Maitland's-Vertebral Manipulation - 7th edition

ijlTITE~\"QRn, I,E,,·E\"A/·:\" .. mMAmITLmANJD'SI Vertebral MANIPULATION Edited by GEOFF MAITLAND ELLY HENGEVELD KEVIN BANKS KAY ENGLISH SEVENTH EDITION

Maitland's Vertebral Manipulation Seventh Edition Geoffrey D Maitland MSE. AUA. FCSP. TACP. SASP Mapplsc Edited by Elly Hengeveld MSc, BPT. PTOMT. SVOMP, IMTA Memb\" SellPor ltac~r; Int~rMrionol Maitland T~chcr'sAsS<.lcior'on. Obcrcntfcldcn, Swiller/and Kevin Banks SA. MMACP. MCSP. SRP. IMTA Memb\" Cho~~Ph~or~rop;sl ROlherlJom, UK Mn.Kay English Dip Tech (Physio), Grad Dip (Adv MMPAA, MAPA Privott Proc1itiOflcr. Mtdind;t, South Auwoll(r. Australia ELSEVIER fIlrrn;RWORTH IlU\"u., ...\"\" EOINBURGl-1 LONDON NEW YORK OXFORD PHILADELPHIA ST lOUIS SYDNEY TORONTO 2005

ELSEVIER \",;,r:~~~~\" Tho: liz\"\" of(\"oooff~ D 1>bitbnd. ElI~ 'lenre-ill M\\in B~ -.I K~) ~Ibh 10 \"\" 'ml'''''' '\" i-..Jiu.... ofltu, ..url_~a>-..d~' \"\".... I.~'\" ..·itb c!be ~ ~\"'n. ud IWM, \"'... 1'1Sll N<>pon(lilbl'puNoac_ ....) bc~\"''''<'Ol I~~'<UOC\\'\" .~>&tra. .. ~'k..d ,....)\" o.-by -.y.-..... ....-.-,. n.........oal ......~in¥- mxonlillJ IJI\" ~i\"\" i!hoa. tilhtt w prior 1\"\"\"\"'1;'\" (Ii d>e pubIi!ber; .... a llCe1IClO pcmuu,nf 1'<>ln<Icd...\", Y'~C In Ibr: t:nnod K,\"' IWICd ~ doe Cop)~'rJlIl'OC~\"I A~\"\"'. 9OT..' .......... Coun It.\"\"\" I \\\\ IT-tlP J'fllo\"..\"\",' rna) he ......,Ill d,\"\"\"1) r\"\"\" E1..... '...., Ikalth ~ Ri1\"'\" Ocrwtrnmt in PIoit.lc1phia. USA. pboDo, (+1, ~13 ~39 J.llO-t. fax' I+J) :13 ~39 :1105. c·mail. hcalllrpami\"\"i\"\"\"~cl......'·ic'.rom. ,,,\" may ~1\",rompk1.)\"\", 'C<fI'<'\" \"''''''''''1:,,,,·b,,,·,~ ,he I'J..... 'c...''''''I'''ge t.,I'J\". ..·....-I...... 'c.. rom), 1»- ''Wppon .00 ronllCt' \"\"\" \"lCfI 'C\"I')\"l'h, an,J Pennl\"IOn- b\"\" l\"'~h\"'l(d 1%-1 Sc<......\"Jedlll<)lll%S Thinl o<li\",,,, IQ7:1 hlu\"hc~\"\"H' 1«77 hnhc~il\",,\" I~I> ~i\"h<.~lllj ..n 2ml St\"ell,h rdilion 1QCY.1 II.cl\"'\"lc<.l2006. 2007 (1\"';\"'<) 1581\\-13, 97~)\"'15lJt>-.Sll(l(l...1 15111'1 lIr (I 'SOb-8!1Ub-ll i.\"......Bn.15lI Llbl'lll')' C.tlIloeuin, inl'ublkation Data A ......\"\"\"'\" ~ r.... 1bi< boo/,. I. fn\"n ,he fln,c'\" bllrary I.lbnlf)· 014.:_11.__ Ca'OII\"'J'llnit In l'utlllc:o'ion I)a•• \"...Acal.Ilus\"\" =-Idl f«1!u> booI.. I> \" ....lmlc fn\\lll the 1Al<..,. orCon:=' 'kdiall.-Iodae is. coa<UI>'l; \",*\"\",pnJ. AJ ...... \"ll~ bccomn \",-:aibble. d ....sr- .n ,rc.ol...... proccdufc.<. ~pm<nt \"\"\" doe ..., of dnot' ........... ~ The ..,\"\"'\" _\",. puN'''''''' Ioa\\r ~ _.10\"\"\"\"'\" ,lilt lIoc \",fornwionp.\"\" \",.bO,.\"\" i. ~~..,I0\"\"\"'.Hau.'\"''''\",aJCf-. ~ <tron~ .....i>ed1O conr..... ~~ \\he \"110...,,...... c->pccw~.. ,Ih ~ k> dnI& ...~••..\".,p;,;,. ,,'nh Ihc ...~Iq,<LoI .... _~ofpl'x\"c.. Working log~ther 10 grow ... ...~ libruri<:~ in t1c\\<cloping counttic~ ~ ..... .. . . ...\"\"-. _.\"\"\"--''''- ,,\".,.~ -----1-\"

Contents Prl'fac~ 10 the seventh edition vii 11. Thoracic spme 301 Prdace to lhe first edition i~ 12. lumbar spine 337 Biography ~I Glcssary J('( 13. Silcroiliac region; sacroiliac jei...I, syml'hysis pUbis 401 1. Introduction 1 14. Sacrococcygeal and intercoccygeal 2. The lIoctor's role in diagnosis and referral for rcgioos 411 manipulaliW' phyo;iolherapy 17 15. Examples of tn:atmcnt 413 O.A.B,e~rtOt1 Apptndi~ 1. MovclMnl diagram theory and J. Communication 23 compiling a r!lOYf'mcnt diagram 445 wieh Q contribution l:IyJ. Graham Apptndi~ 2. Clinical C:lilmples of ~mtflt diagf1lllTll; 459 4. AnesSmtnl 53 AppendIX 3. Examirution ,dinem~ts and moYelTl(nt dillgf1llms 46S 5.. PrognosIs 85 Appendix 4. Oinical lips 469 6. Eumin.tion 97 Appendix 5. Physiot~rlIpy for animals 475 wirh 0 conui/)cjtiOll bra C fdwunJs with 0 contribution by r 1. Ahrm 7. Principles of ttthniq~s 111 Bibliography 481 8. ~lccljon of techniques 183 Index 487 9. Application of tcchniqu($ 213 willi 0 ('OIIw!Jutioo by B. C. Edwards 10. CCr'IIica! spine 229

vii Preface to the seventh edition PhyS'Olh(-r~pislS ..re being calii'd upon II1creasmgly II... Wh,lsl le,lbooks can ne\\'d\" ~titute the- rcal-timo.' acquisition of lIlo1I1ipu1l.h\\\"C skU]\", they <an act '\" a sian· medic..l praet;1I0ners to t•..-Ip I''''..,n\" llUI\\\"er from dard and a rl.ltlio<rn from which the dirnci.ln can t>pi!iOd,os of uncompliCil.loo l>I\" ~ln'rle/rnechanic.>J. contmue t\" impro\",' \\', ith llu~ In mInd. the Il!' l!O'.od ~pinal d,sonl,.,... Manipu\"'li,·.. Ml)'liiotherapy, il is 7th I'd·bOn of l-Crt..i>l;M :\\bllI~~J.uW>\" although hal'ing cxacth \\hie ....1TM' te<l and dcsrnplion of Il.'dmkJue-, is de-.u,lus an Important role to pta\\ Wllmn!he recm'~ nuw ~ ~ ~tills J*>otosr'.lpl'os and a DVDshow- ing \\id«I dIps or aU rdc\\OUII !I,'Chrnques_ 1lus shoukJ and ~Nbi'ilationproceso>- hdp the n'ilder I\"see and appl~ mon·d.:arl} asf\"-'Cbof sr,,,,,1Tk ablbty 10 identify and \"leal\" Ith '-\"'<:h l...Jmique sucft .... sWrtln\" ~'lJun>,1oc.l.l\"\"\"lIon 01 s..--grnent.>! lom'!I and \"pphc;d>on of fum\", mobili!) U!V\"inncnl, ni!UlOOyn.utuC d)'Sfuncti<I> and II th\"\"\" dmamK additions allow srud''nb of m,lOipw3tin' ph}>iothc.apy \\{) enhance ,heir skills musoele ,mlxlL1nc{', for .,...mple, \"-'quires finely hml-'<i Mld e>:perls 10 check and refinc their skills and in hun appl), such skills clinically to help maximi'\" p.ltie\"t sk,lls 04 dlnlCilI \",\",minahon, duucaJ n~ and \",'Co\"I'<)', then the aim of thi~ rev;.;ed edition will ha'\"e t<-'duuc..l1v a<:(uraleand dl,'Ctive tft'aUTlCllt techniques. oc'\\'n \"crue' 00. \"Th.c r.t:\"itland Coocept h.>s bl.'t.'ll 0I1C of lhe con\"-.,-- Elh I-k'llge,eld - Obrre.,f,'/J(\"fl. 5\"~I;:nIa\",f ston<:S of rnQ<I.,m marupuL'IJ'e ph}<IOIh<-npy. Those Ke-\"in Bank$ - RI>rnm\"\"fl. Uk who f\\.wl' been pnvilcged l'll'-\"'gl, IO;l<.\"c.....,f{ M.lUbnJ \"I w(>r\\( will \"nl\"\" how mUch 1)1{)UI~ht \"nd detail goes mlO Ii~' .\\pplication of each individual k'Chnique of examll1ation, rllQbilisatioll or \",a'u!'u]atic'11, H,wing thp npporlunity t(l Seol and pra<:ll<X' !C'dlniq\"\"\" JX-..-furTTl<.'£1 in an o.pcrl wa...' can onl} sen\"C In hdp an} clinician 10 un<l~aJ>d and appl}' n\",mplllat\"e phnio!heTapl methnd~ mon'dfocb,\"el~II' lhecluuc.l setlIng

;. Preface to the first edition M\"l>ipu!Jtion (It the spi\"e i>, aS6(ld:llro so oft\"\" with each col><c, Th\" way l~ then prcp\"\"\"l for furth\"r de\"'<,\\- fa~ diagnosis at\\Cl 'hit or ml~\" methods 0; bruh' force. ~a!i§OCiJll{l11S h.a,·c rnulk'<l in the \",,,Iu\"on opment inlo lhe mdr\" for<:l'ful nu.nipulative pl'OC't\"d- of \"\",,,,puLah'\" treatment from rourine phY5'cal \"\"-,,h· eine. Ilw caul;0U5 and a~\\catt,tude lownds urcs arod their application. Guiding pnnclpb uf this t....atment .. oul.l be largely ~;minated if il\"'~ r\\.'Cognized that rl'll)Sl patient<; can be relie\\'ed br the ,reatmt'fll iollow and ~ then applied 10 :<op<riflC CilSe gl.'flt!er procedun\"'<. hisrorie> in the final (Npl(>r. II should be undet\"5l00d Thef-e Me m'o war-; of lIMImpulallng the c~;ous p..~lknl. 11le first, bo.oU\",r thought of as mobilQ,lnon, i, tNt ..II ~a!ml.'nl in mis boo!< when dOllll.\" b) physio- the gentl\", C(~l\"Lng of a mOYCml'TIl by p\"\",i,-\" m} th- mk,ll oscillations performoo within or at the limit (If thc-..arbt, is.,ruyC\"amed out on rrw!dical n-il'rral the range; the sc<:ood ;s the fmcinl; of .1 mOn'..\"\"nl To the m.my propl.. \" 00 M.\"l\" contributed 00 mudl (rom the limitofU.... range by a .uddcn thrust The dif- roward, Ih... final preo;enlalion of lhis Iloool: I .:1m unabl.- ference between ~ 1\"'0 technique- IN.)\" '\"l'eIJll\"ll'7'ili- lu \"~press m~ grahl\\lJ.. i1dequatdy. Will'\"ul the con_ siMI' \"·!-... comp;oring .. stronglv apphl.\"d moblli/..lhOfl \",>(1.Iruct\",~ help of tho,;,: co,><:emro wilh the Iypin!l ...lh a GOOtle manipulative thrwot, but ~ i!; an Important d1h~_ \"The patient (\"In ..lw...~\"S It;,bllt1<' po,i0!l for Ihe di,'gr~ms, my work \\\\,,,,,1<.1 h\"ve D..--Cn mobil17..ltioo1 if It ,\"\",>uld berome too painful, wht'n'.lS tho- suddenr>rSS of the forcrlut milmpulahon preo. ..,,15 much more difficult any (()Iltrol by the p,'l\",nl P\"rhculJl people Well' asked 10 undertake 1hI' t\",1: TI,e prncli<:al appru.~ch lu th\" \",.., of m~njpub,jon is of mildmg and mliazing the m\"nu\"\"ripl m d..ta,l. so I\" rdate treatm\"\"1 to Ih\"patj~nl'.~symptoms and siilns rather Ihan to dia\"noses, Such a plan \"Yoid, bolh the lhat il mighl m<'t'1 11, IlNn}\" as po:s,.iblc lhe 1lC'C'd,. fur amfusion ,,\",u§«! br diagno5tic litl~ calling to mind w!tich II Was undl'ft.llen, and I am!>Ure that the} \"'ill medilkrenl 5~ mplums 10 d,f{(\"l\\'nt people, and (on- boo abl<' 1O>ol'C how iJ'\\,ah..ble their ,,-utdance has been. troHr5y .......... pathology. lmieN, 11 i5 often impos.-. ib.... In partlCUl,u I \"'1Sh to \"~Pll'SS my \";n<:....-c ltunl<s 10 In...... ..-Nt the In1<' patholog). ;, AI60 \" \"Ill be a~ lh.at und.....,. the umbrella of one dlo1gnostic ti:lt>. lo )lbi \\I J. H\"mmOl1d, ,\\UA, MC5r [Teachers fol' ('XiImp...., 'disc ~ion', <vmptoms and si~ ma~ C\"rt.), Mis, 1·-\\1 Gam~, MCSI' rr\"..chers eerl), 'ill) •.,del}\" and n!qu,,,,diffi'l'l'nllrealrnl...ts. ~!I.\\oS M. Marhn-Jonl::>, MC5P(T\"ache .... C\"\"I.). Dr A w. Only th... spinal Ioint>; from I\"\" occiput to thl\" l:\"Hlwl!. D Ph}. Med. M\", H. S. Cul,h\"w. 8\", Dip Ed. ,,;,crUZll arC discU5!led in this 1xx,1:. \"\"d !hI' k~t hM Mr Lansell Bonnin, MCh (Orth), FlK5 ,1I1d Dr Bry,ln been planned lu 111\"d Ihe reader in logical <t.'<jllCncC frum the cXil11l111alion of Il,e different inlcnerkbroll Gandella. \\10, BS (1.ldbl, \\iRACP{Consult.ilnt Editor. le'cls to the Ier:hnique$ of mobili/.ation applocabl\" in Austr~Ii4.11 /('1...11I1 of Pll'l\"-ii.'l/lffllpll). T\"hcsI' persons by their indi' idual comments and crillos.rn!> ~ .... ronsod- erab~ guid.aoce conammg d,ff~\"\"1 ~ of the work. oarnt.~J tht' tcadung of ph}\"-';lOtherap} >tuoi<'n!, medlnl .K'Cq)IoInce and compos'llun. \\t) lhank\", al'l' du.. abo tOutr,,-ife .. hoso pairblilklOgly rrnducoJ all the dr,l,,'iog\"- I ;lm most gratdul for the murt~y \\·~tended to me durin,!; •• =ent .tud} lUI\" in Greal Urit,lin.lhc Unitl\"(l 5t.lles of Amenca and Cm\\,.da Adelaide G. D. Maitland

Biography Geoffrey Douglas Maitland MBE, AUA, FCSP, FACP {Monographl. FACP (SJ>e{'ialist Manipulative Physiotherapist!. MAppSc (Physiotherapy) G. D Maidand (19U-J, \\\\0lSb(lm inAdel.lIde,A....trallol. corresponded with in IhI> p.-..cl'ding \\~\",rs. In London. Groff h.>J ,\"~tin$; lunchtimt' climea! SleSiSions and tTaiN'd as a pfl)1o.otheraplSl from 19-J6 to 1949 ..fleT 5CT\\'U'1g in the RAAF during the M'Cond ~\\orld W,]T In d~ions With James C\",\"\"\" ..noJ hi~ staff From this Grt'~l Imlain. tour G D, \\-laltlilnd ~\"blishcd a friendship with His fi~t job \"'Mallhe Royal Adclaid\" Ilosp,t,,1 and Gregory P Gri..,\",~ tron1 1110.. UK. They had t'~tens\",,, tl'le Adelaide Children's Hospital. with il m~in inte~1 correspondence about Iheir dmic,11 ('xpctiencl's and on Ill\\, trealm('nt 01 orlhopi>l.,lic and neurological dis- this conh\"u<'d for !l1,.ny y\"ars \\-faitland d~1i\\e,,::d a p.lper. in 1962. 10 Ihe Physio- ordl'N;. Later he oonlinuro working part-time m the hospital and p\"r1-hme on hIS 0.....\" pri' \"lccllnic. After .. therapy SocIety of AUSlralia enlliled '\"The ProbIMru. of fe.... )~'il~ he b«-a\"l-.e a parNIm<' pri' at\" practitioner Tmdting \\'t'tkbral Manipulation', in which he p\"'\" and part-time clinICal tutor at the School of I'h~~o­ .....nl<'<I a den difh.'Tt'Illiilllon bchn..... manipulation lh<.'ra~ in IhcSouth A..slr\"JWl (nst1luleofT~'Chnolng~~ ,JIlt! mobilizanon and Marne a strong advocale of the nOW the Un;\"('I\"S,I) of South AuslralJ.. lie continu- usc of genii... p.lssin, mon'menl in the 1\"\",1\"\",-,,1 of pain, in addition 10 the mOre ITad,I,ona] forcelullech· ,,\"Jously stud\"\"l spent \"',If a day Neh w''''k ill the niqu<'S u\",'<i loincR.'a,;(' r,lngenf \"1ol,,,n.ln Ihis con\\('xt it may be suilable 10 quol\" Jam<.\"S C:yriax, a f,,\\lt1dcr of Barr-Smilh tibrMj' and the exceU\"nl library 011 the Ml\"dic,ll School of the Uni\"\"n.ily of Adel~id\" orthop.ll!dic mediCIne and of majOr influence on the dC\\'elopmenl of rrwnlpulali\\'e therllpy pro\\'ick'<1 by He immediatdy showed \",n intere;l in careful dm- physlOlhl'rapi5ts; ICaI {':\\.aminalion al'ld as;es;m....'Ilt of patJenb WIth \"\"\",m- \"\"'\" rrr....ll.v .\\Iol'IJ.U1J•• pIrysa.\"~Fl>tJrom m,~dtSttdeTs.lntha;edil}''5~and A\"SlmJiIl, /fa- Mn e1frpl~/1g\"J'I.°III~ thru~'\" oJj tr'eo1tJn('n1 by li\"X'fw: p\"\"'in~ movementS \"'~\"\" un<k...- J/'<M'r/millmcy !mlll'I/lr mart' ,'rr'lglh Mind II~'\",. A.'f\"\\'S\"\"lto.'<I in phySiotherApy practK\\'. G D \\-faillo1nd I..amt~d I~ from OSloop.1lhic, dllropr\",clic and TI1eI/ a\"ollot i,lemiclI/ l.·itll III<' /lwb,!i;:ms I.-.:IIIII'/,I<'S bonesetter boo\"s.l5 well \"'S lrom medical books such tlml O,I\"Il/Mlh, ,,1i,.WHlf 'IIrlicoll,rlro,i\", I10r lire Ilory \"\" thusc of M\"r)in, jo;;te.., Jilll\\~'S B. lI-fl'f11'l'1l. Jrlhn McMillan \"kl\\fldl, Alan Stoddud, lI.ob<!rt ,~l\"igne, rt.' jrrkv II chiro\"rllclol'l\" I'''-s..<l''..... 11\"',1:\"'111 \"jrlue Edg..,r C\\·n.L~, )am(\"<; erriax and manl' olher<;, rf fl.1l/l/afuls WorK is-,~ tfWmJlim HchJJs fMl As ,l Ioxtun.... h\" ernp~LUd clinicdl t'>:amino1lilm and a~~1 He slirnula~ Siudents to Wn:e lIeal· 1'J1kf,:dr:f IllS m.1n1l'ld.zlii'f\" /tOlll/qur'S ;11/'''' cull, /rto Ill(.'nt raords from the \"e-ry bt'ginning.. as he- fetl 1....1 tffrd'dJim.; tlafhl'r QIlIOflWlir- /lOt tmlllJl'y QrI''' 'one Of'('ded w comnut Ot'I\\.'jlolf 10 p;lpet' to an.al~-e WMI one is dOIng' In 1954 he- ~larted with mampula· poirt.1,t'II tndtni.J\" got< au! OJ hI) \"\"\" Iolar-'. the Ihc.apy leachjnG <e:>sion~. 11r..\",.ttml.'Su\"\"\"lslIlld '''''',,1><11,11.. prllrlical I\" 1%1 he ~e'\\\"l'<!. an \",,,,m; from a Spl'Ci,ll studlClo rffi>rt of malllp\"lat'Oll 11r,' \"\"IWII j, ex<>mi\"\",f fund, which \"\"\"bled hj\", at1d hi, wife A\"t1c 10 !il1 O\\ers<-\",s for a studr tour. 1'1ll1' 'lSlb•...J 06teopaths, rrl frrquml i/1lff\"iwl, dHr;'l~ Ill/' 1il'S.'lClIl, t(Jf\"~H~ Ih,' chin'pr<>ctors, mecbcal doctors .,nd phvsiotherap\\ llUwjlm/alnr 1<1 a,><,:;S tit\" n':'l1ll '111i, trcnlmC/I1 fflileagues \"'hom the)'lwd helIrd and read about and 50 ~r. Heron/m,,'\" or allers hi, lce/\"\"''Ila in IXcordfllCt' ll'i/Il ,h,remlsr, IN a/J«'ICfO!dl/lll,l:f, lklcdeJ ~ \",ohJ~J<mScJCQrly p\"\",i,k 1M

r ':~-'-'-\",-\"-'-''1i-'d-''-;'-''-'-fu-'_-'i--'-\"d-'ho~'-n-\"'-~-'-\"P-\"-\"-\"-\"-P-\"-\"-.-\"'-\"-'-P-Y-(,-k-O-\" MtllOpanlic ftlnf\"\"lJ~ a\",I-I\"'ft,'I' ~fjll, u'ill,.OJ wh..\"\" how lInd whl~h k..,h\"iqll~'S to pcrfonn. nnd ;\"Irrxf\"c/i<m II) ,I,nll. Sll~ smIJ, rmifi<t<'llC<'f\"'''' 'n'a,J~pt th.-'SC to tile individual situation of the patient') MillS .~...,tI~ IJWI\"\"\"\"\"'\" ,,,,d. if/I'\" C\"\"\" \"\"po\",I, and .. total (ommitm.. to Ihe patient. 8\\'11 ,..Yl1 -«Ii IW furtl'\" M.liUal1d 1\\.;>5 held \" ~ .md \"\"h...ui...· comm,t- C. ria~ 1 /19'4) T..... lbooL 01 Orthop.K'dic \" ...\",llo , ..riou:; prnfCffiion.,1 lIS.'lOO.1hOf>S: ~foo..:..\"\" Pari II - Treatl1\\l\"111 b\\- Austrnlian 1\"Y\"'oolh\".aM' A-.ci.Jlioo {APM whcft, Manipulalil.... '\\fitSSolgt'.nd 1njt..\"C~ he \"-015 on IheSlate branch comnunec for2~ \\'t.\\1J'li 11th Ed,U<m. in \\ ..OOu5 cap.1Citi<..\" ilnd iI Stat.. OI,\"-,*,t\" to (1l.>IIicn.~nn;Jall, umdon. P\"S'\" -10-11) Fed!'ra! (\",neil ior II ye,lrs. In cuuf\"nclion ....ith \"thers. he was rcspon..'ibk for the \"\",,-,ion 01 the G. D, Maitland I:>o!c.\",., .. subst\"\",i,,1 contributor 10 th.. AII!>/\",t.\", j'lIlr>l1l1 <\"f PI'Y'J\",/IWl1lj'll ..s ...,,11 a~ to other stitu!ionofAP/\\ in 1~1%~ In Im,hepul m..-di<:lol an.! ptl\\'5olothe1ap\\ joumab \"\"OfW\" id.. On fo.ward. submi:>sion f>?golrdingSp«ulizahOll in the instigation of Monica M<l,tin-JOIWS 06E. a Iead...- of the Clwtcmt Sodet\\ of l'hy,...oChera~ In Cre.ll \\I.\"\"puLtt\"e l'hysicothefilf\"; a<.V<'lC'q)r ..-hich ...... Bnla,n. M':lI''''''''' was a~1o:ed 10 publO<h ~ ...\"Oli<, which \"-\",ult..,,j In th<.· fi~t ,-od,tlon of \\hlrl>/lll MIl\"'I\"\" .,..b>equ.,mly acr<>plcd in n>odifJed lonn Inrum in 1%-1. whIch w~s 10110\\\\,('(1 by J !'oC<ond ,-.,j,lioo lnaugUlall'<esld\"\"t 01 U\",A\"\",ualian CoIkogc of io 1968. Tf\\c fir>1 c'dihon (If I'c~'wh,'ral Mo\"ip\"lalio\" WM Ph\\~oIh<:rar\"t:s fors\" )'''U\"S and a \" ....-mlx.. . o/lhe Cl.,,,ncil fora furth<.... s;\",p,\"''S. published in 1970, in \"hid.. the famVIb 'm\"'eml.... r Member o( tI~ Ph)\"'iOlhl'rap~' ~cl>l.lrallon Uoord of500.lth A~trill;\" fur 22 Wilrs di.lgram' wi\\S inlrodw;OO . ..\" ..a,lic... co-producrion Chairman ,>I rhe &pt'M I'anef for 1'h~l'i<.>IMilpy ..-ilh Ms}ennikr I liddifls III 1965_ for Ausl... I~\", Examini\"lC CoullCll rorD-..........s 0.''-'' all tho:' rurs of Ift:turing \"nd publb.h.in~ I\"'} .......therapbt5 IAECOP) lor 11 )'Nf$. M...tLmd kepi tINting patients ill> thto clmical \"OJ~ Austrilhan d,4\"'!l\"1e to IfO\\tT for fi\\e )·\"\"<5aOO a \",mallled hl~ m.l1n SOU= of learnIng ..nd adaptu'8 m<.\"n'lbcr ofl~aCJd\"mic \"bndardscommitf('(' for ide\" •. Geoff tre\"tlod pati('JllS in his pri\"M\" prM'h«1 for .111\".her fil'e r\"MS 0\\-'\" ~ yean; Jllli although h\" doscd hi, pr\"clI,,' 111 For hlJ; work he w~s hon.)u .......J wilh .,.,\\er~1 aWilrd~ 1965. \"\" r<:maintd Jcti,'e in treatingp.lti\"nt> unt;119'I~ Mem\"\"''''~Order..\" !he Brilish Empi .... in 191\\1. In 1965, one of M..Jlbnd'ji wishes Came h11..; With FtlJo>,-,;hip ..\" I~ ~U-i1h..n College uf the hdp 01 ~h 0 ...... C.......a..'Y, Hei\\d of !he PhHlo- lhcrap> School South A=Ir..i...n In',,ululI!.'' of Techno!· Ph)...iotherilptsts by I-1<.>n<.>gr..pb in 1970, ..-iII1 a OS)' and thl' South Ausl1'lIli<'In Brandl of the A\"\"trahan furl\"\",\" Fello\"-\"hip by specWizAtion in 196-1 ..1'h~.\"\".u..'I p)' ...~tion, the fiN titrel.' ITU\\lhs OOUI'lll.' IioooraJ}' ~reo.-'uf Mas'l'r of Applied 5ctencc on M\"llIpu!.>tlQn of tll.. Spi...• was n..ld In AdeLudc. In in I'hysioU\\('r~py1m\", Ill<: University \"fSouth 197~ this cvur.;e d\",e]\"I\"-,<1 Into tne Oil\" ye,lr p<.n>t· AI.l~traTi~ '\" 1986_ sr..duatl'oo\"\"ativll 'postgr,;Ju.Ill'diplom... in marupu' br;v\" phy<iulhc....p~' atlill' South AUStralian Instltut\" tiooorilry rdlow of th\"Ck;'r1\"n..xl Serlet}' 0( 01 Technology, no.... a :\\loOSkn ~ <OUt'5<.' ..I the Uni\"'~r5\"ty of50ll,h Alblrall3. Phvsi<.>therapy (CD) H.. WlIS ON' nf Ih<- co-Iouod...-s.. III 1974.. of I..... J-iorIor~ryII(e ...emb\"nlll!\", ui the Se.•J1h Ahirnn Inr......... rional f-edcr..hon 01 OrthoJ'al.'dic M,}Jlu,,1 !'oc~'\" Phr\"lCJtho,np~.including the Group 01 1ll<'.apy (IFOMT), a branch <.>i the Workl Conf.xl.....• \\bnipulab ..,(' Phy-srotl\\eQp~~ M......pulab\\'t' at,,,,, of l'hysi\"llwlOlpy (wei'll rhv.wthc..apy Association or AustQ.l1. (~1PAA), Only in 197~,,, hilc tl'aching one oi hi!; fi,.\"t \"\"uN'S Sw,ss A\"\"'-'Ci~linn o{\\1anlj>ulatiw I'hysioth\"r.lpy in cuuhnental Europe in B\"d Il:aga~, S\",uerldI1od, llid he ~ , through d~on ....·ilh Dr £Inn. (SVO:\\l Pl, (;(>nlla\" A,..)('iMi,m of \"1an unl Th<:mpy lJ'm>o:tor 01 !he MedKill Cli..... and the P<Jo\"IgradUoll<' (OVMf) and Ih\" American l't1ySiC.l1 The,apy Studv Cenl\", in D.ld Rag.oz. tlut in f..\"lC1 IUs work and itk>..s ......\".., iI specUJ(: COllCl'Pi of Ihooghl and <'CIi<>n A»ociation (APTA). ~ather than a methQd <.>f appl)lng lJIolnlpulatke lech· ruq\\ll-'S. T..... MaitlM'Id C<'>llccpt of\\lallipulati\\'e Phys.o- tw \"\",.,.n.,J ..., a\\\"\".d lrom IFOJ.,IT in app\"\",;\"tlQn thcr,lpy 'IS il!x-eame !.:nown emphiiSILCS a \"P\"Cifi< w,ly 01 hl$ .......-~;u>d I..~dcf'ship from;1$ foun,btion (II Ihmking, cQT1rinl>Ous c\\'ah\",li\"\" .. nd i1,;,;e,.~ml\"'\" \\llIdred Own Award b\\ Ihe World ConkdcT-atioJ'l 01 Ph\\\"Sica111'lo:\"<~py (Wc:rn for his life's work in 19'95' - in 1M '\" Zur.wch, Swlt~l'rbnd, the 11l1\"m.,tional Mulland T,\"..d ....-no' A'>SOC;i1l1on (l:\\IT,\\) .....as found...,j,

810graphy xiii of .... hkh G. D. \\laitl,md is a founding member and Eatii\"r in 1987, TImml'\\'. ha\\'1n~\"uHb'CSledMaitlaoo ~tlO\\Ild ,,'rill' about hIS WfItnbuhOfl s.ud: inaugural President A1Ithis w(If'k w(>uld f!N M\\e l>een po;>;oJl>le\" linout /11 myl'ito1'. thl'A-1JJit..llIdtq:pnlIlfIllOlll'flll'lt'T\" di'frrsfron' \"t~, \"d i>1 tI\", IntdldPll('S iffl. the kwinS ~uppnn 01 Ills wife Anne. thl.. rnotheT of I«J\",iqlli'. M,I r,~111T III IF, 1lJ11\"TWdllc Ill.' IVUrIll Ihcir Iwo chikf\"-.... john ..nd Wench: Anne did most of alld his l'dltKTl!4r /'TC'NrolI. l,-llraffmlllln Iotktllil t..... graphic art;. if! MdJlbn..l·s put.licdlion\", l\"J'I \"\"te<, rna<Jt. manllo<npb and ndcotaped J1\\dny of hi_ \"/Jill\"'\"ii' tTJnO.Ii,ra'i'I''1, Ir\",11IlI\"ll Il\"J rr..pt}fN i~ in rours&. Tlw1r continuous fc!Idbad; di\"\",-p1int is ont'of pI'lf\"lUl/ fl>mzl\"f /uw /l'(iic';\" .. UVrlll spclllll;( 01/1 m., \\\"'\" str~fll;th,> of the M...itlands, who an' pracl1t'- ill <tJ'fl{'drl.:l,;; ally illSt\"parable SUlC\\: II.-') mel in England during m.:-:;aund World W,lf Anne wilS aw\",rdcd pruloc- 1/1(' dm-k'V,.1<'tf1 i:\" lfl)U' 0111''1''. if _'rmll I\"'less of the Dutch As5ociation of Orthop.-.cd1C IIJld ImlTr'lml; M..nipul.1I\"·... Ther-..py (' VO~Il). tIl'llT 1'~!;tm<1'('II \",,,,,,Jfi.\",tJ.lI. 1I<'oflolsK orM\"itbnd's work, <'!lpeciall\\ through I\"'\" mod.. bioIogicul b,.~~·/.,,f;(...; thinking lind the pl'OCt.~ of conlinuo\",\" ,l5'ieSo\"\"-'rlt, iI,e 'r«rs':;llffo, l,i;;11 I.· .\"\" ,t!slil/. has l<lid the foundation for the ,.k·n~lopm\\'r't nf con· k'11lpordry dehrntlon~ aOO d\\'SCriptiolls of the physio- tr,,·n.'t1ulum rftl/f\",\"'....pto. II JIJ mll w,,'t:' I\" therapy proct'SS. .¥\"\" fllllyJrn'/0I\".J /\"\" I~ If linus IIJI\"';. Within this conl<'~t it S('\\'ms suitable 10 conclude \"\"Jd'\"1~IOJ'i\"lI nkll.l\",s; with a q\"\"h.' f\"\"n1 Pn.J(~wr L,nce Twom~', Vice II\", IJff,'S,illffi\" .Id'Iilt'd i'.m'IIIJ1,III\"\" mId for the eh,\"'cdlor, Prtlre~rofI'tly\"mtherapy, CurtLll UJ1I' l'r- I'.\",m\"\"d iOl'l/m'I\"'ml/r\" .....mmilwlio'IIII'I''''''r!' sily of Te<:hnoloflY, l'i'rlh, Australia: TI,i, u,,'/I i.< 11'C11 1<'orll, \"(\"y <,,'mi,I,'mN,' '11I\"lIriOlI 1t....·<1tN·. 11'1'1\". ili~tl,e''S'' ..I!'''''lf'/I.1i11l1,IIl.r' Mail/mld'_ ,'IJII,lwsi' PH ;'Cry.areful and 1\\\\T.ml'\\·, L 1. ~nd T~\\'lor, j, K (1987) 11,1' M~illand Ci''''I'I'f'llrJ'5il'<' \"\"'mllma/i,m 1~lIdi'lg 10111\"I\"''l:i\"\" O>nn'pt: As:;essml'fll'. E>..1D\\inaII0l'l, .1nd T\",alment 11!'I'I~,7Jt\"JJ 'iflr(l1lm\",,1 by m01't'mmll1nd foJlolr'/\"li by I'as:;i,'c ~lo\\'CmclIl. Ed~ PiI.lf.'iml TIK'nlI'Y of II... ill IlI,n by lI'fll_<r<SM'J!I oJ:l/;, ''!(.'f:< ofll~ll Lou..., Burk Churchill Li\"ingslone \"\"\"'(\"Intlll 011 tiN' pilllt'lll. /Vl'''' lire !J:J,,,,{iJ, Ille t'JI}' H{'flge,·etd n.uffll riillieo/ IIPI'roWell, TillS b l'robIlbly'hdlN' I' Ka)En~ 11>' '1Iu' ,;n,~11'6c nll'lhcJ po1>;,/['/1' u·;thin tilt di,fi(nJ Ke\\in BanI.,. ,..odin' c{Jt/:l/~IC'l/IIh/'raI'Y ulld ...~ \"\" If mMrl1'll' oil,\" ~1«Uf/llmbof II.' prP//'5<ifpll. Furt-\"\"ord in ~f'!'haUS{' K &Gass [ (1995) MJ,<cItlo4r!tIO! l'h!,-\"\",IIImII\"'· But!('fWorth-lleinemann. O\\fcrd Pag\" IX

