..... pushmgagainstlhe.ightsidcofthespinous l1le palient r<-'J>Ort~'<i I w{'('k la.t\", having had nO pl'llfi'Sl\"\"S from 13 to 17, pushing them towards t....' b.KkacheorstiffnessSinct'lhelaSltrcatm..nt. painf.,l left side, 11\"s was done three times. ROblinn blxamefullandpooinl<S$.bringthebestf\\'SUltOOtallll!d TRAUMATIC GIRDLE PAIN with tl'('atmenl of Ihis palienl so far. Ex.amination It .. .asdecidro to lean' assessment frwJda)'1i to allow all soreness to sub!iide again. HistOl)' Founhdoy FoIlowlf1ga ,·ehicuL... <tCCidl'llt I \",.ee-k \"go,,, man;ogro 13 years sufft'l'td a roIlapseofthc Iclt upper lobe of the All !IOI'l\"I'OCSI5 had gone and t-ladve \"';os almost nil. lung and girdie pam (Iril $>de g...... W'r than nght sode) lIowl\":er, thr patoml stllllwd shffoes.oi on. rising..;md .. tthefiflhthoriOlX~·t'l8«auwofehestp\"'i bn.alh- .although rotIhOn \"'as full, it gII,'e .. general k<ehng of ing ..'as dUficult roughtng \".lIS Impo!i!'iiblt' nd the sorenes6mlhe!horiJOcare;o. man wn unable to hft Ius lefl.:lnn ..bo\\'e tus~. He had two \"\"\",.., blocks, but thee ga,e only tempor-\"1) \"The tnO\\'C'llWf\"I\\>; \"PJ--red nonnal but some twel- rcltd\"(fWU\"'15.12) \"\",he ..nd st,ff.-- ~rned.so il was decided 10 Sln~ the patJenttr.llCbon.

442 MAiTlAND'S VERTEBRAL MANIPULATION Physico/findings 5~ronddoy The trunk was held rigid a. if to a\"oid all movement, The p.1lient Il'P\"rted having felt wonderful for 5 hours, as movements of the head cau,.,d che5t p.~in. On Ihe but in the morning he had felt worse, On examinalion, Idt sidcof llwtrunk, theconst:ml p.~in radiated thmugh- the arm movement h.,d Il'main,'CI irnpmv,'CI and trunk out th\"fifth thOLlcic level from the vertebra around the rotation 10 the lefl was possibl\" through 3O\",This il;an thoracic cage to the sternum, The rigM-sided p.~in. example of a patient feeling worse, possibly due to which was mild and intermittent, would subside with t....atmentso....'IlCSS. but who5e signs show impmwmenl rest. Trunk rotation to the lefl ca ...\"..'d pain throughO\\lt Palil'llts may rompl;,in of SCvert' pain and continue to the \"rca, hut partic ...larly posteriorly on Ihe left afler fl..'C1 Ihal they art' worse, despile improvement in signs, l()\" of mOVeml'lll. Rotation to the right cau,;ed pain for as long as 5 days_ Ilow(,,'er, the ,mprov('1Il<'ll1 in after oW', With lateral (Jexion of Ihe trunk, pain wa. signs g... ideslhelherapist '\" the choice of Icchniqu('S, produced at the ]\",ginning of the mOVeml'llt to the len l'oslem-ameriorcentra] vertebral pressurt',\"-'P'-'atedas and after 2Q\" of the movement to the right. Trunk (Jex- a firmer pn:.>ce'dure, was more uncomfortable than on ion (o... ld be performed more Jl:>adily than other rnov.... the first day, but it still IV,1S not done firmly enough to menls, bllt il .Iill had to be done slowly, Without any cause muscle spasm. The procedure was repeated obvious movements of the trunk, 50 per cent of head throe times. and tho;> res ...1t was an il1crease in lrunk and neo;k extension caused the thoraciC pain. Cervical rotation 10 the lefltom'. rotation to the left. which laCked 