Maitland's-Vertebral Manipulation - 7th edition

144 MAITLAND'S VERTEBRAL MANIPULATION .. ho..'Illymg(\"Iachemsonand Morns, 1%4). this may the rom...tency of ...\", COI1C1'flt' and also called the slump test_ ,,\",-'<I. a discn.-p;lncy in the degn.\"l' ollimllahon of With 1Iw f'dbenl Slltmg on the e... mination «MJd>. slraight legralS>ngperiormed in lhe staOOlng and l,mgpoNhorb,TO,'Shnglnbo!hpoe;lhonScant!\\eTrion> t1wtheraplSt proa.\"lldsas follows; brof.alue 1. The paloenllS aswu to SIt ...e11 t-:k until the pos- 1\\10'\\'\"\"\"\",1 of the dura] ,n'estmenb 01 the $pinal tenorknee.reill5 ...ed~agamsctheedgrofthe exanunabon couch 50 thai urufonnit~.. of the test COfdca\"alsobeeff«tedinthesupi~patil'ntby~ po!iIbon 15 lI1OlImtamed. In ttus ~ 5itlm« pus- Sl,-eiy Ramg M he.Kl me:! neck. Ali an eu.mplfo. a ibor\\,hoel5~toroepor1;anypamordiscomfort patoenllNl)''''''-egJuleillp''infoo- .. lUcheuminalion findIngS do not clear!) idenbfy the lumba. iipUlf'cw!hr (figoo\"'6.Z1) IupolSbrUlgthecausoe_lf~i,~fletionoltheheild andneckwlulfolhepat>enI1J.esSll~reprodUCl\"S!hr 2. HeisthenaskdlOletlusb.x:kslumpthroughilS gluta.l p.un,.and particularly iflhe ....~ol mon'menl fuU~olthlracicandIU1'llNr6mon.,,·hiI..rtthe ,shmltcdbylhPpa\",.\"\"Slrictionofmo:n-mw'I'ltofpattl- same lime pl'e\\'entmg hIS hNd and neck from fle>.- ~h.e~ructu\"\",inlhe,'erteb.aleanali5ider\\li­ ing.Onoeheisin th~p<)SlbOn,gmtlfo()1..\".-p~ fiedaSthPauseoflheparn.TIu5ll!StlSusOOforlhe isapplJed to thfo >hould......rea so as to streteh thondc and lumbar spines. M.nlmum benSion can be lhethorack ..oolumb..:.piroesintofullfle>.ion.1llc' t=rtcdonthecana1strudure1ifthepabcnISlI5s1umped directionolp~ureis4str\"illhtl.i..... fromTltothe ... ithhitthinonhischesl. ischial tubef\"Osilie.. as though increasing lho.·con- To t<!Stllle m\",-emrotsof thc>Cff\\'lCal or thorack ,·erityofabowbyshorteningitssmng(FiglII'l\"6.ZJ) n..•....'\".,rootsortheirsleen.'Sbyapplyingt'-\"/lSion;,.not Any hip e>:tenslon tNt might tal.e place. as ...ould 80 clear cuI. H\",,\"ev~r. in I.... cer...ical spine. in(o.- bethecascifth.!oomexity inc.\"aso-\"<i markLodly, must malion of a similar \"\"tIlre may be gle.ln<od whl'01 the bep\"\"ent~bybrin\"ingthepah\"\"t'sshoulders pattent IS afford<od I\\'lief of symptoms by placing his hand 00 his head (thliS reH\",'ing k\",sionon th\".,fifth celVical IlCrve root). or supporting his dbow in hi. other hand in a sling-like filShion (to re]i\",,, t\"n..inn on tne5e>cnthc.\".... ica] nerve root). ConHl'<;o'ly, 1(\"I'b\"1I'I an somctiml'S be incn.-ased by prolraclinl; thl>shoul- de< and slft'kh,ng the arm acroM ttl front of lhe' body. 1llc' work by Breig (1978) pl'1'SMk ronMderable scopt'forthoughlregardll'lgpos'b0n5andmol\"('ffienls ol5tnlCturesin the ,·ertl\"bralc....w, and thi5i5dlS- CUS6«I inCholpter 10 In ttwpnfa<'e 10 Itw fifth <odit,on olthi$bool.~w\"\",madelOlhe ...orlbeing earried out by Ehey, related tolT'lO\\'emenl olnene in the Cff\\'icalarea, Uldthis 100 i5d,!iC\\.I!iI!iedin CNplfflO Then> 1$ a ruttM It'M: for mo:n'emenlttl lhr cepN- Iad/a....t.d direct>onwithm the ,'ertebralcana] and theinllrnertet>ralforaIlll!n,andttusll!Stsll'lO\\-emer1ts w,thmttwfulllfotlgthofthespine.ThettstiscaU<odthe 'slumpllrlt SJlJmpt~t :~I~~a:k22 The >lump t~t; ~In~ .. whll~ ,iuing 1llc' test is called the slump ltSt for two ~uons. ~ f,tstisthalwhel'llhepatienlissillmgandtlte,-\"\",miner ...ants him to adopt the position deoaibt.-d below (poInt2),mO!itP.1tientsK\"Spondaccuratdyandquklly to lh\"., instruction to slump. Tho\" s<-'COnd l\\'a800 is :h:::h~~ti~; :~~~t'Z:n!n~h~~~~(~i~Zrn =~:~~

Ex~min~tion 145 dosertohis knees. Any pain response in thispo:;i- tion is noted {Figure 6.24) 3. Ha\"ingestablisheda9O\"hipflexionangleheisaskcd lofln his head and n~'Ckfully,approximatinghis chin to his sternum. Sufficient o\\'er-p\"-'Ssu~ is applied to the ned,!1exion po:;ition to.msun' thaI the whole spine from ht'ad to ischial tuberosities is on<'<jual stretch. 'Jl,., range with pain R.'Sponseis rerorded (Fig\"'\" 6.15). Next, the OV<.'l-pK'SSUrt:' maintaining the he<>d and neck flexion is main- tained by the physiotherapist's chin (Figure 6.16) and thenller lefth\"nd is free to palpate his spine (Fis\"re6.17) Figu,e6.25 Fullyfkxedlpine.fromhe~tol<lcrum F;gurt6.23 Effeetofov<:,.pr=,eonw,nedu,ingsJumpte:-;1 figurt6.24 fullyflexedspine,fromlltOl<lcrum Figu,e6.26 Maintenance of ove'·pressute with physiotherapisl'schin

146 MAITtAND'SVERTEBRAL MANIPULATION F1g_6.28 KntttJtto_w'lll~li\",spo~unMr~­ S, lbeN'),Isk'pl5lolddacti,~doo5Iflexiol'lofthe ankle 10 the k.rot-e exlenston and not.\" ~ pain prnsu\",d~ri\"'lsl\\.mpt~t resp<JIl5e (figllJY 6,]9). 4. Wilh I\"\" ....holcspmc milJnt~;ncd in f1e,aon .... ith 6. Whilethened.naiontokneee>.tcns1Of\\posilionis o\\'er-pressure, he isaskcd loe~ll'f1d his left knL\"l!8S maintau'cd, and being sure thai the 5ymptomsall' faraspossible,and ....hilcheisholdingilinlhis 5bblcandrom;jstenl.lhephY5iotherapi5'~ins posHion lhe ranboc and pam response i5 notlod the Solme o\\'cr-pressure 10 thoracic and lumbar (f'Kurr6.28) f1c~;on whilc ~t the s<~me time releasing some of the 11t'Ck n('\\;oo. ~lIo.... ing lhe palicnl\"s h\"~d to be raised 10 the neulr~1 position (f,gu,..' 6.J() Or eJCtcndt'<l(riflurr6.JI). Ileisaskt'<l to stJlc clearly

Ex~min~tion 147 F\"ogut<o 6.31 He~d ~nd n~tk ext<nd<1l in \\Iump l~'l disord\".sjust as much as for lumbar disorders. Whcn firmer over-pressure ;5 required for the as,,;essmel1t, Figure6.32 ~ssm.nloffurth.. knee~.tension~ndankl. th~' procedure can b<.- carried out in the long-sitting doJSifl • • io<lwithh.ad~ndMcke.und(d position - Ihat is, with the patient sitting on the oouchwHh his legs stretchoo straighl in fronlofhim whal happ\"ns 10 th\" symptoms. In the fully slumped position he may nol hav.. a fuJi rang\" of (figure6.JJ) kneee.lension. If he is unabl.. to e.lend hiskn.... In making a judgement as to the findings of Ihe Icst, fullyhc is then askoo, whrn neck flexion has oc>cn released, if he can extend his kn~\"C further. In this Ihcl\"'i\" I'l\"Spm'5eS,l\"'rt;cularl!l i\" relalioll 10 rrlrosillgllw new position the range is notoo and any pain Ileckfkxim, compoll<~!l, are tlte most ,mporta\"l. A pain- l\"-'SPOns<'rffordoo(Figm.,'6.J2) fK'C lack of 30\" of knee extension can be norm\"I,asc\"n Thislcsl is eff('Ctive for all Icvels of the spine, and painfell\",ntrallyattheT9,nOlevel{Maitland.198Ob) should form part o( Ihe examination (or cervical An immwiate relief of th.. symptoms on releasing nl.'Ck flexion indicaies in\"olvt'ment of tht' canal's pain- sensitivestrncluresand,althoughlhe~maybesome I'C'Stridion of knee extension due 10 hamslringlight- ness,thisrang\"wouldbt'unaf(cctcdby releasingthc neck flexion. H\"ving extcnd~'CI Ihe cervical spine. which slackens Ihecanal structures,thepalient may thL'1l be able 10 gain furlherexlensionoflheknees Again, this clarifies the \"xl\"nl 10 which hamstring tighlness is restricting knee extension. Thcre may be some hamstring !\"-'Strietion as well as a canal rompon- entloa palient's symptoms. Wilh a patient who is generally very mobile. it is necessary 10 reach full f1ex- ion by getting his head down betwet\"n his knees. rfhe is very stiff, this will not be possible and one can expect the canal slructures also to be tight. This is seen in pt-\"Ople whocan.on flexion inslanding, hardly reach Ih~ir kn~ (Ihey may even comment Ihat al junior schooltheyhaddjfficultylouchinglheirt~),andthis stiffn~'SSwi1l remain regardless of lheirexerdsing. If Ihe sou= of thisr<.'S!riction is neural,c{'Tvical flexion and extension will change Ihe symptomatic response, while in the f1exw position. Although some pt-'Ople c\"nnol fully siraighten their knees in theslumpcd posilion, it does nol mean Ihat the range is abnormal; 'I

148 MAITLANO'SVEATEBAAL MANIPULATION m~ybenonn~lfrlr 'finn. It iSlne pain response~nd ttw IVhentheaddoorol:ationorlatcralflC-\\ionpwvoll'$ cNngein lnee('xtl'flsion with the release of n<'Ck flcx- the symptoms, neck flexion should IX' released 10 ion that i5import~nl ~ssess the symptomatic behaviour. This is the most Vari\"iolls ofslllmp positiOlll \\\\I'hcn ttwslump t{\"5t is incriminating ~s~t of the tl'51. If, how('\\er, releasmg negatJ.\\'c although the mfonnahon gamed during the the neck flexion effects no change, the slump posit,oo subjecti\\'e examinatIon indicall'S in\\'olwment of IN- canal slroctures,tht\"llthetestanbe takenone5tage can be maintained .... hi.., the lateral flexion (or rota- hlltherby substltullngce..... icill exll-\"IlSlon for the rer- \\'ica.lfIe>.ionu..tfnilyrcproducethesymptoms.Only tion) is minimally released i1nd any i1lterilti\"n In pilm rarely h.u thIS been fQUnd to be neurally po5lhn', but response is notL\"d. If the p.1in isdimin1AAedby noleas- II can be a useful finding, and U5ed as;ln asterisk. ingl.ater~lflexion(orrolahOl\\),thetestis ....'lI~r· ilypositi ..e;thediminishedp.1in\"\"\"pon!It'fN)·~dUl' whentheU5ualtestISnq;atl\\\"(~. 10 rcleilSing one component of the combrned spmal jointposilion. Thereft:or\\\",inthi~_'mtrlllNlIyl\\.\"duct'd The pal1n~lll\\-eS1rvctures In the \\'er!dlral canal lateral Aexion {or rotatJon) posIlion. changes of tht ha'~;1 supporting role WIth $p1n.aIITlO\\·cmcnlS of I~t­ ~ump kneoe extension i1nd rwo;l fle~1()I\\ rele<tse need to t'f'3ol fkoxion .md rotation. llWi thefl.'foKo dl\"l'l\\o1l'lds, w~ then.-\"I'I' eltlwr unil..tenl S)'lnptoms orbiLll:erill ~..,a5.SeS1ied_Jfthevresultinreducingt~pro,-ocr (or central) symptoms with rhy~loracces.sory pTO\\'oali\\·~)otnI5igns,thatthe §lump tesl 5houkl be tionstillfurtheT,itwoukl_thal\\hecaNI\"lroctures periormed inrorpontins l..l;er;Il fbion. rotation or the \"\"'0 combined (F'f\"\" 6.J4) f\\-toiutl.ind, 1984). a\"\"impwted.llusactionisessenhillfordlfl'ermlJa!u'S Oq)tndlngonthf:pit~lll'ssymptomsandsogllS, between joinl and c\"N1 sttuetu\"\"\". ~sooktleUonOl'roulJo\".Ol\"i1to111b1l1i1tlOll ofthf:two~u.shouldbl!',na:ltfIOriItcdirlto C~I slump AnotIwrslump test. '\" him is pnfNrily thf:w.nptesl usedforcen·...lorupperthoroilCicdl5Orders.i~thecer­ ''Cal slump t~ wlUch is p<'rionncd WIth the p.1bl'nt Thereal'l'l....ooptions,8egin\"ther~-starlingthete51 Intheerect~ttinspos'bon.lleisfirstilSledtofkxtus with Lateral flexion (or rotation);lnd note the p.1fn response; then;ldd the stages of the ~Iump test as hNd and neck to the pornl where the cernc.al symp- already<koscribed, Thcserond opt>an is to'ltart in the lomIifirstbegin(orfirstbeginlo~).\\\\~ththr ~ump po5lhon i1nd then add the looteril] flexlOO (figu'\" 6.34)orl\"Olahon. head/l'lt'Ckhrldinthispositlon.hel5.aslecl Iof\\cxlus lurnbu spi.... by pel\\ic flexion. (It 15 oftIm ~I)' for him 10 ~ taught how 10 po-rform the ~hic lTIO\\~ n.ement \"\"P\"'TiItely.) t'~rlier in t~ lumbir flexion range thai the cervical symptoms inc~, the Illlln' positiw is the flnd'ng tNI the canal structures i1re in'-o!\"ed '\" his di~; also, the k-ss 9SI1y lhe disorder will rcspond to C'OOSl'O'all\\'t' non-In..as,\\'t \"\"'''''gemml.