Glossary ACCESSOIO' MOVEMENTS. (a) [>~ssi\\\"e ae<riSOrv <.ot,1\"Cl\".' of symptoms \"'hen rnO\"\" Ihan one joint or mh·\"crtL~)r.ll mm,,--menls, I'AIVM; (b) Pa:;:;i,'\" intc;- \"truclure is ul\\\"oh'oo in a mO\\'\\!lJll'f\\1 costal n'o,\"errw.'flIS, PAICM. DISORDERS. Beca~ a Spe\"CirK diagnosis IS an a~ ASSESS\\1£N'T This term Iw; three defllUliorIs: of d\"lo>nnination which is In!<lu=tly ,\"\"ry dilr.cuJI to !YUle, the d.,,;criplin· IL'1\"m ~ <lS 'the patienl's d .... 1. A!i5CS6mmt 01 the lindmg;;oilhl!eummilbonofa order' 15 used in many pl.>o:-.. m the led of Ihis bolllk. palJenl\"1Udl g;,..... 1hc L\"\"ul.iner lilt- informal.,., The .....-...on fOJ\" u_mg such II term is dclib=l~,t IS m;,>,lnt l'l.\"lUln!d Ie) rn.:aIoc- a diagno>is. Some (O\\.Illtrie!; use the term [V,\\I.UATIO:-.l f;;w Ihl> aspo.'Ct Ie\", ..[<) ttw ,.,ad.\".'. nund fTt\"e to \"bsorb the ~ 2. AsseSismmt of the change.. wtuch lake pLoc.. as .. oSsmtl..ls of the \"\"\"\"\"\",ted IL':l.1 The .. tlen1ati'e is !II !>!Suit of the us.: of a t«hnlqU\", to prO'c Ihe clfed ta,k in dIagnostic tenl'll>. bUI Itus can oc'COme counter- of the te.:hnique on til<' d,>oroL\"\" al\"\" to dC'lcrmi\"\" prodUCII'!, b)\" clouding lhe ,mpocl of lhe relatLod lext Ihe <\"fll'Cl of the Ircalm,,'\" hxhr\"qul'S and th.. treat- thu\" losinS the key of Ihal rel,'IOO le~1 menl Sl.'SSiOll> on the disonk•. [VALUATION, This term is not u:>ed in Ille 1\".\\1 of 3. ANALYTICAL asS<'S,nK~ll j, ,,\" il-<,,«menl made Ihis book. but it ;s understood to mean a form 01 durin);\" Ir(>illme\"t or ilt the rontlusio\" of t~lmeT1t. A~So.'S<->menl (see A,se-smt'nll It take!; into acrount all d.-t;ub of th,- patient's pil.S1 ilnd pre5Cll1 history. IN.> di.1l:n.l<!lc rle\\.il,ls and the GRADES OF MOVEMENT, 5.,... M.,\"e\"'''T1t hi,...,resp0ns<5 to the d,ffert.'fll I\",..Iments which ...i11 HYPERMOBILITY. Sec lT1stabllity. Hyper-mOOlhl)\" I~ been adminisll\"nXl. ThIS mllecbon of mfor· \",,\"hon IS analysed so a' 10 alkn.' under!;taJ\\dmg of ..,In ~,\"-\"\"S\" rang~ of mCl\\emC'1lt (e>.\"mples bein!; the hkt\"ly fuwwoi the p..I;.....'S disorder hype\"\",IL'1lSioo of th....lbo\" Of ~..,) for which the.... is ASTDUSKS. The use at ~ ;1' !he n=rding of romp\"'te mUSClJLuronlrol thu~ prO\\idmg~tabilitv\" each palll!fli se.=UnabOf'l findmgs<lnd IlUItmenl ~ li\\STA8IlITY. This lenn is USt'd onl) 10 meao <In ..has onh' one rurpose; it is to /''S'''lSlrl Ihe milu' riements ncl5SI'\"\" range of \"b0()l'lTl.11 mOH'm.'.Il1 for \"hlCh lho.'n.''' no prole<:II, .. mU>oCulolrrontrol. found. n.cu l$' saves recording lim<> ,,00 m.o\"-o the IRRITABILITY. Irril1bi!J~' means lhat a btll.. acti.·\") thl'filPlSt quickly ........... of ....senlIilJ romts ...h8l milkirf; causes\" lot of pain that t.ake;. a relalL.-...I}' long bn... to Ol'1lle\" In mill')\" cases this is an lndk\"tion thai <:iIU- ~_ Iioo ;~ T\\.'quired dUTlng ......,lUllolhon and t.-mIn\"\",1 COMPRESSION. This is Ih\"al'l'r<)~Im.ltionof OPpoli- p-~ ing ;oi\"l sUr!:t<es, either in a positiun or duri\"g .1 m<)\"eml~lll, 10 asse,s the .>ource of '1'1l1plorns and to IJ\" 1. Its 5usc'-'plibi]jl} 10 becomi! p.1i\"fuL used as a lreatmc~11 !<-'Chni,!ue 2. How painful II oc'l:ome<. 3. Thl.' k'T1gth of timl.' this 1\"'\"' takL'S 10 reco\"L'\" DtFFEKENTIATION. This arplkos to examination p~ures Ih\"l assess which joint or ~lruClu\", is Ihe ($<~'J\"'1gesS. 116-117). JOt NT. This word rd'-'n> to all lllol intra-articular slrue· tur('<;, tilt- capsule ,,00 all Ill.. nOl'-eOT1lraclit\" t!.'>,UC5

xvi GLOSSA~Y !h.>! move during \"'''''ry pas.siV\"dOO dcl,,,(' mO,'Cllll'nl. NEURAL MOVEMENTS. This 11-,\"\" is!lti1J nolell'llrl)' 1'-TRA-ART1CULAR refcrs to llw.'slfUeture(S) (f1) from d<'fined, and 15 .1n unfortunate term boxau;;e it can be thc~bchondral bone to th<> subchondral bone of ~dj~· misunderstood and prtl\"ldl' fud for the disbehe-ers a'lll joinl surfaces, .nd (b) including e'n~\"\"1!ling\",ilhin It refers to ner'''' and thl'lr ,nfmstruclurcas \"Til as to the joint spac~. ,ncluding th~ innl'f c\"P\"u1\". PERI· the connecti,'t' tISSue llul support. them and th.......gh ARTICLlAR ref...... to 5lructures OU~oi' tIlE' joint. act....- which ~' pas5; enol 10 ,..ld mduding tho! au\",,\" rnpsule I. Vcrtd>ral (,lna1 LATE.'\\lT PAIN. s.,.. I'\"in. a) duT;a h) other mminges LIST. ~ J'roiol'di\"e I:lI'formil)\". 2. Folamin.o.1 canOll MA~lruLAnON. l1li5 term is ~ in 1\"'0 dislilld 3. Pt'npheral t1sBueS \"J}'<;: a) neT\\-.'$ I. II coin be w;<>d 1oo.s<>Iy 10 refer loany kmd of h) lIlM'shh..II.-...s 'p.lSf;I\\e lno'emenl\" U5O'd in e\"\"lll'fldhon (W c) support\"·,, h....Ul... In~ltlll,'nt (\",. J',,,.,j\"l' \\lO\\·\"m,~,!.and d) osseofibrous IUnm'!s, <'Ie 4. Up!\"'r limb Ic.nsioo Ie L~, ULTT Thi.~ is the Moolli~ation). eommonl)' uS<.'Cllcrm. but on beconfused wilh other ,Irudu,...;' 1t....I, ,m''''''mg m\"VL'TllL'Tl!>;, AI 2. In a restricted definition, it is u~ed l<l mean. this stilge ,t would be !x:lter .If..:l mo....' ilCco>ptf'd by small-amrlllude rapid mo\"\"nl<-~t (not nl'CC'5,;,lril)' medic.. l pmcl,hon\"N if 'upl'\"r 11mb ne\"ral !\"'rf(lrml'<l .lIthe hmil of a rang.. of movement), mOH'mcnt tests' or'''PI~r limb neural t\"sts', whl(h th,' Il,ltknt cann\"t p....,'..nt t.lkil1g pl.k;,'. ULNT, \"'''''' llSL'Cl, MANII'ULATtVE PHYSIOTHERAPISTS This term 111c11111es m,lrlll;llthcrapists, c1,nlclan, ,'nd thcr<op,~t< OVER-PRESSURE. Every ~litll has a J><l'6i\\\"e r.ng.. of motion, which l';'\\c\\',>ds it.. ach'l' range. Further nor· MOBll.IZATION Thisisall{'lther'pJ~i\"elTlO\\('ffiffir mal mO\\em\"\"t c..n be addL'Cl to thil; pilSSive rangl' by but Its rhythm (X'I' p;lges 5, 176, 179);lOd gr~Je (SlT a stretching applkatiOll of o\\'eT-pn>ssu~.This O\\'cr- p,'g<55, 176) \"'\" such IMI the p\"ti\"nl (OT mvdcl) GIn p\"\",,\"ure rilng\" \"\"11 Cau..,., \" dL'g\"-.... of dis<:omfort or p\"\" .....t ,'''' be,ng perlO<'med p\"in. iloo should be dSM.'S6<.'d befOf'(' de<:laring a joinl DlO\\en\\el\\! to be llOI'lTIil! MOVE~E\"''T. Thh is synonymous WIth the tcml \\fOTIO' which i.> used in ;;()IJU.' EngIisb.-spcaking PAIN. ThIS IS ..-d ill this Ix:lol to ~ t many kinds of \"\"in and L.......... indud\"\" oth..'T scnsatlOnS such countrios. GRt\\D£S OF \\IOVD1EJ\\,T RHITHMS or \"\" discomfurt, aWilrcr>£'SS of. lIbnorm.alit., tr.., i\"\"\"\"\" \\10VE.\\I[NT; fhe:!,e MO ter=; SoeI'\\'\" <>nI~ one pur- etC. L-\\.TE'lT PA1l\\, of\"hich lhcreare m.:iny prt'Sf.'flb- post', thilt ~ I~' d,·\"cribe mol.. ~bbre'\\·iotk-d form the qUilhty of p;>ssl'\" treatmenl lIlO\\\"mrot hems u>ed. lion;; ('\"\" \"\"Ses 166, 167. 190-19:!1, refers to \"\"in and 11ll' h.::1\"ITlll are not essentLilllO the pr<K1ice of pas.i\\';:- tile other S<.'flSIborls which do not rome 00 imrnedi- DlO\\'emmt treatment.~·a\", ~\\' U!oed.as iI mlYl\\S atclva mo·cement occurs. but \",ther ocnu ~t \"arymg t~ aft~ lhc InO\\cmenl, or after a position is sus- of quick l'lX'Ording .u'od c~unk ..tk.n. tained. REFERRED 1'1.1:-'\" ;am pam. discomfort or other sens.otion which ill f<'tl III II place whidl isdt>tIlnt MOVE~I[NT DIAGRAMS. The!;e;are txpl.o,no:d in from its SOUl'«'. RADICUl.AR PAIN: Ihis il; iI h.::rm deMiI,n t\"\" .ppmdices. Th~~,., nul l...~tialto the r,.]atoo to .. rcfcrn.'tl P.~1Il \"hich is &eno.,.ally recog- pr;>('l,o' <If I\"'illment. lhey do, howe,'er, 1M,.... t\"\" dl.... nized (rightly or wronj:ly) to be a clearly defined \"rea lind ...h-anlilse ot fon::ing th\" !her..pilit to <lnaho(\" related to a l\\CI'\\'C root. THROUGII-RANGE PAIN' whilt .he finds when passi,·\"ly moving ;a jo'nl. Thus this is,' pain which is fi ....t fcit vcry corl)' in an av,lil- the:-' iI~ iI self-le.minJ; proc~, • toi'<t<hing nl<->di\"m abl\" ran&, of 1l1<l\"el1'l'''! and whleh conhn,,~ unhl ilnd .. n\",ans .)f communicalion. lhe limit of th\" r\"\"6\" is \"-\",,h,'<I. END OF RANGE I'AIN, th;, differs from thl' above it1 that the p.,in i, felt NATURE OF A DISORDER. This rder. to '''JX'Cts \"r only when a mO\"COlent ha, rl'\"chl'<l, Or almost \" probl ..m IhJI \"'quire consider.. tion in n,lmi'I.'!,on ....',]chOO, it, limit of rang\". An AFrI;R E1'FECT is quite ,md t\",.. tnwtlt pmc,'du,('!;. It m.. y io(lud,' th\" p.. tho- mmmon, and ,f pR\"\"\",tIS Huh\"at;\"c of\" d,sc dlS()Td..r. bi\"lvgkal rroc,'S.><'s und\"rlymg the dborU\"r, Wl1tribu· What is meant by the 'I\\ft\"r \"ffl'Ct' is th<ol, having nnl: f..Clon; such ..s o,teopomsis, stagt of healing, sLlge Jnd stdbility 01 the diwroer. iln<! c\"rtail, p;:r~{)nal f.... tu\"--'S such <os tlw f\".r of mOl'ing.

G1<»>a\"l xvii performed acth'ities in an unfa\"uurabll' manncr, the PKOTECTIVE DEFORI\\UTV. A ('Ommon 'pmteo::ti'\"e p;>tio:'nl may l10l \"'\" a\"aIe of;1.5 h.wing any effeo::l BUT do.>formih~ in tho! cervical!ip1I1e'~ the 'WRY XECK', \"\"ill know all aboul it b:o·tl>o.' follo...ln8 mormng. \",nd m the lumb.~r ,!,,,'lot\" is a 'SCTATIC SCOU(})lS·. C;CIAnC SCOLIOSIS I!! an ,nexact tcnn beau\"\" lhe PASSlVE MOV£MENT. An)\" lr\\On;:mmt of a mobile ~mmt whIch i> produced by an~ mroll5 otho!!\" thdn 'so·«olio!>i$ (protectiw deformitv) (;lin gcrur without the pdrlicuLlr m~ ~lated 10 tlt.ll pdrlKu\\.lr Slog· mcnt's mo'-em....1 is a p.1SSI'-;> ITI(l,'cmenl. It includl'5 alic' p\"In. Iletter kTIIb are LIST or SHIFf (str P\"80 both mobiliLllioo and m.anipulahoo, 131-132 ,md 350). PHYSIOLOGICAL MOVEMENTS, TI>o.'.c a.... adi,,, and pa\"\"i,;> funclional mowmenls. P,'>oS,,-e physIlr RADICULAR PAIN. ~ I'ain. lo~ical inll'rverlebral m\"\"cmem (or inlcr-segm\"\"I,,1 movemcnts) is lIob.....\"i.1'\"d 10 I-'I-'IVM REFERRED PAIN. Sco.' I'\"in. PROOUCEfRErRODUCE. '01.1' aim of physical \">:am- SCIATIC SCOLIOSIS. 50...: r\"'I<'(!ive Deformity. inatllm is Iv provoke, with lest mO\"eml\"llIS, etttler an abronrm.'] I\\.'tipol'L<e in an appropriate ~i'e or. whcn SI:VFIUTY_ A .ymptom 1S <ldilled as s<'VC'\" if the ~\"Ullcd to lllI! diso<dc<-. \"\"Production of the ~\")'mptoms i>elivil)' 111\", Caus<:'> th~ pam n\",-ods to be interrurtcd and ~'0l'rro lx-'(:\",,~ of the intensily of the rain In many (,1'><'5 this is an indicalion that(aulion is ne«ic.'d wllh e~MlUnahonand tre<ltmml prucc<lu\"\", SHI~T &..: Protectll<' DI,'!onnll)'

Chapter 1 Introduction CHAPTER CONTENTS Dealing with problems of diagnosis lth~ ~mov~m~nt 3 'BRICK WAll') 6 Manipulatio'> 3 Mobilization 4 Th«>. , J Manipul<Jt,w: Ihffapy 4 ~ relationship bctw«n lech\",qu~and \"ppropria(~ wording 9 asscssrn~l 4 listenif'g 10 IL.denceT~~(~c~mnioqd~e~of5thinking. the primacy of cJini<:al 6 wmmation 11 R,lat'''9 m .. tm~nt to the history. symploms and !>19m 12 ~~llt ..lId anatytj(al ilssesment 12 Two mher~nl capabiliti~s of th~ body 13 Summ~ry: the 'C(mccpt' 14 _ MunipllL1lion is NOT as man)' \\\\'lIulJ II,.,,' u~ 1.>1.']jl'\\'~, doct not mean thai thdl rn\"\"illuldlion is 'Ihe be all an '~mpincal' t\"\",lm.,nt. Thi~ is largdy duo.'10 ad,aoclS in mockm tI.'dInoJogr. particul.:\"i~· \"ilh th<> capabilities d\"d end all' in the o\\'f'rall mdna8emcnt of pal;e\"l. ol' mod..'m rompulet'S.- Although mo~1 authors on tlw ~ dt5Cr,bc ll'Chmques and technique! only. lhe 002:1. wilh ,'ertebr<l1 di\"\"rd~n; How\", ...r, tho.'SCOf'\" of appli- (allon ~nd the sk.llls of manipul,'hon .'''' not sufficiL.,t1)' err' of this book is .digno.od \"\"th UIO: foUowmS'luot1lion: ....,,11 .lppll.ooaled m many doctor- <100 physi~ dpiMo. II ;,; important, therdafl.'. tnat \"\",n;P\"I~lion Dt$p,u ,r~ J....,~ pflnr /vmg <.,'IfIU'lhing U; Il ~Id be gi\\ \"\" \"\"ITa emrhOl5is so Nt the dpproprbtI,' '/>*t wx', ,.mdl,-\"'l ~.J.lm-t~ lfilnwlr rlrli,>11TSS. ~ders, the ~~r.!' and lhe U!lll't'5, will use maniJ'Ula- MtJIlIJ7I<J~litt' t\"\"\"\"p~ lm...!ly~!hI­ non III lis propt'T conlnt and to it\" fullest \",,1<-,,1 lMllmnll ,>{ktu·!lIKt p.;in bv~\"S r~\"\"lptJ1~ ~t.uupw..tion i5 not lik\" S\"me of l;OIf (Fig\"\" I,ll (~\"\"\"\"~OI'~J t~'bJarlbox' n\",.\"a..q..ny when! the pLty~ Ux'S a tKhmqlM' to h,t;) batt III III<' dU1'C'hon hl' wallIS it tu go. allhough most poop~ lmd ,mJ MrlJt<.;J;.-\"Uyai¥yi\"i tlmr -.t,ll. flJll'u/,'- to to \\b(' l<-'Chniqu\"\", of m.>mpul~h(ln in thIS ....ay. bri\".~ a\"-'tlt _jrr...-..mllJ/roll/ro\".... TM \".~f'1Il~~ r!Ju\"\"lllmpI_\"'\" m~ I/Ii' 'bl\"\"t /lux' M\"C\"1l\"' I~ r. L~lnpulahon is \"\"\"\" like ~ 8\"1l1e of..:hl'ss (ri,'U1l' l.2) mf'lvlJI r.TcrpI III /rlOO<' IIls/al/,n U\"k'\" rrli\"blr ptlllk1IO:S'C'IIJ.'\"niols \"!wI\" d,ffl'R\",1 'p,(\"«\"<' can b.! mowd in lNnrdiffclUll (!mi' &\"'k I'~\"\" Prn\",,,ri.m, Tn'Mnlwl, R\"\"'rl,..h SYIIII~)silllrl, The /IIanipulali\\'C I'hysiOlhempis15' and sp«ific wavs, and where plolllS an.' made and Association of Australia (MI'_\\II), M.lrdl, 1%4) t!e:;lrovw and changL>U unli) tho! l\\o,a.l ~ achieved Although Ihis book is ori ..nled ~lmust ~\"li,.,ly 10 An even better analogi' is Ih~ game of Conlra(1 trnlmcnl by m.nipulalion (i,e, pass;>', mo\"..m~nll, il Bndge (FiKW'1' 1,3/. Here (tlmmlluicatim\" in Ihe 'bid- ding', plays an import.\"'t mil,', a~ abo dot'S the a,S\"Ss- menl of whe\", importanl kc\" CMOS are hkel)' 10 lx\" In lhe ga~, th.. technique of plal'ing the cards requires

2 MAllLAND'S VERTEBRAL MANIPULATION Fog\" .. 1.1 Thrte~hni~ueofgolf Figu,\" 1.3 (onl\".\"t 8rid~ ,o\",idl'red. thoughtful pLuming. E;,(h facd is UllpDrt- The \",rowlh and expa,~,ion of manipulation wilhin ant 10 the whole_ and ,,~[h nl\"l.'ds to be integrated with roulin\" orlhodox m\"\"';cal care is mosl cncour,'ging for the others with knowledge, skill ~nd experience th<.- p\",ierot, particularly ,os goveITLrnL'f1t-nccf'l'(litt.-d postgraduate wur>;Cs are conduck>J in manipulative The 'conc<->pt', as it has come to \"\" known, of m,lI\\;pU- phvsiotherapy. al1d also as there is [lOW a 'spe::ialty lati,·.,trc\"lmcnl embraced in Ihis t\"xi is ba5ed, sllbj<.'C1 of quaU/ieation' within the physiotherapy profession in COlliSE' !\" wa!7'\"\"is, up<m tJx, symptom response (its Ao,lralia_ hen the wort.! 'mampula!i\",,' is accept..:1 slle, its qUQlily and its bch,w;our) to mr\",cm~nh; and by 0'01'<.' medical practitioners. This grenter I1Wl1nmess positi......s, It is the mo,-em'-'f1I!I\",in response that is half \"f the pl;>ce of manipulation wilhin the con,cn'.,tivc of the wnQ'PI's keystone. the olr..,r half tJ(,jng \"n\"lytica1 nwnagemenl of P.'hl~lts wilf. roeurolnllsculoskelelai aSS<'SSJl1L~'t. It is tl.., analvtirul u>Sl.,;smenl that ,.,,,<'als dborders has wme about by a growth in the skiHs and thl' ch~ngl\" in the pain!mmemcnt l\"e;p<IfI.WS during the applicati<m of them, togdher with a growth in the t\"'\"lmrnt. ability to \",late the prognosis to the d<'gl\"l'C of the pat;e\"t's disability. Kcyston~> 01 the 'conctpt': There ,lre thn::c m.lin fc\"tures about the ways in As~sment whkh manipulation is pcrfornwd today Ihat h,we made for its more ready acceptance: M=m~nllll\"in f(SpOnSe .nd i~ adaptation in trcatm~m to thr patknt's current episode 1. The realizahon by tlw medical professiorl of the Sr><citk mode of lnin'i~g whc~ dcali~g wilh a emphasis the manipulmive physiotherapist plaa.'S giv~n di'9nosis on lh~ wnl;nuous analylkal a..essment before, during arid ~ftcr the application of e~ch lechnique during e~ch lre~lmenl session, from session to ses- sion Ihr(n,!;houl trcalmerll, and Whl~1 I\"'<ltmenl ~~ dis<;(mlinul>J 2. The gentleness of the inilial 1\"',1tment lcchniqucs, wilh stronger k>o;;lmiquC$ ~ing us<-'Cl only wI\",,, lhe inili,,1 ted\",i,!u(,,; h\"ve Ix\",n proglL'S.'Wd gradually and judIciously. 3. The demonstrable effecl of such t\",,,tmenl and the rdinl>J information it can provide in terms of dif· ferenlial diagnpsis and prognosis.

Introduction J TM l_a~1l§I Kttplancr '\" mar PI> al<Oll is du. 10: another person or pieeO' or eqUipment. Pass;\\/, rom'l!- IY\\('flI rna\\ ref...- to the ,01ll1'S.o«essor)· mov~lS ~ Conlln~ IINIytJaJ a~enl II!; ph\\<,ologkal fI\\O\\·cmcnts. Physiologic... move- Gtn\\ tnei6 \",fin;w' rr.:.tmCrlledln~ mfnl~ are tho5o> \"\"\"\"\"'<MIS that patients can perform Et'ttU of &e rr.:.!J1ICnt \",lid nn 9~ ~.ntmmt Kti\\·e...· br t!I.l'm5el\\'ol\"); K(K50ry mcn-nnenbii af(> tel d,ffertnlial diag\"\"\"s aTd proll'lO!oK tho5oe IT><nL'IYlt!I\"IlS of tlwtr JOInts thai individuals (.an- not ptrlonn aeli\\ d\\~ \"\"I \\\\ ruch (.1fI 00 perfornu.od on The go.'1M:ral a(cLl'lance of manipulation has nt'\\,('rthc-- them b\\ anolt..... p<'IWll. For t'umple. il is impossible Ie..;\" bet.\"Ilsluw, and Jnanlpulahon,~still far from \"'-oing: l\\l mlal\" am interphalangcal joint \"'th ely, but il can US('(! 10 ils full\"'l potenl;a!. There are IWO reason,;. for be n:;Kall.'Cl b} somC'bod\\ l\"Ise.1l\\en.10\"\", rotalion \"f lhe Ihis, Firsl, Ihe diagno:>lic litl('~ u;;ed b}' sum\" m<lnipu· lllt\"rphalangeal joint is I\\n accl'SSOry rnovellK'l\\l fur lalON, on which lhey ha\"\" b,I....~ Iheir manipuI3li\"(' thai joint. An)' of Ih.\"., mO\\'eml'l1l!; <-an Iw pcrfo'mt'ti treatml'nl. arc unacceplabk 10 Ihe m,liLJrily of the mL'<I- slllwl} '\" al sJX'<.'\\!, £\"Ilily or vigoro\"sly and through ical pJ\"ft~sion.lhe S<.'crmd \"'''SOl' is IMt !l<'me manipu- iMge ,,, ,m,,11 amplilude:; mld ,Ill! b<.' cal1<'d p\"s<ive latio\",\" II\".\" bL,,-'ll performed i\"iudiciou~l}', resulting;n llIll\\\"menls. dlSobl..... - Ih. liIcTi.lur\" p\":)\\'id~ thoe e\\ idcnce. HoWl'H'r, such ill(;idcnts >hould bo:' ~n m their nghl I'I-ss~ m~me\"1 ft'Ia\\I ~f., tell\". pnls' acrnsory Of conw..1 Toquot\" Brewerton (l~): ptly\\iolo~;cal ff'~nl Ch'sp'tr ,Itt ~ of11_ Clt$<\">, t/try mllst br ltJ'l MANIPULATION i\" P'l'PI\"\"iot'; Ii l<tRSlJ IO\"¥\"Jpall.lJ I<'rll. Ihr l1w word 'm.lJUpul.:lt>on' can be> usN ;n man:\" wa}\"$. \"TXulIfm' IIttJI un1!1fi!¥ srNfl,oJ!.IS ~;VTJ r'. ,~ \\lC,hCd.l~, il can be used loosely 10 mO'an ~\\(' m<:'\\'..menl vi am lind. 1here are English dicti<>n.~ry A\",,\"lal\" liUntl\"\"C>YT II ~ (1(10 ........ dl'flO;IIO£IS or manipulallon. and medical dictlOf\\,lry Dun'llJ ,111$ N1V IIrnr ........ 16 (.lX} _';ipII&iIOO dettnilioru:. Medic-al dclin;lion, \"\"1)\" ffUm pTad\"\")I\"ll~r lI'1lrt\",s rrgu14rly .... rh<!M1\"\"T1I 1I~..,n>UIJ be rd~J lorr,lClilioo<-r <md from ochooll05dloo1. \"lampulahon.. upon to Mtmi\"\"lt.lr \"I JtusI nl~ rr«t tDdI dar;; 1Ir..f moblli2dhon and pa*l .... rn(\"'em~'IlI can be, and oflen Illb lWlilJ \"\",\"\"11 illrrJrnu(l( 1 III 10000000 ItID\"'J'ull1\",ms. MC, \".,..'<1 synonymoush'. t'e\\'erth..less, the manipuJa- More 111.'11 40 }·..a~ OIl, IIti.> I> >lilI \",IMi\\'('I~\" unchang<-d I\"\" phrSLolherapi,t is in a ).'OSllion 10 ,U&;e.l prcci:,(' D,....slers C,lI' be a\\'oided by adhering 10 the lollow_ definitions for lernu usN. In lh;~ bool<, Ihe \"'oret 'manipulation' will be u-.ed in IWo ways ing three rule> As a gene,al I\"rm 10 row, any form of pa~il'e 1. COlllmuOllS ~n~lvtical as;('Ssm\"nl mu~1 be carried mm('ffi('Tl1 tedmiqUl\" 01 any Siructure as\" form of oul during Ihe ~rform\"n<;(' (Of a Il'(hnique and lhroughoul treatmenl lre.olnte1,1 for l\\I!W'Om1.lXUlosleletaJ disord<'r5. In 2. nu, in;tial ~pphcaholl of a Il.'<.hmque must be Ih\", \\OJ;(':t wiU {O\\'er ~ll formsoipas>o;\\'\" ......·erncnl g.....tl('. lblN abon', as \"'cU as the <J\"-\"OflC defin,hO<l of manipu1:ttion \\\\\"hlCh fol],o\\\\5. l. The SYPII'tomaotic~.both during Mel aIti'\" apphc;r.1ion of tn>atment, m~t bt·aSo5C\"..ro and 2. .... ~nique perlortntd ,It a ..\".....J such ......1 il has anal\\-sed beftm.> ~g There musl bean awal'l'f\"lCl6 of Lllenl \"\"\"\"\"\"Nliooru.lhal were not l.>kn place before the JX'I'lOn on .. hom II is per. t'\\ idePI al the time of the JOllnl consultation and ilh..,formed is must ~ clanfied befl:R seloe<ting treatmellt 10 preH'1I1 II ~ a mom'l'ul~li1-'r h:.>ch- \"\"\"\"\"\"\"s..>f\"re L'Illbartting on the 'concept' 01 manipuLoti\\... mq\"\" Such h!chniqu~ aT\\! often !,flltle, ..IWa}lI lrealmt\"'t. \\\\hich lhis 1>001< ~,ms to dC5CTibO', tl>ere are ~1Tld1l in ,ange. and .a...l\\ forceful (Oft\" P....i\"'\" 10 I\"rm_ related to thO' word 'm,lmpul\"tIOil which requ;n'dMilicalion. for,1 Edihon). PASSIVE MOVEMENT Th~ l~rm mJnip~IMion embrace:; 0111 kird~ of ~'Sille mOVl:m.nl, Of can be viewrti more $p<':C1fically as a Pas~iy\" \",o,\"\"menl meanS any movemenl of any part :>m.11 8mpliwde manip~lalive thfLlSt le<:hn,qu. perfOlmrti \"\"Iln speed of one person which is perf\"rrfl('(1 OIl Inal persOn bl'

4 MAITLAND'S VERTEBRAL MANIPULATION MOBILIZATION group of !<.-..:hn'que>o. II I~ I>«llU5(' of this mlSCl:>fl«'Ptioo MQt\"h~tkw1 ,s pass\"'.. mO\"ement perlormed in such lholl 1hi5 irltrodlKtorv chapl\"\"- S<.'!S oul 10 \"\"plain til<' .. m.lnTl('l\" (rartirol.lrl) ,n ,...I:>t\"\", to tho:' ~ of lhe mU\"'Im.\",tlthdt ,t '5 al all time;; Wlthm the ..blhty of <Oll«.l't of loIal ffiilllol!o\":ert>enL w,th lhe tccluUq....'S and I~ p-,tM'fl1 10 p\",,'enl the mon,.\"..,,1 if he 'II'\" ''''-'.10 d\\OOSe$ («< PTe!\"'ce to Fil\"5t Edition). ('(InC\\.'\" r\"\"\"'\"their itdap\"'-bilil)' koiOl; 1;1\\\"\" lheirCOl'Tect relationship 10 the ...-hole. In tact. the greal emphdsos on pam and other alllCd s),mptoms. This ('ffiphasls .... eXrLlmed. 10000000hl.. wllh the other aspo.\"C15 of It\\I' con· n-pL Wlder the ~ ...Itl h<\"admg5 thai folio». lI!obzal O'lS~re performed ,n such ~ IIlinntr INI THE RElATIONSHIP BETWEEN TECHNIQUES lheyan lit: ~t(lj bv tile poItJmt AND ASSESSMENT Tho:' IWO type.; of mobilization ..n>: Marupulal,,·.. lrNtmenl c.ln be di\"ided inlO four \"\"'''' partS I. ['\"S.<l''' mon'men~ pt'Tfurmed for lhe pllrplll5t' of rd~\"I\"~ poi\" \"JW.I .-e5Ioring hdl.\"'''Sf:', pain·flft. 1. hami\"\"hon of 1h<\"p<lloCllt functional mO\\emenlS. TheSl\";l1\\' o.f two kinds: 2. Mooe of Ihin],.ing and pl.lnning a) t'assiv\" ~<ill.lory m\",'emenIS pcrforml'd 3. Tre.llmenllcchniques sl\"wl)' (0.... in 2 5<-,,<onds) or qUK:ld}' (Ihree f'L'T 4. AS5C5Smenl Sl?«(>I1d), smoothly or sla«alo. with sll'U\\1l or lo1l)1\".\"'plilude, \"nd ,'ppHed In \"ny p\"rt of Ihe Otmthng tilo<\" 'mode of thmking' [MIl al lhts st<lge ....f 101;11 range of mo\\'em,·\"t. Thl...• mO\\',·ml.,,15 di,;cllssion. lhe fil\"5t fe.lture of the 'C0I1Cll'l' rej\"les to understandiflg Ihe fI.·IM;\\\"(' ImpClrlancc th.,t Ihe parlsol \"\"'y ~ !\",rfunned wlule lh\" )Oint ~urf~(t.'S ~re m.,nipulat;ve tfl.'-.1tmenl he,,, It1 ,,~ch other. Though skill io ..ach \"\"'\" is ;\"'p'''.t,ml, Ihe rtl~fI.~~ of Ih\" skill dislr.lCtl'Cl Or compre,,-~>d_ \\)i,traclion i< Ih\" fI.\"llHO'd for e.-><;h is nul l\"'lul\\·.llenl, E\\'ery manipul,,· !K'parallon of opposing joint surf~C(\"S and com· liw ph~\"Sioth.. r\"pist must always renK'ffibt>r tho,1 the pre%ion i5 lhe .ppro\"imalion, or squ~/ing /><'sr treatm('nt c;,onOI be gll'en \"\"thout p<:rkctly p',r- logl~hcr,of Ihe opp'\",ing joinl surf,lCt'!> formed ex.:>rnilli.ri....., and l\",atn\",nl lectmiques. hI Sustained slretching p<lS6i,·.. mo\\'em.-mK may bo' performed ,,-ith tin)' ampblude o~(lJlatiOl\\S How\",·..r, lechniqu,,, an'the k.:.Sllmporlanl of all lite al the limil 01 !hi.' range_ p..rIs. Continuous an.I)'lk.1 aMeSsmenl he.'l,·ily out· ....eighs tne olherti. Those who SO:!'l.... to copy ao)' particu· 2 l'lb>i'e mo\\ l'lnl'1ll!; perfonned for II>.. ptlrposo> of Lar person', lilChruques, lIlI:\"'-\"y 10 u.-.e lho.'1lI on lhei, maintaining a funct>o.x\\al raoge of mQ\\emo.\"rtl in p\"tienlS. ha~ a Iotalty wrong ide.t of \"\",nipu\"'b\\~ m.almenl, and .n)\"onc~ondL>ct\"',ll.COUf':iCS thai consl5I palu'nts \"ho \"'\" WlCOnSCiou~ or who \"\"n' <t\" lI\\iIinl} of l<rlmiqtJe5\"hook/ bt '·il;~·<en5uttd. .:ldJ\\O:- ;':'ml d,sea:;e ~um ol!o rtvNm.lloId arthnl15. 'Thesoe four parts, along wtth years of oonscious \"\"pericnce and Iearrnng bo,5t.'If on ItIe mode of think.- 1'nSI\\'t~3~d,f<-..tp....~fQl\" iog and ~\"'L <11mb\",.. to provide effect\" to \"nd euorpe min-'<19 pain or rtSIori~g fun-l\\Ing~ in(! mlormabve troeJtmenl pilir-'ru l~ntt'OI\"il _mmL n..,. four m.lio afl!<1S are depictl..::l in figurt' 1.4 to They C1r Ix PftfOl'lMd n ilI1 OlocilJillOr'y l'IIilfllltl or dcrnonslrate their retan,,, 'rnpor!i>occ> to each oI\"'-'r, ilSsmil¥dstrr:t&·\"'I M.:>oipul.>ti,... In';llnK'rt1 should ....wr ..., admme>- MANIPULATIVE THERAPY teMl \"llhout .accurale (\";lmmJllon (,,-turn mvolves Who:-o po.\",p'\" LlI]\" aboul 'manipulaliw IfI.'almt'''t' it both \"\"-...1,,1 \"\"d maoual .killo.l. Withoul acruulc \"\"aminabon, pree;\"\" as>CSO'~1 is nol ~ible. seem,o; impl)5Sible 10 avoid lheprobJem 01 their putllng t\"'\"'',nordi\"\"l\" t'mph\"sis on In.., I\"\"hniqu~,:\" Ass\"ssmenl irlvolves e,·\"luntm); lhe chang\"\" in Ihc compM' pal;\"nl'ssymrlums \"tid mo,emenl signs lh.Jt occur ,IS a result oj lhoc lre;IIn1.~nl 1~'C\"\"hlue(S), ,md it IS this in8 thost.! 11S<.>d by different practitioners .lnd <ll1thors. a>O>eSsmenl that IS Ill<! key.wt\\e of inf\"rrnnti,'c t....\"t- m..nl. Assessmcnl (dis<:us.se<! in filII On pp. 5J-8J) is nll~ b 111(\",1 unfortun,lte. because it pre\\'enl~ Ihelr .....-c. nol an NSy skill to m\",t.:r, and il is In.,. area wh..\", ing 11\", \"'/r<:>l\"picr\"n' of, treatm..nl conc<,'pt, r.,,,,, 'ur· mo\"t manip\"lntorslo>c thdr ,·ffl\"<:I\"\"nes.s in Irc\"lnwnl ,-ey5 or ~Soearch projects wmetimes miss the point \"nd thciT \",,1\"10 ,n m\"kJnf\\ pt\"ll!;nn,;.,,;. wh..'rt Ir} ing to weigh up the \"alue of a p.,rtK:ular