20\" movCTl\",nt, also caused Ihoracic pain, T\"ndernc'SS Will; most rnarkc'<.J Thirdday over thespino...s processes of thl·third to the sixth thor- aclc\"ertebrae The patiffit felt much betler. lind l..ft trunk rolation Treatment waspossiblethrough45·,TransVl\"r$C,·ertebralp~ Guidingfactor5 sure was used against the right side of the spinous processes of the Sl'Cond-sevl'lllh thoracic verlebrae, 1, As symplOms are ,.,\"ere and movements groSSly moving Ihem lowards the mort' painful left side, Afler limiled, mobilj,:ing will need to be don....xt....-mely two applications of Ihis lechnique, rotation of the lrunk gcntiy. to the left was possible through 65', This lechnique did not appear to be superior to Ihe previous pn:.>ce'dure in 2, Traction may be made diffiellil by th.. patil'll!'s the resultsil produced, Postcro-anteriorcenlral VC'TI.... inability to lie on his back withoul pain, but bral pres.ure was then carried o... t twice, resulhng in a perhaps ilcould be donesiUing range of painless rotation to Ihe I..ft of 75', The o,·erall rate of progress was cOrl.idered to be salisfactory, 3, Although symploms and SIgns ha\\'e a unilall'ral dominance.postem-anleriorcentral\"ertebral Fourth-sixthdoys pl'C$sure will probably be Ihe best procedure becao>e it is the main techniq ...e for the Ihoracic I'reatment was contmued as a combinatioo of postero- area and lx'Cau:;e symptom. spread 10 bolh sides anteriorcel'tral\\'ertebral pressure and Iransversever· k>bral pressure. alternating from one 10 the other four First day times, These mobilizations wc~ gradually iocreased in p~ ... re day by day as symptomatic progre:ss was I'OSlem-anteriorcet1lral vertebral Pl\\.'SSurt' was given made, Traction was not given for two ....·asons; the rate very gently owr the spinous process<.'\" from the ...'C- of progress was satisfactory, and Ihl' patient could ond to the se\"enth Ihoracic wrlebrae, The mobilizing, afford only the minimum of lime necl.'SSary for treat· which was done so softly that spasm and p.1in were ment now that he was able to resume Ihe fuUI'l'Sponsi· avoided, was contmued over a perk\";! of 2 minutes, Trunk rotation 10 Ihe lefl impro\"ed from to' to 25°, The \"rbilities of hi. job_ the .ixth day. his I'<'in was only of procedure was repealed twice more, after which rota- tion to the lefl was45·. All other movements impmVl.,t nl1isance value and movement. were full, although including raising the arm, The p.1lienl said that Ihe left trunk rolation and exlensionstlllcausedslighlielt pain had h.,d the 'shng' taken out of it. To avoid joint thoracic pain. Arm movements w..rt' normal. and there SOIl'll('SS, il waS decided to stop trealment for that day_ w.-.s no discomfort \"'ith brt'athing or coughing Warning was given of the f'O':'Sibility of an incIl\"'se in symptoms later in the day, Further treatment Trt'alment was then conlinued on alt\"rnat\" days for the ncXllhrt.'{' visit>, this br\"ok being cou ...-ct by Ihe pressure of his work. The Si'me routine as had been