h~min~tion 149 Th~ ~1V'cal ~ymp t~st is prim~rily y~d 1m ~lVical 0' specificexaminaliontechniquesand tl\\:atmcnl methods for evcry dinirian who practises asa manipulati'·e yp~,tho,acicdison:l~rs therapist. Thl'slumptest is rarely ch\"\",n as an initial treatmcnt For the upperlimb,thc'looracicoutlet'tcst remaills klChniq u e , l l c a n f r e q u e n t l y a n d s . , f d y b c \" s s u m e d t h a t II primaryprocooure.ltindu<k'Sann lraction{shoul- tht'reislikcly tobcirritationofthecanal structures due dergirdledepn:ssion),which provokcs lho: arm symp- to abnormal mo'·emen!. This is certainly so in the low toms (Phillips a\"d Grieve, 1986). Added to this, Buller lumbarspine.Treatmentofthcjointandreasscssmenl (1991)describeslhmcotherbasictcsl5,tho:firstmaking ofthc slump findinss will indicate ifslurnptreatment llS(>ofcervical lateral flexinn(rontr\"laleral and ipsilat- tedmiques are necessary. If,on reasscssmcnt. the joint ,>ral) w,lh the limb stabilized to compare th.. symptom- movements improve but the slump findmgs do not. alic changes. This is also Elwy'sbasictcst.\"Thcserond then the slump may bc the clement that provokcsthe basict\"\"t lltili7£s shoulder depressi<m and either a symptoms. It is possible to predict how somL\"One will mroian nerve bias (Figure 8,5F,as Wown in Butler's recover from SOf'L'llcssprovokro by stretching painful book) Or a radilll nerve bills (Figure 8,(0). The third soft Iissue strnctures, but the canal struduresdo haS,asilsfinalstrclchposition,shouiderdepression not recover at lhesame rate; th,>y are nluch slower, plus abduction and la1cral rotalion, with elbow ncxicm Then1ore. when lhe slump tL'St is used asa techniquc, and wriSland fingc\"\" in extl'fl,ion. SO that lhepatienl\"s care must bc taken nn Ihe firsl day and asscssment lhl\"d reaches thc side of his face. The h..lld and neck o\\\"er24 hours is Ihen nCCL\"'Ssa.ry lodeterm;ne whether canbcplacooincontralaleralflexionatlh('beginning thcstrengthofthete<:hniquenecdstnbt'changed.lfit of the procedure or as the final movement (Figure is p\"rfonnro vigorously, an inlerval of 2-3 days 8.1O,G,asshown in Butler·sbook). should be left bctwecn trealments forsorenL'Ss lOselile so as to make accurate reassessment possible lodCler- Forthcloweriimbthereisstraighllegraising(st'l' minchowmuehhasbccngainro. F;g\"\", 12,6J) with the fool in differenl posilions.such as l!or>;ifk·,ion, plus inversion and eversion (similarly Thc~umpt<'Stisral~lychoscn3saninitialtrcatmcnt wilhplantarfl..xion)andalsowithhiplldduction.The tccl1niquc. T,~atm~nt of lh~joint signs and ';<JCond basicposilion is in prone lying, whcrcthe knce 'tasscssmtntofth~slumpfindingswillindiC3ttif isl1l\",~-dand,ifnccl'SS<uy.addinghipextension. slumptrt3tmtntb!:<:omtsncc<'Ssary Passiv~ physiological intervertebral mov~ments Tllcrearesitualions, hnwe,·cr, wlwn neck Aexion in lhe (PPIVMS) slumped posilion (wilhout knee extension) causes se,·eresharppain in the back Nl.'Ck Aexicm in slump It is necessary to describe briefly lhe 1l'SS sEX'Cific pas-- may then bt'choscn as Ihe firsl trcatment movement si.'e movemenllests for sections of thcspine. even though they are rclativclyobvious. N~ural linktd mo~mtnts Breig (1978), during 1960. was probably th.. first to make the important impact The physiological movements of A\"xion, eXll'flS;on. needed in tl\"'MN of adverse me<:hanical tension in laterlll flexion and rotalicm in sitting and standing lhecenlral\"\",,\"oussystem, This work has bccn taken can be \",peall\"-d passively in Ihe nonweightbearing up by I'Jvey ,in,.. 1978. and extended by llutlcr(I991) positiOll. This ,,<'ry g\"\"erlll test of movemenl is only for lhe manipulabVl.' physiotherapisls. rcquin.>d when it isnL'CC'SS<lry 1o determine whcther loadlhroughlhejointmak<'Sanydifferencetoth.. pain Ilreig ll.1s dearly shown thenccd 10 cnmpare the felt on movemenl. range and pain f'L'SponsesofCt'rvical movemenlspcr- fonnOOin5itting,lcftsidelying.righlsidelying,and The physiol~ical mov<,ments of the spine are pronelying.ThesecompariSOrui5houldbeinvcstigatro lestedpassivelyinthelyingposilion.Thelechniques, when the pat'enl's symptoms and history indicale lhe ..xcept for lumbar lalcral Aexion and lumbar rotalion. possibilityofaneuralwmponent a'e obvious and do nol require description. Lateral A\"\",icmin the lumb,lrspinc,howe\\,cr.iSp\"rformooby Butler has gone further, explaining tesl movement. th.. physiotherapistsupportingthcpaliCTlt\"sfle\"ed to include the periphcral nervous system (entrapmL'llt knt.'<'Sandhipsatarightangleandpi\\'olinghisfC<'1 neuropathy and Olher affL'Ct~-d abnonnalilJ~'S of penph- away from her. When hip rotation reaches the limit of eralneuralmovement).HemakcsthcCSSL'lltialpoinIOf the ,ang<'. lhepelvis lilts Latcrally and lat<,ral f1l'\"ion lhen tah\"S plJcein the lumbar spine. Lateral A..\"ionin lhe opposit<, direction islestro by pivoting lhe patient's fL,<,t in the opposite direction (Fig\"re 6.34) ROlatinn is produced by fle\"il1go.-..: of the paticnt's

150 MAiTlAND'S VERTEBRAL MANIPULATION hip\" and ~ 10 a right ~ng\"'\" and Cilrrying the J<na> Gtntral palpationrouti~ Kro!iIl !hepilhml to roIilt\" his pel,isand lumoor5plne ...Ihtuslfog. Tbc~'palpal_1OU1I...,~k1COftSl$1of InttM:rtcll~1 t~b by palpation .l'oSllioo\"\",jol~ts,\"~,.\"'od-~lJOnfor~ and~fort In re'l.1hon 10 examining IhI> roorma.hty Of llIher\\o>'i5e of lIlteryertrimll mo\\t'n>enb, the mosl important tcd\\- • Assnsl\",foocfta~'~IC1I\\pctl!tu~orC\\ltCkntt nJque ..e thoso.> that follow A pilt>enrs phy~ioIogial of~aling mO't\"l\"Ilmts may aPJX'ar nonnat).... the palpatIon IeSt5 formter.-ertroral \"\",,'ementwill re-,'ealjoinlSlgnsin • ~ngforsoftt,uutcftaI\\9\"5.W~rf\"~allO appropriateposilions. If a patient hasneTw root pain, dttp,~\"eraltoloahlM and wfw>n this pain is fell only in the distal eXl\\'nt of • AssnsillCJforbonYllnomahes.~g.sp;nousprocn! the dermatome, then 1m.- patil-nt's symptoms can fro- position Ind rtlat,Yl:' d~pth quo::ntlybe~produced by the spccific physiological .00000ngfOfmovtrntntanomali<:sIPAlVMSI-!joe1\\Cfll1 movements described on page 133.l1lcse tl\"'lS arc thl' rompari§Ol'lSofmobility,lIndearly,mid,lmraoge sustainl'd positional to::sts and the qUddr~ntteslS,dnd the rest \"\"\"'emcnt:s rcprodUCle the SymptOlllll by ah,'I\"- • M~,in9thepainrcspon!.l'tosoftlissu~p.aIp.atiGr1 ing !he rcLiitlomtoipsofpam-5eflS.iti\\estTuc1l.lR.'S in thl' andPANMS lIller\\-ertebr;al canal. Under the;;l> nn:umstill1£l'5, pas- Si\\'~ tests of mon,'nlef1l of ~ inler\\'er!ebrdlwgments • COfllpl~tin9_menld\"'91..ms an berwgal:i\\'~ Inrnntra5t tollus,ifthepabenl1'la symptoms = g fl1Jlr] ~ in...... ertebr;o.l joinl, in lhe A pillpi1honL..... mllklnon;s performed In t\"\" followlOg absence of o1ny iIbnorrno11Jtv offnO\\ement of the pam' <;equenct'_ FiNt. thot> poltM'flI must be so po5lbonC'd tholt _b\\~ struetun5 in the lertebral anal, then the ttwne~.. no \"tenll f1c'OOl1 Of rotiItlOf\\, dnd so tholt the testsbypolpation,,'iIJ;o.lwo1ysbepositi\\·e.Thc)mdl \"PlI1Il'besU\\ltsOollUralmKl·flcxion!\"'I~~lion be dillicult 10 ascerto1m. but Ii I\"\" d\"wb('nS of It\\O\\l~ (il'_l~ing pronl!or supIne for !he cenical >PlI1Il'). To mmlarclestedproperhasdecibt'dintht-foiJol,.-ml; make the po1lpo1hon l'....mi\"\"tion as ot,o.>cti\\e a.!II pos- scctJon.-Jl'ClSlti,·1' signs of p.lln, restiictiooormU5Cle SiNe. lhot> exllm\",er ~Id make ,t ciNr 10 the piltlent spasm \"'ill be found in one or mol\\' dirc<:tions of Ihl' thatshed<CInot\"i,n'ltobeal\"\"m(ulprocl'dun' pollpabon mOH'ml-n1. It is also nccessan- to point Ullt Howe...er,the I\"\"hentshouklunde:n;tandthat helhould that teshnl; physiological mo\\emMlts either ~cti,ely not comment C,·t'rbally or non-\\'efb;,lI)') on when the OT passively does nol i\"\"olvl' the accl'S>Ory move- examination;';,ori.not,causmgdisromfortorpol\"\" ments of the inlenl'rkbral lI'inb, whered' the p.llpa- until later in thl'procedure-whcn the l'xam\"'i\"r h,15 bon movt'll1el1t tl'StSCdll bl'dirl.'ctly rclatL'<lto tfw> determined whlchaTt' the normal and abnormal find- .JCCt'S5Orymm'eme<lb iog, in tht' rdt','aot art'as, he will bt'askl'<l tocornpare the symptomatic with the asymptomdtiC Sitl'S. Th~pa!pition_.,.,~tle$tseanMd;~l\\'bttd IO!llt~~ts o.w rc<:enl yt'''N there has been rons;der~bll'dis-­ Some waders may questJon the accuracy of the ~li»\" cussiooandioH~tillationintoth .. valJdltyoip.lll\"\"lion tionmdt'tftminingtheinl('.wrtd>raljointn5pQnSible I!LlmilldtionrelidbilitrMOI1'=l'f\\tl)',JullrlGI.(1993) for\"~benl'~S}-ndrome_Jul1 rl 111_ {1<J6.I1. in the repor1 han.·sommariZl'dthewOfkth.lth<>sbt>efodonerelat ofal'l\"SC;l.rd>pro;ect.5.lKl inghrp()mobilJly.Jndpalll~lOtfw5OUI'CPaia I\"\"tierJt's symptoms, ~ is no doubt. in the author's 11' \",rrdllSiorrtIraICllnMdm/L\"'frurnthlSstudyGI mllld, that the mamrulat\"~phrs,odwnrlSt a n _ Ih'$pomt,isllrat\"\"'''lUIIJUl,'{'IO$lf>,bylll'''''''\", abnormalities of support\"\" 1ls5ueS, !he shapes and \"Ul\"ipuwti\"\" Ihn\"rll'l,l. CIll] \"\"It.i,lmtIYIlItJ posilions of bom pronuncroc'eo1nd of llltl\"l\"Sl'K......,tal llCCullltrly<kt{rm\",rlM'ifffll,liltglrofl,ltcll~o{ mo'ol\"rllt\"nt. I--kl>-''''''('I',II IS also necessary to bl\"abk' 10 Sjliltlli IlIl'\" \",roi\"trollly ml'l!lII//\"\"\"ch/,so{ti,c rl\"Iate these abnormalities 10 !he po1lient\"s symptoms dorsai,,,,,,i,t.\"/lisl'l'Spt'C\"tma/ll/aldiogJ!(}sisisl/s ..\"d!hedison:!CT. IlCculllt{flSraJiolog'CllllyCOlllro/irrlJiog\",\"tic block>. Togainthel\"\"henrsronfidence,t\"'-'theraptStshould USl'lhe hands and fingersina general mannero\\t'l\"the rclevantpartofth<-bacl<asasoothing,circular-l)'pe massageduTing which a general imp....ossioncan bl' gJ;nedJstoth\"'l.lleofthes\\lpo.orfidal soft tissucs.This nl,<-'<lnott\"I<.. loogt'Tthana few !;ffOnds, and isin\\'alu- ableingainingthcconfidcn<:l'ofthcappnohenliive pati.\",1 Or ttll' patienl with l'xtrem.. tl-ndcrTIL\"'S.