Inltod~~tlon 5 ASSESSlilOO phb>U'lhcrapi'>lJ>' lJUIlds mu:.t bo.' 50 ope!' thai Ihl.')' mod~ tht...r I......hrnq...... until ttl~1 ocm.,,-e !h<.-ir int...... T_Toclwuq..... 1101\\. ll>ebasK:trealmo.'f\\ll\"'Chnoque mll>ol indudcC\"ery mo<l''Inl.,,1 01 \"him a !budu\", is caJ\"'ble. the 1'1,,\"-110- _ _Tne~a1pftlrlOmk.no\"olrllIoo_r \\oj;Jco1l mO\\:tments ...-.d the ~ n\\O\\·............\"'. plus ;ill poosoible cumbmatiorb. When it CDIIk\"S 10 st'I.',:tin); tecI'~, the lO.'dIruqu<' for b'l\"\"tmcnt. IllS first ~<}' Iu 1o.ncM- the F\"\"\",,-e mo'~b Or f'OS'llOnS th.>l pmvokt' or _1n_ooI>c1t~ R.~il... e th<' patient's symptom~. Whft, lhe symptoms \"n' \"a.,ll \"1'roducoo. the l~chl\\iqur chos<:-n '\"\"y be \"!lurr ,,~ Jhe ~I~t,.< imp<><tant(. of t~'tmtnl t«~n,q\"\"\" \",thel the mO,,\"-'fTler\\1 Ihal ~l~'eo; the symptoms or me <..minatiotl of m. p.n.. nt•• \",,,,,mwl Irnl the \",0* of th;nki\"'l rrK)\\'emt\"t that 1'00\\'0...... th.' s}'mplnm,>- 1 his ch\",i,,. d~,X'\"ds on ~'\" 'nalu\",' of lhe di-.on.!<'r. the '''''''Nit}'' nf TECHNIQUES lhe .ymptoms and Ih\" 'i,rit<lbilil}'\" <\\f th\" dIsorder! Tr'Nlm~\"1 tlXhniqueo; are d ~ UI rcldlion 10 their A technique is the brainchild ~ inC','\"',\"'C\"'---_ _ Ina'Import.>~. MId l<.> tho;> fa<1 <;(>Ill(' poopJe aft' Th(\"I'l' .. re no \"\"\" or imari.,bl.' tlXhniques; sIdlements su~h a' 'H>U mu,IIU'i'n- do it til;\" \".ol\" or ')'ou muSl ill\"'a~~ looking 1m ne'\" It'Chniques ralm than undeo'- nr.w do INI' haw no pI.>« in our thinking or te4d1 ,~ llle ('lr11v ML-Sf is that tI'to: lochmque />lib' doCh\"\"·,, sl;mdinK Ilc:w.. and \"'hen thl'\\ should be modifit...d and its \"'l(''''IOI'I. roth \"hilt! it i, bcil1g pt\"I'formro and USoL.... f',,>:\"fI' I,\" d\"\"\"\"\"\"tr.lle lno, ...,I.\",~ of tech- whc:n tl has ~ J1\"\"'formed Therap~ mmds must ni<Juc'> In n!'IallQlllo tho;> lotill con<:q)I of treatment. \"I\"ay' Ix' Of'\"';/..\" 1H,,;l1ItnT btd<>s_/i,. rnm,1tI1)_ the 'coocq>t' demancb kno....ing ho'oo.- to T~'ChnlqOl\"...s they ..pply to the oont:ll'1 p~ n:wlc It><, ffi,thm,. u...- >f\"l'<'d, the position in t/w, rang:. in thisbook,..m' m.'H'I'cndmgand th~\"l' roc' .... \"'ill h,a,.\" thP amplilude and the stren~'1h or II><' lo.'dmique to the an \"nding So Ioog as palit11ts P~'II1 \"\"ltIl dllfen'llt examination findings.. srrnptorn~:\\nd ,,~am i\"\"tion ~lgJb, th..'rt' \"'ill h.Jw to be 1lolc.1\\l5elh..>st} I\" or mo,emt\"llhal can boo osed a~ a Ire.umenl 1~'Chruq\"e C<lll be 01 dllf\"\"\"\"l amplilud~.. chang~'\" m l«hniqlk'S to fR.'t' lho'! p.. tients or mUSt' .lOd in Jifl~r,,\"l p<lrts ui I.... a' aila\"le ,angc. GRADl'S OF MOVEME:'.'T be<:omc c~nti,,1 10 the ,,~,ccl'l ,}mpl\"ms. The)' n~ \"\"\"\"nti,,] fo, three I'\\.'a!\".>n';' Cyriax (1\"78.,) ~id that Ihe m()l:>ili~.ltionIc'Chniques I. n\",y form Ihe be-l b\",i.l\"r 1~..,chinJ:: ~nd c\"mmu\",,,,hon inciudtd in lh\" \\l.'xt of this book W\"I'\\.' fi .....t pracHsro in 2, 111,,) fon:c the m\"\",pulalor 10 think in much liner FranC\\'(\",'C:ami~'r, 1&'18j,and it i~~\"rt,~jn thatlhe 'bone- detail about lhe It'Chniq,,~'I,,'ml)performed seIK'1'S' of !X'nturie; ago (Cl'ri..\" 1Y7Si» 11.1> (',,!so prae- 3. Thev form an e:!;......\"ri.allflC'lhod of at!bll!'.-iation li-....t t....,,,. \\\\'(' mu,1 al\",,,}\"!; a~ln('lwledgelhal'~ is \"h\\.:\" AXordmg lr'NtnwnL Th.~r mt.'sa'e.lrn......nd no \",\"\"\" thm~ undl'rthe ,un' (E«le:.ia~n.'s1:9), and thai 11><':.- .:ll-o. I]l fon:ing!hl' milmpuLthw all \"'\" do IS ',\",'uk ,he ro.od mao.. b)' <toot\"\"'\" CChill<'se ph)'SiotheT-apm Iuromm,1 tho;, k.'dutiq.... 10 P\"P\", mill.o.o d>e tt-o-\"pOst MWI) ~ !he bed'wUque mud> pron'rlo). rnon' cleml\" If rt'Cottb of all lhe d,lfm.'fll tlXhmqu05 thaI ha,e (l~ of m\"\"tII'tnt 3~ =not al M.'f\\ de>cf,bed ..,~.. tho;> cl!fllunes Wen!: pll.-d ~ atop ~ a ba~ fu' 1<>.d1i~g Ir>d commun,calron For ~~Ia-I~ thinki~g abo~1 lhe IrctlOlqur 3ad fo, anot'-, the ho..¢'1 of It-.. pile \"ould ~ l$tounding IS~ng p,\"g'~s E,'en 1\"\",\"- \"II tht- possibilities would I\\Ql tw,e been In rrrordirg I~at\",.nl exhilu~1ed Th\\\"I'l'h; an 'ffiIIlo<'aSUI'ablcnumbo>r of d,ffur- THE RH'l'THl\\1 OF THE TECHNIQUE i, ,onotlx-r loc- I!fll t«hnoqu<'5. and each Of\\(' 005 un ,nc.>.I\"'u.>bble lor to be C0T\\5rdere<t on ...·L\";on 1(\\\" p\"ssi,-e mo.-em\"nl numbt.'f vi '-,In,,lions 'I h~s !iUt\\>o.\"i;n,,-,,> been SOlId during ~ demonstration 1\"'.. ln...\". 1 ....f a f'l'hent, 'You dldn', ~ach U5 Ihill IlXh· \"'que 1<I\"t y~M' Th~ ..,ply .\",~ \"'Omctimes \"'-\",n, '1 couldn't, I've ncH'r don\" il like Ih,. jx,fotl,'_ This L~ b<'(.llJse Ihl: 1~\",h\"iqlJl: h.1S be\\)n (<lnd must .,Iw~rs be) adapted Iv \"nil Ih\" \".x\"min~hon findlllH-'_ Althuu~h t......'\" <lre basic techniques that mu.t I.... l\"ohht. the con<~pt is Ih..1l mampuJalin-

6 MAITLAND'S V£RTfBRAt MANIPULATION I\",alment lechnique. rv. lhe palient who ha~ a \"erv ,-\"'en be b,,'lC'd on supP'-):iiliun~. In Il'latiun 10 lre~t· pamful disorde., it i5 likely Ih\"t physical e,mmi\"\"ti\"\" wIll \"\"'\",,1 a pai.... thrt>ugh-.anl;\" situation Lnder m~~ll, many m,\\lJml Ill'alments are mitially adminis- Ihese circurnst1lnce>,. thlo tft:hniquc wIll 1M.'<.'d to be ten.\"I:I empiri(allr; onl~ L1!<'T. as tht!scienn:oi me.licu'\" p.:rfurmed; ulCho \"'1\" dOl\", lho>lheory be«Irnt' known. \\\\1t1un mt.odiolW todolV Itv.rc i~ much tNt ... ck:...ly sl<»< 1\\' and smooth\" I<no\\o.·n and undef5l00d T1ten' ~ abo much thaI jo; p.ooabl!, in t',t:hcr the painl.,..., Tang\" a,ailable, or darbeing disco>t:I'(od taking the mOVl'ml'lll inlO only a sln.,l1 ,kg\"-'\" of by day as SCIt'l1Ce l'rogl'tSSeS, dbcomfo.l, l\"l-'l\"I\"inl}' nol into p.un. and Ih\"\", i. still milch Ihftt i, a. )<:1 unk,,,,,,,,,. AI\",. IJ\"\"n:;'; .. n,I\"I ..'ll f..el'l that mu~t be rorlSidl'rl'tl then' ;s much we n n:-:K we know; \"1'1 i>'> me<hral s<:i~'flCe This brin~ us to lhe nl'XI f\"\"'lm\" l<> be cort5lden-d in progres.;.es. the thought ......!' t>e'pru\"ed \"rQltg. A pet- ft:.c1 example of this IS tlte changing knc>w k'dge of lho: l\"IILlhon to a trdmique Whrl\"ll >hou1d the ~Io\\\", 5mOOIh te;:hniqu... be performed? If w(' roru\"dcr IIv:- \"cry neur(>-physiology of pain. as IS .... td...><:ed lnlhe 'galt theory\". Anolhera..... of difficulty IS IOdlG>tl'd in eMy'> pamful di50rd('f, II should unlJ.illh be p<!Tfol'1Tll\"l:l in~. A,,~'''n'!I' 1~fI>;> a Tan!;\" of mon:rrw:nt a, is possible \\\\\"thout lhe pali\"nl bdng abl... I\" I~'el any di~(lmfort \"\"h~tsoe'·e'·. tlu'rld\"ilc,' ,,,,,·I,,,,,i0 \"''''''''y j\"Ji\"id,,,,j j,,;J1/S .>flll Alliwother~'tldof l!>e «all', if Ihe ralienl h;>sachrooic 1tlJ.\",,1 III\",,,. di:,t)n.Jc.\" hkh is ani!, pron,ked b, mO\\crTI\"nl at the end-of·ra\"8'!'~tretchpo>oition. il \"ill probably ~uin1:1. lb.\"\",' facl5.aklni.' dt-'INtnd thaI,..' -.hould nol be dOS' mal>cor riSId ,,,~>n<:'s th,nking when e.;\"mimnj;,. tn.... t siretdung. <'Od-(lf-rang;>. small ~mpliltJde men\"\"\",,,l, ing, or making ,udgl'fTlL\"flts aboul palimts.ln addlllOn I\"l\"\"fnnne<l. pcrl\\;>p~, as a ,Iacc.lto rl>ylhm. The mm',.'''' to the l\"inFl~ we Iu-..)w ,lI1d lho.' Ihings we Ihink we kl\\l\"lW, tl,,,1\"tC a'e thing§ alx>uI whkh w\"cun make sp<Xu, ml\"t would bf: ronsider.'lbly fasle. lhiln Ihe smooth\" lahun§l>r SUgj;'.'l;ta hypothesi>. slo\\\\' lechnique sugge~led abm .... This ml....ns that Ihe In ~ummal')' th~\"\" Il-cllniqu\", (\"I\",tIlL..- a p.,lpaton' t\\\"pc of di.~\"\"1 t~-'(;h' niqut! 0. an ioo\"\"\",,1 Ilocalized]teehmq\",,) would aim ...u..10 b!.' fast enough to It\\l'\" ;.piN! SIlwno-\"'t bl..ng 1 1lIt:'re is much we do know 2. There is much t~e Ih\",~ we know. In...tl'd reach its end--of·range paslhoo bcfOf'l! the ad,\"\" 3. The\", is much more we dn.ooI knuw 4. We can J11ilke \"/lI'clllntkm, O'flt sc8~'\" bogin thl:lr mlr.-cml.\"fll. 5. We can propose I'''IIQII\"\"\",,,. Tht rhythm in whjc~ Iht I~dlrllq~c i~ \"\"rto,mtd 1$ l1Ie four m.>U'l are\"\" of mrdic,.1 I<no\\o.ledb\"C thai .Ire ~U(nti~1 10. tI't qu;llily of t~c Icc/lnlll.x· It may ....'Y fnIm 'gentlt-smaoltl' to )trddo ~1-stKQIO', p;>rtlC\\llarly applicable 10 1re:t11Tll\"fl1 hy m;o.nirulali,e deptndi~9 I)!'l t!'.c d ,\"alCOftd!lOtl 0' t'le pn~nl phr..olhcrapy are omatomv, ph\\\"sooIOffi~ biomechanics and pathology. In all of these, sclenllf\", invI'S!lgalion conl\"'''I'-'' Il' milka' disco\\·cr;cs. AU vf th\"' fo\". an~1S of Wh~n perfollrllng .1I'y t('('h\"i~ue, manipul\"t,,·(, ph}'si\".. medical knowil'dge coIlI,';n dements uf knowns and tht:.api5ts mu~1 t>t:ronl(' ,\" inlimatelr iIwol~ed wilh \"hal lhey' are doing as do w!0i5ts pl'\"rfonning with an unlnowns, spt!€ulation~and hypothl'SCS. A diagnuo;lS ~tra and Il:scondU(lOr'~inlE1l'fetalion of meron' Cl.'l'tO, which I5lhr b..\"ndlild oi the rornpost... is arriwd a' by rdallng the dinical (.,;amin.t!ion of ol THE MODE OF THINKING: THE PRIMACY pam...' to lhoc knotvltdg... in ~ four main an:01S oi OF CUNICAL EVIDENCE medICal knowlc<Jge. DEALING WITH PROBLEMS OF DIAGNOSIS (THE 'BRICK WALL') II LS somehlTlt~ difficull 10 n.'L11C a r.aric-'nr~ 1I\"....ry \"The prohtl'1lts associ\"loo \\~llh dia,,'\"T\\OSi~ a\"oJ diagnO!l' and the eX.lmllMhon findings to a precise> and ,....,,In· lie lilk'S a\", difficult problems wIth which 10 come to I\"'tn!>. I,xen within medIcine. many diagnostic lIlies ingful dia8\"0,is, as well as arriving at a de,.. under· a\"\"lome\"m~'S madequale, inrnrrt'Ct.OI' may br \"\"'rei,· linUd with palterns of symptom.>t<dogy; they mav standing of both the sl,'le and slage of pathologi...1 ch;>nj;('S and lhe \",k\",nl b,on>l'Ch.lnW::..1 implkanons. An example of ttus is giwn br );lacnab (1m). Of 842 patioenb opo:..at;.>d 00. for disc pathology, 68 w~...... found ..,..,,!ldunng Sill'gl(all''q)lorahon to lome <1i>cs lhal were not abnormal in Ihe way anticipated. A•• of Ihis Sl:r;l'\" of palienl~, fi,'1-' T\\:,'sons other 11I\"n disc hl\"''';,'' lion we ... del~rmin~\"I:I for lhese p<1tK:nts' s!'mptom>. TIt\", ~'<.lmp~ me\"\"\" ......t a paho,tt who on. clinical f'x.tnu....tion preo.ents with a .5l1 of s~mptoms and

IntrodlKtlon 7 bble 1.\\ Asrtlgk cl,mcal p~nlat;on r=f have Table 1.3 Division of IhJnklng in di~9nosis and tht Stvtriill diagnostic ttle-> clinical ~ntation to tilt ph~othtr;ptSt r1tf'Otcr'caI/JptrrJf~rivt! \\j! ~~'ffon II: Ont·,M< h.. niallon ) IJiSIO<y(HI \"•.'-\",-A\"~tOolT\"l Known Macnab two Syrn~lom, (S) Thoognt +in H\"tory and Signs lS) 8~chIonfC'i .~­ SymjlWt\"S W.cnablh\"t \"iSign, I.'I..\"bfou' \" \" -Sprotiltion lI.l1ml1blivt HypntOds \"\"'\"\" \" Table 1.2 A single diagnostic tItle may me..n ~riiI Thi::n> are ~ imporLmI rt\"awT!, tor employmg chn,cal pr~lallOrlS Ihis reat\"re of l',,,..;:ompartmcnl thinking: .~ he,n,ation with nt\"'\" ,\"\"\". ,,,\" root irritation' ev,,,,1. It cnabll'S manip\\lI.ltj\"c lreatn\",,,ll,, b.. \"\"od, signs indic:ahng nt....... mot Imullen ma), ha... a db... illhe di,lgno,is i, nl,t prI'Cisc, pn\" Idt'd it is ktl<1wn order with on<.' of at least six dif~t di~gnostic htles thaI thesymptnm,> Me ansing In)lll a neuromU5<;U- (T4b1t'111_ lu.kell\"toll dN)rUl.'T ..ad not from SCllO\\b patholOJS} The probl..m also occurs in It\", 1'\\\" ....... order. Th~t 2. II males r<-ibl., the use of nwupulanon and ana- ~. d patient who has a disorder th.l1 is dia!;rl~'d as 'diS( herniation with n\"r\"\" ,oot \",ilatmn' mar prtsent lvlical~tto..,;,;istdiffl'«'ntillld;~ c1imcally with on... or many dif(crenl sets of s\\'mptoms '\\lId signs and wIth Olloe of many p.1ttems of (\\11.'1<.\"1 or 3. II enables till' ref....ring doctors and !he ph~'..>otht-r.. the S\\'mptoms (T\"foj, '_1) ..rilit. to discuss thc.'ir ideas on \"\",,, rnarupulahun ,\\Corks, \"ithout the 'i\"-\"O'lahons or hypoilleso?s It b«ome5 .ppumt that if lIOt' 1S to ro><: t.....lmL\"t being interpn.'1l'll as dogmatic certainties. It is on d:.l.gno;.t\" alon... one must be '''ire of the real dCfi· ~nliai lhat the..... should \"IW,'y, be unrestriclL'd nllti6.lS5OCiared with makmj; It p\"\"ise and t~fo... a\"enllCS for di\"c\\lssion. This will lead to !x-Iter Sl,r.. meanIngful. So, \"'hat can the ph. <;iothcrapbt 1\\'1\\ on? ,·...vs and re:;earch progr\"mm~ beilllllUnduct(.~i. It IS u~ually pos:oible to detennjo,: The I,;oil<)ll \",\"tween the 1\"'0 C()mp~rt\"\"-\"ts. lhe chniC41 comp.ortmml and Ihfo lheordic;o/ comp;ort.. th.,t no r/i\",,,><, pnxL\";:; IS lI1\\'Qln-d, and rnent IS .itIJ fOf thl.' growth or usefu.IIcnow~. ..... hetl\"', Ihe is a ph}~ic~1 !\\elll'(lmusculo-)kclet;ll ClImc\"\"\", IIW)' ;r«ul\"te and h)'flOlhesize, while l\",>blem rn ~1t Ihal m.l)' bo,> .uit~ble ior tJt:\"lment lheon!tical practitioners Me often too f.u remo...~d by .. physiotlw,.apist u~n~ p/lSoSke mm'em'~lt frum the clinical situ.ltion to assist thL'l1l.1tGln ..1-.0 Within du, (ontt-d ,he manlpulati' e ph,·siotheraplSt. be h.lrmful \"hen clinicians helre--e theIr hrpolh- ulld('rstand,ns lhe patholog,c.-l MId biomo.,<:hamGlI egelI dogmarkaU}. change; that IN)' be p~t,;s~ to base m\"illm('nt IlXtUlI'lU<'S••nd subseq\"..!!lt dwtgt.'S 10 lhccI, on a\"... There is consider~t>le space for ...rrur in the tht.'Orcl\" 11'1;01\"1 ~mcnt of chanS'\" In I..... palient'~ symp- JCOll compartment. ,dIe\",... there call b.. no ermrs 111 the chnical compartment other th.,n ttl<'Se caused by a....tom:. and signs. r\"18 thIS III mend, whM also the e~amlll\"r's lack of kilL Seldom do examination findmgs behe thepatlC!l\"s true ph~'»kal condibon. For .....m('mbl\"ring Ih(' limItations of our \",,;\"ntific know.. a ~I s\"\"~ment 10 be corTOCt ,t mu\"\" fit til(> clinical SlIuation- II it doI5 not til .t IS the lheofttical \\Lodge. it ;s hdp(ul (or the ph}'siotherapist tu .plil the ~atem\"\"t thai mUiI be wrong bfoc\"'use the dinicaJ thinklllg process into Iwo collll'mlm\"l1lS (TolM,' I J); pr\\.':>eflt.llion cannot be \"1'Oflll. thaI IS, Vile p~rt NI11l!~ und('r the general he~ding. ·Il>\\!.. orctiClll aad speculati,,,', and t..... other under the gen- nllS ~.. raling of one's mental pf'llCC»><.'S into two eral he<>ding 'llistor~ and c1ink.1 presenbtion'. lin~ed romp~r1ment! is wmmonly rdl_,\",-'\\:i to mctaphoricall: ~> the 'symbolic semi'p\"rme-able b,,~~ l\\\",'il' Tht\" dividing hne be!>...\"\" the 'th,-~)\",li«li/sl''-,(;' ulati\"e' compartment ind thoe 'c1inic.I' (omp.,rtrneflt ., the 'brid. wal1'. It is not a solid ,,·all; it has rna\"y

AnLANO'S VERTEBRAL MA=O\"\"--- Table 1.4 The 'pcfmCiiblc brid wall' 'marked osteodrthritis' SIlo: certo,nly d,d ha'e gl'OOiS joint char>gl'S, .. hieh wen' ob\",o\"s both chnimJl}' and radiologically. Physically. she h.td. 35 I\"'\" cent redllC\" non in r~np', p\"in on Sllrtch,nl/- and considerable rainless d\".. CI'll\"tus dunng .tel;'\"\" mo'\"emenls. When mo, 00 passnely with the j;!mohulTM'....1joinl surfiK~ w'\"\"c«npres5ed, cnepituS op;.\"fWl9 kI aJk\"..,·lhough15 to tim,- from ...... (ompart- inc~ and dlSa)mfur1 mentto ~ ~ (T;;LW I.':). t\"\"(not \"\",in).,.as plO\\\"okd. mar to ~ot of l>} mp- loms 6 \"\"«\"ks rn-'YiousJv, although she me.-\".>he n\"d THEORY an arthritic shoulder, 5hl! did not ronsidt:l'.;he lud any T~bfllJ Ilh,I\"lrate< ,he relationship bctwem t/lelh.- reaJ dil>abililv. The 'majlv su'}:l'n\" option \"\"itS b.osed \"-\"hear kOO\\<olcdgc and tht'dinic.al' l,:ncn~led~c. Tho> \",,~t feature of me conc~pt 01 this le~' Il'!>t!i \"'Ilh lilt> on the radioklgic:al findinp .. hid\\ ........... inlerprded ~1a1..'1n...\"t, 'V.c must not gel di\\erted by the !heo~al aSfX'Ct5 of .. patient's dISOrder such thai it is to th.. ~m;call\\·. It would be unroiIli:<tk to lhink 1....1 dctrinK,U of the clinic.l1 aspect', ThffI';< ~1111 an ..nor· mous amount ..cdo not know, and till' fhcoory m\\l.~1 be these radiok.g;cai chanj;f:S could n~ oca,Tn'd o,-er ~'t.~1 In a b.,lnnced way. 1\\\"0 ltxampll'S follow. \"The first c\"ll'h.ui/.c!l ex\"\"\",,,\" .. attention being fOCllsed on the the6-weck period, \"nil In fact lho;oy It' more h1<l'I.y 10 racl\"'l;\"'phs a\"d not rel\"ting the\"e findmgs to the his- lory of a \\\\'on\"'''', symptoms (6 wwks). The SC'Cond be 'eI)' long-standinl( although her spnptoms \"-ere eX,lInpl\" dcmom;t\",tL'S how the theoretinl Implica- tiol\\~ of a c<',vic.11 radiogr.lph may not fit Illc dinkal retati\"ely n'«'llt On cJiniCIII eJ<aminal;{\\(\\, her problem siluJli\"n was an ·end..,f ranr,.,· pmbk'm ralherthan a \"throu,,'\"h· range' (gr....., 05tCQo1rmri!isj problt-m Her shoulder responded qUJIt' Sdtisfactoril)' to mobilintion, rej:;ai\"\" j\"b 'Is prt'--t'~acJ..'fb~t\"\",,.talc He 'svmbolic ~\",;.~,meablc bfick walr 11 a model Examplt B - ctrvical spine thai gu~es phy\"':lIhr'i1pisls ill tM· \",od( of t~jllki\", F'gul\"(' l,.'i~hows th\" radiograph nf lhe cer\"kal spine of In t~i~ \",ay t~(y all k(l'~ tt!(\" tt>ouo,~\", r((\\cd,()I'lS a woman aged 73, l'ilrs. who hlld neck symptoms fol- 1m, ing a Ian 3 \" ..\"'\\Q; pre' '''u>ly. Sh\" hod not h.,d an)' ,\"'~11!SSOOtlS. ~,,\"d Imowlnl'l\" ill two ~r1t( ll<:'O:k symplom,.......t 0'.....\"11 o~ day of ....'Ck stiffflO'S». bllt '''dtpendml mm,,\"nrr:en~At tt!e SiI'ftt ti..,( prior to this incidl.\"I1t. She alro l\\.\"<f'OT'ded ,et}. info,...... ti()l'l ~Id ~ ff(l' to 1Io.....om 0\"\" l.oCl( to 1M favour\"bh' to ~\"\" \",,_,ern,,',,1 tre'<ltrnent. 'I'hll.must otIln 0.,., COII'jIaf'!ll'ffit ~id ttlf'tain 3 ' lhco-ctiarl nwan 1....1 a IJCr.lQIl <:.m d<... dup gm;.s rad'ological illfor...:lttOn\" ~nown .nll spttal>ltiw:. 'no:/ud\"'S chang..., and ho\"e ro... potn. C\"\"'·l'1Wly, il can also be said that a pt\"r\"OIl C.1l \"-In> S{'''',,' symptoms \",Ihout tM ptU3ulions iIIld ~b1( ronlratnclJcalJOm for .... ,~ng any rad'<.>!ogic\"l ch.J,'S'-.... a'llNt'l\"Oe'l Olr orllft C'OII\"~rtlnml.ta.JdCOIIta'n A ptfYlfl <:.n have 9'0\\6 laddogN;;ll cha\"9l\" but h;m, l~t d'NCllI ~ [hr.tory. \"\"\"' nd ~IOt'lSIIO IlOpa,\"\",,~tM~'S*..otruo: ~ .asscwd ...... rvalualr<l The oJdVar'ta!fe of 1\"'.....S in!h'S ~ i~ that th~\"allo./loW~edoe root Tho> <:eIYical splI\\i! \"'-'pllrt wos \",. folio... '\" ~ 10 ~Jt' I or bus cbnat th'~kJrg a'TlIt' ~/ !!1m... i!. ttm\"f'll 011\"....-10 I/r r<gl\"_ Elample A - shouldel Thtrt i:; \"\",It\" IrUlrl.Nfllrl....orarrgtrl.lllioll C4-5 A 7-1-H>,u-old hc~lthy woman, bcGlU>e ()f '~houlder :rill! .;J'g/,I Qulmor $JI/!I'l)aI;c>tJ t1{Cl 0\" C5. WIUI be\"\"wc~k;;\"'S5 and dJ...;coI;,fort'. had j10:iOll/!J(\" it; ~1.s<J IVilerNr wbl,,;mIw.1 alC)Q\" ul\\olble either to C4. Tilt'\" is \"nrmrl'mg of111/ II... ;l1lmnlrol1l1 dISC SjJ<lc/'S 1\",1ln<1 C1, bm IlIis is IIII\"t I'mlwllIlCl'd Qt tt>rnb h~r hair or Il'ach fa, eI1OUj;h behind her b.1ck to C5----6 111.1 C6-i. O$lel'Vl\"IIJrilicd\"lIr,~ /I,.,' \",..irln,1 i\" tI\", 'j\"CQ('i'Tlrbrnl joiH~ Irdm,' Uri' Inri c(Cl/J/!\"lrrolly do up he, brn»iere for 6 wl.\"'ks, She IV\"~ h;>ld dUlIlhe TlI<'rc is i'IICI\"OrKhmCIII,m Ilw il1lmwtcbml forQwi,w 0\" II,,, lefl $jd\" III Cl-J. CJ-lllIIJ 0-5. C5----6 only ,~)ti\",J..~ vpcn to her were 'm\"jor surgery' or to Till''''' is 5<'1111 Ilsyml\"\"I'¥ of Ille Sl'!\"'r~,, fiu\"'1 'put up with if, She n~fuse<:l S,nter}'. prdernn~ to put cfCl: l!lis is porliwlarly \"<elllll/ltdfor by roM/wn up with it. 11<.'(.1\"\"\" her si,tl'r, who 'had had e:>'(lCtly the Mille I'nobk'm', was 'cu,,-'Cl by physiothl.orapy'. shol prl'Slll.-.l fvr the So,m\" I'\\'.llmenl, The d,\"/;nos,~ \"'liS

Introduction 9 figu,,\", 1.5 RadI09'\" 0' =-iC3 ,:>in~ itl Exo... ~ B.. CcnO<uI.,:tm: ~\"d rl... curl..I\",,, 11I11\".~m-;ad spi,,~. lmp$<jort sIlo,,-,phras.s \",,--.I \"hoen \"''''.:lking o. \"-\"COrdmg in wriling. Tht> phraseolog:.· on(' uses dean) lhoe way one is ...Xn-rr th).vtlrnrtrrlt' c/~', >e; in rlr ~r\"\"\"\"\"l.pf\"\"Il!' thm)..mg.. and Iherd,,\", If, for e=mpJr.>. !he :>polen tlrsnj~>l \\\\\",7< r/!,rrIl'Il/ prtrivu; in'''1)/1 phra:>e:<; aao wHaled \"rongl~. the lhinkins behind APPROPRIATE WORDING IIwm Must ...Iso be wrong. To s/'<'/lk or UTiu in llTlHrS h.\"f1l1S meart>. 10 \"\"'11; In ll'n'lIS It is tumtial to KI~11~e apP\"lI'riale wo,d'rl!I. It'l\"fIl$. as t!1IS will ir,f1l,1tnct tilt t!1 nkirg p~ of ttlt pnysiotherapi'l 11\", plan of rl'lo1llng 1l>I\"O\",tiul knowk'db'\" '\" a p\"ticn!\"$ presentin;; ~y\"'pl\",n;; and ~;!lns plnces A \"\"'rle .'>.ampl\" rna\" help to make mi. point c1eu. \"\"\"ther dem\"ird on the manipulati,,, pll)\";;;olh\",.'p;;;t. who mu;;1 employ a ~pt'C;al pattern of IhinkinK \"hi~h Ima~il>e a physiothcTilpi.>! pre5<!nling a I\"'ht'fll, Mr X., \"\"lu,l\"\\\"5 \"cry can>iul oeleoction of the \\\\(1rds aoo

10 MAlflANO'S VERTE8RAL MANIPULATION ,1t a chn,c,11 :'l<-'Illl1\\\"r. Til\" p;lhl'Ot, on bdng ;,,\"\"-od to If tl\", Si,m\" '1l.1CShon \"en' ,1skl'd of JI1 ,,>ponl'lll of d\"monstr;,t.: h,s ~re~ of p~;n, pl\"Cl'S hi, h,lnd o\\,('r the lhe 'concept' of Ihe te,t, the .tod....nl would ,lnswer '11 &acroili\"C ;olllt. l1lt' ph),lliolhL'l','Jlist may, in ensuing lhis fashion 10 question 1. dl5CUSSion, .d\"r 10 Mr X'\" '\",'cft),h,t<; p.\"n· To be ITU\" to lheconcept - thai'\" 10 be IfU(' to lhe St'f'draled AI. H.. has Tt'fer~ non-radicular pain in his left 'lheoretical/~pecul~li\",~' dnd ',Ii\"ical p\",-~'lllilllon' buttock lind postL'f'I.>lateral Ihigh, whICh is comp.1rtmeJlt,;-s,,\", should So'}' 'p.1in in tllis/\"m'\" hill' linked with /tis arc of cootralatcrallist on fo.- J\"lllor>:;tralin~ ..... \"\"r U\"on bod)' To h,\"e.......:l the won;b 'sacroiliac p.lin' indicales thai she COUl.D bfo ward flexion. Ihinml; th\"t I.... pdill IS cdu,,-od 1:» ..onM' di:'iord<'T of lheSolCTOili.ocjoinl. CJbo.iousl)· ,t doesnol nM'an tllat,\"\" And the IIO:.W(\" 10 que-,I,OIl 2 w\"uld be MUST be lhinking thio way, but It docs mean that she COUl.D, and is in fact h,ghly li~ly to. be thinkmg lhi5 u\"\"A2. I would inil..ny pain~ pas6I\\'1! mD>1!- w.w. If, OIl the olher h\"OO. ~ nrll'J\"5 to 'poin in this area'. it is qwre impossibloe lOT her to ~ thinking thai menl t~UC5 in an rifort I(> hnpro-.e h,s the pam IS cau:secl by.l d~r of the 5ilCfOiliIK joint. And this is the imporu.nt el<!:rnent,.and.ln essenli.ll OIW ..rc on flexion, and impftwc rangcs of I('ft 1::11- of Ille COIlClV'- eral /le>;iQn and rotation At IhI! ,,'me lime I f.1..1ny reackTS IN)' bodie\"e NI alll:f\\tion 10 thi§ kind 01 do!tail is qUIte unnecess,a'J QuIl1l! the opposite \"ouki hope Kx a l\\.'d1lCrion in the \",,'enty of is lnJe' if theCOf'T'l\"Cl chota:! oj \",'i\\fd,.,; m.>de \\\\,Ih care and '\" ith ItI<' ngllt pauI,'m in mind. tllo.'l'I the thinking Llw rclcrred pain. ConlinUilI ~I will pro:xes must be ngfll.•'\\nd when this is >0, thl' whoM: ~ of \"\"\"mln.'tion. 1n.'atrrw.\",1 and Interpreta\"on prm'ide me with the aM\"\"<'T If my ! .......ghlSo m1J:'it be the best that is possible in relation to tile phast- and pre;ent sl.lb,lity A ~ e:.ample conc:cms • student being ~ honed b)' hoT h:'acher foUowmg tho: student', eumlll- Of the daJfdet are corn.<rt, I will ptUbabl} ..lion of a patient The stlllk'flt has found thai the finish up with mcwement ll:'dmi<fu<.'\" ...-hich patient's left hunod< and ~I;,roIall'filllh,1th~ a~ p<m'ol<.>d by \\cfllateral fl,,~,on and ..~t~.andlhal lIlo·.-e mw poun,luns d,n.\"Chon,. on foO\\ an! fleuon ht.- R.'llis an arc of n'<'traJ I:>i>cl< pam ....ith d s;mullalll'UUS arc of conlralalc..... t Ibi In the LISTENING standing po5ition. the 1..-(1 butlocl pain ,~ ll\"pmduced by rotiItion oft.... trunk 10 th.; Iefl\"ht>n\" is perlo.med It '\" exlraonhnary how oI'ten doctur5 and pll)'SKMhcr. in a Jl'OSIhon of roughl\\,)(l of lrunk f1ex'on. 'The aplSls {in fact aD ~ \"-00 dea.I with peorItl do not r..ng<!'> of bolh st ... ,gnl kg ra,sing and tile ~Iump lest listen, nor listen c.uclully.\".,..~nor \\;,;\"\", \"''I>Sltl\\'dy ,'n.\" normal••\",d tllene ,'n.\" nn ~rologkal dlangiS. enough. nor listen al sufflOl!fll depth. 10 thell pabents. (A\",lI\" PA pn..\"\",ure on bolh l.-t and L5 pro\"ok\" det'p <n>t.al back pa,n u;/rni\"K ii..,,;,//. ofrou~,.\".rl, 111111 is rllrl'f! il \"\"'\"\"'Il'.:tftr'sfrrmt~!J One of the qu<'\"'''ons the stud\"\"l may Ill' a$kN b)' HIVrillS Iii pawt't'; lhe It'acht'!\" i\" 'What do you ttunk is wrong'\" ,th the patient\" If tilt:' I<\"\"\"hing is ori('nted .. round diagnosis lis/millS islJdirr.lkan,,'Il' IS \"rro/lllll\"ry; lislt1l/1'S and p.llhol\"\"y. thi! an\",,'er might bo' ,,,m,'lh\"'I\\ iii... this' Jisd,,,,,,,,.dnrUl'W; .lfnl!;\"\". HrIlrm!: is .Ullund; lis'mUl~ is \"\" tJO{l,irrrJ (The- Ag«, 21 Aug.... 19S2.) A I. l1lt' IA/~ ink\"\",td,.,.11 di\"<C\" bulglllgposter- iOTI)' on Ihe left .,d\". c\"u~inl; ,mt\"t\",n of the 11IeIe 's;;o much 10 \\e.lm about l)'lt,enl:<' prohl~m5. ,f fifth hl1nb\"r \"en'e root. onl)' we \",ill hstt.'J1 11\"s is ~\"ClaUy rete',l11t when ,I is belie\\'ed thai I.... p~til\",ls' bodies (an tell them Thi~ demimSlr,1tL\"l II very linl,h'd ,lppro.,ch. Thl' nl',t Ihlllgs lhal we can onl}' dl5Co\"er by li,~t\\ir'l; to their question rnif;ht b,,; '\\\\,11,11 would you du in \"n \"tt~mpt COIlHT\\(\"I.tS. Our nllnds h.....• to be fn..'I:' nowlIlg. able to tomak~ him beller?' be dinxted. n'directl'd or innuenad by sublle com- A2. I wpuld U\"'ITI()\"L~l1l'nl,to try to Cl'lllr,llil~' th\" m,~t~ lhal I\"\" patient may m~k~ as a pa\"lIl!; remark disc lesion lind ....duce the bult::e. We must be good lis!(~\\Crs. ,,\"d \"'\" must bdin.,. patienl\" subtle comments o.....m~rks. Also. lV~n such a remark has OC'L'J1 made, which innUenCl'S our !lul\\k'O\\g, the l\\!l~vancc of th\" n'nl.1rk mu51 be COIl· firmed by asking othe. related questions. It is lotally unfair to pati\"\"ts to make academic judgements on \",h,ll should be do\"\" to help Ihem, III prd\"rl~\"e to making a clinkal j\\,dgement ba><:d on bctual infoTma' lion from th\" p\"ti\"nls and t\"\",pering this with what h known \"cad,)mi\",ll)'. Ob,inusly, In \\ish'\" itwolvl'S communication of both Ihe \"etiMI and the non\"'erb\"l