Exampl~ of t~atm~nt 443 used previouslyw~srcpc~ledstrongly,andbythelast K'Slinj;thl'rangeofintervertebralmovemenlrevealeda visit movemenls were normal and p~inless and Ihe limiI.1lionbern'ct'nn2andLlandbelweet1LlalldL2. ache had gone. Wilhthepatientprone,strongp,,-'Ssureagainstlhe ABDOMINAL PAINS AND VAGUE SIGNS Idt side of the spinous pr0ces5 of Tl2 pushing il towardSlherighlsomL1iml'Scaused a pain in the Il.'ft The following case hislory is an uample of uncertain side of the abdomen diagnosis where m~nipulali\\\"<:, physiOlherapy was usedasa diagnostic trial. It isinduded in thisch~pler Treatment to show how manipulation, although an empirical form of treatment can be used methodically~ndcon­ Guiding factors stmctivclyasan active yet safe eliminative treatment. 1. Young pt-Xlplc with persistent symploms of a sever- Examination ily necessitating treatmenl arc oflen more difficult 10 help than middle-aged people with similar symploms. History 2 If the symptoms arifo<' from Ihe Ihoracolumbar junction, the thl\"'-'\" main mobilization. are postero- Thisp.1tienl WaSa girl aged l2yearswhowaslraining anleriorccnlral v\"rld'ml p\"-~, transVl'TSl' ,'erte- forcompeliliveswimrning.lVhileswimrning l8months bral pressure and mtation,asused for the Iwnbar ago she had a severe boul of lefl-Sided abdominal spine, and liworderof prefercnre would beas 1i.<;led. pain,andhadtobeliftedoutofthewater,Shewasable to return to swimming 3 weeks laler, and then had only 3. Wilhalimilatiuninlheacti\\'erangeofmo\\'ement occasional twinges. Two months ago, v~gue left-sided betweenT12and1.2asilexistsinthispatient.thc abdominal symploms began 10 return and gradually trans,'erse ,·ertebral preso>llre mobilization could became more persistent, p\",venling full swimming eilher be done to restorc the mowment, or could Iraining. On qUl'Stioning, she mentioned mild soreness foHow the general principle of pushing tiw spinous acrossliwbackbetwl\"CnlhelevelsofTI2\"ndL2(Fi:<ufl' processcstowards the p.:>inful side. Each of Ihese 15.23) during 'oul of pool· Ir~ining <; monlhs ago. principles would result in Iransverse vertl'bral pressures,bulfrornopposilesides. The pallenfs only symptom at the lime of lre~t­ menl waS a predominanlly lefl-sided abdominal pain 4. The inlervertebral ioinl~ T12-L1 and U/2 can be brought on by swimming ~nd, 10 a ksser eXK'1lt, by marlipulated if symploms do not improve with prolonged walking. mobilization Her referring dOClor suggl'Sled IMISh\",hould dis- 5 Th\"onlylwotru\"guidl'StoprogR-ssarepainwith wntinue swimming lemporarily, but that aflf'r a trial walking and pain wilh swimming. If walking can be of manipulaliv<:' physiolhl'rapy shl.\" should go back regulated,and thereby llsed asa guide. the swim· inlothewaterloassessprogress. ming te;l can juslifiably be lriLoc\\ when walking berome;painl~ Physico/findings On examin.1lion, all octi\"e movements Wl.\"re p;>inless but Firs/day active lateral nexiOfl 10 the l<.>flappea,,--d to be Iimill'd belwe<.>n theT12 and L2 spitlOus pnlCe5\",-'S when com- rostem--anleriorcentr~1verlebr~1 pressure waS chosen paR-d wilh the same mO\",,\"1('nts 10 Ihe right, rassively 10 be uS(-d in conjunction with Iransverse vertebral