================~~~ Thepalpaljon\"x.lm;nat;onofth\"spin\"includ~'Sth\" tn'atments. The me<:hanical warmth will dt,appear or follow;ngt<-..\".. bcmMk~'<llydiminishedby the bcginningol the sec· 1. Skm5w\"alinga\"dtemp<.'ralu~. ond treatment session; it maye\\'en disappear by the 2.50fltissuechanges ~·ml of the first t.....atment session. The r~'Sponsc to an 1. ['osilionof,-ertebrae aCI;\\\"e m~'<lical condition will not change fa\\'ourably ~. Mon-m\"ot of nlftcbr.le o\\'er two treatments, and such a response muld wl'lI mean that the disord<'r is not in the province of tile When the,pine isbeingexamined,th\"patimtlics physiotherapist. pror>eandlheskinischt-'Ckedforswcatillgand tem- peratu .... ['alp.,lion for muscle spasm and general lwa,mlh crl:ated by\" local mechanical disorder will tissue tension Ihcn follows. Finally, before testing diXlPPC'\" after two =ion~ of mobililation, He~t inten:crtcbral movemenl, the positionso! thcver!,,- from an active inflamm~tory disorder 1'1;11 not rh\"nge braeshouldbea~in...lationtoadjacenlverl'-~ ~ignificanllyove'lhetwomobil'l\"t,on=,om; brae.Nol too much importance should beplacLod on abnormalities found in this latleras>es;;menl, as they Jreooly rel('\\'i\\nt if they can be \\'rrifiw by radiog- raphy. As there II\", some diff\"rcnces in pro<.:<!du ... The oc'St method of \"\"amining for wannth is not t~ fortestinl; diff<',..,nt lev\"ls oftht' ,pine, each \",illbc same as is usuallr taugt1t; that is, using the back of the d<'SCribed!*parMelyinlhechaptersforeadl5\"ctionof hand is not the bt':'il way to f~,,-,l many of Ih~· t<,mpera- the.pinl.'. Oo.'SCriptionof lhc k'Sts of movement then tUrcch,lOS~\"\" Jt is belter to plaee the full bn.-adthofthe folio\", palmov<'ranappropn~tearca~ndk<.\"-'p it in thatpos- Palpating the soft tissue as.ociatcd \",Hh Iheabnor- ilionf\",a fe\",\" secoods to gauge the tl.'mperaturc, The maJ mter\\'l.'Ttebral segment reveal. information Ihat p.l1m is Ihen pliICM and n'laintxl on \\'anous sites cannot be ga,ned in any other way. Even when all aoo\\\"t:> and below tM symptomatic area and moved othcrphysical k'Sts are ncgativ'e, palpation is positive Iromrighttojeft.Thisproc~'<lureisrepeatedO\\\"l\"rthese Grie\\e (1989) comments strongly On this issue. The sites, romparing tile difft:>rcnt temperatures until a ~.l\\Jreofth\"tiS5uesdiff~ntiatesbet\"'eenoldtis,ue dec;,;iooismade rnangesandnewti>sue It is difficult todescribc the differcncesin the kinds PlIlpationexamination of Mat/warmth that can bc fl.'ll. Howel'er,l.'xpenencl\" teadu.'Sthat~f(>levantvari\"'yisonethat;sfl'llto Skinsweotingondtemperoture oomefromd<'<'perwithin,ratht:>rlhanbcingjustontht:> surface. From the'within'situation, it s<-\",ms to build Any exc~'SSive sweating \",levant to the 1\"\"1'1 of the up and work its way towards the suridee. and Iht:> spineund\"re\"amin.~tionisfoundb}'wipingthehand palmranfeelthi~diFIt:>l'<'T1ee. just once o,'er a wide area, wilh the main allention oc~\"g at the para\\'ertd>ral Mc.l. Rele\\'ant [indinS' shouJdb<>notoo and aSS<.'S>ed at followingtrealment The wa,mlh/heu mon rl:1C'lanllo the manipulative scssio\"s forchang~'Sto the findings. ExC('Ss]\\'e .weat· phyo;iothe,apist is fell 10 rome from with,n. working ing i, not a common finding, but when it isnotcd it its way fo the surl'ace add, 1o theother~\"Xamination findings in identifying the level of Ihe spine in\"ul\\'~'<l in th\" disord ..r. Examin,ltion for lemperature ct1angt'S (mainly The flat palm method ran then be modified by using increa5Cd temperature) is far mOre important than mainly the hypothenar eminence to determine the ,weating..andhasimplicalionsthat\"\"nnotbeignored superior and inferior margins of the arca of warmth Weare taught that infJammation is indicalcd by 'red, The area can bc furtherdefintxl if the warmlh is fl'lt 10 hoi, swelling', bul rednt'Ss and swelling are not com- bclocaH7.ed tolhe \\'crtcbral rolumn. The method then monwith ,pi\"\"l disorders. Wannth or hl'at,on theotOC'l\" istousethepad of the thumb placed transverselro\\'er hand, i, quite common, and it immediately makl'S th\"lamina on one side 01 the vertebra (mainly in the the examiner think of an inflammatory compon\"nt interlaminararea), with the tip of the Ihumb reaehing Howe\\'er,thewarmth,when it is found,dOL'S not indi- Iheinter-spinous~paee.Thesameprocessofrctaining can, whether it is a m~'Chanical rl-'Spon>e or a response thep<J<>itionuntiithetemp\"r~tu\",is&~ugcdis\",,-'<l,l1le to an acti\\·\" disease process. These two differences po>itions are then rhangt'd so that the le\"l'Is above and r\"\"onlybcd<,t<,nninedbyotherg<'neralh<,althindka- below as well as the left and right of the column can be lors, or br the rl-'SpoOS<-'S to th\"fiTbt Iwo mobi]i7.ation oomparoo (L...~ndo, ]99~).

152 MAITlAND'S VERTEBRAL MANIPULATION Softllssuechonges ltoickening alQund lhe apoptoy\"\"'<11 IOint will be li~c Thcs<>ch.lng<Sa~tubefoundinthcligamL~'tous,cap­ pressing againsl lealher; lhel>! al>! \"\\.,,,~ \\'~d~hons ,n lhe l\\ardness uf the leall\\cry fuel. Thld«\"\",n~ from sular,mU$CUlar.nd('(lnn(.'(t\"'et!Sl>UC$;)lIlluclu.'I'Imgur mw;cle spasm.l'alpillIOn of lhcm can n... eallL'TIdcmcs.'l. mUll! \"\"\"enl stresl;es will be SQf\\<..,. <,II\" Spon~~, and this may o·....rlie an old..rleathery f..... hng Thld,('rung Palpall(lf'lrontUluesbyusmglhefulllength~the within lhe muscular tissu.. is usually IT\\Ql>!d,fru......nd poodsolthemiddleand ring fmgt'f1I ofe;och lund mthe rarelyf......lslikelurdleather.Ne'l'l~rt~les8,wt...'I'Ittoick­ ;ntC1'lamjn.ar·lrougharca(fromthcl.. ~ralsurf~of ening isJ>'l'5\"\"1 it h.as a stnngy fuel If,t ill 'old',.nd a thesp'nous~lothclaIL.,. ..Im.arg,nufthe ..rtlCU- larpillorfromC1-e7).lnc.-h.'Chnoquemvol~·esmo'·ing smoother f......l if it is 'new'. both h.ands in mythm .. ,tht'achOther,movmg the skin Itis~rytoexplamtotht'p;lhentlhalhe up and down w,th Ihe pads of the fmgen. f.... as the 5kinal...\"...,.wh, .... gently<'nkJnglntothemusclebel~ shoukfonlycornmentonl~ifhek...fsthal palpatiun is ex<:es6,ve. or tn.ll to conllnue pillp;!hon liel;andutherliOfI tis6ue. lnc.-pul'J'Cl5\" is 10 feel for will lead 10 increil5Cd sympt0rn5 ttw folJow'ngwy_ ..~ uf thickness. swellmg and tightnes6 in the soft Explainth.atwhentheeu\",,~tioni:!lfinlshedhewlll pe-rfurmed Iwo orbon)' contour Ha\\mg be asked for htscornmen15~ tu wtwot he fcelsw,th bssUL\",andalsoforao,abnormalitiesofthegener..l pre!i6-Urebe!ngaPf'lied to IhelUlO!T\\illie'l th.Jt lheenm· ttwe up ina!ionhaselicited.ljis~liIIl-'\",'llrl/ltNplfllo,,\",l­ i:r tllllJ jIISi ............. _;,. thodmtd ur ll'ff, fI ~ \"\"\" and dow'l'l fnO\\'emcnlS.n the a~a. lhe fingers sh<:>uld '-vrlobrntlrrpainffdurtltr_Ittu{_palltnlS5!I\"''' lDfflS..ltc..n,~·....,bethel'l.'MOOfUl''''''.od~,seg­ be rn.ode to slide aud.od ~JOmrn and the process men! to be on,\"workcd and thus b«vmc poomful 8)- repea~_1lu5J5lhenronunued,ll1O\\ingdownO\\...·. therebtlld ..~a.Ap;trticubrle\\·elrn;a)-beretufT>O!dlo if.an abnormality is kit then- referring to T~ 6.J fplaruung the ph)'5Kal e;amUl- ~!hegener;1I.andmore5r055,mpn'SSXlnt­ _1ft'al1OO).,tcanbeSoN'lltNtthc·tlud.erunglSbftnes5 beeng.ainedthroughthefullpadsofthefingffsUl' bt<omts the Part two rather Ihm brin5 the uf thwnbs,.tIwproct'dunl'shoukfbe..\"..atedbulthislfme !he \")'ITIptoms (P..rt <JIW uf the pLonrung sheo?t), The usmg Ihttipoi tIw p;td ofonl) onedig.t of each h.tnd and emph.aslnng the t\"X.1m,~tion 10 the arNS w\"\"\"' !>tiffnel6thenfi15innpoortclllwlJNln'IomlU'ltNlll d~fromtheroomv.lh.a,·et-nfound. ~UlJ'I5Ihescgrnmt to be DUde ~ mobile SO as to A 1N5OOiIb1,- .acanatedeit'm\\l~toon of thes,kand Ies5en the \"'m ~uire<I of the .od~t qmcnt. In Iyptof~~bnorm.ahtyshoukfbe~sothat.a _ dtiililN coindeterm,~1tOn I:lI' made ... ,.... otM\"·ords.it1:5tmaledasthearU5toitho>'OOU~ ratherthantlw.5O\\lrU,t5f'I'_1lwdlSC'USSlOl'lr~ lnc.- most common fU'l<:hngs al this Slitge of the anotherlS5Ul';tIwpootJenthasSOUghltrc.almentforlht S)\"lllptoms. and is prob.1bly W'I.I,,'.arcoflhe ~s) I\"f<.lnurwlKJnaJ't': behindthem.1fthepillJoenlh.osh.adn'CUrnng~es 1. General bghlN55uf muscle b..- along almost ofthcsa~symptoms.thec.auwofthesou~canbe e>:pbined to him, and the requlA'!mCfltsofappropnottc lhefulllcngtholthesp>l'll! trwtment (tNl 1:5. lodear the assumed caUSC' n well as t\"\",ling thc~) \"'ill bor undL\"r$tood by tl,m. 2. Loc.alaA\"a5011hocken,ng,mm«hatelyad,aemtlo oneUl' ~ 5Jl'nllUS pmce56. 3. Loc.al an-as 01 thickening In the m,d-lamina,. trougha ......a. Alhictcncd or itiffalCadoeinot II«d to be pa,nf<.ll ~. Soft thiclenlng\\...·e.-thep06teriorart>cular pdlar orthe5OUrct:ofapatorot'ssymptOlTl§ alorll'Ul'mo\"..Inh'n·ertel»'alle\"els. S. Hard bony thICkening and prominence 0\"\"\" the zJIK.lpophyse.aI;Oints. Thtjdtal.overogtondobnormolspine 6. light.- of the ligaments or localW'd thickening ol.a'>«tlOn. ;:~~~~~S';'~~'=;I.o~t::::~~~~;::~~::;;; fhcolOc.thtloOft-tJsWtctl-anges.l~toughtfttocy one or mon' segments thaI arc imlX'rfL'Ct but tlJ\\'e nO alC;thtmort.cccntthcya,clhcloOfle.thcya.c symptoms of major corule<jucntt. Th<> abnormal spine is bolhdisad\\·ant<lg..od and symplumJl'cenousto for lhepcrson to seek t\",atmmt The abnormalitit'S of 'feel' in lig,lmcnlous, capsular andconncctivetissUL'Sarcttoatthcoldc'lheya~thc 1. Tllcidcalspillc.Theidc\"lspineco,,\";stsofnseril\"of lougllerlhcy feel; and ttoemo~ I1.'CL'I'Illtoeyare,the inle....·erlebralmulurSL');menls(i.c,inlcrbodyand softertto..yfL'e1. For example. palpahngold capsular zygapuptoyseal joints with all of ttodrsuppurting