Introduction 11 lind, picking up 'kC)' ....ords· and kno,vmg how 10 Sometimes the only 5l~ lhal can bf, found 011 e~m,nabon a\", palpation ~Igns. \"'lule- all pb~io­ .\".tabllSto good rapport. This subfect i5 d~a.ll \"''1th in klogICill.lnd functi<rlal n\\O\\'ernents ..\". negil!i\\'e dclail in Chap«'1\" .3. \"'1m,\",,\",/ d~ms - l>Io,\"\"\"\"nt d,agrams hne bcm ....eluded in I..... lext of this boo!< itS an appendiX ~t and underslAnding M~ ~;;i.;:1e<I b!, a!il<. r.tther than as a particuLar chdrte< of the book. TI\",; Wil.'i dont for the p,,-~ n'ason thaI mo,'nnenl dia ing que<tio:lns based on bcl>l... mg that Iheu body a.n ,.rams shoukl nol ~ ~ as a m.mdatory ..x\",· inform patH!nts aboul aspocts of their disorder that else for lhe marupulallvl.' phYSiotherapist. H~\\'er. caru..>! ~ fuund by \"uminabon. ~OI\" ~pk: t'VI'IY e.fcellve milnlpulator goes through thl' pI'OCl'':'li!I of mm'emenl diagram •• although this may be done 1. 'b II ~the thlllg that is wrong~ \"hl(h i5 sore, or '\" il Just ~ from my treatmen,r quite inSlinctiHI}'. In reachin\" Ifle concepl lluIl tt\", book portrays, mm'ement d\"'gram, lx'Come an ~\"\"\"\"n' '1\\.<>, it's nol a silly ql1C'oti\"n to ~S\" wheth~r your tial part of Ihe leaminl' pnlCWS, Th,s le,m\",,!; I'fOC~'SOo 111c1ud~\"Sbolh a lNeI\",r tc<!Chin\" sludents. and alSOlhc b.1(k problem could hal'e any CONll'Clion wilfl t....ching of oneself as one continu{'!l 10 pra<:lisc and learn from experit'l\\Ce Thlnkin8 purely superflCi..111\\~it h~~daches, IVhat ha\"\" y... u nOlked Ih,,1 g\"'('S you IS understandable INr .. ~ may say thai mr/\" .... mtnt diagrams are unncct.\"\"\"'I)· JilrgoT\\. whIch ~,,'e lhi, r\"cling?' onl}' lu romphGlIe lhe Ieamong, H\"\"..,..'er. tM is qUIte a\"..\",3, 'We both a fa1st' ,nlerportahon. their \\'dluc i5 tni'Stimable and th.1t your mO\"C1T\\('nt, look better, c.-n be fully a.ppnrill.od onh when an indi\\idual bul you obl'iously feellh..! your S\\'mplomS men't l>e<ome< tolaUv COlWC!Smt \"i!h,and ill\\\"\"'\"''':! 'n.lhc llf\\Y bo.1lcr. Ale you able to \"\"y Il~n( 'I doesn't f~ fom'ing of ma......ncnl di.lgr;t111S and ~Ia!lng thoem to tilt _ I«tioa of the grade and rhythm of Irl'.:>tmrnl bt.1t~'T, or on \"hat \"ay il ,sn'l better?' 1.'Chm'iOJeS \"hen apphed 10 a pat,...,!';, ~ling ~\\ mplOm!o and sign,., lnIorm.lllon gained b> such qllC!>I1OJ'un\" can \"\",·e..1 II'\" a mandalory rule thar in lesting ~ mo\"emenr of 'n'i1h.....ble mfonnalion.. W~ '''list I,,,,,,,, . .,... m.. <l ,....7rl>. any lind, r..nge plo~ its symptomatic respon!iO' \"'list .ftlI W<' 1ffl<j/ brim, alwa\"s be relatoo: EXAMINATION ,~....:< thin\" of rang\"\" Jlho\"t Ihinking of ~ympt{Jmatl( rL'Sp\"\"o;e G\"... ler dct.lil and d'-\"P'h of e.umu1allon is demand.'lI 1'\\1\".\"< think of 'rmP'om~ withoul thinking of by this conctpt than thai ,,'ith whICh 1110..> \"\"'jori~ of range of mo,'emenl, c1u>iclans ,,\"\" familiar Fo< e>:ample, in the foIIO\\\\'Hl~ li,r of aspt'Cts imporlanllo e\"\"mHl.ltion. t....o (number< t.C'Vtl' t!\"nO:: of pilin \"\"f~out tl-inklng of \",n!l'l', I and 2) Me not cvm\",only u>l'd to tho!ir fullest ,'a!ue, Ntva It' 'It of ..nge wiltloull~,\"k11lll at p;IIO t. The precis<: site and kind of l)~h\"nl\" Sl'mptmns ..... lkto,led eJ<Mninalion ~ 10 r,\",:eal the sm.ollesl (which Can \"\" (lfte\" inJi\"at\" fr\\lln \",hich structures cN.ng<'5 in the beiloI\\iour of the symptoms and the n51St':ll\"Ice \"Ith l\"ilCh dlr«bOl1 01 mo\"emrnl. FOt' ,.\\1the o\\'mploms ue NCTf c{~nll\\g, as .... a, \"ice .......mple, a.n pam or discomfort be relt throughout the <iAng\",ons il p4inful only' .11 the end of the rll~? Dot!o!I 1~1), lhe behniour of the pain wilh mmement lT1dlch the behniour of the ,esiSfal\\C'C 10 mOH,menl \",th'n lh,- 2. r\"l1ction~1 movtmtnlS that l'at,ents C\"n ,1\\ all,.ble range And SO on, Apr,,-'Ciahng Ihe fine dif- demonstrnte to repnxlua: tnrir S) \"'ploms, ferellcL\"S in Ihe ~h;J\"lour 01 the ilbnoomal ..l......\"nl~ of rhe mowmenls is imptralil't 10 Ihe application of this 3. Tht Jtandaro 'C5'f nUl\\'eml'1lt!>of J01Il~3nd 'concepl of tr<':'atment'. which ilillSI\",!.\"S !m. I·al\"e of \\erl.obrill canal and nt'Urill ~truct,,~, mo\\'ement diagrams 4. Couphngd,ff.......1 'no'.-emlffllS. $l'CjU{\"f\\Cl'S and Another fealure of cxamln,'t'on, perhaps the moo.l imporlant feature, i.lnmdng h\"'\" much change in the po!>ibom. S. D1ffl'l\\'tltWlti01lIe5ts «>determine \\\\ltich structure or mon'mcnl component IS in\\'oko.'<! \\\\ ith rt... pairlful mo\\'emenl. 6. 'The ~ mo\"...........tsilnd p.>lpallon fUldinp (the t,ss....,. and joint mowmmts) that ha\\e.In eft«t on the S}'mptoD\\.'>. 1he It\\3rl1pulah\\e ph~\"Siotherarist, during and folio,,· inl; c\\~minati\"\"\" t~11 h..., the 1M\\.. of col13ling Ihe \",fOrmal,on galhered on eXaminlllion 10 make il mean· ingful, This informalion C,1n Ihen be uS<.'<l 10 nppl), the npproprlate t,eatmenl tl'C)U';'1UL\";, en.'''''' (19M), Ihroughout hi~ texL gives prOJ't'l\" \"''''I'h\",is 10 palp.>· lion {'Xa mlt\\al'OI' as ,~xpoul1d.~ hl'rei\"

12 MAITLAND'S VERtEBRAL MANIPULATION t'U-min:lrion findings cn1aln Irl'.llrnenl !<.'dlniques Solme timt' ~nK the clfecl olln\"'II\"\"\",1 ba..<ed on sIloukl efft.'ct 'You 1\"\",,1 as g~II}' ~ y(lU can but ~ cMn~ in the pall'-'ll!'s syml'tonl$ and signs, is a pn_ h.ud illS Ihe d,SOfd\"r \"''''I.uin.>s' fEI jenth, 0., unpub- mary lealu\", of thi~ concept oltr('almenL Ass<'ssIDo....I li>J>ed observalic:w'ls). This is~, but rnany manipuL,. 0/ eh.ln~ effl'Cted by a tech.\"IiqUL' is made in CdCh of hI'\" phYSlothcr~pi.lS do not appreri<l~ ho\", genlle the diffet\"\\.'llt ph)'tiJ..,l nmlponents of a patient's dis- 'gmll,,' can be while still being efft\"'h,'e (_ Ih\" n....'r· order. The ·ioint-mon·IDenl/p.~in-,,--.ponse' compo- enee 10 lh., 'Oy'. p. 1i6). nor do IhL'Y \",,,lize how llenl, the mu>;<;l\" spasm compon,'ll!, :md t.... =tnctf'(! Slrongly the !L.'(hniquL'S so\"'ctimL'~ \".'ed 10 be per. neoral movemCnt c\"mpo\"\"nl .11'(' ~\"ch ron,id\"rlld formed evell Ih\"ugh Ihey may be \\'L'r}' uncomfor\\<lble \"\"parately (.\". Chapter 4) for til(' pali''''I. rNching and using Ih~ e\"tn.'me5 is an Import,.n! \"k'ml'f11. Kro,\",\"'dge ~bolJI ~Iholog'j' helps IN Ih the 1~le,p\"Ia~ rion of tht l:Nr~ in \\'j'mploms ~1'Id loign, 1~.I<lh Yl'I anothL'r f''\\Jlu,... is the manner in whidl tho.' det.-Inj n~cssm(flL It,,.. borh r:ompaflm<:n3 of the actin! and passil't lest mOl'emenb aA: cl.amined and n-llk'<l 10 I\"'-of lhe \"\"Iien!'s lOCth,til.'s tnal all' Iimil· 'iY'!'boIic W1'l-~l'MO!abIe btirl .....r _Iir!l<:il 00 btaUSO' lhey pnn'01e spnpiomS for examrk-. a togelll(r ,n lilt tlwnt \"9 of l~f lher~p61 p.olient m.I} Ml'''' IUs ieft lhoracic symptorru. onll whmhe l'l.\"iXt>e;.lhe fourteenlh hole III a round of golf A p<ltieTlt's I,,~mcan pm;<~<l11l a SL~\"\"mgly nevt'l\"-<eflding His standard of gulf i. t1wn n.'<lun...t for the \"\"\"'I four numbt.'To/ dilferL'tl1 Wd}'S, ..nd the pain call also brlw,'t' hole<. Becam;e tillS IS th\"only time hi' h.os pain, and the in a Ile\"er...,ntl\"'l\\ nllmber of diffel1!1lt way§. T[\\ onder_ pain alwar~ It')(~ b}- the nHI day, lhe phl\"~i<:al exam- stand that mo\"ing a joinl in a parl\"\"I\", mal\"lJler call i'\\o.11lon J.'><! theassessmml of imrrnvem''tlt from t\",,,t- l'wdu<Y an ache i~ just one asp«1 of unde\"'tandinj:; \",,,nl will hmgO' around th\" gcM-swlng mon'menl•. and Ihe beh\"\"iour of the srmptom~ from the four. \"\"in resJ\"l\"5e'l. Anotht.'f \"\"1\"\"\" is to know wh.ll Ihe lL'CIlth hole oowards. The aim of tho:! phpkal e\"amin doff......nl n'Sf'O\"\"\"'\" indicate, Th\" imporl~nt part of lhe ation \"'ill be 10 find a mOlemenl or combination ..f mowm('nts IMI produce« pain n'mpar~bl\" with the (~I is 10 kno..... how 10 modIfy the t\",atmenl m disorder. res?\"\"\", to I~ ckang<\"S in the 'svmptonll; and SIgns'. Kn<»<ing and underst.lndu,& the p.tbent's pain - its Dif(,,\",nti~Ii'Jn tests an! spec...1 te>ho thill arc ,,>00 site, its bt.o+Ia'iour, its responSl5 to pos.<lions, its who..... a J\"'S'Sil-.:' I,.... mon-..nenl, uwoll-inl; s;m\"llll- resJ\"l\"5e'l d\"nng mon\"nmts of exammation and of .1ot'OUS n\"\", ~I of ..I \"\"'~t two joml> or <Jth,o,r m(t\\'e- \"\"\"'I COffipont....ts such <IS TlE.'lIral struct.utr<. reprodue<.$ t\"\"t\",alment.a> \\\\-1!1I ~ It:> ~ following In'atment- ~ paben!'s symplO<'!U. n.... method is, when lhe t~\"'t IS c ..... r-<:ul, positiw iniorm.~lion Ihal fomlS the prrmelMslS for lle\"\\mI..,,,r by Ihis method. E\"en hl1\\\"\"''' m\",emenl is .. t lhe point in the riU\\Jo:e of \"'Producing u:o;ed Ih\" wnrd 'rain' .....tricts its import.meO' \\.x>c\"\"se the pain, further mOl\"('(j\">CnI b prodllCt'd in one of Ih.' mmy paticnl§ do not hal'e what th,'y call f\",in, so tll\" two componenlS involH'd \\\\hile at lhoe s<~me tIme the mo,\"em('Jlt is r(·dllceJ in Ihe 'llh\"r component. rh\" wmds di,r:tmrj,Ir/, an </u..\",,,,..,,< \"f r\"\"/Vi,,,\"\", or a fe\"lillg of t\"st is then performed in the !\"CI·cr,.\" marllll'r. Th,~ syn'ptomalk n\"'ponse(i.l'_ n'C......,... Jl'Crc\"se) confim15 ',j'lfrrcllOC' at a pJrheul,1r 'ite are '-'(IUJUy Import.lnl. whkhcompon,'nt I~ al f'lUlt (,..,. 1'1\" 162-163 for .. c1ar· Perhaps the I~Ord di<roflifrJrl should I'C used through- ifying e~ml'l('). oul the !e,1 to \"mph....ize Ihe impornnt role Ih.~t ~\\'mploms play RElATING TREATMENT TO THE HISTORY, SYMPTOMS AND SIGNS Re\":ornmg thetn-.llment ~ion b I ~ilal part of the Ir&ltmenl II muSI be recon:I.-d in lIUCh a Il\\.lnner ~ 10 tnfOfmallon I<nmo.·n from the ·~ticaI. specularil'\" cumpMtment l\"l;\"ther '''ith the 'hl'~Y and dinical indi(ale the effect oi the pre1iou5 trNI\"\"-,,,t.lhe pain presentatIon' sid\" of til<.' 'brick \\\\',111 of the palK.·ul's .....ponses dunnJ: a treatmenl tedmiq...... and the 1mme- di\"\"rder will ioo\"ale 10 the physiOlhempisl th\" stage nf th\" palhologic..1 (hanges (\"s.umlng !lwrc is p,llh· d,,,teeffect of the ted\\niq\"\" (pp_ 75, 108-1lJ). 225). Ology) c\"\"sing Ih\" ui\"\"rder. This innu\"nces Ih\" Intcr' pretation of aS5('Ssmenls of Ih(' changl'\" in a paliL~1l's ASSESSMENl AND ANALYTICAL ASSESSMENT symploms ..n<! s<gns during In... lme<ll, ThIs hnkin}; yet separating of ,\"\" !\"O romp.:>rlm<\"llb, while al the A'SCS,m('rll ha< always be<''' the ~\"y.rone of thi. le\"t. \",\"ell durlllg the ..... riling of the first edition in 1962. '\\SSCS5ll1e\"l \"'ill al\"ays be 11..-:. kcrstonc 0( rrogl\"CS6loo.

l~troduetiG<l 13 figu.t 1.6 Tht 't .IM: ;mp\"'l.ntt of ,\"\".Iy:ICOII~tf't.~tnt. 1,\",_~1 t«\"ln ql>tS alld tQ\"\"~ o' 1b~ 1\"111:\"1 .\".5s<.,:;/;mo.',,1 d\"mllnds of \"\"'\" m~nipul~lil e phl'~lo­ not \",hie'..ed, dOO \",h, \" mO\"l'Tl'lent or symptom lherapi5la mmd that is' doc'S nOI impron! \",hen il should han' in \",l~­ lion to other m\"H·m,'nl~ or symploms whICh lultOf' \"P\"\"1. A~il,' ,md tu ,.,.;:\"we mform..lion. ,mpfOved 2. 1'1;'~lk and \",n\",~t,,·~ In the analy,is of the info,\"\"lllion 4. Other tr'-'.ltnl<'nls Ihal might be u.ai: deciding that because sucf\\'and'>U<:h 1;1 hnpp..'fljn~ wilh t\",,,t- l. D;sciphn~d. methodical and logicdl in ils usc of m~nt. an mIra-articular into,.'Cli,Ml, f\"r (·~~mpl.\" m1ght Sol'\" CIhP i\",ticnt lxolh'r, infornMt,on WI1\\' l.'i th\"\", a 11<'«1 for '~ssessm<'flt' and 'a\"alltical S. TIw ...ltd-n>;.,,11 of l,..,atm\"\",l: making S('TlS(' OUI of a a.~mE'nt\"'Al'l:'11't they the Solm,,? No,lhe)' are d;/b- l'nt alth\"ugh Ii'll'} Me bOlh ,ls:se;\"n\"\".l. While a<.....S- ,ornpromiseend-~ult, de-ciding wh\"tOO mmnlcn- ance lreatmenl ;,; indic<ll.'tl, deddillK \",\"'>lh\"r the ml'nl \",milt\"\" p ....,,'inS Ihe lalu... of .. te-chniqul', \"rmptoms and signs mdlch \"';lh eKh other and dJUh'licill ,l.S6eSSmentcoH....s. wider field of im l....I'g;o- with the whole ston- qf the coUlplainl, etc. non and ~sing {Fisutr I 6) and Cdn b<' wn\"id,'n,d The .........1.:11 prlX\"e\"-\"'\" In' oked In 'alloll}'lKal .ossess- under~ go..........II1<'.adi\"ll of'lTh1king r.....NIl'S fit. \\\\ hm mcnt' ..re sunpl\" Ih,nLng !f>:;:iol/1v, Illoullh lhe)' 1\"\"1 do not fil it i~ ~. 10 hunl lurt~, .nd re~lf\\gre.lrerdctaiL . mmk.. vertical thinkmg ancllaleTal thinking (DeBono. 19S01. inducti,e:h:nl.ing and dNun\"e thinking II IS 11.<1<;\"9 felll~,ts fil ii.n mJIO'1Hll5p<\"Cl of I~t in th15 a ..... th.11 the '~Il!''' manopul.:lll\\\"e ph,.--sio- ~\"LIf f\"'lu,o:l; do nol fit. furt~ .~r: ,u,therdp'~1 s/uJle>. As IS II5UiIlly ntt1kd sla~ b, Hunkln lunpub- ILohN ob.-...n-a~., \"'lour i>CIue\\-ernemsare limited 1>\\. ~ the ..\",\\enl of ,-our latMai anclloskallhinl.ing In Sl'fl(\"Tlll !l.'rJlI'. il _ ...no; makmg 5e1l5e OUI of \"'holt TWO INHERENT CAPABIlITIES OF THE BODY tJ... p.tI'C!n1 i~ .blt> to Sol} .md demonstrale about lho.> dGorder. 1 h;\"llpph\"\" to: The: body\"s capacity to adapt 1. Th\" hislun m,.I<mg the onsel of Ihedisorder Ill. or illS aSlonishing kI rc;ili.;ce rhebodl\"srnpacit) to ·ad••pl lJ,;, ,l(cl.\"pIJble or \",~sonab!e. when rclilR'd both fl) to chang,,;;' forced on 'I bv rong,~\"LII db\"\"rma\"I,es. thL''' II}S Ihe dis()rckr affects I\"\" p\"lient, ..nd I\" lhe Irauma end lifelong h....w) \"'nrk. Knowing this to be d physical c~~min.llionfiaJinp {,loCI hdp. u. to pul our eXaminMion findings into a mon: preciS<-' conte,r \",hil~' m~kinS m;s<'Ssm\"\"t>;, I\" 2. The e~anlln\"tion: \"\",king all of the (;nding~ com- other ,,\"o,ds, it a p~lil...t h~, h~d \"II ~(cidcnl nr disease '-',11Ii,-,r in life, lhe body's Cdrability 10 compenoale tor l1\"tible wilh e,lCh other ~nd ~l>o with til<,' p~!icnt's the damage can be.o compklc Ilmt the< ~bnlllrnJllind· disabiJiti~. ,ngs rna\\\" ha,-e Hltle 01 no bt\"aring on Ihc l',..,..,nt;ng dl-onl\"r. 3. 11\"'ch.lI1ge5 that t~I<e pl~ccdurillgtNalmenl: \"'orl<· \"'& oul ,,11l' lrealmen! prediclions ore \"Om('lime,

14 MAITLAND'S VERTEBRAL MANIPULATION THEOflEllCAI. KNO'.',\\£OGE . .• figure 1.7 flo.......l\\aof1 ~tliting re'~lJorcSt\"p •• \"d ClIttCAl. -:<QRI\"\"TJO:'f \"\"\"te_1< f.. tbfO~llc;>l ~nd ci,olOl t\"~~e .....i\\h -~L-s ------. .~f'Ilrsdlgy; H.SyS FICJ IIIld 1Il¥nUOll'lS T...,.....,'\" \"ted Ily~ H. I>o<tory; Sy, <yr'p1.....,.; S. S'9'\" TES'\"TNGOFLr.£SEs (fr(ln'l PIlt§'<'OlTlle1VPl'of(/I('~ScrlIl9BB~ \"d T~or. o:ds. p. 1<100. Owrtfll Ljyi\"\"l.t<lm'~ RQIflIChIttlI woth !K\"\"'Ss...... of .... pub/ftI'otr 1 The body's Up.ilcily to inform 2. Th. mnlion>hips: bI'Iu\"\"n Itr/flIloJIlC' and ~\"mt'nt: K\"\"-'Pmg the ~hc..lllI\\',l and theelini.....l .....a in s..·.:ondly, p••heo.ls' b,xlirsrnn MIl\"\"'\" things r\",btl'CI to Iheir corn.'Ct into.·I·\"rd~hnnshiI'S b) \\'ISUilli\"inE; rhe their d,sonll.'r that \"I' can ne\"'!\" de\\<:'Ct c-.cn b)' th.. 'symbolic 5<'mi-perm\"ablc brick WAil' rnO!oI thon)\\Jgh phYS1QI exami...~ho\", Thl'loo-' are 1ft-'\" qucntly ~ublle mc<\"'ges that patients m\".\\· cnJnlllenl 3. TIlrory: Not allowing th.,.,rdical knowledge on, ,,,w.! Ihl')' c.'\" be rricc\\cso;, n..,,,nly way the m~nlru· (which in fact Ill,ly Ix! fi\\l~l, or Ih\" L1Ck of il. to I.,tivl.' phy.,,,lt'crapbl 01\" elicil th,'\",· ,ul'lIl'hf'S 1~ by ob.lrucl Sot..,ing or fi,w.!illg dmlc.,1 facts Jislmlllg tn IJI1IIC,,15, and by cnwur\"ging tllCm 10 m\",,- tion anylhing thnt might be re1\"\"llnt, irrl\"'JX'Ctilc of 4. A'''',;lIIlltt ,m,1 \"\"\"Jyllml ass,','sl'I\"\"\" Validathm, how tri\"i\"l or Ulumportanl il m\"y S<'<'ln proving each Slep in Ihe chni,al situlllion. FJawle.;s ~n~lyli,al ~ssu~menl is the k,'y.ton\" 10 this con· 1'~lienlS who aN' 'tunoo in' to their bodv will Ix! cept of manipulative physiotl>t<r\"py- more awareofth~~ubtklies.Thi.;'; a proc~of L'CIU- clliing patientS to nolkeAnd report trivia, Forcxaml'il-'. 5. D:amimJlkli!. The.... \"I'(-' a number o' d\",r.'lCieristks in response to the question, 'What efflXl did Ihe 1ll.1 trealmenl hA\"e?'. a patient may Oily,·1 don'l \"now-I of physical examination' itill to the usc of lhe can'l e\"plam tl - il just feel!; dif!\\,nmt'. Such 111 StAre- concept m 1 demands an 'immediate--repon'!e question' A) Making usc of the JXlli('t'll~' function,1 move-- j pp. 35-36) - 'Is it a fa,·oura~ difference or an unfa,ourill~d,rr..\". ,-\"\"\",?' menls, \",Ih ... hich lhe) (;on derr><lm'lrale theIr dISability or d~. Thus \\\\\"1' re..ch.An under.;t:anding of ... \"\"r the:-' dis- ordct\" .. and whill it ;,;do;ng 10 the patk>nl (ow F~rt J.i'). \"\"yb) 'The Imporiall(\"{' K\" ''n to rombin\"'tioos 01 mo',,,,,,,,,,!>; thaI prodUCt\" appropriate ~ymplom­ SUMMARY: THE 'CONCEPT' alie nesp<>nses. d Kno\"mg tho:-' pnnopkotl 01 di!fflet'lti.tion h <::»1.'11ha1 se...WJn:s thaI male up rhlS concept of Im~tlnl\"\" atl' founded 00 an und..\"\"tandmg ni tho.' fal· 1'\"S1s. and the methods of performing them. Io\"in~ 10 txJint... f\\i1ruraU)', molny of lho.'m are d} Ha'·ing a full appft-'I:....hon th.:>t pallen... mclud<.-'d ut the ml'Ihod~ that oIh\"\", \"5<', b<Jth dunng treatment ilnd when leaching manipulalion, but tho' Can \"\",... diHerenl KI'lOS of \"\",in \"ilh,n ...... phase; ,,,ill \"al'}· 'rom pen;<:>n to pttSOn. The funda- one disonkt\" App...'.Cialm8 the implications m\"\"tal ide\"\" IhJ' ha,e particular importan~ in this of ·pain-lhmlly.-,.-ange' ·ft\\d-of-nng....~n', fO.......'ll a\", \"knti{ied by bold prinl. 'Ialent pains', 'pain inhibition', and und\",,- standing the 'irrilabilily' of a d,,,,,rd,.,. Wllh lIs \\. DiIlglI/J:5i,: The \",alization th.~t, allhouKh the\", i, Impli,ations fur guiding trcat\"\",\"t \",u,h i\" mooicine Ihal is ~lill unknown. nt1d e) Milking 115<' of tl!StinJ: mOL\"l.'lllents while com- \"lth(lUgh p....'Cisc diagnosis is not always possible. p<e5Oliog lhe joint OoUrfa~. 10 romp\"'\"\" thalpain these need be 110 bill' to preciS<', effl'l\"live ~l1d rl'SpoIlSe With Ih,lt fmmd when compression is i\"fur\",ati\"e manipulalive trealment pro\\'id<.~llh\" not applioo during the.arne test mo~\"ments t....o<omparlment ('brick w\"lI') melhO(I of Ihink- f) The depth oflhe detail of palpation <'Jmminallo1l ing i~ adopted of softli.,,\"1.'S and \"\"c\"\",-~rymovements g) The u5<' of 'movemenl diagr.ms· in an\"lysing physic.,1 \"Xill\",n\"t\",n fi\",lmf:.~. 6. A\"I\"'01\"ialr ,,,,rilil/S, fll'C\"uSo\" there are milny unknown ilSpecl~ of tlmory, answer,; 10 'luestions

l~lroduction 15 \",Mod by pfOfe!oSi.ooal peopl.,> \"\"barding II\\(> effl.'Cl> of th\"\", lechnr'lucs \"hen muscle 5pa>'\" Irmits rnmcment. 0{ maNpulativc IT....tmenl must ..I\",~yli be flex- f) ReLaling the 'srad<'5' and 'myth.m' 0{ ~ ible, n....•.. r d08m~li( and n<'<.'d. 10 Ix> pfOll'(l~od loy niques 10 !he elini.clll findings and an) coornr- Ih.· u* and ..xpla....tion 0{ lhe ~\"T1lbolk semi- ptnneabl<! 'brick ...alr_ l'L\",lpa~_ 7. u,!....i\"~ UMtning attentively 10 the roal......t>.- ....'CfV g) t:51ng a;,l{'f1,ls 10 highll~ht the rKOrdin~ of word In oWl optn-minded and n<>n-judStmtnt,t1 m.l.;<lf infonnation from the \"\"bjecti, .. and m.ll\\ll... Utlin.. p,tlitnt.., y'\" questim them.. Th\" phplc:al \" .... m.n.llhOns.. i!; a '\"efJ' dcr:l.:mding 51<111. n-quiring a hIgh Ie> d 01 self-c.llidsm. 9. ~lj\"J! Irml\"\"\",1 1,,'111' 1risI\"'Y_ fY\"lpt\"_,,,,; _!,:I\"-: .\\Ithough the hellclin$:state the b.uiliol the ~al­ 8. 1<'(h\",,/,,,,,,, ment roncrpt. the tI\\\"J.tmcm b ,,100 mll .....n<:....1 b). ..} An op..-..,.mu'lded ..ttitud<' to rre\"lrnem I«It- \"hal is knm,-n .... the diagno<t' of lho:' p.:ltoenrs niqlH.\" L~ .......... li.:Il, Ihus bemg able to inno,,,I.. do:;onl.... {-<tr\"p_87l. T\"\"'ln'ml.100 ,m\"Ol\"\"\" \"-'Cord- f.....ly, unhinde...d by theory, bul ...laling IIw ing lhe fine delalls of the tfftct!l of tKhniqaes I('(hmque< 10 fundional disturban,\" nnd pR'- both during d following their !X\"\"form~...,.,. Th,,;. is an es.:... tialln\\nll,·m.·nt t>f INalrnenl. sent;ns 51gn5. bl R..cording Ih.. l\",hniqu~'S by usmg Srad(.'5 of 10. T1U\" bOO¥', jnl\"'-Tl\"\" Qlwbjlir...\" a) Beli..,-ing that th.. p;!tknfs body Ius an ~no'­ \"'''' ernenl. rhrthms of mm\".. nK'll! and Ihe mous Capacil} 10 adapl and accommooale 10 .y\"'pU>m,'h( r~.\"pon~dunng lhe k'(hnique. SO diwrders with\"\"t causing symptoms. ~s 10 qu~lify lhe mooe of Ihe lechniqu.. for 11) IJd;evinglhal Ihe pati\"\"n I>ody can lellihe a(ur,lle rommunkati\"\" pati\",,! - and therc{ore. th\"'\"gh lhe palienl, c) AdeM underslanding of how 10 treal pam by Ihe manipulati,-e phy,iotJ,,:r;,pbl - subtl\". but u,in\" r.>M:ill,lImy k\",hniqu~'S. which are lol~l1y ,·,1,,1 informal;\"\", abuut Il... tilsnr,k\"f. wh,ch '\" p.inlU5 and do no! include lin)' \",.,..lr!Pms ,,,rv imporlanl 10 a5S<'§sm.,nl, I,....,l.mL~ll ~nt.l \",hHSOi.,,·~'r Such I\",almenl is not u>ed rn olher rrognosis cnroC'l'l'ls. d) A Similar und..rstaooing of lhe appliClltiun ot .. IT IS OPEN-MI'<DEDNr.SS, \\1E..''TAL ,\\GILITY comp.e55ion fOKe of tho:' joint surfaee.; ... hil.. AND ME''TAL DISCtPU'lE. L1\"KED WITII A LOGICAL A.\"D :\\IETHODICAL PROCESS OF perf<.»'mlng osdllalOf)· mo,l'm..... I,\"hniqu..... ASSLSSI~G CAUSE A\"\"D EfFECT. THAT ARE Such I...·almenl is also \"\"\",har 10 In,. c-once-pt. THE DE.\\IA~DSOFTHE CO'CEPT. e) A >lmil,1IT under-landing of h\"\" 10 ~dapltoxlt­ Nq\"\"\"\"Of t ...ahng stiffness• .md r:hc: modir.inS

Chapter 2 \" The doctor's role in diagnosis and referral for manipulative physiotherapy Adapted from the original text by Professor D. A. Brewerton, MD, FRCP CHAPTER CONTENTS Ankylosing spondy otis and mtulutoid arthr,tis 19 • Org~\"ic disordr:rs not invol~ing 18 Ner.oe root pain 19 r tnt: vr:rtebrae 17 N~r.o~ root pain and manipulation 19 ~C9nancy 16 Ntr.oe rool patn and traction 19 Qistasl': Qf the spinal cord or cauda ~l,Iinil Impending n~1Vt 1001 compressIon 20 The ~rtr:bral i1nt~ries 18 TII~ remaindtr 20 Vertcbr.ll di~i1$e 1B Posture and won: 20 Spondylolim.~js 18 Psydlological factors 20 Osteoporosis 18 '0En',} pat,ent who b unJ.:rgo ~p,\"..J mobilization musculoskeletal syslem. C0rlSC'<lUt\"l'ltl)\". tho;:, second purpose or this chaptl'r is 10 outline for pllysioth..'1\"- or manipulation hy a ph}\";othl'rapist .hould have api.ts SOme of the hrO-lder is..,uc:s that a doctor must c\\!l1.idcr in the aS6<.':>'mcnl. h.,.cOI'.ulkd ur howf' ,'CCl'S.~ to .. doctor, who Ih\" dual S\\lCCl.'5S de(X'nds IMgdy lJ[l roll.,borat\",,, m,tw\"\"n l'L'Sprlllsibility uf determining thc diagnosi5 and dedd· doctor ,md phySIOtherapist and \\'ice versa. The doc- tl)1'~ mle is to \"\",ke a bn,),ld d,agnosi.. orda\"\",rKalion ing tho,< tl<!S1 trealmen!. 1 h/:,c!orc. lhe first purpose of of the di\"\"rder, and to diSCUSS chanJ:cs;n ll'll' clinical Ihi~ chapler i5 to guid<' doclQrS ..~ to the t\\-pcs of \",twtlon that may de-\\elop during the course of P.1!ll'I1t who ~h()\"l.1 Or .JIould not be Tl'ferred to a rhlY- t.......trnent iottlNapist for m;)JUI\",. .. h.on, mobiliLIt,oo or tr~ of ORGANIC OISOROERS NOT INVOLVING tn...tt'If' \"PlOe. \"The lThIln Iffi'Ipha.sis is on ronlraindica- THE VERTEBRAE lions 10 su<:h In!alment. Unfortlln.atcl}'. any guide to The cl,mcal hi,;tory and I'\\amination by llle doctor are \"\"\"..~'tl,ll in e\\dudlllJ:\" wid.. '\",Hiety 01 disorders that ~ c.vonot Hoi be Nso....J entift'lvOf'l an u\"ah\"\", of nlav s,mulale splll~l p~ln (TaNr 1.1). Spt.'Cin\\ anention i. a\\wa\\\"s f';i,·~.\" to the patient who CaIl move tho;:, rele- pn\" en r.>CTh. How~·er. there h.i!,\".. b..\".-... deta,l«! 'oIud- I'ant po,rt of the spine fll.'t'lv without discomfort le> ,,( th<- \"\"\",lis of ~atmoent or cootroUe.i tnals. At \\ l05t of the m(lre >oeriow disc1llle5 thaI an' commonly 'luot,'<l In textbooks cause dial;JlOSticdifflCulhcs. MOJC p.........~lt 1t is still essl'I1tl<ll to draw on tile ...~p'-'Ii<.'n<:e and imp~ions of man)\" doctors and thCTap1sIs as I~~II as contemporary e\\'idcncc. 11'IC I'hysiotherapi\"t n.\",st a666S and I'~.,minc the patil'\"t belore rn,atm('l1t is bc~lln, and \"'p,,\"'Il'(lly durmg ,1 coun.e of treatrru;nt. Without the atoilit\\' to d\" this no phvslOlhcrapist should und~rtake the forms of treat· ment Mr Maitland d~rioc... Tlus type of N,ami\"\"tion is detailed and expm. but Ia~cly coollned to tlw>