444 MAITLAND'S VERTEBRAL MANIPULATION pressuredirec:ted against the lefl side o(the spillQus the righl side 01\" the SpInous processes ofnl and TIl pl'OO'SOl from Til down 10 1.2. amung at reducing the pushing towards the painful sidt'\", This wilS carried \"\"t act\",e hmitatlOn o( left IiIleral f1exW\"n (contrary to the four times, each ttml' l\"shng approximatt\"ly a minute. principle 'push towards the pain'). l'he5e two mobil· wilh an assessment 01\" the pdhenfs acti\\t'\" koft lal~....l izations IO'l'n\"carril'd out Ihreo. limes in eaeh dlf't'(tIDn. f\\exion be!Wt\"l'1l, Thill mO',t'f1'ICOl did not appear to The p.lllent W.lS asled 10 ...a1l 3.2 Ion (2 miles) More change. b ...... Uastlo asses& the liming and the !Il'Yftl1)- 01\" pain, fjfrhday 5«:ooddoy Tht\"n. ....;oJ no paIn with walking thiS moming. and on The patlO.\"nt ~ left abdouuna.l palTl$ 01\" 5hort exo>minalion left liItcr-al fl\").Ionsho\",ed shght unprm'l'- duraliOll after .u.om (SOO)\"d) and agilin after 830m ....,.,1. The foorth day's trNtment \"\"\" repeated, and ,t (900yd).Aet1\\eIeflIait'ralflexion looked unchanged. \"assuggestt'd th.1t ~ O.3-km (Nlf....-nuIe) swim should and there was _local vertebral SOI\\.'flCS/l from the be attempted. pfe\\'IOUS day's treatment As no reason muld be i>('t\"I\\ for assumIng that thepalienl was(']!herwor.;eorbe!· Sixthdl/y Il.,., the previous day's tr@atment was repeated She Only two momentary Iwing\"\" wert' f..lt w,th the swun. wasaskedtorcprotherwalkingt~tbeforebll'llkfasl. Lateralflexionhadimpm\\'edalinlemore.\\'O'rystrong pll'Ssurt' against tl1c left side of T12 no longer pn:>- Thi'dday ducedabdominal p.1in. Th.. tl'l'atment of the fourth and fifth days was l'l'peat~'d, and a 3.2-klll (2-lIIiIO') swim rain was !Loss scvere with walking this morninl\" Left- wassuggesll'd. sid~'<ltwh'g~'S were exp.-'riencro once al5SOm (600yd) and onCl'at 740m (BOOyd), As this indicated possible ~t\"nthday progress,lho!samemobili1.ingproo.\"jurewasn.'IX·at~\"j Nosymplorns M;uIK'd from furtherswimmmg.laleral flexion appeared to ~ unch;tngcd from the shih day. Fourth day 1\\ was decick-d to di$rontm ..... In'atment, as normal swimming trairung the pl'eCt\"ding day d,d not produce Twmgesol pam expenenced WIth the willkJng test anysymptolTlS. were approximately thesame as on the p\"-,,'iou. d.1y Althel'lldol\"thepatlellt'sfuIl5UJt\\l1'lft1rillI\\ing~ Lat~ral nexion appeared unaltered. It was ldt that tlu5 $hould have Impl'O\\ed, and OIlS(! that the \"\"alkmg gramme \" months 1iIk'r, she reportt\"d that there had test should h;weshown further p~aftL\"the thml been no further trouble. daY'l trl'atment. T...... trnent WolS tJwn:oIore alten.-u 10 trans\\'ene\\~ral pn'SSUJ'I'onIy. buldll'l.'Ctl'd against