Euminition 153 Iigaml'fltousandmotorstructores)thatarenormal in every respect; that is, none isdis.~dvantagl-din anyw\"yby injury,wcarand tear, slruetural anom- alyordiscasc.Eachmotorst-gmentispcrfect 2. Tlreaucra.~sp;\"r. The average spine is \"at ideal, and dOl'S not consislofa series of ideal molorscg- ments. One or mo\", of them are abnormal in some way, even if they are not eausingany symptoms of major consequence. The joint or joints may be imp<.'rfect because of: a) Congenital or aequired struetural anomalil.,. b) Degl'Iwrati\\'echanges e) Oisease proces!;<'s or changes resulting from traum\" Although the average spine is ddined as having no symptoms of major eon.o;equenee, this nl...>ds qualification. Some p<.'Ople have no symptoms whatsoc\"er, while others tm\"e minor symptoms of a kind that they accept as normal (Maitland, 1982b),Thethreckindsofimpcrfeclionintheaver- agt' spint' are explainl-d as follows: • Th\"re are people whQ';e spine is dis.~d,·antagl'l:l by a congenital oraequired slruetural anomaly. Examples area cervical bifid spinous process f;gu~6.35 Spi\"edi~anta-gebyd\"\"lantlumbif~tnOU$ laekingolleofitsproccsSl!$,thoracicorlumbar prl)tt$S [R.prod~ from (19B2) TlreAlJ'>tmlionJoumalof spinous process inclining lowardsthe left or the PII~rM\",py,2B,withkindpl:f\",iulo\"ofiuthorsind righl (Flgurt'6.J5)ora cortgenital fusion betwecn pubti$he'$.) the second and third cervical Vt'rtebrae. which is • Th~ third group includes prople whose spines not uncommon. Such ano\",,~liesare of themseln'5 show e\\'idence of joint changes due to diseasoe painless, but lhey do indicale eilher asymmetry proccssortraumaandwhodoha\\'esymptoms, or lhat morcslTl':S5 is plael-d on adjaeent inter- for which they may or may not have had ade- quat~ tr~atment yet who ac\"'pt these symp- vertd>raISl-gments. • De;pitt'thepn._nceofintervertebraldegl'Tlera- ti\\'echangesduetowearandt....~r,oldtraumaor toms as b<:!ing normal for them, despite the fact olddiscaseprocl\"SSl\"Swhicharenottotaltyinac- thalthesymptomsinterfercwiththeirnormal life. On examination their joint movements are li\"e, some p<.'Oplt' do not have any symptoms painful whenstretehl'd,and plpation findings wh\"Isoe\\·er,\\Vlthinthi5groupsomespines,wrn.\", areob,'ious palpatl'dors~tchcd.arepainlessandsomehave aminordegn.'eofpainordiscomfort.Alsowithin 3. The almormal sp\"'~. The abnormal spine is defined this same group of patients with degt'nerative asbeingasymplomatiespineforwhiehlh~p\"rson intervcr!l'bral joints there are people who do seekstreatmlOOt. On examination, significant com- haveadeg~ofsymptomsthatareclassedby parable signs will be e\\'id~nt on palpation at th~ them as being normal. When tht'ir spines are appropriate intervertebralle\\'els, The Iitle 'abnor- palpatl'd orstretchl'l:l,theyalwaysha\"ea degree mal\"isusedtosignifyanabnormaldegreeofsym- of pain (ascompan.'d with the previous group. ptoms rather thanabnormaljomts-which,ashas which are eilher painless or complain only of been stalcd. may be lot.lllypainiess. discomfort),Oflhcsesubdi,'isions,group(l)(i.e the ones with congt'nital oracquin.'CI structural anomalies) is quite diffe.....nt in kind from group This labelling into groups highlights important clinical (2) (thOSl-' with anomalies associated with degen- conna-tions between symptoms and examination find- ~rati\\'ediscascortrauffiilticchanl>..t),andshould ings, which can be assessed by the palpation examin- be regarded to be so. Th<5e patients are only ation. The \"alile of having the diffenoot groopings 'disadvantaged'because in all other n-gards the enables therapists 10 rccognizeth~diff~renel\"SbctwC<'ll individualsegm~ntsfittheidealgroup palpation findingsthal rclate loa patienl\"s symptoms,

154 MAITlAND'S VERTEBRAL MANIPULATION and lOose tlut arc not Ilel:CSSarily rdat<-\"'. Such diffl'!'- Bony onomo/iN - pt)5;t;on of ~,Ub'Ot eoces Can then al50 be rdatl'\" 10 l\"\",t\"'l'nt \"~p'-'Ct­ ations. Forexamplt>, it isposslblc to rcoognil.e. lhrough Bony poin15 and mterspinou. spa«'5 are palpated l/\\to inlerpretatiONlQf the palpalion fmdings. thilt the next. The l'p of the thumb nf t\"ach hand is USL'\" 10 pal_ realistic goal oItrtalment may be a mlIlImall}' symp- pale lhe bony oUlline 01 the SPll'\\OUS p ~ first. t<>mallc 'an'ragc' state or a pain-fnoco ',\"'erage' stale 11lere are two importanl pland in whi<h 10 a ....oss ratMthanan ·ideaI'SLlle. the position of the spinous pT\"Qn'SS('S; the fir'l;t is lhat Unfortunately, \"ery fu,,' prop'\" 0'''1' the age of -Klyean;ha...·atot;llcomplernmtof·ideal'inlL.,...·~\"\"1 they should lip centrally in lhe So1g.1tal pLane, and tlw join!$. 'lOSI poopk-, for ON' re;lSQn or another, fit into one oIt\"'\" 'ncrage' groups. If a group of 4Q.}'ear-iHd S{'C()f\\(j is that thf'y should lie rough1)' along.an a!'Cof a prop'\" who had no pam or disrornfort and considem:l single sagittal circle. That is. lhe SPlJ\\(')1I5 p~ theu \"'Ids to be normal ....ere ..\"\"mined by palpation.. abnorm.al'hes .....ould be found m Ill.'arl) all should change evenly along lhe normal k:ndohc or 'I1x-quesllOn is,\"'hm such a Jl'\"\"IOl'l has a i>pOOtan- kyphotK ron..\" H\",,\"f'\\ ff. nonrul I ;oNIJon!, .. Ith n.ogard eousonset Qf n·rtebral pam and!ioeri.s treatment for it, to depth or promlT'M\"T\"ltt\" should bE- allowed for wllm how dOl'S ~ e....1TI1J'IeI\" dlffermtu\\e betwt'm the find- m~ that rebte to the present problem and the- findin~ interpreting the positHJnS in lh,s plane that would hn.. bftort Pl1\"'«lt befow the 5pOOw.eous onset of the- ned: p\"m 7 A Simi!... difficult) ari5e5 \"'hen With regard to bony anomal;e\"., the features that can att.-rnphng to detf'nTl\"\"\" the degJw of dit;a.b'hty that be determined by palpatlOO IT\\Cludt\" abnormal d\"'-I- (';Inbeattributed toa rea!f\\t 1l1jUryand thrdqi;..... that allOnofa.spinousp~fmmttwCt\"TltriLIllne\"\"'lo-.l is attributab'\" to pre-e>ostmg )'CI pain1es6 'a,,,,,,,,gl'\" or with ,\"ertebra.l rotation; ab!ienceofOllC' pl'OCeS5of iOllltfinding!;. the bifid SPlf\"lOlb process; abnormal f'OSIl'OO of 0IlC' 1'.'= ... oU t _ m.n.~_ If an interve111'bra1 joinl suddenly ~ painful for no oln'lOUSdlS«\"nUble ccni<;al vertebra relali,e to Its \"\"\"ghbour; and 05leo- ....MOn, it 1$ still lJ>Otit hkl'ly that tlS:Wf' mangel> Iu, .. arthntic OSleoph}.... formalJOn of the INrg\"~ 01 the 0C'C\\lrR'd If thesf' recenttlSSue change ha,\".. OC'C\\lrred apoph)\"seal joints. inan·ideal'jotnt\"lheonlvfindlfll)Sthal ..iJlbedetKted The abmnnalities of del13DQn of spinous pn::ICel6 by p.tIpaticnn:aminanon WID he 01 thE- 'fleW' or 'l'r<Hll' and pllI5lbonsoi \\...,-tebr,)('(';In be oonfirnwd by X-r.al'\" l1nds-as .....lth,fort\"Ump.... asprainedanlde If a pos<lional findm& is IonpoL1nding. the sha.peoltlw If thee _ ....1 tlSWe changes ha\"e oo:urrcd in an ha,,,oISlIOCialOO \\ertebfafo will d'IoInged from thetr 03S1\"mptom.llhC 'aveTage' cf''f\\'i<al JOinl. 111m Qr\\ ex;Im- symmetrio:a.l aPPf'arancP 10 acmmrno<blf' the changed inallOn by palpahon thert' .. III be.-- tissue changes supe..impoo;ed on I\"'\" oIJl\"T 'aWl'a~e' tiSSU/.'ch.mgt5. positions.. 1hf' articular pilLar abnonnallloes that indl- cateOiSk'oarttuitic('\"Obc)findmgs~read.l)'detImninl.\"d Suca.osIi in diffen.'llllabng betwcoen 1M new and old changes makl!S llw progn<.Jllii, related to both the suc- by palpation.. and can also be ronfifTl'l<'d by X·ra)'5- If cess of pfl'!;L'fll lrealment and the likelihood of fUlUl'\\.' the changes are 'okl' .and Iotall) inadJ\\t', lhe bon)\" ~~. f'ohlCt 10 a _ . thiS is ;on exammation skill that can be taug.hl. margins of the exoslo5es Win be hard and clean .. Ith. If these recent tissue change hoi\".. lJ\"XU1ll'd in a out any sign Qf soft or lealhery CO\\enng. symptomatic' 'a,'~rag..' i!egmrnl, IMre will be '=rnl' Common findin~ are discus6ed III lhr rell\"\\.anl tis!;uecholnj;t'S superimposed on lhechangesthal were chapters. already pamful whc.'fl slretched or palpaloo. Il<:<;au.'ie MOvt~nIobnOfmolit;rs the pahl\"\" had ~)'l1ptomsbefore the ~cerb.alion,the palpable tissue chang<'S will nOi be;l~ 'old' as lhOS<' in Mm·em....t is assessed by USIIl8 pnssure through the the pIIin-f~ 'a'<'ra8<\" gnJup. Diffe\"'\"tiation bt'lw(..,n Iipsofthethumbsagamstlhespinow;p~fin;l lhe ·fK!w· and 'old' ch.~\"ges und<,r lhcso.! circumslances Two Or three oscillalory p<l6lero-antenor mo\\·emL..-lts is nluch more difficult dl'>' perfornll'\" al each le\"el in tum, mO\\'ing fairly quickly up and down lhespine. until a b\"<'Ocral,mpfL'S- The abilily to diffenmtiale betW('l'J\\ lhCS<' lissu.. sion of romparali\\'C movement (bolh qualily and range) is dl1crminro changes is difficult to !<,ach to incAperi('l,coo practi- The mm·cm\"ms creatoo by pn.OSl;ure on lhe spinous tioners, but a method of thinking al1d assessing Cilrl be proassescanbeassessNcvrnmorefinelyby,arying the di=lion of the pn.OSl;Ure.., inclining them left, right, laught, which will provide a baSis for dcvl'Ioping lhe cephalad and caudad. Combinations of lhc.'S<' inclin- lll\"Ces\"\"ry ~kill. ations Can also be uwd. NOI \"nil' ~ho\\lld lh\" dirl'Clion Oflhc pressure be \"aricd,bul tI'e p\",-'Ci\"\" point nfcon- lacl on lhe spinous proccss should also be I'aril'\" This will product' a change in lhe mo..\"memoccurrin8at lheint<,n'l'rll>bral~gment