18 MAITtAl'OO'S VERTE8RAL MANIPULATION Table 2.1 Di50fd~~ that may \\imulate spinal pain and is N;;ily mistaken (or inlcnnittcrll c1audicalion du.. 10 penphcnl artli\"rial di.wU\". ~rv/coIP(M L~_,po,'\" THE VERTEBRAL CAROTID ARTERIES Malig'llnt ty...ptIldmopllthv f'l,ptie .Itt< \"\"\"COast's tumour The n~1L-IJral GUObd ar\"',\",,\" m.ly be occluded b-,- ather- ~1fIetV ............... R~~ osderosis, or by d~or dl'fom\"l) of till' spine. Some SubI\"Idr.oid hamlDr~ of the \\~ rare 1~1l':S fnllow,ns man puLation M\\-'l' P:ar..~al\" tlOC \"0'\" been d ...... to ocdllS'Oll 01. N UlJury 10 the \\...,n.,obr.tl Co~.., ~ ~isnst c.a...,)Iid Mh.'Ties, part>cuL,.I) on rotation or \"\"t.nsom 04 Obst....rno.. of IM.I Dr the ned. Befofl' po..'Trc>nniroS; all\\ motnllZOltion or m.uup- f'l>.ymyJ911 rtlwmn.a olation 01 the neck. it ~ '-''flllallo ao.k specific.llly for mxartl:1a ;m~ ~,..mproms SUggeo;lins \\-erld>ral cilroIJd artery dis· Cam1lOt\"a 0' colof' Of ...,5e, particularly iIJlY~I..-ordl5l\"rbaJl<l'ofvlSion \"\"\"\"\",,\",' Otlln prMc n'OflCl\"\\aS 8rono:llooJ(~'\"DrnrotU rel.Ired 10 ned: pol!llllre. The phy,ioth,eropist mold OtJ>oe''''''g~_ Et-:liot-(l~ Kl'rltlr rotate the noeck fully III both dire<:tiofl5. and hold Co'ON..,art~~ <'>Ieh position for a N:W ~S to be certilin th:ll Ih\", Prt<Jnancy dOl'S not prl)du~ symplolll!l bLfore .Ittempting l...·Cfl \"\"'II t an...rysm com..mi'lllltd seoe_ gent!.. mot>iliz.llion, £x.~mirulli()(\\ fo, \"ertebrobasiIM Sjlonol cord tum\"\", ill5ufficieocy is dis<,,~ on P.lgCS 242-246 M:mo'<'(l3flI<at~\"'9(\"\"\"\"'1 Hjp~_ Hlat~s ~err I S>~ ~ Gill bladcl(r ~;selse Herpn IOSI(' p\",hl<'l1ls M~ (,1lI\"'-'<.I by ball di,,,ase. hi,lluS h\"fni\" (If VERTEBRAL DISEASE ;\"'!;\"''' ]'''-~t1tinbwilh dOl\"S<ll p.,in, nr n'l.ll;\\\"{~iy minor p\"ptk ul~r\"lh,,, cau,ing lurnl>.1r \\.>.~el:\"dl<', <Xcl\",i\"\" A dAS$ifiCiltion 01 the 'l\"rtcbr~1 <'>1\"\"--,,, of spinill p.1in of till.\" aorta <>r II\"\", arteries ma\" p\"-\",,,-.,.,t with lum\\.>.\" Il1dudes m\"nr well·kno.... n pathological disorde,.\" ,\"1;11 l\"l walktng. ,-,,, pati\"nt \\\\ ith dOn;.,JI pain ~holild (T\"Nr 1.1). In pradlce mtlISt paticnl!> ha\\'.. changes lnat be tn.',ll,xl with\"\"t h.\"''''g had a eh....t \",diogt..ph. Are diffICUlt 10 da~i(y. and it is usually impossible 10 nuke a pn.'Cise al\\illOI1lical di.1gr>06is. There is oft\"\" a 1he.... is no Ind\",.. llon for lJl.ilrupulalion ,f thl' <,a\"\"\" b.ls15 of und\"'\"'rin!; <k'gl'OL'f'atiw ch.lng... And this is 01 pal\" I~ not \"ithin the sp\",e 5Oml\"times .Iggra,all.'d b)- ,lrams.md ffilno.- trauma PREGNANCY Gener.llJM'dieal ~t.ndradiographs of the Sf'!1le a.... e>6Cf\\ti.a1 \"\"fore ad\"\"\";1ll: m.mipulalion or tho> Pn-gn.1ncy. '\" In,. l.1-<.t monlI1~. it; ...\".,nkd b\\ !K>ml\" aUI\"',\"\"~'S \"\" • conlr.llI1,hcabon to mom.puLIl...... It Sf'lnc at any ....-cl \" moe that the p\"·gn.\"\"'r prescnls ....·o::h.lf\\ical and tl.'du1.ic..I prot>Io.'Ilb. but il markal pain b dl....rty orism- SPONDYlOLISTHESIS alinj; within the spire thl\"f\\.\" i~noA\"\"'-\"\"ute oor ~ manip- Spondylolisthesb is .I eunlralll,hC<lhOfl to fon;eful uLaIJOll pn:>Vid...:! <tn..<ibll.\" pll'CJ.utlOlb art\" taken manipol.llion al th.'If k,-o,d, bol l\"-,,,tmenl is oft..... SUIT'l-s.sfuJ ,,11m dil\\'cted to the \",lief of a pain originat- DISEASE OF THE SPINAL CORD OR ing hign..r in thf, sp\"\"e. CAUDA EQUINA Oi.5t'ase of 1l1l.' spinal cord or <:auda l'<jUin.~, 0' an} l'\\'l- OSTEOPOROSIS d\"nc\"\"f p\",~~ureonthem. is an absolure<'(lllrrai\",dica- tion to any f\"rm 01 mobilization or \",,,mr,,I,,t,,,,,. n,,~ OskOporOSIS iS~1l i1bsolul\" c\",,'lraindicatIOll 10 manipu- IMion. and this ,\",strictu)l1 \"pplil'S \"i,;o 10 conditions appHl'S .'H~l tv the slightesl sY\"'I'toms, M'eh a, I1Illd likl.\"ly to caus<' oskoporo'i,. including t\"-~'t!lle,,t with bilatcr,,1 paral.\"lh,'sia~ in thl.\" fen Thc krill '~pinai sleroids. Age in i!!>elf is not\" COl1lr.indieatiUll tn manipul.tion, and somel1!lh\" mosl worthwhile 'esults sh:nosis' dc<cribes a clinical syndromc lhal is usually \"rl.\" obl\"ined in older patients. p\"'lh,Cl'<.l by a mas,i,'c dis<' pro/mslon compres~in\" Ih.::caud,ll'qlJlI1a. This l\"l.\"Sults;n p.~in in b\"lh k'g<, with pn'i;n\"\",,\\C p.lm, nWllbne:;:, \"nd WCak,lCS' on ,,\";Il~.

Th~ doctor', mit in diagno'i' and rd~rral for man~p~laliv~ physiotherapy 19 Table 2.2 Vertebral ca~ses of spinal pain of rain molY hdp; if it is beyond theeloow or kn .... root in\\'olwment ;s pf()b.~b1e. 11 is abo more ~\"elr If tht: DevelO{Jmemol fumo\"r p~;t1 incillde~ paraesthL'Sia\" or othcr q~\"litil'S SUggl'St· Sponrr.,.lohsthe.i, Soe<.-ondarycarciooma ing ru'fye irritation, \\\\'ith root i\",·ot-ement, a gentle Scoliosis M,..lomal\"''' spinol mo\"cmenl \"'\"y ,,-';,dily prOOuCt· radiation 01 Hw,molJility pain to \" great~r dist~nce th~n woutd otherwise be V.ti\"\", uncommon !nftoet'on eXpllCkd; ond maintenance of ~ ~pin~1 posture, Sotc!> as Staphylo<occai rotation of the neck towards thi' pain, may r\"produce di'orders Tuo.rculollS the root symptoms il tile p'lSition is held for W-20 f_MiI Sl'Conds. De<;enerotive B,uceJio mel;t~nsi, D\"c I\"ion' \"\"thout NERVE ROOT PAIN ANO MANIPULATION JnnommClary root <:ompre\",on arthropathy Experts do not ~ll ~l7\"e wh<:lhe' \",~lierlls with root Dis< I..ion, \"\"th root symptoms should be subjl'<:!l'd tn foru.ful \"\"nipula- IInl<:ylo'<nq ,pooct'yliti' tion_ Some claim that It i~ justific><l if there arc no neu- compresSion Rheumatoid ~rthr,rs wlogicaI,igns; others adnx\"te manipulation provided Di'\" 1\"'00' \",iO, rompre\"ioI1 R.it.r', di\",a\", the symptoms do nol extend bl!yond the \"Ibow or the UI~\"'tl\"' colit\" knee, usin!; the argument th~t\",fercnceof pain that lar of \",in.1 cord or ,\"\"d. (mhn', disc.,e n~..,J not impl:' root invoh\"cmcnt. My own practi«';s eQuin\" Psori\"'\" to a\"oid lorn'!\"l manipulation for \"II p\"tients with any O,te03rth\"\";IOf e,'idenl\" of ne\"l'e root in\\'(,l\\'cmctlt, but thi' is\" con- apoph\"...aljoint, Merooolic tro,wsial issue that \"'ill not be settled until there ha\\'~ O\".ol\"\"\",i, been detailed studil'S 01 p\"ti,,\"1o with root symptoms HWro'to'i' Osteomallci. \\Q determine more aCCilliltd)' which do \",,,It ond which tn'tability do badl)'_ IVhile this knolv1ed8e i' awaitl-.:!, it is prob<lbly Unkrlaw\" \"is<: toe~d\"d,' Ir<)m /o\"-,,,ful m\"nipuhtion oil patiellis froumo P~gd,di, ••\" whose symptoms ilpp\"'\" to arise from root comprO'S- Fmcture sion, however mild; but to pennit mJT1ipuiatioll of Sue\" fracture patients with p,1in of J similar distribution, pro\\'i<Il\"ll Subluxatbn that it i. conlid~ntly di~bnosed ,'s being due to sponal Lig3mentou, inju,,! derangement witho\"t mot irl,\"ohcment Ne\\'erthek\"'-S, it must be adm,tt<'d that ph' ,iothL'rapi,ts \",ho \"'\" expert ANKYlOSING SPONDYLITIS AND RHEUMATOID at p.l>si'e \",obiliuhon and nhlnipulation ,omdilll~'S ARTHRITIS prooucedramiltic rclid of symptoms from am, pain or sci.>tic\". e,-cn when there ar\" neurological ~Igns_ Also, Ank) losmg ~pondl'lit;,; and rll~um.'toid \"rthrills both il i, probabl:' right to milkean e~Cl'Pti(m when a pati\"nt c\"mmonly affect thc \"piJlalliJ:~n><;nts.which <>co\"sion- h,1S root >ymptoms of ,'cry long standing 'md then .,lIv mav I\"ad to sublu~alion within the (ervic\"1 Spine app<.~lTh to gl'i\" stiff r\\l!ck or b.1Ck dUl' to.' mechanical arid ra~lv to ,uddl'l1 death_ E\"idenc\" of am' inn,lm- de,angem\"nt of the spine unrel~led to the chronic matory a~thropmhv 01 Ihe ~pitlc is an ~~...;Iutc mn- n~l\\'e mot pain. 1,,,in<lic3\\ioo ro tll'Ck m~nir\"lation, e\"en if the.... is \"0 chnic\"lor radiologKal e,',d,'nCt' th\"t the in\\'oh-emcnt includc\", the cer\\'ical spine NERVE ROOT PAIN NERVE ROOT PAIN AND TRACTION Root rain due 10 a disc protrusion Or ,my loc~1 degctwr- Trilcti,m Can be ~pplied constantly to a p.,tient confined atin' dioor<ler m.1Y do\",inat~ tl\", clil1ical piel\",\"\", pro- to bed \"ith \",,\"ere foot pain \"ri'ing H\\ II\", «'\"I';oll or dueing much mOre p~in and I'\\'Stricti'ffi of spin~1 til;> Itlmbar spitle. or intL'rmittently on \"n outpatt~l\\t Ellown\",nllhan its wld(,flyinS cau,,\",_ It is one 01 the first ba\"\",. Traction in bl-d is lJS<..-t m05tl) for paticnts \"'ith essenti~ls to <Iecide wh<:lher the\", is ~n elemenl of root particul\"rly p~inf\"l ;;ci~tica tlMt has not settkod altt'r pain belon! choosing the best trmllHen! for a pali~nt tfe\"tm~nt by b<!d \"'Si \"tOile, TJw tr\"c(;on undoubtedly This is e~w if th,''-'' is a hIli root di,tribution of pa,n immobililes the lumbar spin<' mor(' dk'C!iI'l!]y. and accompani~odby paraesthesia\", but \"ery difficult ,dlen probably the di,lr\"ctlOn atds in p~in rt'!id th\" in\\\"okement is pMtial. The ext~nl of the rad;,ltion

20 MAI1lANO'S VERTEBRAL MANIPULATION InUrmittent traction mobili7.ation and a sm,,11 amplitude of movement should be perfl>,:tlv S<lfe (or.lI p,ti,'nls 111 this mix~od Inn,rmittent traction on an outpatient basis is p\",!er- group_ Ewrything'depends 0\" the ll-chniqu~'S\"5<.od; \"0 .1bly given daily. a\"d can be applied 10 the cerv,cal or one would recommend the uSC of traction for a p~tient lumbar spine. Cervicaltraclioo' for patients with arm with \"\"ul.. lumb,ar bdck p.lin or forceful manipulation pain thuught t\" be due tu rool comp....\"SSion has Decfl for J pati~'Tl1 wilh 5<.~,llic\" or brac\"'a] nt'llroP.lthy accom- lhe subjecto! a thorough study (Brilisl, Medienl !o\"r,wl, panied by ne\"rolugical signs. 1966), This .,how~-a that drtually \",,\"ery patient had marked relief of pain during tf>c application of the Some al'lhoritk'S advocate mo\", dear-cut indica- traction, which was usually applied with the head in a tions for Ire\"tmenl b.~s<--a on Ulore acrurale di\"gnosis, flexed position. Oflen Ihe pain rel;et lasted lor a matter bul it is doubtful whether ~uch ,,,,curacy 's r~ally f~,J5i­ of hours, bul the treatment did not influence the nat- ble Aithough the origin of tf>c pain may be located ural history of the mndilion or the long-term results. at the COrTl'Ct le\"el \",jlhi.. the splOr, in the absen\"\" of TIlTce-quarters of Ihe palients lmpro,'ed sul>stantially rOOI symptl1rns it i5 often only possible to mak(' intelli- within a monlh whelher traction was used or nut. This gent gu~'S.<;cs as 10 whcther the cause is a degenerative means thai inlermittent Imchcm for Oulpatientssh.)\"ld or protruded disc, \\'~r!<'bral in~tabihly, dcgenerati\"e pmbably be ~,,'~od for p<'ti\"nl>. with SC\\\"\"\" pain, changes in an \"pophyscal joint,., ton, inll'''''p;nO''s lig.'- who will be graleful for the t\"mporary \",lief of p.1in \",,\"'nt Or SOme oth\"r preciS<' djagnosis, FurttJermore, e.'en if Ihe m-emll r\"te of \"-,,,overy is not improved it i5 impossibl .. to bri\\'~ definite indications <lnd con- Lumb\"r trachon is commonly applied to patients with traindicatinns for treatrnenl within Ihi5 iil-defil>ed sciatic pain, although the~ has nOI yd Ix\",n adequ~te gm ...p of ['<,lien Is. Nor i5 il wi.w to say calegorkally statistical eyalualion of the resulls. which technique'S are mostlikdy to b,' dk-c!il'('; diff~'1\"­ enl man;pulat<:>rs gel their best results wilh different IMPENDING NERVE ROOT COMPRESSION lechniq\"e<, At pf('S('nt all that can be said is that whm thc-sc pat;\"nts are t\",ato.>d by \"xf'I.'rieTlCcd physiother- Patients bctw~\"n ttll' ages of 15 and 35 y\"M, who apiSts man)'o! them do well. and they ~ppo.>arto 1\\.'CO\\'er more rapidly Ihan wilh other mdhods. Regrettably, we develop acute lumbar Or a-r\"ic..11 pain are mo\", lil«:Jy must await more detailed investigations a\"d assess- to haw lrne disc protrusions Ihan olde' IMti\"\"t,. ments before anything i~ \",ore ddinite, L\"mb'\" pain in the younger ail\" /Sroup frC<JuCl1tly I'r~'Sel1ts in a way that suggests the likelihood of 5Ciat- POSTURE ANO WORK ica in the ncar fUlure, and this is a conlr~;ndication to Any physiolher.lplSl ['-eating a p,'tienl wjlh spin\"l pain manipul~tion shuuld ~\"to\",aticdlly r(:v,ew with the patie'lt th\" uS<: of Ihe 5pine for aU l'\"eryd\"y flCIivitie5, emphasizing any THE REMAINDER posture or \"\"\"vement th,lt ag,gra\\\"ales the p.,in. II is wrong to C()nC~'Tltrate 011 ,;pin;,1 \",,*,ili'~.bo\" whill' the Although the &\",at majority of patient~ who cnmplain patie\"t i~ rq;ularly making the pain worse by >Urn\" of spinal pain cannot be dassificd or diagnosed, this unwise jXlSIU'\" or by a rep<'.,tcd activity al work. mixed and complic\"atl.-od groupcontalns thepatk'nt:; who Me mC6t suitable for lre.l!ment by sp\"\".l mOOiliLMiu\" PSYCHOLOGICAL FACTORS or manipulation, The <-'SSen\"\" of selection is 10 choose patienis whost' pain originates i\" the spilw, and then Pu\", psychogenic pain in Ihe ncck or b,lCk is not Com- exclude all thos(\" i[l whom the'Fe is any evidence of mon, but \\irtuaUy all chronic spinal pains are influ- invoh'ement of lhe spinal cord, cauda equina, n(\"n'e e\",cd by social and p~ychol%rical circumstances, and rootsoryertebr,,1 arteri~'S, and tho,., with any evidence the doctor's assessment is ne\\'er romplete if based on of disease affecting their .'ert(\"braeor spinalligamenls. physical ground, alone. Gi,·t't' a e1Mnre to taik, many pat;~~,ts w,th lhese symploms pom out their probl<'OlS In the management of Ihis large remainder lhe\", and make it OO\"io'\" that they arc suffering fromdeprcs- are virtually no absolule conlraindications to Ire\"l- sion, anxiety, marital or social problems or som(\"thing menl, pmvided the correct technique'S, as o\"lIine-a by else that demands help in;11; own righi, Sometimes the Mr M\"itland, a\", chosen. The main obje'Cts \"f trmtmenl patient has be'<Cll t\"ld thJt the problem is 'arlhrilis of are to usc Ihe g.'ntle;llc<;hniques that will produce the desired \"-'Suit, and to m,,,t,fy Ihe t.-.calment on Ihe b,'sl> uf the p.ltienrs progress and rcpeated rc,lSSt.'SSments by the physiotheTJpi5t. Trealmenl starling \",ith gentle

Th~ doctor's JOI~ in diagn\",i, and ,~f~,,~1 fOf manupoulative pIlylioth~,..PV 21 lheSplfl(\", and ...isht>s lobe 1\"fOWC:t<'d from the ra\"\"ges anti-depress.:, e drugs Of\" ather trl\"atTnl\"ol. Th.,. IS a of a ...',despread, cripplmg d....-ase much belteT\" approa.ch for mosI of them lhan t\" l'l.'tn...1 While il is true thai p.11......ts. \"ho:>e ~'mptoms ~ \",to physKallreatm=1 marprl'donllnanUy ps~chological in orig\", benefit A chronican\",e'') stale m.ly be a form of dq'res6ior'l, to be !reared acrordi<lgl~, or 'I may be bas<.>d (m a oonsilkrably from marupuL1hon.lJl<llhe general sup- per5OO.)!il~· di5onier. (lb, iou:sI' lhe person.alit\\' (\"..nnot uu..port g,i~ b) !hi> p!w»ioIMr<llpt>L radJ} bechanged but dlCSl'patl('fllsof'tenh.1'elOSlg!l1 \"pproKh 10 and recognize thai they ha,·c h.1d other s) mptom~ du.., to fl'nSion.llwy m~\\ besurpnsmgly wilhng IOdl>CUS6 Ir~lment can rlt\"\\'er be an adequ~tesuklitubl>for psv- Iilc>ir pain in psychologl{dIIC,m~An expLmahon U\"II 'somelcnse P\"Ople get p'-'phc ul,;.,ts, whi\\eolht.,.., I\"we chologlClll help, and briler k>ng·IL-rm results. are U!U- Il'I\\5C nl\"Ck muscll\"':l alld a p;,inful \",-\"Ck' mar be und..,.... all) OOlau,...j by doclor <lind pallml facing up 10 the !toxxl and accepled, w,lh obvious \",lief that the C~ll,;o;, Is nothing more st·ri\"\". real problems_ Fu,lh.emlOre, prol~ed physical tn'al- Sometimes ol double ;'prro~ch is r~'<lu,,,,,,,j, WI\",,, m~~ll With ;JlClifft-rent result» may confirm the p<ltlenl's p~lo~~lls cannol ~CN'pt ,11 once Ih\"t the pain is ps~'(ho­ logical in urigin, tho>y moly lole\"'te the sugg~tion Ihat suspici.)IlS Iholt the problem 's an \\KbalUc d;,;\"\"sc I!>;,t ps..chnlogical factu~ pl'Cdom,,'abl> provided tlll.·y .l'\" ;s loud,fficuH 1011'<'<11. Thisd~rirllon applies 10 many abo lold l/lallh\", ha'ea nUnOf organic condition Ihat p.~li,'nl, who go f,om Ihe';II'i.~t 10 IherJpist r&:civil1g ,,1.11 probably re,;pund to ph,-,icallroalmenl. \"\"~'ilr. of u\"successful trealment. Among p.lticnts wilh chronic spinaJ p.lin th~re are many with moderate or \"\",,_ depression. They N.'jecl ,mmed,al.,]y any suggestion tholl Ihcir problems are pt»chokJgical, and usu<llly they will r>oI talk about thdr probk-ms until lheY h.I, e recei,-!'d a course of

23 Chapter 3 Communication (with a contribution by J. Graham, MS, SS, FRACP) CHAPTER CONTENTS At initial ron~ultatiofl5 40 History (wibal con~ulta\";onl 40 Non-~rbill communi~tion 26 Ikhaviour of 5yMj)tOMS (initial Vl:rbal wmmuniCliltion 29 conwlta,-,) 4J IntcrYkwing 5lr.iII'i 28 Pai~ r ~ d.rnng Itst ~T~nt5lln:tlill Wording 'lulls 29 consultlit 01'1) 45 P:ilr.lllclrng 29 Bias 29 At subsequent treatment scssiom 47 Cha\"¥S in symptoms (substquert Brr-.lly 30 Stssionsl 47 Spontaneous information 30 During iI t,eatment session 48 Kt'fo\"'Grds 30 Changes in pain r~ponSC dUfirg rea~sment of Errors in v~rbal communication 30 test movements (subsequent stSsionsl 48 Misint~rprcting 31 Pain response while one is ~rfolmin9 a technique (subsequ~nttreiltment !oession) 4& The reason behind the question JJ Pain response after a technique is performed ~umin9 34 (during a \"eatment sessiGn) 49 Verbatim eumpks 34 At review se~~ions 50 Immediale-r~on~ qu~tion$ 35 Questions during a ,et,os[lCCtive a~5e~sment I. At initial consultation 36 (ilfter each tt-ree to five treatrrerts) 50 2. Oarifying wbjmivt\" assessments 36 J. Subj~ di~renm 36 When Pf09r= has sIo...ed or stowd 50 4 At su~u~1 lrtatllM'nts 31 Changt$ in syrrpto'Y'S at rrview loesSions 5. Non·~rbal ~ 38 lCqwonh JB following iI breat from treiltment 50 Sp«ifkity 39 Condu~ 51 an.., of the mOl;I important 'bpecb of thb cone\"!', of a.~.ment. il j,; the as.ses.Itl~'I11 of the pali\"\"ts' ,'war\\.'- nl'55 of ch.1ng<'5 10 thei, .ymplorl\\5 t1~1t is the mos.t \"\",,,ipulat;.-!' pfll siotherapy. as SIMt.'<l in Chapter I, l~ important demellt. The only nK1hod uf getting 11u_ .1,>o(.'SOoIHl'nt, and this has ~n further t.-mphasilC'd b, i\"fomMtinn is ,'j\" ,kill in c\"ltlmunic.,timl, If il \"-\"I\"lres extending the s\\\\bjO'd into ,'n\"li'tlcal ,lso;essmmt (\"',- rp. 12-1)), It is. as hM bern \"\"id,th,' k.-ystoneuf th\"\",m- ..tdting. the n.\"\"t irnporlant pMt .,r this sixth editi\"n IS \"\"pt, and ,f the keystoncnC<.'d..> luMher n.>fining. this ji~ in the ,kill of n.otrosp<\"Ctiw a_'!Otlll~ll [n ,,->ffO\"p<'<:I\"c \"'tthuu' duubt \"nde,.t.1nding tho, ~klll~ of communjca_ non with Ih.. P.ltl<'f\\t In mro>.pe<:li'·e d~ll1enb

24 MAITlAND'S VERTEBRAl MANIPULATION throubhout In'.ltmcnt. It is for this reason th~t this New in/ormation to Hny person m~kes sense to that chapter h~s oc'Cn written in such deta,l. person by theircomp,,,ing it to whal is Hlre~dy in their minds (me\",,,ry, mil!'.,) Skills of communication wit~ retrospeet\"'e ilssewnent are ley,lOIles of the ron~pl, as this eotlllibllt~ 10 .\\-lr Maitland is prepared to \\'isit carefully and pill;ents' awa,en= ot the cMng~ in Iheir symptoms thoughtfully Ihat subjective world of his patients to Dr John Gr,lham has put fo..:e into projecting the ensure that he reall}' does approJ<im~tc his way of importance oi this chapter by writing an introduction. thinking to that of tile patient. Dr Graham is the Visiting Specialist Physician at the Flinders Medicat Centre, wilh important roles in the His ,'pprooch conveys \"ery dearly that he cares Pain Clinic and the Coronari' Hypertension Unit and his knowledgeoi wmmunicanon, with all its ramifica- aoout his p\"tients, that he und\"rstands that they ha,'\" tions, goes far b<>yo\"d the s<:opeof this t\"x!. &'Cause of resources which will help them to achie\"c specific sue-- his skill and ktl{lwledg,,_ I am plcaSl'<l to begin the c~'Ssfut outcomes chapter with his \",troduetion, which is q,\")tpo in full He enters a close, point-to-poinl, moment·to- Th\"h\"\"lth proiesslOn~1 who h,15 Ih\" good fortune to moment k\\.,<lback 1001) wllh his p,'lienls, Theycan ~r­ po:;,;ess or read this book On manipulative physiother- ceiv ... this, and co-oper\"te the more because of it. His apy wilt l:>e exposed 1o the thinking of an ,,,,usually cj'e cnntact, r\"ady-t<>-l>'Spond smile, SCnse of humour, cleM and pc\":\"pti,·c nund touching Ihe l'''ti<~1t in ~prropriateW~r!; and at appro- pri~te limes, allow hIS verbal me5.<age to match his As one who has had the opportunity o( watching notl-vernal communicatiOf1. Mr Maitland a,~s p.ltienb both directly ~nd \"n vidc<1-t\"pe, I was on the one hand excit~'<l and on the If he etlC()unters difficulti~'S, he is prepared to ask other intrigued to see OI'CT and o\"er ~gain the tech- questions which darify or sp<'Cify, Or make it \"as;er for nique, of a highly skilk~ communicator. the patient to find an anS\"'er. It is this communication skill which you haw an In his language of comrrlUnication, he fr\"'luently oppodunity 10 I\"am as you \",od lhis book Just as y,'u may wish to read O\"'.'r and Ol'er a!'lam ~ particu- re\"eals to the paticnt th<,t he has mofl.! than on\" k'Ch· br ~s,.,.,sment method, SO 1 recommend that you nique a\"ail\"ble to himself and to them. For e\"ampl,\" read and l\"<.~rcad tm\" immensely valuabk' chapter on 'One of the thillgs I could do is ..', implying that the/12 communicntion are other things. Mr MaiU<>nd spe.lks~lxJl1t 'how I think', Hbout 'a,,,,- HI.' also frames his qu~'Stions ill ,,\"ch a way as to Irheal HSse$,mcrlt' nlld \"bout 'nexibility'. allow pati\"nts tn find small cha\"gl.'S both during thl' He understands th.ltl1exibihty in thinkinb ill\\-oJv~'S session and in l:>etwecn ses.s;ons. Th\"y know, therdore, 'inv\"ntivel1l'Ss', 'creatil'ity' and 'trying a new w~y', but always evaluating the new way against old \"'Hj'S where to look for SUCC<'SS By m~king his own hypoth<=s explicit to himself I-Ie is evcr p\"'pared to try a new SC<:!ueme, Thus flexibility is 'not being rigid'. He understands thM 'the he i5 fn~' to confirm or ceit'Ct what he disco,·ered. map is not the territor)\"'. A map is a representMion of 150me people l\"<.,<,lIy newr do k,>ow whHt they are try- territory. Names are represent~tjonsof things ing to achieve with a jt'Chnique, so Ihey dOll't know they ha,\"e already disproved a hypothesis which H\" ha. developed his \",lid metaphor of 'the semi- permeable brick \\\\'~11'. Brick \\\\\"~jJs are opaque, and \",,,sn't explicit to themselves.) hard 10 bct through. So Mr Maitland says \\'Sing a technique ',b>ow- On this side of the brick w~lI are the history, symp- int; what you want it to do, while performillg it. toms and signs (HSS). This sid<' is op<'n to the clarifica- Consider this m~5terly piece of reframing: 'the tion 0/ more degant and precise hi,tory t~king, correct checking of wh\"t the symploms are and \",reflll elicit- patient has l:>een a problem to get belt\"r . the'\" ing of physical signs, The other side is 'tho.> pathology', is a \",,,alth of information in that.' R\"th<'r t!Wl falling and thot is mostly infcrred. into a pessimistic or negative way of thinkil1~, he decides to find out why\" patient could Ix> H prob· The chapter on commllnication is about this side of lem, knowing thHt this very matt~\"r '''Ucsts U\\,lt the brick wall, Clarifymg I-ISS is ch~'Ckillg to 5<'.. that wme spt.'Cial extra information is '\"mb<>-dd~'<1' in the the message se\"t is thc message r~'Cei\\-ed problem. H\" is prep_aced to s<-'Ck 'illll'\\·jdeoce', think of ',my o\",tho<1' and pion......r the extension of concepts (oon- sider the 'Slll111p' tt.\"t). The que,Iion for the teMher b<.'elJmes 'how would yo\" P.lSS on to the student the information th~[ she needs about that kchmque ,lnn what il can do? Or for tlwstudent, 'What exactly is Mr Maitl~nd doing here?' 'How can I do it as well?