Appendix 1 Movement diagram theory and compiling a movement diagram CHAPTER CONTENTS L-whcrc,L-what 453 S,~ 453 • The: movement diagram: A fuehing aid, a means • Modification 454 ofrommunicalionandstlf-Icarning 445 • Compiling a movcmcnl diagram 454 • Pain 447 P,447 StCpl.P1 455 l(a]wlwt 448 l(b)what 448 Stcp2. l-whm: 455 l(c)quatify 448 StcpJ.l-what 455 P'PJ «9 Stcp4.P'andddin~ 456 Step S. Bthaviourofpaln PI P,orP, P' 456 • Rtsistlntt(flftofmusc!cspasm) 5t~p 6. R, 456 R,451 St~p 7. Bthaviourof rtsistanct R, R2 457 L-whcrt,l-w~t 451 St~p 8. S, S' 457 R, Rl 451 • Summaryof5t~p5 457 • Modifitddiagram base linc 457 • MusclespaSlll Exampl~ - t1lng~ Ilmlltd by 50 ~ ~nt 458 5, 453 ~1I'OllId!lr~lnt\"\"\"l ...... THE MOVEMENT DIAGRAM: A TEACHING ~·R'rrdllCld.tmoomoSousm~aff«tsmlo AlD, A MEANS Of COMMUNICATION AND SELf-LEARNING -..nIringplM\" •• gImoa. \"\"-/suspn .. The lTK)\\'ernent diagram is intended $Olely a'5 a tronCWOI.almllll~~tJisfi'nJimtml~ly teachmg aid and a means of commurucat1on. When IIOmortJiffi·:ultthlmgrogmphyaupl;t'.lIOOut uamirung. say. postero-an!e'rior movemml of tl\"It~,n\"\"\"_If(JltIyIiOfMbodYlmilldj\",,\",la the 0/4 inter\\\"ertLobral ;o;nt produced by pressure dvottnrtk~_ (Snow. 1965) ontnespinousp~(stI!\"FigurtlO.59).new­ TM~tdiagram IS a ctyrIamic map~~~1'lg thcquillitvilflC!qlliln\\ltyofp;l~~mcnlpe~1VUl comers to this method of examination will find it bvtMmln,pulal~pohy5;olhcrapistdufi\"9hcf difficult to kl\\OW what they an' fl't'tlng. Howe'er. the movem..nt diagram mah'S th..,m analyse the -eXllminationofanyp;l~movcmcnldirtetion.Thlswili mo\\\"emL'Tlt In tl!rffiS of range, pain. ,,-'Sistance and muscle spa5m. Also, it makL'S th..,m analyse the indudc Inc amollnl b!:haviou'and n:lation!>hipsofany I1lQm,er In which these (actors Interaclto affL'CI th.. ibnom1alpl1~llfir.dlngo;~ti.c.pajn.rMl1lnce.

446 MAITLAND'S VERTEBRAL MANIPULATION MlM:menldiagramsareessentialtath~ understand,\"g af the r~latiarlship lhat th~ variaus grades af m~meM have ta abnarmal jaint signs 11lC movement diagram (and also the gradL'S of mm'e- discussed only from theelinical point of view; Ihal is, ment) are not nt'a.'SSolrily L'SR'Tltial 10 using passive dISCussIon aboul thl'pathology causing Ihesliffncss is mo,'ement as a fonn of treatmen\\. However, Ihey are essentiallounderslandinglherelalionshiplhallhe e~eluded \\,Jrious gradL'S of movement haveloa pati\"nt'sabnor- A movement diagram is compiled by drawing mal joinl signs. The\",fore, although they are nolessen- lial for a person to be a good manipulalor, th\"y are graphs for Ihe bt!haviour of pain, physical resistance L'SSCnlialifth<'learningofthewholecOIlceptofmanipu- and muscle.pasm, depicting the position in the range Janve lreatment is to be done at the high<'5tle\\'el at whichf'ach isfeit (this is shown on thl'horizontal Mm·emenl dIagrams are esS<'nlJal when Irying to \"\"p- lineAB) and thc intmsity Or quality of each (which is arate the different cOmponenlS that can be felt when a shown On the ,\"\"rticalline AC) (~'ig,m AI ,I) mo\\emeni is examined. They Iherdor\" Ixocome essen- tial foreithl'r teaching other p'-'<>ple, or for leaching Tl,ebaSl·lineABrcp....'SCntsanyrangeofmo'\"emem OI1e·s sl'lf and thereby progressing one's own analysis from a slartingposition atA to the Jimilo(thea'·erage and understanding of lreatment techniques and iheir normal passive range at U, remembering that when efffft on syn'plomsand signs examining a patient\"s mo..