'..m,\".\"~ 155 \",e..\"The ...me procedu\", isarrio.'d out thearticula. of ro'$ISlanct' until the end of rangt\" is \",adled; that is, then- IS 'Tl!SIStanct' through r~'. When crepitus .. ptIlu.o' e.och Ieo...l, compali\"& both the ...tali,-\" lJI()\\ .... pl'l.'Senl during \"\"\"ement. ,t will be pamles& If It mml of ~~l ~.els. and thor \"\"\"'emenl found at IS unas.sociated with pr'C§Cf'lmg symptoms and pa,nful ifitis-.ociated. .I.~ 1l\\!E'O\"ertebralle\\e/ 00 the left with the mo'..emmt tIw SAme le\\el on the ngilt. In 'ide;ol' joints, ..'hm the s)'no'I'~1 jotnt surface a ... Slm,lar '-ari..lbOnS of dlNCtion and rorotld ;II\", strongly rompT'l'5.5ed and \"\"\"'ed, the \"\",,\"emmt will Af'PliftllO ttwo ..rticular pillar as described abrn-.,. for be painltoss {MaitLrnd. l~l.1here;llre cin:umsla\",,\" tIw Sf'U'OU$ processes. Hm'-e\\'er, Ofl<' of the most u...... .. ht-.,., pain is e\"p'-..-it--ncN dunng;ll large amplitude 01 fuI leSt mcnements in the ~pilW is ..chin-n! when lhe rang\", and it is 5OfTlt.-times possible to hciKhlen this thumb pl\\'S'>ure i$ applied ,n .. «>mbincd p<Jl'ilero- pai\" b} holding the joint surfiKe'S finnly rompft'S5ed ~It.\"\";or and medial direction. This di\"\",tion of mo,-.... while moving the joinl through lhe sam\"amphtude of menl produCt.'!i\" maximum ~I;d\"'g of ,n., apophr~al lherang.. loinl ,mm,'<!iatcly undl.'T the thumbs. If this direction 01 mOH~m<:nt is p<'rforml-d throughout its tOlal rangc Il<lving m.ld\" th\" d\"l\"rnUtlil\\ions reg...rd\"'g IiSllue from maximum foramina I op«ling to ma\"imum fOr.lm- thickenings, bony prom\",ences, quality of mon\"lTlent in.l1(1OSLns-a \\'cry,-aluableasses>m('fIIOffle\"ibility ... nd rangL'S of movem\"nl, it becomes rK\"Ci'SSilry to md qU<ihty of mo\\\"C1IlCflI at the apophyseal joint is rclate the pain rcspon5<-.... 10 lhest- d ..t,,rmil101tion.~ t'\\01 fNd,lyob\\.ilincd. Also, by .arymg thchand and finger only is it neces.sarv to mlW which lnO\\'emenlS either pll§ltlOflS thc!ie postero-anlC'riorpn.'SSurescan be per' pro-.'oke the pa'n for wluch t.....tment is50lJght or pro- lonned in.such a way as to prod~ iI rotary rno,,·, duo- Ioco>l pilin onIv, but tllS;IIOO roecessary to dctn- llll'I'llor .....tl\"l'alflexionTIlO'l·..mmt mille .. helher the !Il..on<.tItions al\"ll ft'lilo besuperfia;d or deep_ It may be ~ry to ;IIpply firm pl\"e5lW~ to ~t~bucsoftM,\"I~ctnlmouon obtalfl.m ;II('CUU~detemllnabon seg\"letltsllld\"Ilypu-Ofllypololobil'~thtollgh ... st>ffjain1d0e5notrol'C'e5l5arilyca.-pa~,tmilY .... Ofmdoftl~t&mlltt,suffm5.s.lIdspasl'l. 5udlabnoflNll~lfind'll9SranbeclqNct~onii wefl. h<Jwt.,,-ft\", be I'I\"SJlO\"Sibk for an -.oated ,amI 1>'llM:Ill~ld,agf1lm becorrungpainful.The501Tll('IppIil5tothicl<o.-d~ IMpi,n~ffltby~pil'fntduringp;llpiluon oft,sSUf;llndmoYl'mfnllsmost,mportant Mo\\'ement abnorm<l1Jties coos,st of the following' hyper. or hypomobility; abnormal quality of move- ment through r<lnge; stiffnl'SS and spasm. Sllch abnor- The pain response felt by Ihe pilticnt during the palpa- mal;ti(.'5 can all be determined by th\" palpahon being lion examination of t;SIIUCS and m\",...menl IS mo.t ~PI'hed ,n a m.anncrthat prodUCl.'Slnter...crtcbral m<J\\'(.k importanl \"The pilin or diKomfort may be fdl L.thl.... mmt. Abnormahties of mo..-ement should be q ..... hfled throughrangeorat themdof r;rnge; it maybe l'eltdeeply III temt5 not onlv of the ~, .. il.lblc r.mge of mon..nmt. or it rNly reproduce a p<ltient'sr\\..fermds)'ffipt0m5. but.lll:sobyanychangein!hl'normal~runningDlO'11'­ Superficial and deep local pam can occur Lf\\ both IJ\"8\"d through the range up lJo!herod of the available ·ntw' and 'okI' situations. Se\\'eno pain fell by ttw r.>ng\\'. 'flu!, may be di!;turbed by such factl:n as mhribc pau.ent when only modent\" p~ IS applied to ;II dwIgl-, s~ in suppcor'll...e capsular and ligamen- 50ft bS6Ue, or is .. ppl>ed to produce mD\\-emmt. is IOUSsttuetun'S,orbyproh!ctl\\emU5Clespasm. alw;II) ·new·. When .. pabent has I1'ferTed palO Uwt In malunj; detemunatiom, ,t is important to point can be reproduced b)' palpat>on n:amination. the md,- out tNl a hypomobik- JOInt O!\" a h}\"pct\"-mobile joint anont!; that il isollSSOC'i;lted .. ,th .. ·new·disorder. 15 no! ~nly a pamful joint. I\"'e..-ertheless, the qulIhty of ll\\O\\ement and range of mO\"ement must M~~nto(~rtrbror be \"PPn:'Ctak>d befoll' attempting to \",late the ..bnor- \"\",hh/':ll found to the possible cause of lhe patient's Tesling mo...ement b)' palpatIOn imoh'es techniques S)'mptonlS thoot arc u\",-od for trealment as w,,11 ase\"arrunalloo.\"The An 'old' hypomobility has D hard Cfld-feel at the tl'St seocks information not only of rang\", bot alSl of the limit of Ihe range, with mo..-emenl before th.. limit of 'end-feel' of th.. range, the bl.'ha\\'iour of the p;!ln the range being a smooth frktio,,-fl'l-'C movement. A throughout the range and the quality of any resistance ·nl....' hypomobility, on the other hand. has stiffness or mllscleSp;!sm that m.,y be p~t.Such inform,'tio\" occumng earher '\" Ihe r<lng\", building up in strmglh is determined both for lhe ph)'siological mowmL'nts

and for the lICffSSOry l1lO>'ements of g.'pplng. rocking 2 Po..l~anteriorlyonthcarticuL.. pt1Lor(F;,~II'\" aoo waring or gliding. DC\"tailt'<l de5CTiphon of the ,-\"') t«hniques is gi,·m in thechapt<.'r.Ion thedif{crmt sec- 3. Trans\"l'T:!eI)'OI1tlwlateral5Urfac:~oflhespinous pl'OO.S'l(F~\"\",6.J6() lions of the spine. Tlw pa5oSi,.~mten'l'Ttebrai U'lO>·cmmts are pmdllCed 4. Anleropa5leriortyonlhcbon)areaofthearticuJar by pr1'$&Ul'Capinst palpable J-U of the 'ertebra, and pillar. U - p~ureshouldbt appUrd at ttwright~ to llwleSlClnthenbefurtlwrdeflnedlOdeilemuni:-the appreOatl.'the mo\\\"(\"ment ofthe'·~1 in rd.1l>OO to joinl disturbanu In glNterMtail to> ,arying thedir«- ..t~I~.lfthep~.,applM!daslsinglo' boo. of the atxn·\" four mo•.-ements (ib folJo.,...... and by slow ~\"\" the ,-ertebnl ........· _ 1 w,ll nol be appneciated It aII,if,t is appbed tooqu.dJy. ,t can be '''1)ingthepointofrontxt .. ,ththP\\<I''I1o'b.-L ontel'prelL'<l only as shahng. Ho\\<~·er. tl th<I' ~ 1. Vmy>nglltt'i1lC1''''_pwIm.>4\"tl'riorly\"\"llw.\".n IS app1>ed then relaxed and reapplied. and this is 01<5 prvass, 1ht' dll'l'CllOll (l/ I~ JnO\\emeflts con ~ted two or three times a seoond, the amount 01 be ,'anc'd betwC('f\\ an Inchnallon Iowards tIw Il1O\\mwnt lhat can uke plaa w,lI be re.Kltl) appreci- patient's hc..t (fIX\"'\" II};/I) and an ondtnabOll lowardstus le<I'l (r,,(,,,,,Ii.J7b). atedltlSalsolmponanllNltlwtl'Stshouldronsisloi no mon> than two or three {)l;Cjlla\\KlflS Men' mo,·ong 2 Vllrymg IIw IOCItt/lllitm paslm>-<tntn1orly lJtIIT II... quickly on tothene~t,ertrt>r\" lflOOm.1nyoscillations Ilrlicular pillllr or tnmSlYf\"t proct'SS. Thislestcanre are employed ona \\\"l''l\"Iebra btof'on' chanllongt,.the I1eKtOOl',('Ofllpansonso{rangean'lC5Saccurale \"ari/'dintwoways,Fin;litcanbe,oc1ioedtoward~ When examining movement, the first p~ures the pat;\"nt's head or lOward~ his feoet, as sta«xl should bcopplied extremely gently. Wh\"n 8 s«tion of aoo,·e. The ~ood ,·~,i~tion is to incline tn., p<.>5tero-allteriorpn..'SSurelat\"rally,awayfromt~ the5p,neisbcmgmo,·edinthlswoy,llomorethontwo \"PlnOUS pron'SS (fiS\"rt' 6,3&1) or medially lowards t~spinousprocess(fiSu... 6.38b) or thrt'C gentle pressUl\"C\"S ore applied 10 each \"ertebra in tum, If there isno pain rt'Sporu;c to the gentle rnOVl- menl\" the amplitude and d\"pth uf th\" m,,,\",,n,,,nt 3. T\"w5t'f'S<' n1ot\"\"\"ml ll\\,:mrrs' I!~ sP,/W\"\", procts5. This is IllCrea;;ed. again wllh only two or thrt'C pn..'9iUll.'!i ,anbevariedbyincliningth.>directilHloftN. applicdlOeachvertebra_Thete5tingshouldbe,,\"pei'tl'd mo·..elJH,'(lt toward. tN> pahL'llt's Wet. towards his more dl'eply until pain or abnormality IS detf'Ctl'<! or head or, e'\"\" IT\\Of\"I:l importantly, through an an: unttltlwmOlil'Tllmta<ruevrodindicat1'5th.ltthejo,nt whichendsasapostero-anteriormo,elJH,'(ltaga~t !\\asapoainlt>s6rangeinthisdiroctionlfpamlSpro- IhelaminaorarticularpiUarofthesamesideofthe duad dunng JnO\\._t. or if phY\"ical A'5istartCE' or ,·ertebra (Fig\"'\" 6,J9). prol«t,,\"musclecontrac:bOllisenroun\"'n.'\\Idunng ttw mQ>-ement, then eKlftlt should be ~ ()ccao- Figum; 6.~.~! show the dlft'Ction of the ll1O\\-ement sion.IlJyafuU~tmavnotbeposs.iblf!untilthe applied to thepn>CeSi5l5 iUustraW'd '\" F~m;6,J7-6J9 - . d ~tion. beu~ pain with JnO\\'<l'rnent When lest1ng JnO\\enwnts b}' ~l~tion k'duuques, rna)'notbte>'lodenluntilthejoonthasreack'dIOthc first eo;ammabon ID plus I) the ,....-tmra 5hou1d be thought of as being a \"f'hen' lNlClnbt JnO\\ed ,n any dtr«bon (f'lr\"\",6,4J). Similarly, when mo...ng one, ertebroI lry., !io1~'. a tral& ~\\.Ifl>nal\"'~tmayOlllybo:possibkat 'er.;e!yd,n\"CIed ........\"ftMfllagamst'tsspinousproeoes (Figu1f' 6.44). the ll1O\\'ingelf«t il has on othef.5l\"Ctiorl> t~ 1«vnd e\"\"..'nauon. wtten the wuew~ have oftlw,l\"r1dJra5houldbe\\isualizedffWtrto.45). lUctedtotl>efimVla\"\"\",,~ThlSlScalledl~ Ha,'ing nsuahzed the directions of n'lOnments of the,-.,rn,brabeingmoved.,tiseasicT'lO'isualize .. hal '0 plus r aunsmenl happens to the ..ertebr~ abol'\" and the l\"ff1ebra belo.... \"TIle costovcnebral jomts arc tl'Strod on the same manner (Flgur1'6.46). As well illi ,-arying tho> angl6m pressu~ appliIXI to asdt'SCTibedfortht\"mtervertebralJOmts.exccptlhat the'·ertrt>r..... t.... pollltofrontMtatthl'inter..ertC\"b,al thcpressul'Cisdirected through the anglc of each rib joint should al50 be ,',uied. For aamp.... if the C2I3 in tum. joint is being ~~amioed by p<l§tero-anterior unilAt- Thefourpnmarydi~bonsinwh,chthepres5urcs er.llvcrtC\"bralpn..\"5Iiureuntheleft.thepointofoontact ~re appliL'<l to the vert\"brae are: .should be ..ark·d by pn..-jI;U1\\' on C2, t1~n on Cland la~t1y L 1'Cll!itero-antenorlyonthespinouspTOCt':'ls(l'igulY on the C2I3 joint line. Tht'S<! tests, carried out effec- 1>.360» tively. wlll !\"C\"eal nolonly the particularinterv~rtC\"bral

EQminJlion 151 flgu\",6.36 (oIl't:>\\.ltfO-Jnlenorprnw~onlll(~ptOCtU. 1\"\"11lIPo.l~Ill-Jnlefiorpr6SU~on~JrlfCVlJrpollJr td T....nsvtlW pr6SUrt on IM....I wmttoflh:'fH\"\"\"'1'f'll'= pi\"\"\"\",F'''I\"'' 6.37 I'I»tero-.nlcrio. p'''''u~ on lhc spinous (oll»clin~d lo...ardslh~ patoenfs hUd, (llIlntlincd lowarlls Ihc IlII,cnfsfut