COl'l\\mumc~tion 25 \"\"yThb book goesalonJ; towards oKhM'\\'ing these b\\' Stl.'P, \"e Co1n denio\" a hIgh Ie\\-..-! c{ ,kdl in unCOV- ering mearungs. l\\'hom wt' Ic~ language ori!;inallr, l,.\"Oals. You Cdn bUlId your .,~~ from \\'OUr own we did in fact build It W{,n,l by word, grAdually incn..'.l<tng our undel'Sf.lnding of the sperial meaning lmowlcdge, and from Ihe wealth 0( Mt Maitland's of an'- ,,-ord,and theronrexl in whicfl.t Wa!> used Any other k'\"c! of comrnul1ic~tion can be studll.,j in tho: ~rr,,~ ~Ild e\"J\".'ricn.:e \",pressed in these p;!~ SAme ~tep-by-.;tcr m,,.,,,,,r. Whl'1l we have~kllls\"tlwo I\",ds, we can nlll(h mo\", comfortably use the,~kilJs ~t \\105t people COll5idcr th;It rommunk.lhon bet.......... lhe So'm\" time or in sequences t\" S('rve our goals of \"\"0 P<-Wle who spe.,k the same langu.lg\" is ~Imple. skilf,,1 and comfortable oonununication n.utine. automatic ,Uld unromplk.,tt.'d, 11\"\"\"\".,r, C\"\"\" &.fl\\'rts in comrnuni(ation, such as VIl)l;inia Satir In norm,,1 household C(Hwcrs.ltions there arc man)' and \\-lilmn Ericl5on.. hJ,-o: spent th\"',ISlI1'1;, (If hOUl\" \"lStann'S every day wh,.., misunderstand inKs occur Ieamin~ ~ oML'n alion and by prachn', ct'OO6l1l8 \",O<'d< tl\\oughliull.,. a.nd makmg mdll~ n\",'tak~(leis. Each of us has been ilwoh'ed, at one time or \"'lOll\",r, in llltlO) Theu'sua:..... dq:>en<kd t;reatlyoo thctr will.ing- ness to learn. and m learn b\\ :rial and t'fTOl'. cht...:ktng ;l con\"\"n;ahon wh,.\" he orshl.' fails to irnp.:lrl a pomt of out tt., ~ c{ their patients and cl\"\"nlS as ,,-ell vil....·, finding it difficult to put thought; inlO words. .os IMir friends znd rela.t1'lS. This lack of Slt<.'Ce§S can bo.o H''Y frnstratinJ:, f'i'rl101l.lrly A good \"a~ todl~................. ab\"ulouro\"'nstyleof inlo.'1\" ie,,-ing is 10 n\"\",>I'd II on ,-,.leo-tape or aU<fK>.-tlpe if the otm.- J't\"\"'i'lI' ha~ a di~t potnt of dew and lind pl\"y it b.\\Ck tn \"\"r;o.'l.\"\" ,md to c\"\"\"truetive pt'Cr5 ... 1Sh<5 to put it 10 \\flU. Within a group 01 people,the or SUpt:'rI isms. SUlh ~ pritCtke can gh'e a 1>\"'''1 oppm' tl1o....... ot a corwet\".1Uon oftm cha.~ rarid~ a5 each h.mit,· for us tu notic,' the possibilitiL'\" for understa\"d- pl.'fSOn leads the conH\"I'S.Otion off at ~ partICular Ian- i,,/\\ nnd for misunder::t.lnding our OW\" \",,,rds and nusKent can orrur ju>t ;os easily in c«Tlmunication intonalion_ l1\\c skill mll,1 be denlopl'd tn a high i\",,'el between only ,,\",0 pooplc l\\.ormal wn\\t'fS.)tlon. there- if a r,1I'ent's rroblo'rn is to be understood ,,'ithout any 10f>', is not as Mmpk and straightforward as mi~rht De d,'iall being mi£sed. SKIll In communk'allon is nect5- thought ,-;an' If ,,,,,lructions ........J to begi\\..... to\" paricnt•.., that Tht..... arc two inter\\'iewing skills of whICh thera- an' I\"Q!6ibility (>f being mISUnderstood \"\" il'0I-ded The ],eJ,rT\\tng or tIus art or.J;,ii1 r'l\"qu~ p.>t~ humiJdy. pists \",ust he ..wan'; th,.,;,:, arc hl'aring/l\"tening, and cllri'}- and .self-<nticbm_ Without them.1l'JOd rapport !l«tng/looking. Ther.'pists may well hedr whal the} \"lth patll'J'lls\" ,II not be achie>-n1, Words, phrases and f'''peet to heM rather than hs!<'ning to the words the IIlI bon need to be cho«cn carciully wbton asking questIons to avoid bdnll mb.ufllkr~tood,,lI'Id pdhents palient uses TI,e foli\"wing quotation is worthy of mllStbE' listened tQ can'tUlIy.., that the \"...·,'nlng:;of the ,,-'«,.'(hng words the, use a\", not ,,,,,,,ndet'5tood, WI\",,, (ommu· ~(tJm'{ i5 il..:~',l'1{aJllr\", .•\" \"rl; 11••1;, r, lit... il I,icahon ;nistah-s do <xcu, dunng this I<wminl'; pn>cC'_, the phy\"otherapist should 10<\\k at h<~lf for d;fknjrn'\" \"\"\"\"\"Iy Mm.,~. Hmri\",<~' JMI> ,,'t'o the rnis!<,keand not blame the patient (fur tho:' purpo;;cs li,lmm!< i<ad~ H.·mllS i< \"'-\"tml~; 1~'\"iIlS of ([\"nt'- throughout this book. the p{1y\",OIho.._pist will be rclc.-...d 1rJ ,IS 'she' and thr.' patient as 'he1- d...,.,rnf, ,,1m.1_ IINri\"S is ''''1,,1',,]' blrnlll,,;' (her the yea , \"\",n'- c~rlooo~ baH' alJ1X\"OrN INI QlI ....'J\",rnI dN'rl\",... ~.\"..,21 \"'''S''''' I~, dcplCl the probk of mffimunicalion. r,X~1\\'3,1 i> an e-,.n>llmt \"nd ralMf c~ er example. Simll~r1y. therapislS rna) 5<.'C pahents \",th.\",t lookmg at their r1\\\"\"\"'es of e'q'rt.':l.'>klf' and br)(h Idng,mgc II .. u...last t!uw'lines lh.Jt bear gte'lh51 <igrulica\"\"-\"\"'\" Looking (olJscn ingl b It....l1 a ,kill, tl\",t i< where it dIffers frum merely ~ill!(, &'eing is pas.ivc, looking i. ,leli\",', s.c...ing .. n..\"It.,L looking is an ncqUifl..:l dl\"ciplme listo:r.mg a'ld obSCflI nlll'~ ~rtlill sLits in corr,.,u~,,::,,~or Do<:tcD, COUIl5elJor,o, phY~loth<....ap'st!i and fX\"Ople 01 :rio...! _\"\"ulwrd nutty other pron.~~l(lC1S \"'110 an' I'l'qu,n..-..:I to und....• st.md t~ prnbk~ofth..~rp.ltienbr-.::I to appu\"\"iate ;~1k'l lhe ,ornplcnlies surrounding communkallon Clear, sucCl~ful comml.lni(ahon mav be difficult to achie..., l[>'tflI/ml'QII/! It IS not so difficol:. howcn'r. 'when we d\"\"\"lop way, TillS ([mid ~ \",rvillg. tt~lnll Sl!ul\"ws so lkldly ll',ml\"lllwl oflhinking aboot \",,,!Xt. \"\"d Ix-hadour, th,'tlwlpeach werd. word group M.d 1>el1a\\ iuur to be d,,,,,,,,:kd 1/ dldll'l rXI,r\"\", tilt' IIrOllglir Olil/ \"OjS hi III.\" mma'. '\" il i, ,'ttcntion tu one le\\'\" \"f communication (tor c>;i\\ITlplc \"\"\"\"\\'r1\"~~ibJr tlml II,,· lImed ill, '\" 1i'/rll\",1 til\"\"'/!!. mil!! \"'I1Il'1lt, mNning\"f \"..,rdsjc.an be practIsed until. stl'P to II~ f\"',1> of IIU' >II, ....<D):\" Ifill! fittl'd !JU';r ml~1 way rJj /~\",b\".<. alld ig,,~n..t 0/1/(1' 'OIrI, 1h.1t did IIot, II 15 a/,.,

26 MAITlAND'S VERTE8RAl MANIPUlATION I know that CommuniGllion mnslslS of both .-,-,·ertNl ;In<! you believe you ,~bal compon'~IllS wilh Ille lallef including .up«ts understand what ~ch as lone of ,·ot«. you think I said, 80tk verbal and non-verbal rnmponenl~ a,~ f'5sonli.1 but, ~ltmUlts of communicalion ptocesscs I am not sure you realize that n.e nO'1-,·<-\"Ib.l1 component con.~~lS of the nuMIC~ of what you heard beh;o,iour tlwt must be ooscrwd and interpn!tl...t by is not the pn)'~'pistand.-d b\\ her .... hen ~~ ~;ol.s what I meant! to lIlO'patiFenL !lfIS>i!lJr 11m! till' IlmlY'r's aU\"Jlliilll 'l'IlS art\",1'd by I,i. ,.,./1l:T llIe ,erbal (QT1\\ponenl =Jui= ~~,11 ,n lh<.\"choo!;ong \"\"'/~'flnt~\", ur fro\"'\" of milld. o/bolh word. and phra-e; l(l formulal!:'\"qucsoo.ns.. 11 is <-\"1UJlly \"nport~nl IQ 'read. mark. Iellrn and In wmm~ry: inw~rdJy dig.est' the fi~llill'.~~Iso' the chvice \"\",I \"\",mS\"mc\"t ofllH\",I. III >I/cll 01111.'1 I tno3' lhal youhdll't\\\"yot. i f115 10 K'\" arllJt'llllS \".\\lIf;IIYIl5 p''''-';Ib/r wll vIII' \",lJn'$l.llld lrlldl ''''ltd ~\"d \"''''lllt(J/''rI'. (So' En,CS/ euw<>rs, 1m) \"'\" 11u,,! I ..Jd Lst...UF~ is rtfrij, c1 roursum .\". IhIll is m'trrr it n.eThese words put bo:-fono: uS lWQ olm facl$. first is II Jtr- mn'rlf/lwring, Htrtrmg IS / ; tlwtt the person listening to \",hal is being said fre- quently dOCi NOT ~<:wratcly 1\"''<1r whal is ho:;nll >aid, I~n\"\"s dnnIlnih 1It1f'11lm. H,.\"ril1~ is rwUltnrJ, e\\'en lhOtlgh he thinks he dot\"'. Seoondl)', it 'S oft.,n NOT u,>Jcr>l\"od nor hl!,'.p~l<-.J wrr.xIJy (WT Figure (;\"fc\"\"'K l$/ln .,.\"\"in'd rf,snplmf' 3.2, lSi process). (11or ,,~, 21 \"UI:\"\" 1982) RrgrtrJm~ Ihr ,n\"Js: L<Q;lIlg (ob<m,,,S) i, 'Isclf~ ,1:111. 1/'01 is 114rc.... ;\" undo-rsund WNI you lhink I saId /fIIJers/rom \",,\"Mf/ yr.'illg Scf'mg is puss;\"..; look!,,!, mOlJ-ds.rr\"..' loop/mi. ~fi.....' is IIta, ill f«1 \"\"'00 i,ilctl1'f. Seeing i~ \",!llIml; J,,,ki'Ij<;~ 1111111:'1,,;....1 ,1<>111I='1' uio;cipllllc lG M~,'lanoJ\" 11\"10) undersl.,nd NON-VERBAL COMMUNICATION wl\",r is S<lid; IIII' \"\"\"IJPld i~ liral wlral tl'e li5lmr' II/inks is sma may. i\" f\"cl, lor si'g!ll!y dilfrrl'lll from 1lw fi\",t aSJ\"'C1 (If rommuoi\"\"ion that muSI be whll/hos IIlYn :i<lilt alia l!lrrojiJr<' /I,r 1,;!l'Ilf\" 1l,1I,~ Sl~ is lI'w l'IOn-\"erb,1 or 'bod) Llnguage' aspect II /1tf'1IlJfHIK\"II'SSIl\\\"<'· ,s th., \"'\"\" qrlll .11)11 of communicalion. llIe im\"\"ct of \"on\",.,rbal ,ign\"ls Is usu~lly stronger, quicker and mon: dil\"t.'Ct Iha\" Ill\" impact of word~. The siJo;nals are fn.'(juently more inform~ti,\"e than words, and howe the \"d,·,\\\"I.lgeuf t.~nsm'lflllg m\",~~ U a .u~S(i(>Us ref1e,( action before suffio...,enl lime ...........a!\"\"-'O.l to (~the MI .....Qnk. llecal.lSt' non-\\\"erbal communi. (;otlon is reflex in !)'P\" and tlwR\"for-f, less easaly roo- lrotled. \" an be to<l\"\"'tai to \"\" Jl1OA' &\"\",uinc II also !\\as the a<!\\-antagc of eXpre:s6l1lg more subtle II'IO!S6ages more l'rcci:lely and distin<1i,\"cly than G1J\\ .....ords. 1l>ere arl' of course m.l1lY non_, erl>al S1gnal$ltlall\\te consciously used by the \"\"lient and \",hid, uo not ah\",ys ~g\"-'\" wIth tt'c;r 'Nbal ml'SMges. It is \\'~\"'y import~nll[l \"olio' the \"L'l'baland 1I\\.lIl-,erbaJ mt.'SSage; logether and 10 be aware of \",hen IhL')' match (ClllIgru- rory) and whm lhey don'l m~kh (in<:orl);.ucncy).

Communication 27 In any \"\"CI11 il is Imf'O\"Jnl to respond 10 (and I\\-\"!>('Cll mimic them if lhel' ha'e an dCUI\" 'wry \"lock'), 10 ha\"e 1lOTI-1 commullIC,llJ0n5. ous MOOS io the SA\"'\" <or! oi pnsitioro as theirs, and To m<l1.:c lhe l><!>.1 uS« of tJw p;olienl'S nnn-,\"efb.11 l\"\\'CI1 10 include brt\"alhing It! ttIl.! \"\"me I1It\" and speak· mmmuni<:dliion, the rhr~iotherap~1 n«ds ll) tx· \"CI1 Ing w,th aboullhe\"\"m\" Ioud\",-,*, iol.....nd b..'fl'PO_ All of INs would Ol.'t.'d to be don.: in. natural anod rom- ob5en'aTll, aIen and 1\\.'(;\"PIi,'e. Sheshould CDrl!tI:Iou~I, look allhe palM,nl from lhe bcgJmung.. so thai • bas\", fortable w.... It is important foe' this mab:tUng kI be of In'~1 can be e<l.1bl..Jwd wilhin the Ii...! fe... rmnules dOOl' ttracefu.Il~ 01' a.lfull~, and nol til be foKed 01' ol bring wilh the patient. /'\\l\"crtheless, it would be unnatural- unn..~ble fur an ~Ic 10 <k\"\\'eIop \"l.ICh • tTu!;1 within .. short time II oould be \"ppmrn\"tt. tor ~ I\\s ,.-ith 'erNl rommunKalton. the phrsiotheropi,t \"\"\"\"\"', ha\"mg re«l,ed ulbdti5f,,<:!o.y trmlmml dso:-- ... hen>, 10 be ~U'>pLCioluof the new u.e.-\"pi<t. A \"'''ror \"hould not 4S>-uIll(' ...... ~ inttrprcting the palil>nt'~ t-ldlmS IhlS mighl ~ as ioIk'M-s.. nu.1rKe5 correct\"', brcau\"C' hL. rrame of n ~ ;\" 'It _~ tn.11 PI\\-\" \"''''' tw\"lml\"'t>. ha\\\"(_\"n'l be;.... ~I.K­ prol;>;lbl, qUite differenl from Ilt'~ 1'1150 <.he kl ces.sful Knowtnf: lhal, I would like rOll 10 I.ncm- lhal I \",-'«I rourhdp, fo,,'ol,l 10 Jookdos<C!yal .... hal I doand be \"\"-dre of het- o\"n ,!.lb.' oi 1TIl'nt.l1 ..od php;ocal for you 10 tell me aJ',lhing lhal raises any q.....'rll'S ~-O\\I may ha'e. I Ol.'t.'d 10 know ,111 you can t<>lInw, e\\\"l~' \"'dl being.. becau\",\", il alfl'C1$ how she interprelS the Ihml9\" Ihal }()U Ill\"y fed M-e Im'lal or unimportant. Alsodon'l e>:~l a cure, or you \"ill be dl><lppoinll'<i If p~tienrsrnm-,erbJlsign;lJ:, Whl'\" \"'-'Cl'$Silr),\"\"Y po5Si- I join Ihe lit>c 01 fa,luR'OS' ble dS6ompliollSshe m..'y m..1k, 1'l'lJled Itl h~ nuance;, \\\\!l1ot yN' an:: tl1en a.kin!' is the reasonabk ll.'<IUl,.,t should be cLarified so lMI mi~interpt\\'l.1liol1is avoided. y\"\"nl 'jonk before leal\", and raisin)', th\" ide,. of 'h\"w Like\" i5>e, if Ih...... is\" disparity b.:lw ......... the '<'rnal and 'H'lJld you know wh,'\" rou can trust lhe helping per- non·, mal m~s.1ges. th\" CQfI'CC1 interpr<,lalioo nl.....:t, son?', The patient's llUan«'S of behaviour call I\", c;..trem\"ly injoTl\"\"li\"\", and '<l can those of th\" ph~sio­ t\"besoughl lherilpLSt. If ~he 1\\.~1db hL~ nllilllCCS 0/ ~ha\\'iollr well and h\"\"dlt.'S h... own nuances well, ;;be can g~in IN> The p\"lienl's faCial expn..\",~ion an.! ey\" m\"v~­ patient'sroofidcr\\(\\! quickly and help him to n'C('I;\",7.e \"\"d\",cnL, \", \"el1.s l\"g. foot, MOl h •• nd movements her Cona'm for hi\",. n... Inn\" of ,'oice, lho. inlonallon \"'\" e~I\",melv inform\"ti,·\" in pr,widlng SI'0ntano.'OlI, and ..\"\",oc:i.'I.-d fanal =rresSlon are abo COlr,por>ntlS of non-' erbaJ COD\\DlWUCation that can be u5<'<l IV &~,t informalion. and the physiothl'f~pist ~h\"uld tle alo.'fl •.ifl..\"'! ,md \"'l'\"rfX\"'!o \",Ie'I''''. thC>oC me,;s.'g;,s. It was iol\"r- Peop'\" ha,e d,lf\".....1 ~1Jt>es, ,j,if..~1 char- adlTl$lJ(S, d,f~1 k\"e'\" of intdl e;~, and <0 on. ..-.Imf': 10 redd \" nowlist \\Isin!, tile words, 'His moulh During an inten jew wilh ~-......-pariffit, t!le' .....Olpllia· tin~ ph)'siodlO!1\"p~t can ilda.rt her m:annensn.\" 10 ht Wb IVtl'at!l<'d wilh un,po!u.'ll langu,llS'\" (Macdon.lld, !us.. She should follow h~ paltems; she,J,ouW 001 tr\\' 10 c\"\"n~ him 50 HUI Iw re5pOOds 10 her p.ltren\\5. l'li'tl) ~wa\\'olnprt'S6:tlfthi:sa;;peetis IOsa~ thai the patH:nt'~p«uliaritiessOOu.ldfonn t!le\"romm<lfl d..'nOO\\ l1>ere is much to be \"'amed and arrre<'<aled .n the i\"\"tor', no:>! the ph~\"SI<JIhe\"'pl5t's p'-'CUhanne;;. It ~ \"Il:''' of non-'·ero..l coounwue<>llOIl, and the A;'<Id\"r is \"\"t-inle\"'Sl;nJ; 10 d'-<O\"er 1>0\" w\" came IV oue 0>' n r't'COmmended to read a l<'X1511cn \", &\"llIyCom..,~nioJ­ Il'Tfl of p'-'t\"ubJdtie< in a unique w,,~~ wilh many leam- ing~ trom mottK'f and falher as wdl as frum other ta'\" (Alb\") Ie, 197~) and 10 10110\\\\ up the rel<.\"\\anl refer, people wllh \",hOnl we ha'e H, l..:L played aoo \"'Or~l.,j. l~ ~ed m lis b,t<hograph\\ So 100. th\" p.\\li\"nl, by .. differeol Hfe \\oo.rtlC); \",'mc to his or her own p<'Culi,lntil'S_ Wh\"n \"e now ml'Ct, II In the paragraphs \"bene. non-\"'erbal commWliG-.- tx'C()m,-'~ II task of SOme 1tnport,mcc to mo,,, into lion has been ~ b it rela~ kI the question- an \"daptablc Pf\"'itiOfl lhat fils comfortably wtlh Ihe .InS\"-\"\" situ.ation during lbe .....t,e...ll' e euminatiul of a patl\"\"I',\\ p<\",ill<'n, IMlldl.r and Grindc, (19'5.1) call palM-...... the followin1: i:s a rommon .....mpleoi ho......... lhi. pnxl't<. '\",,,tching \"nd pacing' non-,-erbal n~ of beN, iou.r can be U5<'d \".-hen It could incl\",t\" ouch thing5as sitting with ,,,,,hC.ld at Ihe ~nll' ~\"gle \", Ihe pallent's h\"\"d (though not to namining a pal.....l·s ;oinl mo' l,\",\",IS, Ouring lhe physical e\"\"\",\"\\,1tiul oi 11 pall\"\"t's mo'..,ml'flls, the ph\",ottkrap~tmoty ....y to .. pallenl, 'I \"ani you to bend. fon-a\"h \"ntil rou feel di'Komrort in rour bilcl<. As ~ II> YO\\I do \"-\"\" an~lhjnK> srol~ and immedi\"tel\\' stand up ~I\"\"W>. \"II.m'. lk>pil\" the P\"-'C~lon of lhe inslruc\\ton, il is common for a patient to bend huther and furthcr, fedm\" mof'\\' and moee dis- comfoet. During the bending fo\"\"ard the i\",henl tThly, 'lulle \"n(()nsdou~lr. dl~play a \"\"f\"\"erbal mess.lge such as bi.);inning to purse his lips. If this is5CL'Il br!ll<' physioth~rllpisLil will ~nllblc hee to $101' him bending iuelh\"e, \",tum him t<> the npeight !X\"'ili,>t' and ask him jf he fell an\\' discomfml. She is then able 10 n~instruct him on th\" neco.'SSity to 'STor', Ihus maJing the lest precise ~nd SAfe.

28 MAITLAND'S VERTEBRAL MANIPULATION VERBAL COMMUNICATION continu\"\" 10 shuw an int~rcst. but when it is ob\"ious that helpful sponl.:mcous infonu.lllon is \"ot fort!\"\"'111- n,.;:, prt:>Ce;S of obtaining a c1ea, pkturn of a \",'tb,!'\" ing. sh~ may interpose a question at a \\'olum\" slightly symptoms, \"iU,.\" at an initi.1l cof\\SullatiOfl or during Ih\" grNter Ih\"n his, whil<.' al\"\" invoking non-verbal 1<'Ch- course of t.....\\11'r\\('n1. dlt>ends vcry much upon suc,ess- niqucs such as rai''''g a h\"nd, or t(l(lchillg his ann just ful vcrb.,l m\"\",,unication. For some l\"'Oplc ,')(pr~'SSing befnre starting 10 ask lwr qUl'Stirm. TIlis lends to int<.·r- Iheir thought,com~~ oasily. while otl\",-,rs ha\"c dilficulty rupt his t,,,in of thought. .,nd mmns the qlJ(.~liOll can Howc\"cr, commurUmtion skill\"can be 1,,\"!TI(!(i. Later in be a,k~xl without the n.,•.xi lor a calculated incrca,., in this chaph'r, examples of COrl\\'c,sations betw\"\"n a paliont and a phy,iothe,apiSI are gi\"cn fo, thc pur!\"\"\" \\oh,m<'. nl<' \",ar,ipulati,,~ ph}'siotl,.,rapisl. in pa,tiClI- of lwlping thc physiothcrapislto learn the special com- munication skills n:.·qnir\",:l fo, accuralo a.<;se:iSmeol I,,,, JVpeatedly use; the stro(lgl'St form of 110'l-\\'l't\"b.11 communicatiOfl, \"'hich is 'Iouch'. In summary, i! is in'portanl to ,c\"li,.o that the patient's responS<'S 10 qu<:stions will be modified bv n,., .....·ticent \"\"tient n~..-..ds 10 be kindly told Ihat it h, lifel<~'g b.1ckgroond of e,pcrienccs _ thai is, hrs SC('ms II<' finds it hard 10 talk about hi, romplaints but it 'frame of \",fe\",nce' will be diffe,,'nt from tlw physio- ;\",\"'C<'S.\",;ry for him todoSQ. Heshould ber<.'as\"\"red IhM ther,'pisl'S, 01 .....lMI import.,nce is the f,xt Ihat th<.' heisnotromplaining but rather Ihatheis informing. and physiotherapist's interp....IMion of the patient's sl.!e- that what he docs no/lcll her, ,he will nC\\-er know. m<.'nts will be influe'-w:ed bv her O\\\\,n 'f\",me of refer\" ence'. These comp\"\"eols ;hould be borne in min<;\\ To bain the most (lut of an interview with a pati~'fIt, throughoul e\\'<.',y treatment ,.\"\"S'O\". Ihe physiolherapist should Iry to 'fffl' lhe kind of problem the p,lI;enl h~s; she should put h\"\"\"U 'in his INTERVIEWING SKILLS shoes', so 10 speak. and lel;t be secn thai she under- Prol:>.1bly Ihe firsl requirement during inle',-;e\"', with 0'st.,nds his plight. She should show thai sl1e takes him p\"Iienl~ is lho,t the physiothe,.'pist should \".yin ron· his word, \"ven if she has doubts. Her facial expres- Irol of Ih\" inte'Yie-ov 8l \"lItim~'S. nus is difficult will, sion and the quality of her voi\"\" should eng,~,dcrcon- Ill<> garrulous patient. However, Ihe gar,-\"lo,,5 pllti,,,,! fidence and show empalhy. readily \",ve,,]s all of his problems, wher\\,as il Can be extremely difficult to draw out from Ihe \" ..Iire\"t There.\", many ways in ,,'hich Ihe phy.iothcrapisl pal\"ml all the information Ihatlllily be f<'<luired. c.n modify the qUl'\"5Iiom; she needs 10 ask 10 make Ih~m \"\",i'-T for til<> \",'ti<>nt 10 unde.-stand, Ihu, maki<l!l R<.'tainioll coolrol ul Ihe inle,,'ie'\" wilh th~ Ilarru· il easi,.,. for him to \"->Sp\"\"d more accuratdy. As dn lo\\l.~ patienl is fundamental. In Ihe inler\\'iew. it is use- ex,,'uplc, durinb an ,nle,,'iew it\" i,np<.>rtanllo\"~ti,e ful 10 be able 10 stop a garrulou.~ palient as S<XIn as Ih~ I'\"/ifill', Illllgllng< whcne-o'\", possible, even pronouncing information from him <'ilher: words as he doc'S wheth\", it is corr<.'Ct PfOl1UJlC~'\\ion Or nut as this makes lhings that arc said Or a\"l<ed much exCt.~s rOllr own ability to ,'~simi]ate il. Or cJ\"arcr, \",,,ie' and quid\"\",,, for him to ull..t\"r:;tand, No • changes to a subjecllhtlt you are not finding question th.;\",fo,e should con lain I<'cl1l1icaJ terms, and w\" n~~ to walch for a puzzled look, slightly dilating \",Ie,'\"nl. pupils, ro,'ing ~)\"cs 0' \"Ilel'l.'ll fad.11 cxprcssion, a\" indi- Caliof\\Sof th~ Pi,lient's 5eorching fo, a m~Jning_ The stop could be called a 'dis,uption', alld this can be achieHxl by saying 'I'm serry, but whalln~'Cd10 k\"\"w It is import.\",t to rcmembt<r to u5e Ihe following is ',naming th~ la5\\ sllbj<.'C1 you w<'re foUo\",ing. or 'I four stralegi,., was int<'n'SINJ 10 h,,1' ~bout X, rould you Iell me more abOn! thai point?', 0' 'I'd I;ke you to remembe, this l. ¥'.,kslowly. mallerY, but may 1 come back 10 il after I ma!<c myself 2 Speak deJiber~tdy. de.,re, about X in mo\", detail' \",I<3, Keep 'lu~>Stions ,hort. A w!rs.,tile physiotherapist has m<lny ways of stop- ping 0' changing Ihe conversation. as welt <IS an abIlity 4. only one quesh(}I1 ~I a lime. 10 rc'CalJ the subjt>ct th.1t the patienl nUlY like 10 relum loindu\"couTS<'. Each of Ihese aspects m.,kes it easier for the palle\"l to ans\"'e, questions a<curntely, II is important always to Another app\",\",ch is lo\"llow the patient to say >om\" !x-a, in mind that Ihe patienl is in unfamiliar sur· of wh.11 he wish£.'!; 10 say \",h.l\" lhe physiotherapist roundings, lIfld that his =mplailll is his all-pervading thought.lf quc'Stioosarc long and \"wkwatd, Ihewotds mav jusl encroach on his mind rather than mal<e an imP~ct. Thi, may lead 10 Ihe imp()rl of the qUl'slion being lost. At .m initial inlen'i\"\"\" il is natural for a pati~nt to ha\\'e a strong d~'Si\", to expl\"in all aspt.'ClS of hi;; problem

Communicat'on 29 thaI liE belil.··..l'5 om.' iInporttnt. Tht.\"\"*\"\"', ~5lw:>uld \"\" One ,en- important element of the inil1al inh.'1'\\'leW S\"en a R'.:l5ONbly fn.>o> hand 10 l!XJIre;5 IheoIe ~ Ho....... ,.... ill no slap> should IJw, in~ bot- .illowed wis inslsht it pron.J.... mlo the lind nl p'........ lho.' 10 S;.'1 oul ci Mnd. By aIJo\".·in)j the patiml il dcgn.., of pabenl is, for this gUld<:s the ph.-siotherapi,1 as to how rontrol...>d Ial'tudf.>, IN ph,...JOlher-olpblcan Jooam mud> aboullhe pat>enl iba p\"-\"'fS(II\\ ~ ......1as I'lis problem For I\" conduct !he f'eIIWnd\"\" of IIx: Inten lew. Bv lhe O!fld CXilUIflk-. the mantW!l\" in which the I\"'hcont milk... his iru- liaI5pO!11<ml'olls Olfflmenls aboul hI» problem leIb thc of tM inlen-;\"w, thO' ph~\"lioIm3pi.>t should be abk-Io l>xamllll... lilt' n-lah\\\"f IITlpot\"tilrlre he plil(l\"S on eddt of milU. a ..,.\",.....\"ble judgemt't>I.os to !hep....en... ~<, blht~ \"oct creclibltit}. lilt- Face., of his problem For .,,~mpk, illwO P.~timb arc tllklllfl aboul lheir shoulder prubk>ms, one patient WORDING SKillS \"\"rmay thot hi,; ~lTIl i. too .lillto tuck the b~ck 01 hi> PARALLEllNG shilt into his trousers, while the other may S<ly h\" ha, TIllS h~s 1x'cn !ouchi'd upon on page 28. and it is (Mlly so much pain he is lInabl\" to V,'t hiS h,md behind hi. back to tllck his s,h,rt in_ On th~'lwo\"taten>en15 alone, It:,'mt b,· e>.per\"mce. \\\\'h~l ... lIW~nt is this. W~ a it i,; likely lNt each of th\"\"\", IWO p;.tient:; wili \"\"'lui'\" difl,,~t t\"',lt:rnent Such milial sponlalll'OUs comments p.>llcnt is talking \"ben,. ~n asp<.'Ct oi his probk'fll, his wilt &how the pall,\",,!'s athtude oowards Jill. prob~. mind is running along a spL..-i(M: line of thought. II ... and 1l1oI\" abo indicat., h;\" 'I'\"\"n thN'Shold' <lJ1d pain romlhkel\\ that, along th,~ spoe.;ifk iiflO.' of thought, he could acceplan(e hal'e mo~ th.m one he' wi5h\"llIO \"\"P\"\"\"\" _ in f,,\", Who:on a pallent is respondmg. toa quesl1on, he mil, there could be thfI.c or fou' p('lnts. To Ink>nupt hun include in his reply a comment O\\Itside the 5COpl\"nlthe m,l\\' rna\\\"<' him ..,.,., h~ pbo.- in hl5 .tOO\\ ~, q~bOn-Fort=mple,\"\"ma} hil.\\e~asLro·\\\\\"hen unb \\\"l.'U. the therapist. Are in dAngt-r nl \\oslng)\"\"\" did the s}mptOllb bt'ginr', and ,n his noply he nu~ ha\\l'lOCludo.-d lhc comment !hil! he had chang<\"! job<. p\\.lre, 00 no! stop him (unb he to']U'>l rambling on), N'C<lUSll' tf ~ou do interrupt he i. lik<\"r to lose his place H\" must \",,\\·.. Iud \"\"\"'\" \"\"\"\"'\" lor !>a~mg thlS_ Pt.'1haJ\" the 'ch,1ngmgnljul:\": IS A\"l~Io.>d ,nsome 'yay loa chang.. .md \\'00 rna, well ~ imf'O'l30t points that he' may m hiss}'mploms. n... physi\"'ho!rapilt <hould tt>e...-fOI'\\' fa!110 I'l'ffie\\·t'al an.' lal•.,.lilag\"oflhc 'l\"cstJOfUng. interpose the queslion,'Oo yo<, ,etale tlut to the onset BIAS of yo\"r symplom.?' and tll\"n follow with 'Whe\" \"',,\" While the method dcscrib<:d II\"\", In,') som\"tln\"'\" be tll.I?'. At Ihat momenl in the .;;\"Iog\"e, the p~ti~.\"t's appmpri~te, it is importanl for the thl'rapist to he thou!!lu P'<X~'$C5 cenl\", un the chang\" III jobs. Jf the alq .... thal· ~bo\"l' question i' interposed at Ihll stage, the ,,\"-,wer will bt: more accurate and \"'ill be mad\" m(11'\\' quidl:- 1. Som\" peopte ~re '·ery 0iX'n to .uggC'S(ion than if the patient is ~lIow,od to ronhnue taiking. 2, So\",,, p.,opte Are \"e~' opposed to sugge:;tion. ch\"\"glllg h\" tram of thought Con\\e,..,.,l}\", if the ques- Thl.-\", '\" a ~ItiU irlleam1ng WhL'Tlto use any particula' .1\\ Ie of question - 'A hme to use it and 3 time n;)l to tion is lefl until a later staS\" the p:u:iel11 \"lit h.l\\e to usei\" start afl'Kh to re-onentall' hi:< thinking before he can Tl\\ion> ..... skiJs in ~ wonhng nl q..-tiQn\" th.al the ~p1y This takes extra hmt'. an.J thoughls thai might pb.'JO!herapbt shouki Jearn il '~' is to bt h;a,e been 'OIl !hi' tip of h.>; lOnl3tW' to mention ma~ ~ 10 'Is maximum dlcel The first of thoe:\\le is that. unJ.:0s6 (are is tal.en to pI'e\\\"ef11 ,t.the pf1~henrPlSt'S ....tonu~....~ bot Io5t Th.- skill of malung use of the qut.\"1I01\\S 'nll probabh hI\".,.l blas_ II is mo:o;t impor_ tant that question. .hould nor bo:' b\"lSt'd in any ..ay P.11io:'nt·S I \"\" of thought i>. 'mmerbl'ly ulual>k. lbe tuwards the MIS\"'\" koped for_ I\" fact,!Ius .tatement only dan#!\" w,:h ~ teduuque 1M'S in losing one', (an be carri<od OIleSlagt> fl.rtht>r- if lhe physioth<'Tapist is hoping for a 'yes' aflSwer to a p.:1r1lcula' que..hon, OO<.'n tram of thoughL This p1r1lliel''',-,:of 'l\"\"\"lions with aS5l5Sm..nt i. bett\"r \"\"Tn\"l if the 'lu,><;tion is \\\\onJC\\J \"\" ~ p;th~\"rs rnomtat p\"\"\"\"\"'-'S to' an important skill 10 that it is biased toward, a '1'1)' ~nswer, for example, den,lop. when a palient ,wends for lilt.> third In:atmenl and Ih\" ph~~i{llh\",apisl is hop\"'~ tt\",t 11<.' wilt hal'e ,h\"wn When II quO\"Soon i, appanmUv m,sunderstood, ,I\", some ,ulJj<'cti, ~ ;.mpro.·cml'llt, ,hecould ask him, 'Did m.· la~t t\"'.llmenl m\"k you WOT!lt' in any ,,~y?'. This p/'!I\"'.n!lrmp,<t >Jr.mfd blank I,\"\",'if, not tho- patient, for the Comnlurucalion error; she should nOle the mi5un- de~taoding ~nd lI~c1< it \"'.g_ by rl!phraslng Ihe ques- t;Ol1, if n,'CO!SS<l'v in several diflerent \"'''ys)_ For example, th\" ph;'5ioth<>rapisl could !!./Or, 'I'm SOtr~', wh.~t I rNlly meant wos, did so \"rId 50 \"tc.?', II is Ihl, 1'1\"(1((>51, of self..:ritici>.m lhat '\" ou, be,t t\"ach<-r,

30 MAITLAND'S VERTEBRAL MANIPULATION ... iU mfh...>,,« the pallo.'Ill l<' \"\"'> >OlJlething Jilc, 1\\0, or he USl'Sa \",ord, such as ~turdav',\"'h,ch mU$tha...e ...\"\",1 not much \"n\\'wa)\" To ilSl:, 'Are you feeling ilny bl'O.'Il stdled for a rc.uon. The rN5OI\\ ;;hould be sought bt.'ttl.'l\" frofP the Last Ire~tmmP' \"\"ll innuenre hIm \"\"It. .wrule ,tlSshU fresh m tl'M'p\"lient·smind. To follow lhe (esp«ioJlly if !he C\"\"'~.ut' mlllllT... l) to\" anh !>il\\ Ulg.. p.olio:nt's Ii\"\" ofthoooght b iI b. policy than fol- '¥L\", ltwnk ~·ou.l Uun!. t am', ra~ than giving ho-. the lowing one'~ 0\\,,, l,\"\",of thought- n>QS1 in'port.:mt mfo;>f11'Uhon rontained in !he fil'Sf n.~, 'No, w\"ll not\" much ;m~-w..)~ S~mrn;lrv of ~w'Y~w,ng>lills; BREVITY lklain conlto! of 1M int.rv_ ~;m.u.~ lilt p;lI,mll~allh.il'lfol\"1lallon g,....n is WhL'fl ~sking qut.\"hOl1> and ~'ponding 10\" p.~tOenl\" im~r!anl!O Ih~ ph~sioth~rapSl ,mswc'S, the nlimber of ind\"'idual words used b)\" the Us. tht pat,~nrs languag. and words \",h~n~r manip\"lati\\\"e physiothcr,1piSI ShOllld be kept hJ ,m po<sibl. absolllle minimll\"'. 11,i5 i1\"(lJds ronfus,on in the mind Sjxa' slowly <>f tho.· P.,hl'fll and miSUlldcl\"Standmg.. and it also «.'n- ~k d.'ib.ral.'y ,;o......~ time. Ilo\"eo.·~, ...·hen using ron'('1'S<'tioo 10 [(r\"p qJ\"lions loon establish rapport\" ,Ih a 1'-1tl('nl any numb.\" of \"ords Asi only or~ ql>61 on al a I,,,,\" Allow spontant:OOts ;~furrn;lhon, ~ I~;S may rtYtal can be ..,;cd, ,md the, should be arromJ'dnlCd bv non-,p\"'-'O'ly of plc....ng ,.,..m aboo.t Ih ~lress upcri!:r.c. of til. pa~rl ~I SJgm'. Usc para dir>g sk,' IS Oflm .. \";nglc ....l>Td Can a51: II question ad\"'twrely, Be: a\"\"\"~ II a I ti-s of po55ibI~ ~ ,n tilt lind th.ol \"\"\",,,,\"ord1\\\"'11 nnt (Irll\\' 53'·e hlTM'in a,,1J~ the romrrlOll1C3llO/l ~ question, bu! will ..I~ ha!otm the answ~ becaUSl.' the Usc 'mlbad. loops fur dlmlOhon and ck..... mdmt;ondillg p.'tit.~I's thinkIng ~ are thrust imo Ill.> quick answct\"~iIUdtion.For~mple,if a p.:tlieIl.! has >aid Ih.1t the polin 1IJ\"'l'00s ~~ both ~i<l.,.;of his b.K:1:, the q........ tion. 'EqUilUy?\", calls For. much l11On' rapid ..nd pno;i II'\"!' re;por...c th;l\" dOC\"<, '[)o.-ou S\"1 mo.... pain on ~ ERRORS IN VERBAL COMMUNICATION s,d\" than the olher?'. Another lolood word is 'bo,'Cau....•. Thai JX'Opl\" run into d.Fr\"\"\"'IJlties of misund\"l\"OliInding rOO\" example, 'I couldn't \\\\,,11: for half an hour' Thb b is indisputable, but thl' whole SUbjL'(\"t is 1'\\',,11)\" much easier to undersl.lI>d whl'll we examine Ihe 1,.,1Iow;rtS a SL,\"'mcm of locI, no! .1 comp\",i\"\"n; co,,,\",,rl ,t 10 d id~a: wmp.'nwn by askillg 'bo.'(\"~u~?', 'I (Quld,,'1 \\\\'nll: for half an huur.' 'lk>ca\"\",\" .. (!'\"'UbC)?' 'Be<:au.., the pain in my bacl: w<>5 killin\"m,,: Thi' isstillnvt a mmpan...1t1, 11\", wap i'!101 tit( U\"ilQry till,! Ih<- '1a~\"\"\" mlt 11K' ...,asl<. 'Is that the sam... ~ u\",,,,1 [If won;e Ihan \"6,~,1?\". 11111110:,111\",01. (ll.'k\"'''',I':18:1) SPONTANEOUS INFORMATION \\\"''hat this ....ally means is th.tl a thought is a reprtSel\\- tdlion of <.om(\" e~\",-'rnaJ tlung (,\"1:5ua.I, lIudilory or Another important <lull Is thai of ililing q~'on>- III ~uch ......). as 10 pro\\'ldL' OJ'i\"O'\"I\"ni!ies foe sp<lf\"IU- ku..-.tlll-otic). A mIIp of Adelaid<' is .. rep...-sc.-nUII(ln of IlL....\" commenb in lhe p;llit.-nrs reply..~)\" spanQ- I'I«IU>o comment is far more \\'a1uable Ih.1n a dlroct Adelaide - it is not actwlly Add.lId..... but mo.-my .. ilR§....\"t'1\" to a dill'ct quo.~tion. Th,s IS becaUSO' It pl'O\\idcs quahl\\- 10 theans.....,.,. gi\\L'f\\. The qu.lIit)\" is of the I:ind coding of some dat,-, ..bout AdeL1id<'. TIv Illform.1lion Ityl prov,des an ln~ighllnlo lhe patient'~ pcNOt'Ia.!t1J1. hIS \"bili\" to aco-pl (or not accept) his symptoms, in a hum.'\" ,\"11'1(1 It; such .. map (or II\\CI<kI, or rep...... ... hile also pUllinS his symplOO\"l~ in a mnl\"d thai I~ COrrL\",1 for him 15ft' pp. 28 \"nd 36), \"\"\"tabon) and IS u~ to n,..1.<! 'iefb(' of n.:.\",' o. old ,nformation. Then. is il trnn5funnalioo (or a coding) wlll:.. ,l Uu\"l': bo,'«>fl1~ a pem:v\"nn. I\\.,lmms is always dassii);ng, lind mapplflg 's L\"OiClltialJy the ~me as \"\"1mlllg llte ne>.1 ,;t..1poinl is that people opemleoul of llxoor inter- nal maps (modL'is) 11<11 nut \"I ditl.'Ct SCllSOt}\"expt'rience. The)\" G\\Il ol1ly make \",n;., of new in/ormalion by com- 1\\.\",,,pMing it wilh whilt Ih,,}\" ~lready KEYWORDS COdl'li. J~n.lll}·. a patient's an~\"'er lu a que.,hOll 011~'Il includes Since people code their informati..,n at dill\"1'\\'111 a pI..\"\"\" U\\31 l\"'luin.'l; \"n i\",,,,~dlill\"fuJl{I~>-,'I' qur:.:itm, t,m.,,; and in different ways, Ih,,)\" lend to ha,., Id~ link\",) Iot;.-thc. ill Ihcir O\\\\'n indiHdual ,,\"ay~.