\"mL'Iltofanyjoint,il is only consideKod normal if firm proportionateo'·er-prl.'SSure Therompcn.nh<:'On<id. .edinth.diag'amar~pain, may be applied withoul pain (seep. 127-128),ltmal«'s proleclive involumarymu:;cle spasm and SjliIsm-fre. no difference whether the movernL'Tl1 depicted is small resi~tance or stiffness or large. whethl'f it in\"ol\\'cs One joint ora group of jointsworkingtogether,orwhetheritrep\"\"\",nts1mm The components considered in Ihe diagram are pain, of postero-anlerior mO\\'cmenl On the spinous process spa,m-fr« re5;stanct (i.e. sliffnL'SSl and muscle spasm ofC-Ior90\"ofcervical rotalion to the left from theneu. found on jomt examination, their relallvestrength and Iralposilion behaviour in all parts of the available range and In relation to e\"ch oIher, Thus the Te\"po,,* of Ihe joint to lk'CauscofsofHissuecompliance, the end olr;,nge movement is shown in a very detailed way. The theory of any joinl (e\\'en 'bone to bone·) will ha\\'e som\" 50ft· of the mo\\ement diagram is described in thi~appt'n­ lissuecomponent, physiological or pathologicaL nms dix by discus.sing itsoomponents S<'paralt'ly at firsl Ihe range nf the 'end of range· will bea movable point, The practical compilation of a diagram for one di ....'C· or ha'·ea deplh or position on the range line. To locate tion of mowment of OI1ejotnt ina particularp.ltienl hall way through Ihe rangt' of the 'end ofrange·asa follows 011 page 460-461 gradeIVandfilineithe,sideofitaplus(+)oraminus (-) sign allows the depiction of the force with which Each of the above oomponents is an exlensive sub- Ihis·endof ,ange' point is approached (A. Edwards. iectlfiibClf,anditshouldben:oalizedthaldiscus.sionin unpublishLodobscrvalions) Ihis appendix is deliberalcly limitcd in the following ways. The spasm referred to is protective muscle l'tlintA.th~sta\"ing pcsitionafthemovtmenl,is sp,lsm S<'Condary to joint disorder; spasticity cauS(.od 'mi..bl~andischosenbythether.lpistdependingon by upp\"r motor neurone disease and Ihe ,\"olunlary the d.:med df~t of th~ t~hniqut coniraction of muscles is e~eluded. Frequently thi>; voluntaryoontraction is out of all proportion 10 the pain being e~perienced, yet in very diK'C1 proportion to the patient\"s apprehL'Tlsion aboultheexaminer·s handling of thcjoinl. Careless Imndlingwill pro\\\"oke such a n:oaction,and thereby obscure the real clinical r.ndings.Rl'Sislance(sliffnesslfrt:'ClIfmuscle.pasmis

Mov.m.nl diagram th.ory Ind rom~iling I mo.... m.nl diag'lm PoinIAlheslarting~,tionnflhemu,·\"menl,i,also vari~bll\"; il1; po6il,on m~y bl.\" the l\"dl'l'ml\" of r~nSl.\" oppos,te B or somewhen.· in mid-range, whicoc ·e. is most sUlli:lb~ for the diagr~m, For ..ump~, if ee - ie..1 rotallon is the mm'l\"1Tl('n1 being n-presmlro and thep\"inorlimlt.. t,ono«ursonl)\";nthe!ast 1000<>fthe r..ng\"', the di..gr..m will ~ d.....rly demonstr.. t... lhe beha'iourofthethn.'Cfact~iflhebaselinercpn­ fig_AU -, ~ senlsthcl~2(fralhcrthan9O\"of('('l'\\ieJ,lrotation. Compkt..... of .. _ ' . '...Md...... Forthepurpo!iCofcL:H1t)\",poaibonAisdefinedbysbl- instheran~n-p<e'il'f'ltedb)lhebasclineABlnll>l.\" ..bo\\·... eumpll.\",'fthebasehnen-pR'!iel\\I59O\".Amust bl.\" .. t the poslhOn \"'1111 tl>l.