FOgu~ 6,38 I'ost~ro-Int~\"or prffiu~ On th~ Ini~llIr pilll' lalln,,;nrd lat~... Uy ...:ay rfllm I~ ~,nous ~5. (bjlllClinrd mrdilllyto..anls'h~~inOllSprocrn F\".,....'6.39T...~~~.iftslthtspol'lOUSprom.s prl\",,-ont unly whe\" joint mon-ment is stretched to lhe hmit of u.., range; or the upp<Jliile may be the case, lhe ,nc1~posll'fO-lntmorty joint being too ['i'mful ..\\en when it is at rest It may IOint at f\"ull ,,00 the mo\\'ements of the jomtlhat are \"ary in other ways too; if pain sl.utsl'arly in a rangeol afl«1l.'d, but aoo the manoer in which e.:lCh mO\\'l.'fTleTlt mon\"n\"\",!. il doc\"S not alwaya worsen in thesamc pat- isaffoooo tern when the joint i.\\ mmcd further. For example, the pam ~It during mQ,'ement m,,~' be quite moderate Rrs/KlIIS4'S 10 \"\" mlJl'l'mn,ls. There are three \"anable.; until approaching the hm't of the rmge, when it sud- to be consld~,,-od wh~n determining the m.~nncr in denly inc~ tQ berome !it'\\....... On the other hand, which joint mo\\'cment is affected: pain, muocle spasm and physical resist,lnCC. It is important 10 I'{<ali,.\" H\\M the patn ma)' irocTlebC.'In inll.\"OSlt} CUIlSiJ...ably inthP Nch of tllt'!>C factors, when p,,-'SCnl, may follow one of first part ofthi' ll'IO\\'t'mI'T\\t, and then mamtain a ~y many different pallems. Pain, for e\"ampll', may be degl'ft' of pain until the hoot of the rmge i'li reached (>n Appondix I). Dlffen>nt patt<.>rn; oi beha\\'ioor of pain\"\"lmredifferentrrcatrnentteclutiques. Ph)'SI(';iII~oithel}-peoffl'redbycon~ fibroustisiSuecanalso,al)'('OI'ISiderablyinil$~w­ bon.:\\b·m.ntbdorethel\"niloithe~ma)'bl\"per­ fectl)'free,w,thl'eSlSW>oebcmgfcltatthelifl\\ltofthr range The amrlltude ,,00 stl'l'f'lgth of lIus slight ..,,;ist. ancc\"lso\\'ary \"\"idI'ly (,.\".. Appendix 1). ~ \"ariabQnJ alsoinnuel'n'thel}-peoftmltmerllteehniqueusro. Muscle spasm;,; till· th,rd ,anable U\\ nolTllill joint mo'·l'fTl~'flt. l1>e rangl' of mo\\~\"\",,,nt may be lim,ted by \\\"L'T}'strongmusciespasm.orthe!iopol.'otflmaybl\"ofarype thai ise,\"ident only if a joint mO\\'eml'n! is performed in a particulM way. For e~ample, if th\", joint is monx! slowly and ca,dully. no nl,,~le ~P\"sm is fdt. bul if the mo\"cmmt is qu,ck and jl'rky. spa~m protects the joint from mo,\"em\"nt that wQuld be painful. MO\\'l'mcnt5 u\",-od in trealments. therefore, mus! be modified to su,t

6..,figu,\" Po,t.m-ant.,iorunilat.,al pr.»\"'. inclin.d l~t.,.lly~nd m.,ji~lly Hgu,\" 6.42 (a] TransV(rs< p'(SSu,\".lb) Indin.d IQ Pl\"1..., ~nt..iQr

160 MAITLAND'S VERTEBRAL MANIPULATION Figu,c 6.~5 Dirc<:tion of mo....m.nt (1.4) of th~ S(C1iOtlS of th~ .... 't.b~.ff..,!cd byt\"n'.... rS( prtssu,~ [P) Figu~6.U Thrttv..w'of'vtrtw\"cin'golfNU1Q;rss;,t painful. Sheshould then dctermine how tl\\e intt'nsityor vi....1,c.lila!'oo ofilSSjlh~riCllI ojimcn\"on. (0) Antc.ior vic... area of pain vaTi,'S if the \",m'e\",,,,,t is carried further Ibl Postc'io...~.., (clAn ,\"glcdvICW into the range. If pain is nOi too great and the movement the particular combination of beh\"viour of the pain, can becarri<xl further, an a_m\"\"t of the possible resIstance and spasm (..., Appendix 1). Tange should be made. When physical resistance pre- vents a full range being achievl'd, the type of resistance When any of the passi\"e movements arc found to be (that is, wheth,.,. it isa protecti\"e m\"\"\"Jesp.l>m or just pamlu]. the ph~iOlh<-.,.apistshould ende,wour toassess lightness of inert structures) should be notl'd. at whal Slab't' in the r,'nge the movement becomes These tests will provide information about joint dis- orde.s that is more vaJuable than that detennined by t<'Sling in any other way. Details regarding kaming to it'd th~ factors fOl1nd on joint movement. and a method of Il!COroing them diagrammatically for pur- post'S of communication and teaching. aree'plain,xl at I\"\"gth in Appendices I and 2. It is sufficient to say that an \"'tremdy vaJuable and detailed assessm,,,,! of int\"rvertl'l>ral joint movement Cd\" be made by this examination

Eumin.tion figu~6,\"6 MOVCmCnlOlonc,pinou,prott\".lfcn, To understand .rld treat joirlt disorders, it is impor- adj~\"!\"\"ncbrac.P\"lr.n,vc... prc\"urc tant to be abll.' to rt.-<:ognize the different relationships between the behaviours of pilin, resist<lnce and musell.' When lesting these mO\\'CmM1!S il is necessary, whcn spa>m within a range of mo,\"\"ment. Tht.')' can be best an abnormalily is found, 10 make thrccwmparisons: apprcciatt.od by depicting them in movement dia- grams. An intert.'Sting parallel can bed\",wn from C. P. \\. With mo\\\"('mM1ts to Ihe joinls above and below Snow's (1%5) comment 0f1 geography and econom,cs lheonebeinglest,'<I.. C<'ogral'!,!/wouldlwincoml'rmem;iblewi,/r<,.,1 2, With movem,,,,t of the joint on the OPp05itc side. maps, They'l'l' rrduceda t\"'mendo\"smuddlfoffaclS 3. With what woold be considered to be normal for ;n'o oomdh;ng)/O\" \"In mld al a glm,a. Nmv I thaI pin! suspecleronom;csisfimduml'l1lallynomorediffimlt lIum grogrllpllyexcepl tlrIll ;(Slll:.>\", thi\"gs m \"W'ioll. As tests vary for differt'lltlevdsof the spine. each le\\'d Ifo\"ly somebody would i\"'....,' a dynamicnwp will oc des<Tibcd separ.ltdy in the relevant r,h.apler. However, \",k'vant information in general terms is as If the words 'passive movement\" are substil\\rted in the follows. quotation for thl.' word '''''onomics', the movement diagram could \"'I'll be the 'dynamic map'. Appendix I Many of the procedures that ronstitote interver- dt.'SCribcs the th'\",retical bad:groond of the movement tebral joint movement tests havl.' brtn outlined in the diagram, and then explains the details of how a mov,'\" ...Ievant chapters. Other tests (passive physiological mcnl diagram can bccompiled for any test mm'ement, mte\"'ertebral mon,ment) a~ only range. No one whether it be cervical l.'xtension, postcro-antcrior aSJ\"t'Ct of examination technique can bl.. considered in prt.\"Ssure on the spitlOus PI'OC<!SS of C4, or combined OOIation. In fact, it is thecombined findings with differ- movemM1!S. I'Ilt tests that give the final information about movement Ilow,,,,,,,, thl' pK><:,'<I.ing tests by palpation techniques Regarding these appendices. it is essential to app\"~ are the mO\"t important, as they reveal the range, pain, \"iale lhal the movement diagram is intend,-'d to serve resistance and mo,;;cle spasm for each intervertebral only Iwo purposes. These are joint tt.'Sted, TItey also test aCCl'SSOry moVeInents as well a, the physiological mowments. Th~ tests can 1. Tocnable theno\\\"i~ to analyse what her hands also bc us..-'d '''\\'ery eff,,,,Ii\\'e t,..,alment techniques. are f~ling wh,,,, moving a joint passively To undcrstand and trutjoint disorders. it is important 2. For use as a means of communicalion and t\"\",ching tor~nil.th.di(f .... nt ...lation,hip,bdw~nln. bl:haviour of pain, resistan\"\" and muscle spasm witnin Passive physiological mOYCmcntsofsinglc a rangc of movcm.nt. Th.y Can bl:st bl:app..ciated by intcrvcrtcbraljoints depicting tnem in a movcm.M diagram Dcscription of the sJX-<:ializcd test is different for each individual spinal joint. The'\" are two important occasions whenexaminatiorl reqoiresan assessment of flexion, extension, tateral flexion and rotation as they exislalasingleinlervertcbraljomt: 1. When lhe prccedingexamination has shown that thl' faulty joint is stiff but not painful 2. When a joint has suddenly become fixed in an abnormal position The information found on examination is also uS«! in assessing improvement in the range of movement that may K'Solt from treatment. To ..'Stimate the range, the examincr mo,\".\". the int\"\"'ertebral joint through a full range of movement between palpilble parts of the two adjacent vertebrae. This movemenl ;s compan.od with the following 1. Move\",,-nt found at the juint above and below 2. Muvem,,,,t found on the 0pp05ite side

162 MAITLAND'S VERTEBRAL MANIPULATION 3. l\\lo\"em~....tthatcanbeap'-\"Ctedtobenormalfor 4. It may be n<'\"a-'5sary to determine whelher ~ pain is that particular joint in that particular palient, arising from the spinal joints or the pain-sensitivt' considering his age, build,disorder$,etc. structures in the,·crtcbral canal or intervertcbral foram\"n. De5cription oflhe method for testmg each spmaljoint from t\\1t,ocdput to the s.lcrum is given in the chapters Diffcrcntiating pain from thcspine and from the for each section of the vertebral column. These move- peripheral joints mentsaretested· A patient may have gluteal symptoms, and routine • Through the range available examin~tion may not dearly reveal whether th\"y are • Bystrongerp\"\"\",ureat tt.eend of the range, to caused bya hipdiSQrdcrorbya spinal disord\"r Howev....., in somedrcumstallCl.'Stestsmaybeperformt:d di\".;em the fullest raoge possible and todetcrmin{' which dearly difft'renliate between them. ll1ese cir- lhe'end'Of-rangefeel'. TheosciJIalorytest cumstancesarethatt'itht'r(i)lhep;ltimtmaybeable mo'\"{'ment is performed somewhat mon-slowly than theoscillatorymobilizationtn·alrnefltt~-.:tmique. todemonstr.lteamo,,~oment,orthat(ii)trn,cxamlller OIFFERENTIATION TESTS _ may find a movement that incorporates concurrent movement of the spin<' and the hip and reproduces the Diff~~Miation t~slS h~'p to !>Or! out th~ !>Ourc~ 01 th. symptoms. A differentiatioo test can be used under pati~nt's wmptoms. Tests may help to d~t~rmin~· suchdrcum'til\"\"\",anditcanha\\'efo\"rfXlrts~thatis, fourdifferenlbut relatl-dtl'StS. Each test can be per- • Wh~th~r th~ symptoms arise from Ih. spin~ or a formed in isolation, and the finding of any One can be cllf1firmedbyeachoftheth\"\",remainingl~'Sts. I'\"'nph~raljomt • Which S9inall~1 is th~ $(lure<: of Ih~ symptoms b,ample • Wh~th~r symptoms aris~ from tl1~ n~ural strllCtu~s Pari I. Examination shows that, when the patienl orint~rv.n~b<al stru<:tures stands and twists his trunk fully to the right, this posi- • Wheth~r symptoms arise from th~ spinal Joints or tion reprodun'S hisrighl buttock pain (Figllrf/i,47a). This is the kind ofcircumstancereferll-xl toabo\"ethat pain-sensiti~strueturesofth~~mbralcanalor can be used to ditfell-T1tiate between the hip and the inm~rt~bralforam.n. spine as the SQurce of the p.lin Differentiation tcsts af'\\'sJX\"Cial tC!'lSused duringphys- 1. The pati<'\"nt is asked lolifl his l.-g off the floor and ical e~amin3tion to sort out the SOurce of a p.ltient's tok~;traisedwhilestillrotatedtothcright.He symptoms under certain difficult circumstances. There then rotatcs furtrn,r tolhe right and over-pT<-'SSure are four reasons for performing differentiation tests for is add~xl to be sure his pain is slill reproduced ,,<'\"rtebralproblems: (Figu,../i.47b). I. It maybe rM-'CeS&ary to determine whether a pain 2. He then places his hands On the physiotheraf'lSt\"s disorder is arising from the spine or from a periph- shoulderforbalallce, which 1t';I\\'~'SherhandsfT<-\"'. eraljoin!. The buttock pain must still be present in this pus- ition(Figu,.,,6.47cl 2 It maybe 0~\"Ce5S.1ry to determine. when pll-'S'Sure 00 17 reproduces a patienl's symptoms, whether 3. The physiotherapist then stabilizes the patient's tn... symptoms are arising from the joint betWet'!1 pelvis, rctaining the reproduced right butlock fXlin 17/8 or To/7, especially when the same pressure (figu,.,,6,47d). The palienl is Ihen asked to on T6and T8 is painless Rolatrhisiumbarspirre'otllrlrjt,tlwlis.drrolllir 3 When it is necessary to St'parate the symptoms Ille lumbar spirrr (FiglU'e 6A7r!. Slalr whl'lller Ius arising from the neural dements from thoscarising rigi>lbld'oc\"/\"'irrr/'ttU11/lslIrrclumg<'d(u'bicl,,,,illbr from the musculoskeletal slruclul'O;'5. They f~ tllfcas.rijlllfpai\" ,scuuS<\"d byu hil'disorder} or quently occur together, whereupon skilled nam- drc\",asrd(,,\",ich will brl),rrusri/'lrel\",i,,;\"ca,,5I!d inahon iswquired to determint' whetht.-r the ocural lJyaspillald\";lJrder} compotlCTltisintrinsicandprimary.orwrn,therilis s<xondary tootherextrinsicdem<-....ts provoking an Par/2.Fromthestat,'t'3pa;itiongiwnaoove,thephysio- irrilati\"e effl\"Ct on the neural elements therapist stabiliz~'S the patient\"s pelvis 10 pre\"enl .t rotating, and asks him tolwisl his trunk still further to thc right (Figu .... 647/)