Communication 31 People (uneOf1>eiously) rdrie\"e information from 'fhere are very many influences tllat lie behind the Iheir minds whL'Il they he\", words, and communica- lors rwed to check what the \"'-Xl''''er acc\"\"ses way n patient expJ'l'''ses him\"\"lf and, although it is (\",tril'Ves), The retrieving is calkxl 'a transdl'ri\"\"tio\"al impossiblc t\" identif)' all of th\"\", he\"\" some common \"\"arch' by lk\",Jler \"\"d Grinder (1975b), i.e. thc person on~ nl~'CltCl be mcnlio\"'-xl. mak\"\" a derivation thrm'gh a sear<hing process, Let \\L> look al lhis in I~ context of a physiothempist carrying MISI NTERF'R ETI NG aul an inte\"'iew. The words thai she U5<-'S an! a way of repreoentin,; what she is thinking. By understanding !'irsl, if \" patient hilS a hil;h pilin tolerance h,' will,,,e the possibility of using 'unspccifil>d S<'arch la\"guage' weak words \\\\ hen expressing the level or grade \"f hi\" or 'increasingly spL'<:ified \"\"arch langu~g\"',the physio- 11,,,di,ord.,,-, theupist gains great power i\" choosing ,,\"olds \"'dl \",,\"miner will make an error of judg~~ dnd devdaping modifier 'luestions as \"~ enq\",rl's further in the \",,~rch for mL~111ing meotif ,he has no! pkl<l'd up during the ;nt,'rview that r'OlIowing gencral introdudory remarks would his pai\" tolerance is high, This I'<'bellt b \",,,ally rMi- corne the pre><:nting complaint, \"hich allows the cent in talking about his ,Krn'S and 1'<1i11\" Theopposile physiotherapist to he'\" an 'unL>(hted' expression of the probl\"m,1t is here that the physiotherapist can greatly may abo be thc ca\"e; that is. th\" ,'xamin..,r m~y increase he.r own skill to obl~i11 an accurate tr~nsfer of inform\"tion from the pMienlt\" herself. \"rongly judge the s,,,'crity of a p.1tiL'''I'\" problem lhe pnxe\" could be calif;(! inlerp\"'tation.. but it \"hen the patient ha5 a low p\"in tolerance .,tld uS<-'S alw~ys depL'Ilds upon accurate checking with the patient to confirm that \"he h.1s th\" right mcaning, This exlra,agant language such as 'excruciating', 'agony', is ,1 f,,,,,xlb.:lck loop, W,II'OIII f;ed/>rlck Imps, (omwHrlim- liO'I h(liI'l.'rPl peoplr :IWIJd \"\" al II\"\"\" rist of bemg ,,'ry NC., 10 describe hi> pain i\"oCCllrnl,'. This also mmllS tlhlt the hNrnr is really a\",,,,,, of the danger of making assumptions. HIIi\" I\",i', lol..,.u\",-e In\\ oh'~ multlple factors, e,!/;, cul- ture, pt.\",r !¥Oup eXp«:lations, ~nd the reason for play- There\"'\" mam' identifiable\"'\\!Js wh\"n' mistak~'Sin \"\"rbal «,mmunk\"ation can and do occur They <xcur io ing a symptom or point of th\" problem up ordCl,,\"o thc physioHlCrapisl's thinking SUTTOlUldiI'8 the \",king Lo'\" I\"\"\" 101e11l1lc<' is agnin mulhl~ct'-\"I\"l, aod ttl\\< of the question, io the word. lOSed when asking the 'lueslion, and then In the way in which the palient p'ltienl may uS(' exrr,\\\\,a/iant language ,\"ch ~s '<'x~r,,­ heMS ami interprets what i, said. The \"rror, ill!: fur- ther multIplied by the patient', thmking proceost.'S in cialin!l' and 'agonizing', preparing his respon...\" and'\" the words he Ihl'n uses, Th,> word, m,1y COI\"'C\\-, tile p\"vchological impact of Fir1aUy, mistak,~(}(cur in the ph\"siotherapist's thoughl processes in inlerpreting the patient's answer to her injury upon the palient, or his nC<.'d to impress othlTS questioo. Fig\"'\" 3.2 sl10ws lhe,\"\" are;1S for mislake., in an L'Xample where one qUL'Stion is asked bv the physio- \"ilh the '\"\"riousn~'Ss' and <;hange in his lifestyle con· therapist, answe\"xl b,· the pot;enl and then int\"rprett'd s<-'quent upon tI,,,, injury. Alternati' ely. the p\"lient m\"y by Ihe physioth=pist Th\"'\" arc th\"\", m~;n \"rea\" \"lwre ph~siotherapists be wantinl': to tx' Sure Ihat Ihe phrsiotherapist will be gentle in Ihe examinnno11, as\"\"-ss\":',,nl and Irl'i1lmL~,t make mi,tah'S during an ink,,·iew. The first is not expre,;,;ing Iheir thoughts clearly, as in the ditty '\",hat Some olltsidc is''Ul'Ssuch a\" an lI\\surJl1cecla,m may you he<lrd is not what I OleanI' (s,\"\" pp. 2:;\"26), Th\" ,.,c- ond is misinlerpreting till' pMient's answer to thc alter the dL'gree to which th,' s)\"mpt\"m is prcscnt~'<1 question, and the third lies m the \"rN of ASSV\"lI\"'C a either psychologically 'If somalically, CtlllSt.'io\"\"ly or Tnmlung of Ihe p\"tient's answer, The \",ords cllosen by til.:> patient and the intonation used may be quit(' ml,- IJt>CO'lsciously. The physiotherapJs! \",-\",d, to rccog\"ize leading, The5<' factor,;, Iherdo\"', a\", ~\"'~s ,,·ith which tn.. ex~mincr 1l.1S to t~k(' th.. gl\"\"atL'St ca,e, It is wiser and underslaod thai people always hit\"e rea,ons. COn- to confirm the meanmg with\" patient than to IN it pass, This 'C011firmin!\\' is a f\"-'quenl rl'quin.'men!. nut ~ scious or un\",n\";;o\",,, ph;sicdl or psychological, lor rarity. th\"ir eX;let mode 01 pn'SCnlalion, ,,,.d Ihal it expr~'SSeS a certain need. The physiotheropisl should therefon' never be critical of the \\Vd\\''' patient pR'S<'lllo, The, cry 1'n.~nl.1ti()\" il\"\"/f is;l me\"sage, n~-'eding to be d~'Co,kd just a. much o' the ot~r findings that thr history and ex<1rninntino' rewal Secondly, a p.lticl1t may be reticent in t\"lk,n,; ~boul hi\" symptom\", e'·en though they are \"\"lficiCl'tly restrict- ing for him to be \"-,,,king tr\"atment. It is extTemely \"asy 10 misi\"terpn~ thew, erily of the disorder if this aspect of the patieni'. character is nol p<.'l'ce;wd, When il i~ perceived the physiotherapist should guide him to talk ~bout his ,;ymptoms, eXplallllll); Ih,lt wilhout his c'Hlperatian \"\"ors of illterpret~tion wi[[ occur and important infomwtion may be mis\"\"d Thirdly, when a p\"ti\"\"t is not fluent io th,> language of the phy\"iotherapist, hi, only means of exp\"\",-,ing

32 MAITLAND'S VERTEBRAL MANIPULATION E~, Thor.pi.l ),011'_\" c E~, HEARl>G I<I'LI U~R:ST\"!,OrNG THE QUESTIONS E~, 10111'''.\" Ellor Error Ttl' REI&l~ SHIN) Tl-E OV:STION WHfCN IS _000<T'o,,\"\"\"''''\"'''''''ottl;s ....... Error .-TOBEASKED ....1~_or\"\"\"'rr~l>o\"l4>d\"\"''''' rot <ni<,\"'od Tnol.JrlJa\"\"\"\"'e\"\",'holie''''_rT>J<fIW:t ~ng.~\"'''il'''\"ft<;iorn_c.II>rJIld_ 1. \\\\I1,,, ... , ...oI!1en moy tie _odl'OlI)'h<n \\~\"'!Pdo \"'-pro<\" nlorrnoberlre<11l'.oe<l\"\"'\" ............\"ID<iO\"\"\"'\".1r'lI 2ndproo.,.. \"\"p,\",*,. \\\\,ORDINOffiE QUESTUI CON3:DERNGffloREPlY T\"'eror<x:ccn\"\"'\"'tM~\"\"~\"'\"'\"\"\"CIOOSrot ll+:>-Mthol\"\"\"\"\"' .. _\"'hOlJ(j'I..,.tnIt~~ =pto;nt\",,,...,._dillrlOlYJlreao«1llfoJr,,,, ,;,,:,.tyBl<~r\"\"I1lI~_.\"need>lok_ _~\"\" r_ ,,_ at !he P'1\"i<Jt'1e-rOpOl AWl \"\" rfIemOI'/oI(iI<l._ .... ic\\Od\\oOCl\"'''''~the _'ioo \",\"l'be~orolOCW'~ 6ti1prt1<O\" 5thjll\"••\" PUTTINGTI1EI\\.'IS\\\\t:RINTO\\\\'CJR()$ f£MUNG Io.~D UIIJERSTANIllNG THE WORDS r.tra,stot.t>o<-g>tslt'01.tO\"oc......-.gtt-.e,JeS,\"\" USEOtlTllE PATE'ff3A.'1S\\',\\;R ......~.,W<>r>:l.\" \"\"\"dI:IoJI1lort>op<ll.... _lor F'o:.rr.'ml)' \".dfl\".,c,,\"\"\"Os\"\"'<l1 'llicul' ttophys<thor'l'''''''''.Mollht''''''l''',a'''Iad>.<I to_'ldparllctAoo1y\"\"\"\"OOocrb .\",.,... ,no.~,I<>T:>. Ttl<\"\"\"\"lIn ........,.\", mt¥<<lg cl '<per\"'\"'\" ''''''JtMn \"'_\".,., - ,Tt~pr.-. qu\"'tono to re OW ,of'\" INTERffiETING TIH, AN,I'iER ~_oIft~~<1oo''''' .....~tJo . \"\"IO_\"'\"polienl'••~_I \"_oNl(OI'It:ofhf<\",,oo;<p<oler,.,,(r><>.>:Inghor . .~ ...j~oI!'erJlll'~oI>fT\"'~rmj OO'/I\"VIglt/JII....-.rotoorhd Ithpr.-. RHATIW THE A'lS\\\\{R TO T!'E QI,IESTIOf'/ _ _ . .~N~\"\"\",I''''''palIer(s,., ~\",.oilt..~_\"lacll_\"\",t'\" \"\"\"••<p\"'I\"\"\"'tIIIl\",,·..'!>eopenlO mI.oremn M I l p r o u. . DHERl.!lt\\'I'<O T1'E NEXT OUESTION ft>t..,.\"e41>Cie'llkroo~\"\".·~mlO_'\" lr>lq,..\"'n.....po:iJ'o'eoltht.e<n<yoltn.p.I.\"r• .,\"\"\"',tIle~\"\"N\"\"'(Io'JlQues:01rr<.J'I . . bo .. h_ r\"\"\"Msb<enroerror~lOlJ<if'o~\".\"ttt ~.tIJo\"\"\"\"\"Cl>oro.·ror~'>fs9hp-oco>.

Communication l3 ho><' b.>d his <ymptom< an: mar b<- to gC5liculal~' in ,In ex..1ggl'ratl.'d manner. II i~ ~h.l1 to rt.'<\"OgJllZ.. \"\"'I fta' of find'ng 0IIt loOmtI\"ung is stroously wrong, or \"\"\"h nllil~'S ofbo:h.1,'iour olJe \"\"mph' ~Ihodsofnon' a 0 ~Ik fo' tb:' \",nloat and as50CQted proftsSoOrls ha~ralt<l non~~tbal (l)ffl'llu\"ical,o~. !>ft:au\"\" v\"\"\",1 oommuniC\"ahon, wh'ch \"ru eXill:<;\"••lleJ when of difficult V<:'b.-.I communic~tiGn v\"rb,ll commonication is difficult. B.·c,,,,.~ il is 5<1''<1,1; 1<1 CJltulal difft,tnc\"\" \"mll-MlSluJl:t\" III<' p;;limrsJ\"a~,III1;, JIlt' /JJ'.lfSI<ltll<'mpl,:l', Known ~I or psychologIcal probItrftl; \"\" 1wb to\",\" ImfpmVlI.';th \"'lok\"t-Jm,J\",'o! Fourthly a p.>tienl'. \"\"hni<: background ,nnU<'fln\"i llolt--siclnl focus on tilt <nIO;I,nonq symploms or on Ih\" manJM>ri~\"\",hl' 3dopl~ on ~\"'p ....\"\"inl; h~ problem. me ,mp~tI\\tflt of symptoms Pmple from som.. counlr;('l; are hardy and tOI,gh, wh,l.;· In oth~.. counlri..,!hl'y \"\", .. xp<-\"CloI<1Iogrnan and Th. ,ndlV1dual ,llntsS tllp~lltncc '<:'11) 00' \\\\'h'k>thc\"hoI.o family fIodsolroUnd lohclp n..\"',Ih dre;slO,i;. \"'ol.l\\;ang.l\"t(. ph~~r.p~ \",-'O\"(h lObe \\<'ry a\"ilreof lho...... ethlllccha .....t\"ristics 1<>\"\"Old THE REASON BEHIND THE QUESTION misinterpreting Ih .. ,·\",bill ,1I1d non·n-rb.,1 m~s,l);~'S. Dunng the learning std~ of .'..Lng palifflts questions F,fthl~; 'I. IS (l;lI,\\' lo nti~judg.. (or inlerpll't wmnsJr) lhe expf\"CS6,lOrl of a paliml5 disolt>ilil'l \\\\ hen filctors such\"\" Lligatioll, f.o.nuly or 'lOcial situ.,ricJrI>.. or fiMn_ \"nd mt<.'rp!l\"bng their \"n,<;Wer'lI. It is difficult to know' ~l prol:>lems an: in\\'oh~'d. II '\" ''''l0ally msy 10 01'''' Tho,..\".\",iIe\", lo sl.tr1. )udlo;\" tlw inn\"en\"e of a p,'lk]1t'~ psych,-, To,wn,d ~llch a.... certa,n questions lh.,t 11.1\"\" h. a.>mmunt<:ation mL'I\"les lhe \"\".,nin\". shnuld };,.-e!he l>e Jsked 10 \"'\"id 'til\" fiIl~W of lOCKlig\"\"Cl\" b\"mj; polnt<'d \"I lhe th.'r.lplSl q\"'''''.....''' \"bOUI dil.....,~ in pal\"'nl the bt. fit of an, doubt. al 1t>asl until II is p.\"'en llut,. f...- mp~. the emotion.l.l elemcnt is a pollit,\"!'. \" ilh cen ical disordO'TS, fQ- e>.ample. or tho< pur.- m\"ior f\"'lor III thc P\"\"\"'slenc.. of h... ~pnptoo\",. FIl,.\"lllcntly s,,~h judgement\"; ~Oln only be made (and \",b,h!} {If ('••uda \"'1uina on, ohcment in lumb;or disol>r- \"vd~ II is n.·~ 10 ~sk \"bout th\" dl<.'d of n..\"t:md perhaps .'/\"'111,1 0111> be mOld,,) in 'l.'tnlSpl'(\"t. It i\" i\"t\"r. activities. of sitti of i;<.'lting up from a ch.lir \"ft,'T s,l- tin~ fo< n.llr Oln hour. Or theetfr>cts of coughing.. sncc:r.ill~ esting th.11 M,I..... (1978) makcs lhe \"ta!emenl thai the pa~1 (his ,11\".\"\",,1 'IS moocenl ur\\W pW\\cd gmhy·. and deep in,.pu-abon,l'tc, BUT du!he tho.'f.1pisb .1\"'d)'S \"-now Ihe \"-'olsOOl> behind r t - q....\",.,on..l And do the)' S,xlhl~'. WIne p.illents will onl,. commenl on lhe know whal I\"do w,th an JIIOj\"l'T \"\"\"'-'Ihn' g<.'1 un<:' En symptoms thaI ll,.'II1a'n and do I1\"t comml..,t <.HI <llh\". \"Ih,,, \"orti,. lhey h\",e to l..\"rn the reasons behinJ 111l' aslX\"Cts ()f the \"ymplums th\"t mOly ha\\'(' impnlwd. It questiom Cl'ttilinl~ ttK:' (\"an be I\"ught \"\"\"\",oilhe Il,.\". ,,·ubj~'<:ti\\~l'SIl\"\"L\"\"\".{.... pp ~l)\"reulih....od.lhe!tL1J<'d 5OIlS. lUlder somecirrum,.tJ~bul r>uI ,,, ,\"1\"\\' {irrum_ phY>;lOthc.-..p,,,t can St.\"\"- lht'po<,I;\\'\" \",Joe of~SI'm~ \"r.lncccant'<'cO\\<'m.i. \"Jlu,; ..........,tof,,'\"'m~'UCdhon (S<'\\' F'gun> ~.2. lst pmr......) is pmb\"blv Ih\" k£,\\' to mo<l t\"'\"lomallc chdn6C5 r.alh..r than acwptm.-; P<lhl!T\\ts of th\" problems\" b<:-giru1er has, rollin!: this i'1lo ()I1e ~al\"\" appr=ch The Of'1X'5itr ~i\"','T;on mil)\" r,., equally misll,ading. Finally. a mlSlak,'n inlerpll'taIH,1Il c\"n OCCUr when\" duuc:a.1 \"XlUtlple nuw \"\"'I..e il ..\"sier lo uoo<'rstand paik.....r~ ~.\"t sl\"Tnptoms .~ .lin e~ertatlon oj One sptcific questillJl asb>d of pal\"-'nls w,th low \"I. ,'....symptoms thaI areal,,''''s pn.-senl bUI [umNr problems l~. 'How dOo.':> 'I f..... ,.,hen )OU firsl mter>- ,il}. S\"ch ~ pali,.,,! h.l.5 rom.. 10 'K~<'Pt a Cl'rMin \"dkl'f\\ In t...... mornmg b<-ior.. ,\"ou gl1 oul of bed?\", foJ. amount of d'!KomtwI a~ t>c\"'8 nom,a) \"\"d tim\" \"h\"'1 l\".'wd b)'.· And how doc'S it fccl Whl'll you first l)..t 0,,1 \"'',<;(\\0Of ~ m :h\" mornmg~·. Th.. ~liblllghis p.-..\"t pmbk'lll. he b [,\"\"1, lo ....p..\"\", .II for askin!: the first qaesuon IS that me theT\"pist l\\('('(j,s lo Imo... \"'heIhcr 1_·.... deg~ l'f ..,,\\-mty-{ordbablhl\\·) lhan \"oold be prolonged rest ~ t~ s>mptoms \"JrnPiln.'d ,,-,lh ..xpn--...-d b\\ \" palit..... I\" ith Ihc .sam.. pain bul w!'Io is no.m.,II\" symptom-free. \"'\"t.shorl-tenn and \"Iso 10 know \"hdho... Ih\"I\"'b\"\"l IS \",lken<:'<l by Ihe .ymptoms. or whether he \\\\'~kens and then ~ecomes aWM\" of tJx< sympToms- Th\" twu Mis IIwprnaticrl of In irlforl'l31JOn ~ poudIlt' dt.t' 10 COlllIJIOn iU\\li\\\\\"tt\"S by ~ F'llieni II.... th.1r • o.ffe~n~ in 'Id'vidLJa) plI'~ II(ttp~~t't ...~ich L \\,....... hc ch.ln8fl position in bed j,uch ti tumin/; may I~ to diff\",tnt ~tbal and non-vt'~al p'.\",nlalions of tht pain trom l~ \"'gon ones,d,'lo lhe ulh..../ .... ft.\"\"Is\" \"h,'TV Iw'nge uf pam • A ~tict~t pat,t~t, i.l:'. Illt paftnt who is u~w'l '''19 ~J \\\\'h,,~dOl.-.. n.,ftooelit~ to ......a a ,rt'tvint irformatio-l clut to SIOiciIno b) Dol-'s he \"'-'l\"J lo ha,·t been in bed for a subs~. Ii\"E period of tune befol'e this oc:a..rs,. or does 'I

34 MAITLANO'S VERTEBRAL MANIPULATION occur if he chan!,'l.'S ~ition almost as soon ,'5 AlthooJgh I.... foilowingcatchphr<lSelake$an \"\"In:me he lies down? '\"leW ot the probll\"m. II OS one ,,'eD worth I'l!membering: c) Does lhe \" . ' . di5.Jppearquickly without gt\"l' f\\[VERASSL0\\1F. ANYTHINC ling any \"-on;(.' throughout the n.ighl?This wttCT If we add to the possible mistakes ....~plaincd abo,·,' the \"-\"'POn5e ind'C,lt.,,; that the physical ~amina­ communication problems cr\"al,>d by l,mgl'''h't' diff\"r- tion should be able t() dctcrmin\" the provoking en<:'leS, pE'l'SOn.llil}\", distr\\:Si;. etc_,ll is ..~sv to under- jlOSJllon and mo,'ement. In t~atm\"\"t it will be slan<! how physioth....apblS can both ~Iand ttu~ po5lbon oi the p\"tK.'n1 and 1hi5 mO\\-emeru and be misunderslood by the l!lerapt:>t ..·hieh ,,;11 prob..bl\\ be US«! as the IfCatment h:!o:hnique 2_ H\" ITJ.1Y be wakent'li by 'Ill ulC....i\\SI.'ll intens,ty of the VERBATIM EXAMPLES aclung. suWlCienlly few him to hd'\"\" to get out of bed dnd ...;ill:; around un\"l tt... ~ aching subsides. It \"'as ....rv g.-atify-ing to I'l'ad thai )1acnab (1W7), in his If the therap'~! OOES I<n.c>.. the ~ason bdund lhe bool &d:IIchr,<:on5fderro the dialogueof history t:lking qu<'Stion. h:ls !>he g<>t tlx> answ\"r' f\\'l! So. not ha~\",S the answer bas<'d on h<:r r<:\"soning, wh\"t ~hould she sufAaer>lI} import,lnl to portray it 'n ..-erl>.lbm question do? The thin,!; she should NOT do i!> \"\"lie, e thai '<he does ..... ,~u... ann.·.... lI.nd mlWeomolhene'lquestion and MlSWt'f fom'. TI,i\" {rom a m,\"\" of Macnab'ssl~lUr<'. (this ftappl'fl:t far too Nsily, and lkstl\"O\\'5 the .al,dil\\ of the sub;ttn, e e\",min:llion). The 'nexl qUtSl1()fl g\"l!5lhe i'lClusion \"r lit\"ral quoialJons ina book theel.... could l;>e, 'J:)oe, the \"\"-me thin\" haplX'n if \\,ou lieon Ihe \"th,,, side·. If the aru;wer is 'NO·. that is; hccan lie on rnent of ~!rty Takmg an ao:ruralt· history is 00 I\"\"other sid.. withoul any problems, th.-n il;\" likely tI) kooo. unporldnt than making iln a«Urate ~ t ot be a po5l11onal factor. If it ~ the position that i:; lhe the SubJo-'dl'''.lnd ob]ect\" echanges lhallal.e p1a~duro C<'lUSll\", fher, til<' ph}5lCal ex.am\"\",tion will \"\"\"eal the 'RR: Ircatmoml. For tillS reason '-erb,llim le~t 's used here mO\\<'Jnt'nls in ~in ~ilinns thm pl'O\\oke and ~ the symptoms. For treat\",enl, whether the SyrnptoIlb to pro\\\"id.: ~uidcli,K.'S which will, it is hnpt>d, help the need I'TO\\'lIk,ng or n<l! IS a ><--paralE' decision thaI is physiutherapi>t to adl;.,,,,-, the d,l'U, of '-l<:(\"uracv and ma<k al the conclusoon of bolh lhe sub,ect:i'E' \"'00 the m;nemenl rcquiI'l'd for good ~1. p\"}\"Sic.., \"\"amlr>ations. HmH\"\\<'I\". if the a\"'Wel\" IS that ,I makes nod,ffl.\",\"\"e how he h{\";- h\"~stiJl \"akened The pnxt'5l!i oflea~ 00... to ,,-on:I que.tions, and by mcn'l!l<.\"'t:! aching. \"h,,:I> fl>l'C\\'Olhim 1\"1$'-\" o\"t of bed- 111m th~ probli!'H m,,~· r,., an inflamuMtory disorder. \"'hat aUtI)matic follow-up (!ueshons should be ashd or ..I least hav\" a I~rge mflammatory £omponent. lheret'on-, qws.r\"\",! \\\\\"\"t other su\"\"\"'tiVl\" qocstion when c<:rt~in answers al>! g;,'en, [,In be ha.sI~Jl('(t by $houk:\\ be asked? 'What happens ..·hm}..... 9-\"1 Ulli of unden;umdin& the &U;dl'li\",~ thHt n\", p....'SL~ltro \", Ill<' bed'? A.I/S\"oLYr. his back Should be notabl} stiff, not \"\"C. t'SSarily painful, it should tah- in ,,~c('SS of 1 hour ait\"r following dialogu..,. The guidelines should nol be rising refore ,t wea ... off, and it may not atway. mm- pletelv 10lJ$<'r\\. She J1O:.»' has ttw- an;;wt\"f to the onginal mterpmed .os preacning to the ignomnl. or IlWtmg q~ he has either wylosing Sf'Or>dy\\os>s. an they\"'\"read.,..., as !odtooIchildren; mtrad'>c\"l disorder or perhaps a locked joint. pn'Tt to show the ASSUMING e~k'T\\l to \\\\ hich lhe rule 'never assumt' anything' should be MI<en. Similarly, Ih,,}' nlS<.> show th~ prllCess If a palienl \"\"~'~ Ius p.1m IS 'constant', il is .. rong 10 ~V~ that he m<.>aR5 cUIlStant thrwghollt lhe day of cnnfirming messages SO as to avoid m\"tak\"\" int\"r- and \"'Ilht. He may m~,m that \"'hen he has pain ,t is.1 pret;>lior>s II is IT\"OOt'l\" ....al~lk to undenJlAnd thai we cannot avOId malmgassumptions or h}~-but ronst.lnl pain, bul it isn't present all da;: long. Jt b if \"·e mak\" any ilSIIumpho,..; \"\"phcit to ou~k'~, we ,mportilnllo check the Il'IOTe e:xact IDi!aning - oonsLo1nl meaning 'slead)\" or 'unchanging in dq;ree', roast.ml are on a good position to know lhat I\"\"y ,,'re assump- '\" locallOO, Of ClJn:>lant Cr.-er ti.ln<e' tions. and to know when Ihey Me wl\"(lf1g IIr confin\"cd or in need of chanJ>ing. Thl>y w,lI alsoshow how accu- racy can bl\" aduc\\\"l.'d wJlhoul the p.>timJ be1ng made to feel be Os being t.....loo .os an ,m\"\"\"ile, and ,,·ithout imtating him by \"\"cessi,·\" n'p._\"I.ihon of quc:;tinllS. In fact people hav\" enornlOUS amn\"nts of informatL(II1 ston.>rl in the compuler thm we call the mind, and illS ... gmuiroc \"\",p<'Ct for Ihis mallet\" and a care for lhe quality of oor rommunicahon lhal pns us I!'><' poI~ lial toenate .. good relationst\\ipt'IW1IOnrnt'T\\l. Before ,'~k\"'g B qlloi!Slion, il is vital for Ihe phy.,o- ther,lp'sl to be clear aboul four Ihins:;s 1, IVhal Jl is she \"'islles to Jcno,.. and why. 2. Whal IS the be>t possible way to word it J.. IVhal d,fferenl \"..,..·cn might she &\"t.

Communitation 35 4_ I low the ~ble \".\"Iy to h..... quesbort'i might 5. At Sllbsequentt~lme\"'t sessllms, questions about mflucn.... her planning: ahead for dle roed question., ch.1nges m the s) mptom,;. II IS probably the bst of ~ thott f\"kki Ol.It the good 6. During a trmtml'l\\t SCSC>IOO, questionsmout ph)'Siotheraptsh from the Ie$~ gaod .. ) Changesinpain~dunng~ment of tesl IDO'''t''I'\"IlC\\1ts ,mA mi;t;ake that ocru...... t.a,nee nwnipulati,·.. b) I'<lin ~ wlult' al\\.>c:hnique is perfurlTll.od ph)'SlOl.her<lplSl:S is the a«epting of iln IIns\"'''' as being c) Chan~inp\"-in~..flo\"\"l\",atmt'r'lt <ldeq,..,te ... h<!n in fad it isonlr'-agucly informative, Os mc:omplde, or l'5 in u...1Jfficil'tlt depth_ The te;bOl\\ to' techmque IS J*riom...od_ the ph)\"!l.uthlT.lplst accepting the in.ldtquau> \"ns\"\"er i. At \"-..,..j...... sessions, qUl.':>litJns: is us,..,lly tn<lt she doe» not de~r1y unden;tand why shl.\" i9 IIsking the question, ,md th.m..fore dOL'S not ..) During a retra>pectl\\ll' asso..'5SlJlC.'I1t know the numbt.-r of \"\"perate IInSW,,'\" she \",,,st hL\\lr b) After \"a.;:h three to fi,c I\"-,,,tments to m~1 the requirements of the qUL\"Itions. The \"!pne c) When prog~s hilS slowed or stopped I't,'.'son Call lead to ~nother error; thM of ililowing ncr d) Following d break frQlll treatment. lin.:: of thuught to be di'''erted by th... p~tic'nt. usually \"ithout he. realizing it. The g\"-~ltl\",1 pcr<:enlal;\" of a physiotherapi5l\"s patients 10 (\"Mbl.:: nmst ,·\"Iue to be gained from th.. foUow- \":,',,k treatment ju,t bernu<;e of th\"ir pain, while all ing \\leril.:ltim tL...t m lerms of I\"~ming how to a,'oid rommuruc:ation ~ the physiotherapisrs question~ other aSp<'Cts of their pmblcJll,. as f<l. as they arc ron· ....ill be icloot1fied by the IcttL'l\" .Q\" (qOl'Sl:JOn), her \"'''1Cl'1Tll'Cl, pal.. into ins.ig]1iflC\"'~ Oulya thought proce9SeS ....ill be idenllfil'd II~ 'rr (e.... m- ~malJ per- i.-'s thouj::hts); ;:md the pII\"ent's ,-erb.:ol responses .....ilI~ identified i15 -A' {ans....er). centag.. of palJ....lts \"ee,k t\",<llment because of ...,tho'r In the verbatim texIS that follo..., die rommunica.. pairtless stiffnes, n;-sulring in loss of funclion., or m....... lion sl,Us ......mplif}.. cerlain aspects. de weakne<!>. ~ \\l'ea.tmmt cuncepl \"'hich tlus b\"ok A....amle!iS of the body\"s (,\"<lpacit) to inform outl.ne. is cle.rl~' tIOlll<\"le th.at takes into llC'OOW\\t p.oin Not irritallng the patient. Kt....'P,ng qllestiOl\\5 brief. to tn..- \"\",elusion of all l~, but It dcoes l'l.'OJgIlizc thaI Maling features fit Assuming nothing. t\"'\"\"lOST patients are pdlients bl-atUSOl' of pain; without COlllroll\"'g thp intervie,,\" p~,\" would not be pat IS. The J'UTJ'O\"t' in .<l1S- l'~ralldi\"g qUL'Stions, mg tM point is that,n the ,'('l\"bI!t,m II!xts lISl'<i, ........r1y A~king le~ding qu~\"Stions. all ref... to a pati\"\"t's symptoms of pain Using spontaneous IIns\"l'rs Knowing tht' question·s purpO>(' If p.lln were tI\\f! only c:onsideration, the first qU(..r Emphasizing/using h.'y \"on.b Immedta te-re5porLSl.\" queo;riOl\\5o. I,on \"sked of a pall\"\"t \"I an imti..l consullillion would Whm tN> p.otM\"ot's problll'1l'l i5 poll1\\,. \"ith or ,,,ithout \"I\".,ys be. 'WIlCl't,' is 'our p.rmr'. Ilowever,\" pati\"\"t lom't~>d ITIO\\ \"men!. guidefuoes for polrticular qut\"Srion> Co\\f\\ be dJ5CUSiSed in tt... followlllg groups: 11\\;'y rloply blllntl}, 'I don't hau· any pain', wn.:reupon 1. tmm«lii\\t...~~ que>llOllS - immediate ~ Irai~ manipulilli\\(~ph}·sioth..\"'pisl might fl'CIlo!it questitln.. in ~ to crrtam of' the p.otin\\t\"s staremenb. and wonder, 'Where do I go nn\",?', Therdore, Ihe 2. K.........ords - words that Indicate a p<ltit'nfs 1m.. of opening qUl\"Stion ~houtd be, 'As far as you arc (on- thouf(ht_ cemed ... (pause). at this st.'g\" .. (paU.'iej ... what do 3. Specificity - assisting the patil~ltlo m.u:.. \\'00 feel, .. (pause} .. , is rour . . main problem?', me.mingful ~ __,:>,menl. IMMEDIATE-RESPONSE QUESTIONS 4. At i\"itial consultations, questions .,bout 11) Tht· history Many questions hot,(' to be askeod of a patient during .. b) Th\" b•.'hll\\'iour of the symptum, firsl «InSUllation, and the polt......!'s \"ns\"\"\"'l! to ~ Q.J~stioru; about pain ~sPC'nst'. during t...-st que-lion> are norm;oll} sllltemmts ol flld Howe- ..., mO\\\"Mnetl15. durirlssu~llfC;1tmrnl -.oRs..M\"\"\"\" it is. the ('fted of m;,atment that is '0 be ~, \"nsw,'!S to Ih......, questions ha'-\" to be changed from slslmrnrls of fllCr to ro<I,pori\"\",s. For ~ampl.., .. P.1ti~t may 31l9Wer a question by sa~ing. 'I h;,d pins and needles in my h.,nds when I hemm.:d a sklt\" This is a slOlkl1\\enl 0/ fact ilnd is of no \\'illuc as <In a9:!<\"S,m\"nt l,\"l~ It is \">10\"''' what would nil'·\" rulppt.·ncd with ·hemming a .lirt' before treatm ..nl.l-rom a communication ['<lint of 'ie'''', tn.: asped to beemphasizc,d is trotth\" st.'lcment, 'I had pins and needles in my hands when I hemmed a