\" he.ld facing \" ...,ghl for- wards; simi\\.ul)', if the base line n-presmlS :ZOO, pos- IlionA is ... ,th the he.ld turned 7O\"1Q!he left (.tS6Uming 0lhr.>r,·..n.a.tionsofthe~UneA8MedeKribed onpagt\"459-460. ...of COI.II\"Sl' thai the nomuJ \"'l'I'\"\"~ n~ of rotabon ~ PAIN 9O\"Io ...~~1 _.PoonIB~IS\\:tleu:trMleofpH5MrrIOYmIt'tlL and~\"\"\"\"\"beyondu.. ...._ofxtJ'... As!herntJ\\-..meflldiagr..misllHdlOdeplct ......lcan P, bl.\"frit .. henexammingp;u6l'·... rntJ\\\"rolII'llI. 'I must bl.\" deartvU1'ldentoodthatpoullBl'l\"pl'l'Smtsthe treme Theirutial fact 10 be etabtishN is whcth<T the palocnt ot PASSIVE MOVE.\\IEI\\.'T, ..nd thi>l tho:. lies , ..nabh·, tw.san}·pain ..ta1land,ifso,whtother,ttSpr>esenlal ~~:~ponanlh.beyond the ......In.'me of KI..... .....,;,I (II\" only on rntJ\\emenL To begin the e~~ 'I IS -.wned heonly ...... pain on mo...emenL The,ertical ..xisAC~lstlwqlUlil)·Ofinl<'n­ §ilyofthefactor1brinSplotled,poinIAl'l\"p~ts Thefirslslepi:slDrJI(»·... tlvjoinlslowlyand~ compll.\"!e ..bsence of the fKIo...nd po,nt C nepreer>ls fully inlolhe rang... being U5ted,ask.ong the pallCr\\l 10 Ihe\"\"\"\",mumqw!ll\\'orlnlensltyofltlefKtOrlQwlUch I1\"pOrtlll'lfl'lediatelywhenhefeel5an\\'d~fortal lhe ...\",mUle' os prep;ared 10 !oUbj«t lhi: penon. The all. The posilion ..1which thl5is first fell IS noted word 'maximum' 10 \"'1a11On In'mt\"1'NI'\" IS obnous; ,I me.. ns poml C l5 II>l.\" m.lXlmUm miens,!)· of paUl the Theseron<!stepconsistsof§e'\\t\"l'illsmaIlO!Clllalory e>:aminefisprq>aredlQf\"'O''Oke ·\\'!.uimum'in\",labon 1nO\\-.,men!<> in diff\"\"\"'l p\"rts of the pam-free r..nge, Io'quahty' ,,--krslQtwooth.-T..--ntloll p.arts. Theya\"\" gradu..lly moving further inlo the ...n~ up 10 the point .. hen> pain is flr.it fell,thuse:.tablWUng the exact 1. ImM\"'lIy - .. hro tho.' ...,,~mm•'.r would Slop lhe poo.llionofll>l.\"onseIoflhep\"tn..~isnodangerof t6Iingmmemo.'rltiftl>l.''painwilsnotnt.'<:CS501ri1y ex.acerbationifsufflcienle..rcis~;mdiflhee:um· inlcn:lt'bulbhea~lhalifsheconlmut-dthe merbe~rsinmllldthalitis!hev...ryfuslpro'o'oc..hon mon'menl inlO grNler pam lhere would Ix> an of pain thai is bemg sought. Thepotnl ..t whichlh., exacerbation or lalenl ....aclion. occursiscallroPI,andismJrledonthebasehncof lhediagram(Figllff'AI.J) 2. Nalllrt-whenP,n.\"Presentstilt'onsctof,SOly,but- locl pain, bul as the moveffil'nIISCQnlinued th\" Thus!hcn'a .... t...ostepsroe;labhshingP, pain .p~ads down Ihc leg.. lilt' l\"Xamlllcr may dcdd... tn stop when the pro\\'oltod pain ~3I:h~ Ih\" 1. A singl... slow mov...ment firsl. lo......rh~m.lringofuppt'l\"ulfa~J 2. Small.\".,.;illatnrymo...\"n\"nIS. 1bis meaning o{'nlouimum';n relation 10t\"loCh rompon- lflhep.linisreasonably\"\"wre,lht'Ol Ihepoint found ...nt is dis<:u~j;l.\"(\\ ag\"in lal\"r. Thcu.lsic dlagr~m is rom- wilh lhe firsl single slow mo\\,,'menl Will be dt'l!pl'r III plctedb)\",-crllcalandhuriwntallinl'SdrawnfmmK therang... lhanlhalfoundw;lhoscilialorymo\"...mcnIS. andCloml'\\.'tatO(F,s,,,.. t\\J,ll Having Ihusfound where the palll IS firslfl'lt wilha slow muvemt'lll, the oscillalory lesl mo\\·...m''OI1S will bl'-eilrriednut inap.uluflher~ngelhalwilinotpro­ vok......~a\"\"rbalion.