Figure6.47 Difftre\"tiationt~t.spi\"ala'l(jptripheraljoi\",pai\".~'II.(aIRatatlontalheri~hLlbjPatie\"tbal,\"clngon\"ghtleg a\"d\"\"\",·pr~,ureaddW If the buHOCk p\"in ise\"uS«l by\" hip disorder, lhe Diff\\\"rt'ntiating symptoms arising from p\"indoc'Snotdw.nge.lfth... bullockp\"iniscauS«lby intl\"rvl\"rt\\\"brall\\\"v\\\"ls a spinal disorder. thep.lin will increase The 5eUlnd differentialion is used when, for example, ParrJ.Wilhlhep.ltientslandingonhisrighllt.'S-his transverse prt.'Ssure dirt.\"CI~-d towards the righl on handsonthel\"-'rapist'sshoulders,andwithherhands the leflsideofthespinousproc~'SSofT7reprodums ovet' the i1i~c crests laterally. he is asked to Iwist his lefl-sided symptoms allhough tl'\" same mOvem<'T11 p\"l\"islolhenghl(on h;s right leg) withoul any spinal applied loT6 and T8 is painless. The queslion tIu.'n rotalion. If the pain ar;ses from Ihe lum!.>arspine the arises, doc'S the faull lie al T7/8 Or TI/6? The steps leSt movement willl.>e painless. but if il arises from the I~kentodifferenliat\"are\"sfollows,andtosimplifythe hip. the mOH~ment will reproduce Ihe pain. discussion it is assum~'\" lhat the left·sid~'\" symploms arisc from 17/6 Part 4. Wilh Ihe patient sLanding balanced on his right Icgand hispclvisheld motionless, he is asked to 1. The therapist appli~'S the transwn;e pressure 1017 twist his body to the rlghl.lf the pain iscauso.'\" by a with her left thumb unlilthe left-sided symploms spinal disorder Ihe right buttock pain will be repro- arert.t'roduced. The vertebra is then held in a con· duced,butifitisahipdisorderlheteslmo,\"ementwill SIanl posilion in relalion loT6(Figure6.4&). bepainl\"\"s

164 MAITLAND'S VERTEBRAL MANIPULATION Figur~ 6.47 konrol lei \"\"ti~ntI»13need.ld) Stabilizing th~ pel,is 2 V.r,th ht-r right thumb, the manipulative physio- right On T6 with her lelt thumb. E'·en gentle pres- therapist cardully applies transn'rse pres5U,\"\" to sure will result in a lessening of the reproductod the right on the ~pinous proces~ 01 T8. Bffause the Idt-1;ided ~ymptoms because the prt'S5ure between ~ymptoms are 17/6 in origin, there will be no T6 and 17 has b<-en released (Flglln' 6,4&). change in the pilin respollS(' because the position of 17/6 has not changed (Figure 6.48b) 6. If the traosverse pre;sure against T6 is \",versed, the pain will be increased (figll.r 6.48f). 3 She thcn changes the diroction 01 her tr,ms'·erse prcs~urc on 1\"8 from Ielt 10 right to right to left Differentiating symptoms from a joint and from Agam Ihere will benochange in the pain responS(', the neural structures be<:ause the position of 17/6 has nol changed (Figurr6.4&) A palient may ha,'e right buttock pain which is provuktod by full-range forward flexion from the 4. She now changes her hand positiun so that her standing position; overpll.'SSure is applitod (Figure right thumb pusht'S tranwersely on 17, din.'Cted 6.49a), The pain may be caused by movement of the towards the IX'tient's right, until the symptums are lumbar spine or by movement of the pain-sensitive again reproductod (f,gur. 6.4&1) structures in the v...rlt'bral canal or intervertebral foramt'n 5 With 17 held stationary in ,..,latinn to TB, she now gently applies transverse p!\"\\\"Ssurt\" towards the

Examination 165 F;gu.. 6.41 (rontal (~l RetaIning hip rotahon and releasIng lumW. rotation. (f) Pan 2, .etaln'ng rel ...~ lumbar rotat,on and ,ncrtasing hip rotation One differenhaling lest is to ask him,whilt:>in Iht:> Oifferentiating symptoms from both neural and fully flex<.'d p<l6ilion (figuTf 6.491ll, toflt:>x his chin to musculoskeletalwun:r'S hi$ch.-s.tandasscssth(>ch.,ngt:>insyrnptoIJIS.lftht:>re is IlO change in thcsymptoms. ovt:>r-pK\"Ssureshould One of the most difficult kinds of differentiation Ix> applit-d 10 the nl.\"Ck flt:>xion ~nd the symptoms ~1~rswhenneurallestsareposili\\\"easwel1aSjoint rea~(r;gurc6.49b).lfthebullockpainis i\",,,..ascd by tM nt'Ck flexion. the disordcr musl havc One of the m051 difficult kinds 01 differentiation, $Omc dcgr\"\", of canal/foramina componcnt; ifsymp- whkh is relatively new and very much harder than lhe toms do \"olchange,thedisord(>r would s(''em lobe previous diffeK\"'l,liations, is trying 10 differentiate a fre.e of any can~l/foraminacomponent. One point to pcr:;on·sproblemwh<7lnt\"Uralt..s/sQrrI1OS;I;ueQ~Wl'lIas remember, however, is thal in Ihis posHion his fool is ju;nll..sls.ltis,·cryoftenonlyonreasscssmenloftreat- notdorsifl(·xl.'d ment K\"SullSthat difft:>rcntiationoftht\"contribuling The 'slump ll'Sts'can also be uscd lod,fferenliate strncturescan lake place. Tht:> trt:>atmenl of MrsC. bet',\",\"'I1ajoinlcomponentandaneur~lcomponenl scfvl\"Sasannample.

F\"tg....,6.41 D<fl'rrmtilItion~iIIl~\"\",[\"T_\"\"\",,,~puW\"'!IlM....-silfOft5SoIT1U1th<\"IIIrt.WMo 1'Ia'\"'~'\"\"9I,,\"T1·llimalioMh,p:lfIIgmtlyadll\"_Ift'I'lftIDth<nglllagaom.tlN....-s~oIT';l<:lacld _ _mMW'Wprow..'tI01IwItflaga~lht...-pI'OCftJoITLldI' ~~~I\"'Jth<\"\"\"\"\",~oIT710lM , Wh ~..,.,n\\.lo\"\"\"'JIhtT1-T8mal.JOnShlp.!JtfItlyacld ttlftSlIItrStptt$$\\Oft' ExfJmplr increasedbyaddlngslump to the lhoraticand lumbar MrsC.haspalnmhernec!<andpatnlnboth5rnpula spine,byadding~e>:tcnsion(smglelegsorboth ~reaswlthtnerighls;debeillgworsethanlhelelt;pain to-getherj,nordiditprovokeanyotht-orsymptoms.Her can spread inlO both arms bul Imds 10 be more in the range of rotation to lhe Id\"t waS)Op\"-orcenl Jes!; than lelt thlln in the right what would be her full [o\\'er-prt'Ssure) ranSe. and il OnexamilUlhonofMrsC.'scervicalspine,ccrvical \\'ery ..asilyproducLodherleft-1>ided\"'--.2kpainspread- nexlon wasn.ostrieted by about 15 pcrccnt and gavc ing down and laterally in Ihe left supraspinous fos.s.1 pain in the T1-T3 area centrally. The \"\"in was nOI area but nol reachinll thc shoulder nor pro,·o!<inll any

El<lImin~tion 167

168 MAITlANO'S VERTE8RAl MANIPULATION arm symploms. Rotalion lo lhe nghl l.ack~'d only :ro---JOpercent,therewercnochangestolheO\"l'\\ical 20 p\" cenl of he.- range of lnO\\ement, bul it pTO'''Oked signs_llo\"·e\\'er\".,,·henl1l'Uralsignsha, .. beerlpn.-smt IefI-sKledncck ..ndupper-scap\"laTsympioms.Jfthis for .. long time 11K')' lI.'nd 10 be man\" difficult to treat. 1TlO\\t'mt'n1 Wi15 earned further she then had a ~ro­ llwl«tutiques\"''eredla''i;oo around in'.rious ...·.~ dUC:lIon of he.- \"gill scapular pam. ...·Iudl spre.ad from butwilhoutanyfnourabll:'clfect-MT$C.woukilo5e lhe base of h.tr neckdo...... 10 appro\"'m.ltely T-I/5. Her thO' gain in thO' neur.l Sll;J1S on euml\"\"tKln \"\"thm rilngeofe\"tl'f\\SlOn\"ked35 per cent of norm;olnnge. 24hours.'Tlu5p.lltemdKlnolalt... And it ptU\\ol.ed Ieft-sided scapuLu ~m .lind emt,al TIle nv;1 Step ...-as to po6-ltKln the ~tienl sup,.... uPIX\"\" thoracic p.lin. \\\\The. testing the \"Pf'l\"'\" 11mb I'M:'U- ...,lhherheadlater..lI)'f1e?c'<ilotheri#>t..mherright ral lnO\\emefllS \",-,lh both ;urns, the left arm ... ;is dIS-- arm held In the po5-lll\"e \"\\Imber I c~1 po5-lllon. hncll~ po5-lti,·l;' in lNlill.J<:kedelbow('l(~ranS\". sn.. was then treated bydouble leg stn.ght1eg r..JSlng. And there ... OIli bngllng throughout hl'r hand.llnd ante- gradually pushmg the range of the straighl1eg r.ising ri<JI'\" ftbo>o' bul no O\"I'\\-iall symplomS. Addm,; SLR to unlilil reached thelNllImum{'1\\k'nlofparnlo ....1uch I lh~pro'-oI.t>dned<,scapuLuandarmp.l,naswellas ....asprepared toea\") ,t.Asthb ...,asunsuccessf\\l1 In p.lm in the fil\\jijt\"nloo lhelefl SIde .nducingimpro\\\"Cmt'1ltineilherneuralorjoinls,gns. the It'Chrtiquc \"\"as changed 10 hanng her l)\"ing supinl! r..lp;>hon exami\"\"tion 1l\"91ed a promment tho- r<JCic spinow process of T3 ( ·h,ch '5 common). and bUlwilhbothll.l\\Spmpp..'dupintostraighllO'gr\"i$ing lhe sp,nous process of T4 as $e'I m~ <ko.'Ply. positions and thl>n u mg the cenical later..l flexion PalpallOncallsed local pairl at both leq~ls,bul at T)it ttodmique to \"-'Produce her ~rm symptoms_ This was was a shaTJl'C'\",moll' surface paIn. \"nd ..I T4 it w,'s .. ..lsounsuCCC!>l>ful. SO I thench.1ngl'd thi'lll'alml'flI<o dl...'.P u'ntral pain that she \"'as in lhe ,;\"nlO' pu5lho\" bul the dhow rwd,-e monlhs prior 10 her hm'ing t......atment. her f1exin\"~xlen,,onll'Ch\"'quew,1sused.Thiswasal50 s}\"'pIlMns wc,\"\"p\"-\",,,nton wakins (ralhcr than al<· diSdppointinglyunsuco.-ssful.Onthesanll'day.... ilhhl'r eni\"ghl'r),wilhpai\"i\"th,·who1coflhec\"C\\·icala a. lying normally supine, with one ml'<1ium-sized pillow, and she had noabilily lu tllm her head to l'ith\"r sidt lhetl'Chniqueofunilato::ral pressures on theleft·hand wIthout causing pain. sn., had had a mOlur vehicle 5ide of her neck and into hl\" !lCdpula and elbow a\"'a, acddl'fllin 1986when'>he,asthepaSS(>J1ger,w..~ina pm\"oked deep, local pain whl'fl pressUIl' wason lhe ur th;>t was hit from in front ..nel she' h,l her he;Kl ()Il articular pular of C5-C7. SOl' was abl.. 10 guide me as lhe windSCTftr>, She had suffered symptOll15 01 van- 10 lhO',1nglefor \"pplylnSlhepressurt'. and the main able \",_Iy bUI righl-sided only...nd she- had not point wa5 C6/7. While performing the technique Mrs responded to ..ny of the tre..tments thl:' doctors and C. spontaneooslycommenled th.11 she felt thIS was!ht' phys.lOtheriIpistshad;Klrninisten'd()o,erthe3weeks right lhing to do bt'CaWol\" ... hil.. shP wil5lying then! prior to M'Clang .......ipulatne ph~~otht..,..py 1......1· (wilh hi', left arm in the number I po5Itioo) it ....~ ment. lhesymploms had bee1 gradually increasing; markrolyimproving. lhl'\\-weft'nowmthl:'right~oflhe.rm~faraslhe On rea5lieS5menl, ~ was \"\"prowml'nt s)'mplO- ..Ibo¥o The only gu~ irKhc.tion for her prob...... malically ..nd her reo-Ial ll'lO\\emeflts imprmed, Mns neural rathtr than;oml ... as thO' fac'llhal arm ..lthoughnotlo!ht'idO'.It'nd·~htto..\"\"·l'I',theneu­ S\\\"lT'rtoms w~ ,\"')' ,;ogut' m thl'I, dlSlrihutx.\\. and raltests.lso imprm'ed, The t«Ivuque \"\"as performed tht're ...·ereno e-TOOtirril.UKln!Wgnsoneunun.l- twice,andshesairK'd,mp\"\"\"·!'fIM-'ntonhothorotSions. lJ(lI\\. Ho¥.'l:'\\ \\iNC.1s<> had thereolal Sll;J1S and ()o,'er !lOl\"\\'erallrNtmenl ~ Mrs C. made good S\"mpiOOU ot a ,uinl component.!iO II ....;os lhe aIm of progress\"'ilhcurrenl moI'nli:ting tedmi<jues, and shO' lhemmaJm-almo..'fltslobeonmledlo\\\\ardstheO\"l'\\i- was totallr free of thoracic ~in. From 5 pm onwards caI5ll':\".•\"da56ol\"55meflt,...asrepe.. tedl)·perforrno:dfor in thec\\CI1'ng shO' would de\\'elopsymplomS in lhe roth lhe «'nIkal md>calors \"nd the neur~l indic.IOI\"5. region 01 thO' first rib on both SIdes. w,lh the right being TIM! inItial trNlmml was oriented towards lhea.'f\\ \"\"I grealefthanlhck.-fI;~'lTlI'lishO'''·ouldha\\'l'srmp­ ~plneand theT3/~ are.. (tll'..lment was !he palpatory 1or1\\5g>.....-rally in the whole of the \\lPper limb on thi' din... , t)·pe of Il'Chnique. which produe«t a ' ..ryquick same side as the first rib symptoms, bul JIC\\'ef on blMh resporlS('lO all ccC\\'ical mo,\"emcnt but did not producc sidcstogo::!her.SOl'al\"\"comnll'l1tl'<1thatitwasdiffkult IInyeh,\\ngeintheneuralmo\\\"Cmcnta,tenskedsiglU). tolumherhcadlotherightonlt\"-_occ..sions.. Ha\"ing proved this, the treatment was lhe\" ~witched My intentio\" on that parlicular trcalment d\"y was tou·\\.\"jjngthe\"euralmo,·emenll\\.'StriC\\ionsandthcir tu differentiate betw~'Cn the ,\"\"urn'S of symptom,- I'-,i\" \"-\"'pon\"-'S. The lechnique ch~n was the First of that is, how much W;IS neural. how much ... as 10.... cer- the three standard tests (Buller, 1991), ~nd although vical and how much WaS upper lhoracic. On phySical thesesho... ed changes in th......ural signs by about I'l<ammatiun. using Ihe upper 11mb neural tcst,thl'n\"