,_---'J~6~~M~.~\"~\"~'~D~.~'~'~ER~T!:'~BR~.~L~M~.~'~'~PU~l~.~n~O~'===================== _l\"\\'. d.,.n.~n<b ltw \"nnlCd;~te-r~Sl' question. Q 'Wh\"t is it \"bout the pain th,'t n\",k,,,,; yo<, 1,,,,1 'lin,,\" d~ tho,t wmr.l~ with wll.'l woult.l h.we IMp- it is Iikf, a pillCh.....1n''ncr, ,1Ild pt',...>d if yo\" h.,d he!nllwd ~ ,lnl llefo~ we bo:gan t\",,,.menl?'. \\luch nnw is w.src<! and ,,,Iu~ble inior· Q \"Where do you tl't'llh,' l>e\"\" i\" 1'\",,1...'\\11' marion lost if It.<, mt'lhod I, nllt ctlnhllu\"l1~ follo... f'd \"Th\" p\"li''''1 \"ho mad\" this <t\"lement had 1I .harp CONVERT SlA1EMENTS OF FAClIN'll) COMPARISONS intcnniU\"nt pam deep in one spot in hi< t>unock HI~ n........ are II'Iiln\\' ~ to lho.\"\"'p',t', <l\"\"\",h<Jn> tMl hislory ofepi»<ldil: back and bultllCk piI,n \"uuld Iw,~ I<'d the \"\"..\",mer to ASSUME thdl II<' \"'M de«n'bmg a \"Inan! sl.. \"'m,\"'~ l.f f.ld and \"hoch. if aocepllod dl fae,,\" piochl'd \"\"rH In hi-\" b.lck, when.'~< hi> wmploul>I ,,,h\"', 8\"'\" r..be Impn!SSions. Foro.ampk', 'oUIm'- \"\"ere rel\"\"-...:I by trl'.:Iring hs hip. ins lilt- qll~tion. '1-10\" hal(\" \\'l)lJ ~~ the patient 2. ClARIFYING SUBJECTIVE ASSESSMENTS 1IIiI)''''''; 'Bt.'1!<.\"l'. tholnl< ,'u,,' Roll\"\"'!\" thao J~uming that this rrll~ll1l' hoe Ius,mp\".... «l.u. n..\"lt of I~dlm~t. the \\.........\" d\"'l\"rll'I\"ing till' \"ft~'Ct 01 t~ ~t tn.'.11ment. there m.ov t.... p~r1r<:uLar il>p«t51,... rr>ed altt-.- firsl ;trw;! st.>t..........,t 'bo>tter' must bl> loIkw-ed hI' '!kotWr than ...ecoruJ <:orL.wI.:>I>OR$ ,...hich shoIlld be foJk'''ed up, \"\"\"\"'''', '8l'nt,.. than rrlllfl?\". ~Ilct\\l.'\" mdllll; .,.~,.. [n such as til<' p.1tiol,,'t h\"wing paIn rul\"~ 1m ~hoel;.:uw;! 9'CL< on firstlhm& U\\ the morning. 00\" pam pronlled .:JctuiIllo>ct. 'Ill,\",.., ltun\" v\",!' m.lV be nwdmng bo-Itff t>vwatling lhan \\ho, 2~·hour ~11\"\" he had foIlowiOj:; the treatment (of \"Itich he had bero .....mt'dl. Q 'How\"\"\"\\-ourlq;,,,t!lW.l1llnj;\"- monu\"'S'\" n... folloo<ing ......mpb _hould wnJ\\ \"hen irTlITled,.. ~respons.l'~ must bo> ~ ..\"loman- (.aJl). Th<.oy ;I.\"'r~\"'ll.od in g p\".tuillu,tr..'\" I\"\"dif- A \"Oh. VERY GOOD ' 1;\"'\"'ler\"\"t l..ind~oI.IIl5\"'('f'ith.ll ' N:' b\\- p~tlCnt,... 8<'<:aU5C ,I '\" import.mllo lnoow how ttw leg ~~-mrt'-\"\"~ are changing In respon\"\" 10 !Il...lment. the 51.11.......~11 \"The gTOOI''' ~re: \"\"er:-- good \"\"\",t be fun\" danfi,..:I. Four 'mm<.'d.i;ltc- I. -\\I iniri\"I ..........ltatlOll5. 2. CLmh,,~'>U~Ii'''~Inc:nb, \"\"'fI'O'lS\" q.......IMb a~ IV' ...... <I. cumrJes 01 whal 3, Sub,o.'CtIIC d,ffcr'cn,ns. m,ght be olSked: 4. At subso.-qu~,,' lrNlnl('nl>. 5, '\\,on-,crll.ll r'l.'5J'l'f'~' Q 'How doc... tI\",t con'JI\"lN' WIth )C\">Ierday Of\" otho... mominj;'''' 1. AT INITIAL CONSULTATION Q ·Do\"ouITM'.:InIOO~C>-\"I'\" At lhe fir.>! rone;ult.1h..n ,I p~t..... t rna, tid\\(, \"ymrtolTl5 Q 'Is there ..n\" d,ff1m>nn, b..'lwem tho;- reeling in that could be ~n,inl> fn:om a «nical dbord..... (Jl' a glmo-- humeral lii;;ortk,r. Oun\"8 the 'il1bf;.'CllH' \"\",mmabOrl\" ~O<Jr right.md ld't \\togs now7' the 1h11i,~.1 m;l\\ rn.'ke tho: oommmt, 't k,,-~ it \",,,5th \"\"'hu'\"Q '&'me as the 0Ihr... k'J: - '~Ilh ,!UK-I.. m\",-,,,ncnl!.·. 'The immedi~te-fC5pon>eq\",-'S­ ~t all - li\"n...hi,h the p~iothcr~p;'lnm\"\"ll'I..,,;\"; lOO~rent, Q ·QUld. mo\"ementsof whal?' 3. SU8JECTIVE DIFFERENCES \"\"d lh,'n, (o110W1l1g th<\" r~ht~1t', \"n.\"',,', ~>k tn \"-'Sp'-\"\"'\" to the quest\"\", ·11< .... ha,o! you bce<,t, ~ Q 'In what dir''Chonr. \"r patJellt will often re<plfld ina \"''')' thaI ;ndicat\".. thilt he Q •A..., ~Otl ~hle 10 ,hnw me thnt '1\"lck mm·{'· me'\" 11\"'''?' I,fe-els then:: i. a diff<.\"r~'fl<;\" }·\"t he lln.,bl.\" til ,,~pl,'''' it A palit.\"l may h.wea dl'fl1111c I)pinioJl ab\"ut wl\",ll\",tlils dcarlr As a compomson '\" b<.-.:nf,sllught.th\"lrnmediatc< wr\"n~ wllh hin', /\\ny ~'~I't'('S6ion \"r Ihi, kind \"-\"luin::s rt'<port>C q\",-\",linn can \"Iways be asll-et in Ih\" 1t..1l1< of i\",,,,('(li,,I,, r\"II\"w-lIp S(l th.lt the poinlne makes is nei- thecxample \"i\"\"\".lt ;.;\\ ,,,I,,able way<>f CU\"\"\",t\"l!: th,' lher Tl11>ul1derslood nor ignored. I'or ..>.X.unple, h\" may say\" 'When J g(.'! the P'J1Il. ,I 1\"\",ls like a pi'lCht'<l nerw' \"nirtform<1li,esr\"lcmml i\"t\" \" IIsdut a'ml'''ri......''. Such a st\"l\"n\",,,t,, alS<.! ,m c~amplc \"I\" 'ker\"'''rd''. Q 'Ilowh,w\"roub~\",n?' A 'I r,,,,lthat wmethinl\\ in my b~cl<. h\"s ~hitled: The ;nl)l1cdiah~-r<'Sp<1nsc,!u,,,,!i,,n is: Q 'Is it a fa\"ourable \"shifl\". or u\"fm'Ollr\"I,I,-?'

Communication 37 l'atll'l1!:S a\", able to fe.>lthmgs WI Ihl.' ph)'siother.lpist nus depth of qtICSli\"rung'\" n,'Cl5Sary al tht> first aSSl.'SS- ........bk' I\" a$5e5S by '\"\"y phfsK:al ex.uninatioo. SIw:' 'S then 1l\"I',lnl upon the panent'~ Slillement II is 'eI)\" ment SO tItiIl the panenl Itslms !he pnrision in a,.....('r- importanl thai a ph~-siolhenpbt 3houId iOCCt'pl wrul!hc \"\"hent $/I}\"\" and put it to g<lOd _ ' by _o(}-d\\wl'n ques- 'ns thai is being soup.L AU four 'Illation> are ne<:nWI)' !l(lnS.1llII_-\"\",,,..,Ure-.rolthl·,ahll'cfhis!>tlllement ,mmedia~que;hOn>. Q 'Iow han~}·ou been?\" (3) Q 'Hm,!tasitbo:o.'n?' A ·It f,oelsdiff<>rcnt: A 'The fi,..l bun;t of ,rocA'diblepain W<15 al3am' TIme c;ln be Solwd by asking s,mplr, 'Is it a good d,f· fercnro or;' boJd dilf\"\"\"nce\", insre.~d of spending I,me IT T1n:;~i$~<I~I....,....tt!ftIrt;lh<'rukr5h>,I.m- offering sllllg,'StiOIb as 10 tI>c w\"Y~ on ,,-hich ,I might be (tiffel\\.'l11. Tn fact. the patient's anSwer to the '!\\ood dauJrt'JPlnsDIl.li,wurr ifllris isUlluswJ~,od ifiJ is Or b~d d,ffcrcoce· q,,,.,,!ion mar \"iv\" more answers thilll{'Xpt.'Cloo \",Inll'll hJ alII '\"\",,\"....,11 Mil im1llt,I.rINr,,~\"b/' ljIIJ!Sliml m\",II,' \"\",rId/,inK Iron la 1/11'frJl\"\"-'I!~. 4. AT SUBSE~UENT TREAlMENTS Q 'llow does In.,1 ,omr\"~ with YOll. usu,,1 !,;'I- All lhe following =p~ an! n\"5pon.oes to the- fi\"\"t I<.'moipain\" q~hun ask<! al the ~nmngOf Nch Ircalmenl~­ sian - 'J-k», h,ne '\"OIl \"'-\"_,,,1', 'Bot< has il beenr, or (4) Q 'How has il been?\" 'How are '00' An': diU....,.,!? II ·s.,tun:lav\"'a'ilmuchN.'lIerdlly· 1\"\"\"'\" is .. \"'-~~ fDor ttw pab••...t 10 un&rstand n... kind of i~ial.... ne<J'Of'S\" que;'rion req\", ...'.Cl lhill ...... h.l:s .. ,\"'} important role to pLn in thl' a»es;;. m,:flt of dl.3ngll:S (for gooJ or ,II) th\"t ..\", takmg plaoc.. hen! is: at the tn,...tmenl session and frvm \"\"\"\"\",oa to \"\"\"\" ...m. TIle f3ctshould be\"\"plall'l\"d 10 hllll \"I ttw firsl sessiorl Q Is lhal unusual?', or 1lEfore beginninlt tneal- mmt. oou d \\\"OtI h.1\\\"e had da\\'S \"htd> \".-.e that ,I 's romparisons the therap\",t needs. \",OT just m\"\",\" bctll:T, as you\"'y Satun:l.:ly .. a;;?' ',lilt\"m,\"15 of f<>ct'. ThiS subJl.'Ct Is discu~>ed \"\"mo' (~I Q Ho\",h.1sltbrenl' fully in eIUpl\"r·to N,,\\ ..rlh..I~. if the following <lia- logl'\" i< lookcd at in deplh. it i' poo;sibie to \"'.., that A A 1ot,Ior bt'iter.lrs incMlible' there ~te mol\"}' <.'xamplc,; whe-.e Illl' p\"tiL~lt can under- stand tll<) n,...'d for compari\"'tL~ -l~,. in fact, beinlo: \"\"\".J.'£T II scrm 1....>OO\\I*lr I<J lISSU..... 1tI' lIltS Il1NJt educ\"k'd as 10 how he \"''',-,,1, 10 think. sulJ5l3nt\",! '''lpl'l!~Jrnl_ ~\"J 0\"\" ,I r_ 1>ro/lnNy (1)\" 'Notloobad·,oo·(;oodlh.l.nKrou\" \",/~tl'll /c:llrml\"'fllt. /ionnw./ oronoa if/~ (C1I- Q n...'mmcdLltt. po~'qu\"\"tionis \"An,' dif- fo:orenl from us lr Of '\\\\'hatd~tII.a, O\\Nn' s,d,.... ~ '\" rurrd aud aOfS n<!f rr'/lIIT<' nUll frml~7 (21 When a pali<.'nl \"1iL'nd~ lho.' \"\",\"ond session and Ir\"\"'rue,,l? Ti~rrf\"n' II\", i\",m\",lint<'-\"'''I~'''~ SOl}\"!> ho.'., 1\"-\" lho,> \"'III('., ,t ~ .. neo::~'1 patl of 'l\"rslilJll ,hOI/hi l~' ,Ihmg tilefiJl1m,'irrs Iii''''. lhe- NUGJ!>Oll proc,..... 10 confinn his s13temmt Q 'Ooy-ou mean )\"01' arc lOOperc\"\"1 and we \"'\" ,lop I\",alll\",nt'·. or 'Do ~'ou nol h,we \"n~­ Slrongl~ thing lei! in til<' Will·oi ~\\ mptom~?·. Q DoJoum<.\"\"JOU''''rIell'''''\"bctI,.,.nor ...~l' A 'That's ri!;ht. (6) Q 'How has it !>t'{'n?' Q 'With all J d,d la~IIi~,did I stu il up at alP' A 'Abitstilf· A ThaI's right: fT n\",,» i\".......,.flJt'r '\" lbul his n\",m frr/l<!gS rrS.'f to ;;Il~\"\"';'''' HO\" YT. It <b'< 'JOt qualofw ,,,,. MI/!- Q 'lI\"\" dId }'Oll fl-.:l \"l,<:n you walkood oul o[ no, in \"\"\" 1<00 <II ...... 'hr\"\"\" >iITj/11IJl if ~ ~\"ld here compared with Whl'n you ,,,me in'· r.:tllfrlim.iIll\"IJ. <11'liIl'SS.1hri\",.\"t'Jia!t-F('S1!'J'bI' II 'Just tll\"\"\\1\"\"\" .1IlLS/mts: Q 'And you had no ~acti'llls I\"tcr\" Q '00 ,'OU me,on <tifler lhan usualr II 'No: Ii) Q 'Ho\" has it be<en;\" ill 'I \"as not wakened last night br the pins .:Ind m.·..'dl..... · Th\" imml-'diat<:-IL'SpCt\"Sl' qUl'Stioll is Q \"Is th,ll unusual?' (8) Q ·How h\", it box,,?' 'Worse .

38 MAITlAND'S VERTEBRAL MANIPULATION 'vmnit\" is.J. ~t:ltrnl('f\\llhat must ALWAYS bl' c1ari- S. NON-VERBAL RESPONSES focd in dL'Pth \"\"\"ny 11Illol\"S\" p\"tient \",,11 m.,ke lhis n...pon>t. whffo. on mo\", dct.lilat ,m'<;'SIigahon. the oompltA wl.>r.><.'f\\,ng \"'\"'y be lrealment ~ f.tlho:r th.J.n Ihcdisonk'f .l:So'lrh.l\\mg been nlMk' ....Dr'§(' All of ~ abm., eumpJes 04 immediale-responsl\" ques-- Q In wh.at wa} h.h it OC\"l'll w~\". and !IO on lions ha,-e bem mated tl,,.~ .-()Illmunicalion, lout tt..... ..... \"\",n,' (\"O(.J.mples when the t:!<iIm,..\". must n.'C (9) Q '1Iowhiuitbeen~' ~a l'I(lfI-'erNl ~ eilher loa q......-.tiorlor to II '~......,~: n..ao e>-amin.llioon tI.-'Sl D>O\\L..-nml Q ph}~pro.t II ·Anddo}\"oulhinklhatis&omIhl'I......tm.·nlr 'h ,: 1N1tSl '1uaJil)' such \"\"'p\"-\"'6OOfb. for l!>.omple. in ~ to the que;tiorI.H~ h;os ,t been'\"', It.. !\"'timl \"'\"'y \"-\"'-POnJ ~1Jl\\p1y by ... rinLH~ hi<> OO5e \"The inm-.'\\iiate-- Q '\\'o\" \"-\"\"\"'}..,.,firslawa... olitbt>ingmon:o response que;,tIon '\" !'Of'C~' Q 'Thdl doesn't tool- 100 ~_ Do you mean il IT II IS 1J<r.-tler (oJ, I'll toa:;i; tlrr q\"rslum Ihi-> U'mf /I) ha~ beo>n w~\"', de. r1iUlft\"'=~f'V'lIIl'JnJ\"'''''Il('!~''Tlll(rlilol!l a<kil'X ifil (1,,-' >On' u1k'TI IWfillJ>llnl Il'l'<llnl<'tll. Examplt B II 'I'.lirl .. \"('00 afk.,. llefl \"\"\",' Duri,,~ tho.> phy.;\",,1 e\",,,,il\\o'lioo, whL'\" Ihe p.'rient·, mowmenls are bdnlo: k'SIt.\"d, the pulient n\",y screw up Q 'Do you n...\"n 2 minutt;>!;. or an hour or sot ius \"yes o. m\"ke ,n ,'ppmpri.>!e cringing mm'CmL'fl1. '¥he\" such \",,;meL'S 01 ~I,\"\";our OL'Ctlr. the phy,io- 1\\ 't would ,,'y II ~to1rtt.\"d to lx'Conll'.>Ore within the\"'pist must relurn the p.lli'~l1t's joint 10 a pain·fn.X' \"q\"arkr of an hour.' po5itiol1 nnd im\",ed,,,tcly ~,k' ET WlwI \"fcd, I\" br ,tdrrmiucd ;~, i~ 1111' Wn'!!I'\" Q 'WI\",I ,~actly did you feel and wn.:,r<= did you \" ',,,',11,,,,,,1 ,,,n',,(,,,,,: '\" 'di\"\"rdrr S(j\"\",,,,,,,' f~~l,t?\" ..... a;, tlx-re any,hine ..1\"\"r !lUll,>, Ira, /1,.. 1=1\",..,,1 /1'(I\",i,/II,· \"rilal~ It is also nL'Cessarv 10 (0110\\\\' up then with queslions to Ihr<!, ...J\",lrrall,J \"hl,!<\" il \"\"\"1' ,.Jrr,o, J< II\" \"\"Il'- determine whether Ihe pain was an increase ,n i\"t('fl- \"\"\",-<\"\". ,,(Jlf<S lI,al I\",. \"\",,,Itttl In\"\" 11,,-. sil\\\", or an increMl' in thedi>nibution of lh\"\"ymptorm.. I,\", Other common nu.\"Ula.'S thaI n.~IU\"l' an imm.,,,hdte- Ilm\"J'\" (for allmplrJ ust>l \"\" tilt' /ll'Illm\",,' response question are: th<:' first mOH'I1l\"\"ts of sq ......z· ing ~ eyelids or \"'onlllng the 1l<N'; altering the II'(I\"\"'J\"\" paiition of the t...ld; dLonchlllg the Ie<!Ih or fist; and pursmg. thehps. Then' an.' man)' rnoneloadd to the list. Q 'Are you able to teU ........lh.:r II ,~ ju.t o,()n.~ ness from m~ thum\"\". or i~ ,t Iht· protoltcm ....1' an\" lrealmg wluch ... \"'iln.' ,;on.'r fT P,,'~'I, \"\"\" of ./1IId~ able UJ d,f:'rrt,,:>.ll\" Iht Sl!rt'N'« illlnl< \"\"\"II t-~J III /('II$l t:ro-lhrrJ:;.<fI~ \",,1\"\"'~il\".StlrI ,1\"\"\"lJ\"JlrnIIS~\"\"'~1 A 'I'd say 'I \"'00:5 )\"Our thum\"\": KEYWORDS Q 'Good - ~)\"QU. Th.1t's mosr ht-lpful.· rrequenrly dunng qut'Stionmg .. patleOl wm use a word or phr.ose lh..l1 Ius a .-.pt.'Cwl slgnifKanoe. FailtIn' (10) Q 'Ik>.- Mn'}\"\"OU beenr to m::ogni\"\" the. ml.\".:lftS 11>..1 ,m opportunity 10 impr<:t>e th<:' ~t:mdard of the assessment i5 lost, and the 1lw,'I;o,rruk_ P<'\"~.,,t willlakc a long Ii\",.. to \"1IS\"\"''f, assessment made m.'y thL'l\\ be Incurred, ,'nd m.l' not 8\"\" mLKh information th.J.t i5 comp\"ra- 1\".:_ It.: nl.1J1 8\"-1' \"\" 'tem-b~-ilo.>m d<..\".,riptic:ln 04 tho> Th., following dialogue is a true n.'COrd of the ques- sJlmplu\"\",he felt from thellme immedi;>lcJ.. following the l.'~tlr~..,lmenl unlilthc mo\"\"\"\"t the qUC'Stlon '110.... ,Inll<mmgof a p.>rticular ro,tic\"t .. howas not a good wit- haH~)'OU~?' is.lSh>d. Tho.'P.lh('llt musl be pem,il- led 10 My Wh,11 h., feels is flL'CeS\"lry, pnl';dt'd lhe ness.. Her m,lln symptom WlIS aching shoulder physlotht'rapist d.,.,,; ,wI I\"\", [MImi <{IIN'IJI/(·I1'ie'l'. The inlllwdi\"t\"'n:>spo\"\"<' qUl',IiO'll, which shot,ld t><\" J<h-d Q 'How h.~\\·c youlx'(;,n'\" lb 'ILlickly as app\"'pn\"te, 15: A 'QuilL' wdl1l101nk )'0\".' Q 'How 1uI~ your ~hO\\lld\"rIx\",,,?' Q 'o.,.,r\"II, what cfk'Ct du \\'U1I think th.: 1a,t A 'J\",t th.. S.1m,' - \"\",.., ~i'1ce Monday' treatm.'llI 1>.1d?' or '00 yo;, ft~1 IhL,lasl tn.\"l- m..nt h.\" nhld., y01l any WON'!' IT There nr!' IltV' lI'iI1S~ 10 Inldl \"1! 10 and \"'\" I,m·, Ol,e ~ ',IJ,r' anJ Ilk' all,.... lS 'Mmwuy'

Cornmunial'<Nl 39 Q 'Do you mean I\"\" soreness has bN>n ru~1 tile A 'It ...as SO«' \".two- rOll were trNting it' Sd.~,. Q 'Is tins the fll'sllirnc lhot it has been ~dllr- ing treatml.'f\\t?' A 'Yes.' A 'Yes.' Q 'So Ihe I~SII\"'illm~\",t d,dn·tdQanything ...;th<!. to help lh\" shoulder '\" to m\"ke it wOl1:>C7' Q 'Is it stH[ sme?' A 'No, it', just the s.ln\\t\".' ,\\ 'Yes.' Q ·You h\"w rt\"fem'd to the should.,. as ocllluS Q 'Is il JlIst as so'\" as it Wdson Monda)'?\" pm·ious!v. and toda)' you are tallcing ..bout A 'Yes.' sorenesr;, are ~ dlffenmt or a... they thl\" Q 'If it b IIOlt' 5On'. wh}· do you k-cl il is ~ju5t the same ftoeling\"OO you are just using difft\"rrnt wonb1' same- as It \"'ilS befon> Mo'ld.ly\" A \"Ott, I don'l know.lr·sjust thatil hasbo...\". ,son-· A 'Well, bl,ocause it is achIng just the same a!> it w ........henl fi~t began lreil~L' Q 'Was II 5Ot'! ~fo,...,?· The 1L5f rould goon, but\"lltMI is I\\{'G'S>\"lry b to know, A 'lsupp<liSoeSO.irsiu~tthesame.' 1. I low to spolthe bnl'uafle limitations Th~ diso:ussiol\\ resarding >01\\'110\"'\" may \"-,,,rn Ill\\' I,i,;\"l 2. How to get Ih ... p,ltil'l1t to ,<\"m:h for helpful to justify p~llril1b the 1\",1I'~1t for clarification. How- e..,,-, it is ,..:ory Important for the manipulilti'·e ph)'slo- arulw~-n; by 'f'<.'('ific questio~. th.,,-.lpb! 10 \",. olCCUtate. beo::<lu.<;(> II is the 511b,..rtn- ~ I thai fn:<lllC!ldy J'W'ides f.....\". .nd ~ It is ll<.'C~ 10 ha,,, only a lillIe und\"rstnndll1g to aocu~a~uUonn.ltion than does the ph)\"'5ical ask\"Nnl'l'lt realil.l\" ho\"'somd>tlCh who has pain (Ml insist mat II ~ TItt' COtla\"l'SdllM quctrd $Iftl' \". IIntl,\" Sltli~fltCftJrynor the ~, bKao« the original pain has not c\"\"ngoo.. fro'\"CVf/lplrl~; II pal~1 ,f~ 001 cllli1tl.'lI\" /r,-r dt'SlTiptioll 'IlCImrg' 10 ';;oml~' u·illlOlI' \",15011. from SI)\"'\" 'hm~ Ilk' e- en lhough there iii ~ supenmposed. The lalUC' of h.J~ mg Cilrril'd Ihis ..nalytic-ill assess- palit'fll hJS SOIh1 i/ \"omdd SI...,\" 1I~1I III\"\", I\"., ,\",,-~r ~ chal1g~ r;f ...,ml.' km.1 ill Ii,'r symplllm~, rI~prl( Ih( firrl IIwl ,hi\" ment of tht' subjecthe changes thrllugh toa cunclu~oll iPls;Sf5 Illat ,hI' ;j ',Jrr ,.,,,\",'. Tlrr lITo!>\"'!? mq1lirV \"111<' Ii..... >n the fact that, now. the phvsiot/wr\"pist knows OlCrejor['(Il>II!Plllf two Ihings: The pa\"~....t us..od the word sore~' riltl\\cr tho').n I. II\"r techn;,!u\" dId not improve th\" patient's ·.dung', which shouJd a\\crt the phY\"'oIherapI~1to the symptoms facl thaI tl>en\" /Ililj b<:cn a chan(:l\" in lhe !'\\'1nplOlJb This Olli' .,cord. tlW' keyword m tlus e'Qmploe,. dem.:mds that 2. Her teeltnique did produce SOI'Cl1C.\"5IS, \",hich holS the physOotherarisl rt'COgrlim; tile impllColbOl' of the wOld ~l1d the...\"fore kno....s tlut she must question the no! rer 5ubslckd, pat.....t until the significilI'l«\" anJ meaning of the word al'l\" cbrifioo. Ther<.\"fe-, she musl ch.>nse hef Irl'alm<'flt technique to \"'-Old ttwt ~ W,thout the information b<'>ng The patient tn her \"n~.u statement said thdt her clanfled, a wrong tl'Chruque m,ght ...ell be used. sboulder had t>ee11 sore 'since Mo\"day·_ jrr~\"'fX'<::tl\"e of how poor a witness the pallent is, Iht!\", must be a There .on\" mlIny l/u!anlXS of ke}·WOrdS. such as '110, \",,,son why she dlOS<': spont.mrou~ly to rnl.... tion l10t much·, or 'no, I10t {'Wllv', which indi<:lIl(' there is Manda\\'_ \"The rom'ersation s.hould !here([)l'l\" oontmue, something. alld so should be follow~'<l th\"mgh, If a u.;al'ld jo1lm~ing is theacluJJ n-rNl;m record pat'''''1 &'ys 'tod~v it's all right\", this indicJ!o.>s that y~'S­ Q 'Back al lhe beginning 1'0\\.1 made the (001- terday it \"'~Sl'·t- follow it up, ·Nothing .....ally· 11I\"a115 ment rh:tt .'our should~'T had beo.., !\\CllV Sl~ there is something. Th\" list could go On for l\"I...,; II>,., Monda), What is II that mahs ~ou rl'lall\" the imp:>rtant thil1gs al1\" don't miss the key woms; and son.'T1CSS to Monday\" don't fail in following them through ro obta,n I\"\" con\\p\"\"\"\" \"\"'SWeI\", A 'Well. !>e<:llUSt' Ihal'. when It Milme SOft': SPECIFICITY Q 'W,lS it ..ore on Sunday?\" The use of exlrli\"me altcmahl'escan a~ist the paticnlto A 'No, ,t was Monday.' mak\" ,In ~llsw\"r \"'lsier and mor\" itCcurate, NWl1\"riCi,1 scales lllay also be helpful For t'Mmple. tht~ pi1til'lll Q '.....'hl... on Ih\" Mond~y were rou aware of the mal \"-'flO.1 being 'somewhat be\"CT', The physiolh\"f- sorme..r apist can make this specifIC by I'''''' iding Ih\" p\"'li~nt ,,·ith a o-1O;;calc on ...-hich the pabent must pl..n~ his

_~40~~\"~A~I~TLA~N~D~'S~V~'~R~TE~B~R~A~l~\"~A~N~IP~U~l~AT~I~D~N===================== own assessment of rl\"Ol'res5. Pen:entagcs Iib.....'is<' rna} communication guidt~\"'l's f',.t...·t.,.,h<.....'SS, II 1S ...~lJ)' l'l! llS<'rul. \\~J extremeo; may' the pallent into todi-i<!e the pa\"''''\"\" ,oto two typt5: the first IS lhe group bcin\" more ~pccirLC_ For e>-ampll.'. dunng a relroo<p«- whose \"\"\"-,,,t historl mloln... IraumiI; the st'COOd is li,\"c ilSIi<5SIl'I('ll the patient may report bcin\" 'bcttcr lhe group whe... no IIlJUI)' c..n be \"\",ailed or, if an This IS a \\'aJ;Ue stillement (n!.>le,,, sl.1lcmcnl, no! a com- injun: can be recalled, illS,} tm'\",1 01\"', such .... a <lighl ~l.andthel'h\\\"Siotherapht \"\"tll m.>kc the p.lbrnt h_ing(> h.-ll dunng l,ftlllg thIS se:ond I}-pc:' is l'l\"I')' be more specific by n-plymj;. l)l) mu ITINn cu!t'd\"',lo common, and II ~ , l\"}' ,mportant III det<!mU..... the fac- which lhe pa~fs ~ IIU.y be. '01> no. IllX th.J! tors thaI contribute to lhe.> l;'IIlIR'I of It\\(> pam 10 enable much bo.'llcr' the state of tho;> a.boomI.11lt.. to be ~ and In-alt.'d..:t,ech,el_ Sinularl\\. when lakinS\" pabenrs h~ thl.-ph~~ lhtnpisl mil,' mqUln''''' ro ,-, long 3S\" some mcidcnl Comml1JUU'lDoo probk....... ~ ... g..,,,t\"\"l in ttw his- ocn>m,d The ,\"ague p-1bmt \"\"'y <;;ly. \"Oh. ~ ago', lory taking of the!o<\"C'OOd group of patients beca.,;;e, 11;I lhen> is no obl\"ious InJIll)' tJuI h.l»cau<ed thedi5Ol'dcr, while the &1rrulou5 pabenl mily \"'Ply, '\\\\dl. I ttunk ,t \",uch prubmg IS needed 10 dct,-rmme the predisposing was wtll'lll,,~ in India, or m.nbc;1 WiIS 8urma', To factors im·oh·oo in lhe 0I\\Sl!1. In this sirnahon, lhe rn.:Ikc l'lthl..-r \"-'Ply I1'IOn' spoofic. the rtl,~,nt\"'-'Mp;st pahellt does not appn.'CI\"Il' tho! fine qu\"lity of d('1aiJ (flUid rollow up or mien'\"\"\" wlth'2 yl·,' .... ')f 2Or. th.,t the phY\"\"'lh,....Ip\"IIl.\"lolr'\",. Thl' following Io:t is but one example 01 the probinI: 1ll'fi'SS<l'}' in the his· AT INITIAL CONSULTATIONS lory lalingo! the >;l'(:,md group M pal;\"nlS. (0\"'\"II i. impo,;,;,blc 10 \"\"cry JX'$Slblt! 'q\\lestion- ET if / nSK n (17)iIN'Iy <lim-'nlll,,,,,,'iml, Iw\",ny, by his sl'mrl,1JlfOtrS <tHolll'r, Ild/) me (\\II\".<I,..,1I>Iy 10 JII~I.'r. ~1l\"W\"r-qLJ~li,,\"' Mll,latinn th\"l Illi~ht <)C(\"\\lr dllrirll!: s,mld rI\"\",,' 1\\1'15 of iii, 11i>lory Ij'lw!l he f''£'1., orr lt1LI1,,1 ~\"\"SlJlt,\\lio115. Howe\"er, once the ;ntwd\"cliol1s mOSl i<lIil()r!l1JlI. Til<' I~I;'IIS Iho/IIlt' im!IQTlnr,llo III<' 1(till S<:'rk lain, ifllllyd<l I~,t lIIrfiM <1\"\",lo11<\\JII.<Jy, and h-,Im;\"\" In pronOllnCe the pMi;ml'5 rlnme (as he Q 'How did it bo.'!;in?' prorlOlu1cl\", it ,1nd p\"rt1aps rl'Cording it rhonelkall)') ET Till' may !<'It\"(' m~ 11I1l'1lI.\\: toa'\" when it I.-\"a\" 11.11',· 1x.\"-~1 completlod. the 0p\"'njn~ qu~tion can 1.\", A 'I don't know II lust stm1t.od achmg aboul 1 made 5u«inct if Ihe followin~ guidelines ,Ire otlliotro w\"\"~ ago and it isn'l gL'Ihng any \"\"U.,,-.' I. If the p<ltil.'nt has n'a'n:ll' had a mal\\lpuL1hun IT /lIS \"\"\"\"SSlIr~ lobJOll' \"*,1 I,rrcif'!t.t...d II~' pill11_ under IIMosthesia or has ~tly dL..,~rded ~ ~up­ aM1m' iI ,,~ ItIt'Clwmal1 or 1101. If Ihr'>T m» mr port, lheopcnillg questi<Ul might be, -IJu ~uu h.l'e inrikl1ll/!;l' I'rrcll':lal<'ll ~lJ\"t;;aM, It ilU!ln/lttT 50 lri...alllt' diJt.<n·' I'rmtJl1M I:, 01' lit' 4«:;11'/ anvthinglll the \"a}' of >}'mptoms 1>0\\'\\ l' ~itJlf!l1l ·,h lo;': 'Y\"Il'llllflS. fkfivr ;.ert\",g :1,15 2. 1f)'QU know that the paDent has had some form of \"~1. it \":ilY .....;or linwJer IW t\" koow ifJr hiIs;w treatmenl wluch h.35 bet'n ot t-o.......·t;t and tNt he f\"ft'iorlS fJJl$IXfr<. J/Jr lID, IMy\"., prm'Iih '''' may be .1.111 <tal''' \"f bcing able 10 n'tUm to ,,\"ark,. hy ItJ mo\"Xn,.:\",~ ,'-'lwtonall ptltfm of. pIIr~ lhe Of\".\"ling '1uesti<Jrl mighl bP, ·\",\"hallln'~...... !>till unabk-IOOO?' ,kw..r dL-.J\"\" -.,1 t~ \"\"'IIt'IYn 1',,,,,,,,-tr tJr hy 3_ \\\\'herl \"01.1 \\<nco\" lhal the p.1henl hil$1I chronk dis- ItJ IIIIS b,1d of pmo/pi/iItllll{ o!lSt'!;ur I!~ prrsml order, or has .1. disorder wluch has Inlolled multi- ple area', theopo:ning question might beWnat are ~11'trJ\"'_ your probkom< al Ihis sLo~!\", or, 'What is ,'our ~IAL' prOOlem no\"- >\"_ Q 'H,a,-\" you ('\\',\"1\" h.ld Ih,s, or anything !il\" it. The n.'SP'J\"\".' I\" !he exam\",er's firsl qUl.\"§.llon ,,-ill Wore>\" guide the nl'Xl question intoo\",.' of tWO din.'CI'OIW f:T 11rm.\"'o\"\"~I<'ftM,,.IIn·..~lwmllll\"\"\", '\"\"',,.. I. T1I<.' hi~tury of Ihemmpldint IJ.. '-is Ilral I'rttoftJlIS tpi~n; '''''''' ban mllM 2. Thclxoh.wlouroflhes}mplom... 'ji/Jr•.,.i/i;'all(II,,\"rt:r.-fi,rr does 'wi 4;social( II,,,,,, uch will be discussed S<..'jXU\"<ltely. wllh IllS 1\"'\"5<\",1 pru/J!OIl, U\",;.-I, !1M boY!! mllt,1 'arthrilis' 0' 'dis< Ir<i.m'. HISTORY (INITIAL CONSULTATION] A 't\\'o , Hislory lakin!; will be di\".;-ussed in much more det<lil lajc, (Ch\"pler 6); he,.., the di\"\"u,;s;oll ,..,I\"I,'!! 10 q\",..CT I rail /1('1<' Jm'rIIlJY li,JI/,; in sel'<\"r.!I''''.VS. brll pro\"\"Nyll,,' 1/\",,1 mjr\"'lmlil\", bff\"\"SI.\" I,,', pn\"rlll thouglll< art' dm'ftl~f QI<IIlg 'I'\",t IrL\"ltly'lillos\", 10 ;11('I1d a link 1111\". t\",'ifyill.~ 11/5 '110' \"\"s\".,.r_