wa~ ,\"-'Striclioo of dhow extension causing symptoms I then lay Mn;C. pl'Ofl('with herhcad fully laterally in thedbow and spreading down the forearm and into flexed tn the right and her left arm in the upper limb the/inger.;. neural position, which was the same as the testing position. In that position I performed unilateral PAs on On placing MrsC.',heild ina p<:JSitionofeithcrlat- the first rib and tTansn'T'5e process of Cl, directing the eral flexion and rotation to the righl or a combination movemmt in a PA dil\\.'Ction plus a caudad inclination. of laleral flexion and rotation to the right, and then This produced only local p.1in and no thoracic or arm adding the neural test, the ~ymptoms in the arm pain. Following this, all areaS had improwx/ subjl.'C- would incrcas., dramatically and ber range of elbow th·dy and thc physical range 0/ mo~ement in both eer- exlmsion would be limited by anolher 10 p\"r cent ,·ieal and thoracic and neural tests was improved. I Lowercc\"'ical extension was limited and cau>ed p.lin then repeated the technique but In a much full\", lateral in the area of both ~upraspinousfoss\"e. Forward fl(·x- flexion to the right for her head, whkh I held in this ion w\"~ not reslricted. but she felt thesymptorns m~odi­ position with my knee. The t~'Chnique produced local oIiy in the l\\.-gion of tho.' first rib on both sides, which symptoms that spread throughuut her left arm, par- spread up butb sides of the c...rvical area to the occiput ticularly at the elbow and fingers. On rdea~ing the PA part of the t~'Chnique, the symptoms provoked by the The symptoms we\", <Xl\"al on Idt and right. Her range technique were as just de5Crihed nn the first rib area olrotation to th... Iclt was 65 pcrcent, cau,ing symp· The technique l\\.'Sullt-'d in an improvement of all com- toms in the lell supraspinous fOSS<l and the left side of ponent>.; t~ thoracic wmptums on U'rvical flexion llerneck,whereasrotation to the right was 75 percent. had \"onewmpletely, her low extension was full range and it atso cau>ed pain in the same left-sided a\",\" and asymptomatic, and her left arm nt'ural test was although it was less se\"ere tlmn wh~on the rotation was almost asymptOlThltic as wdl as having a full range. to the left. She had a full range of cervkallateralllp~ Shecomment~'<I. 'My whole arm leels SO much light\",· ion to ...ach sidl\". l\"ach causing a pulling pain in the supraspinous fossa area OIl the opposite side. Using l1'l£' fact that the lasl technique produced symptoms combined mon,n,ents, with lateral flexion to the right in the supraspinous foo;sa and throughout the arm to bemg the ·primary· movement and adding rotation to the finger.; indicated that the upper limb neural test the right, these mov...ml\"nts provoh-d equ.ll SUpr,l- findings were definitely posihve. with the source or spinous fossa symptoms. At [\\() stage during this exam- point of restriction of movement being thai the lefl inahlm was there any reproduction of pain in her right ~k angle. The resull of the diffen,>ntiating rouhne of thoracic area ~prcading from approxim.ltcly 1'2 down sorting out the problem indicated that the arm symp- to HIS slightly to the right of the midlin.... which had toms were !leCQndary, not primary, and that the cer- been one of her primary symptoms in the ear!i(.,. treat- vical findings were p<:JSilive. Also, positioning her in menls and could be reproduced quite \",adily with Ccr- the lateral flexion position and using the palpatory \"kalmovements. technique indicated that this was the main source 0/ the right thoracic pain; tbe pain ,n Ihe leU and right The trealm(·nt k'CMiqu... J! this stage wa< perform· supraspinous fossae and the left arm in parlicular all ing the l<.'It upper limb n~,,\"alt\"\"t mo'emenl with Mr.; had lheir origin al Cl on Ihe lefl and the adjacent first C'shead in the norm.l1 straight position and laterally rib at theC06totrans\\'crsc junction. lIexoo to the righi, in all three J'O'Iihons. using the elbow exlen<ion upper limb neural movement as This wa~ the best tr..-a!ment response we had had the trealment t~'Chnique. The effect waS producing no throughout her treatment. and it only remain~ to be improvement in the neural It-'St movement, but it did .>cen how much of the impro\\'('ment she retains produ«' some impro\\'em~ont in the U'rvkal mtation and movem\"ltt.llowe,'..r.flexioltagailtbegantopro- Radiographs ,'oke som... syn'ptoms in the rightthor.lcic area be\",'~\",on nand T3. This gave me an indication of the eff~'Ct From the physioth(·rapist's po,nl of view, an e~amin­ 01 using the upper limb nl'Ural movement. I then ation cannot be considell.'d complete unJess certain facts chang~-d to producing a PA mo,·ement on the right have bet'n clarrfied. For example, if radiographs ha,\"e hand <ide against the Ii\"t nb. In Ihis ~ition, I was bt....'rl taken the physiotherapist sh(llJld endeavour to somelirT1l'S able to pro\"ole symptoms in f\\cr forearm see them so a~ 10 u., more aware of the state of the e'tending from lheeibow to the fingen; of her lefl arm spine u.,ing trcat~'<I.lt is important to be familiar with On rea5SCSl>ment. thecer\\'iml mOn'rTKonts had improved the radiological app<.'\"\"ance 0/ the normal ~pine ~ for conside...bly but tbe upper limb neural movement exampl... the contour and position ofvertehrae, and the was unchanged. This told me that Ihe firsl rib area playt-d a part in the cervical componenl thal had no sil.\" and appearance of disc sp.1ces and inh\"vNtd\"al effect in the upper limb neural component. foramina. Thi~ knowk'<lge helps the correlation of

170 MAITLAND'S VERTEBRAL MANIPULATION coos......;lal and developmental abnormalllles \"'ilh B'i1f<rppralSl'1 physi<:al findings. ,...\" rhYlliotheTapisl should find oot if lhe patk'flt has had an extended rourw of slom:\"d Aclrot ~~ts(slrmJing}!;lIhllgl therapy, and ~ld know the e><bent of any ostm- (Otherjoinb;'1uJ(llests) porotlCchangt5 caU!ied by such twalmenl. Although it 15 the PfO\\tincr of the medical pr.K1ilDwr 10 exdude ~©®ROft ©®IQ+'::;'::=~':'~ from rrwupuLalin' ~lment pabenb wIth SIP'S of cord or cauda equlna compression. 11 ill our Il'!Iponat- When appticabW ('if n«t!S6iIry' It'!its), eg' combllW'l8 bLIJtylQbI';I...all'of~dangers. m<>r1! tnI)'oemenb; '1awd~nlS; romp~ion/di:strx­ hon,; ,·t\"rtebral al1er)'. different... tion; slump; al speed, OVERVIEW 5USlained.r\"l\"pNted,t'tC PHYSICAL EXAMINATION (PIE) - SUprM, SW lymg, ProN VERTEBRAl/GENERAL FORMAT e.g.: neurological naminatlOll; ....F, l:L''T. LL.'\\'T; pas- si\\\"eperiphe.-aljointlt'!ib/other 1OO'ts;>someIric1t'!itS, o••,\"'''~ palpatwn l'XaJlUJ\\o100n (It''mperatull'. s\"'eallng_, soft tissues, position of ,ertt'br,\"\" l'AIVMS); PPlVMS +rorrecl/O\\\"errorr«t deformities and eff«ts ~\"Ip\"I\" C/wt(trS#' notdjor ...lmmJ tt'Sl, (\",,(tWIIIl/ drmon,trtllwn/!cst5 +diffen-'fllial;on A$ltriskOlS)'l'UgtJ IIl>t'\"ditm,t0l\"'t~,t

Chapter 7 Principles of techniques CHAPTER CONTENTS Smooth rhythms 119 Staccato rhythms 179 • A technique is the brainchild of ingenuity Manipulations 179 • Rhythm 176 • Rhythm/symptom response 179 • Manipulation 180 Rdcascpain 178 Type 1 180 Trcatin9iJ<lin-through-rangc 178 Typc2180 Trcatingcnd-of-rangcpain 178 Manipulation undcranacsthl\"sia (MUA) Trcatingmusclcspasm 178 liItcntpainrcsponsc 179 • Summary 181 • Changing depths ofrhyttlm 179 There are two ways of manipulating til<' oonscious asse,sment skills when compared with the techniques pahent.Thefirst,bcllerthoughtofasmobilization,isthe of treatment. Nevertheless, tht-~ are limes when a tech- genllerCQaxingof a movcmenlby passi\"\" rhythmical nique fails 10 help a pa!it:>nt, nOI because it was the osaJlahOl\\5pcrfol'Tn('datthcbeginning,withinorallhe wrong choice of t\"Chnique, bul because the technique ~mitofther,mg\";lhe:;econdislhefon:ingofamovc- waS notexecutcd skillfully. mentnearthelimilofU>erangebyasudd\"\"thrusL1lJc difkrrnoceb<1wC<.'I1 \\hesc lwo l<X;hniques may seem nL'g- The tcchniques described in Ihis book are intendcd ~gible when comparing a strongly applied mobilization tobe-a basis from which innumerable variations can be withagL'fltlemanipul.ltivethrust.butthereisanimport- deri\"ed, There is nolimil to Ihe number of different antdi!furencc:thepaticfltcanalwaysR'Sistthemobiliza· techniques Ihal can beu~d in trealmenl,andlhe lion if it should become 100 p<>inful, whereas the techniquesdescribedshouldbe~enasabasisonly suddenne;;o; of the forceful manipulation prevenlsany and recogniud asfonningonlylhetipofth iceberg. cootrolbylhep<>tient It is important Ihat techniques of mobilization Tht~ art two form5 of ma~ipulatio~' should be mastered before manipulation is attempted. 1 f'assivt rhythmical oscillatio~5 i~ diffc't~l pas- Tht:>tl'Chniquesprescntedhavebecnk.eptloabask itiMs of a ra~gt of movtmt~t minimum, but it should bevtryclfrlrly understood Ihat 2. Manipulalirtthfustsnta'thtlimitofarangcof therearenoSETtechniqueslocoverallneeds,andthat the way the methods are described is not meanl to be- mo\"\"mt~t \"...,n as the way they MUSfbe pcrfonned. They can Ix> adapu.,jfromthisbasistosuitthen...edsofthemanipu- In Ihis book. strong emphasis has been placed on lali\\'e physiotherapist, as well as thosc of the patit:>nt. the relatively greater importance of exam ina lion and One of the ID06t importanl features of the oonccpt lhat this book altempts tocstablish islhat teehniquesare notusedinanysel,rigidpattem,butshouldbevarieci,

172 MAITLAND'S VERTEBRAL MANIPULATION mod,filod, !\\.\"-el'S\"'d or new ones ,n,,,,,,hId unlll lho:oy te<:hniq\"\" performed, the further away from the ron· \",hic'elhcinlentionoflheir5Ck.'CIion. tact poinl that lhc ll1O\\'eme-n1 Can be prodlKnl, the A TECHNIQUE IS THE BRAINCHILD Qf INGENUITY finer will be the 'h.\",d' It should .bo be ~id that the Ass\"iIIdc\\~ with pr~~ ex~, llw furtherawa), from therontild point thallhc mm .... phyS>OlhrnptSlsometimesfin<h;thal~rnnspositi0n5 menl is produnod, the mon:' comfortablc il \"'ill fm to ott-than thI»r<bnbed ,,\",f'a<!in\",andslwl'Nlrl'Nl~ dwlg~ 10 suit ton- .......... IrN5. thepatienlln.-forex.ampW,Cft',iCiIJLaler.l~ effucb,'\"1lle moA Important factor III lIIdIJe\\-1ll8 the ~Lati...• physiother3post's UW\"\"\" trunl. arms tnObIh1~bof\\ IS \\ellmmg to llen5C or 'bl' lnO\\...-mcnL It and lYnds lnnsmIt the Lalen! f1nom to the pabCnl's em br hkned to llw w.r in wtum on.- fftb for llw heOO and llI'C.... ;ill beulg figutatl\\\"h ~ted meslul1301cogsmlhegearboxolacar .. henrnanu.tl1y togethft;. .. !Uk' the Llleral fIerion mo'ement is pro- changulgprs(F;gurr 7.1); llwlnO\\\"emenlStalung ~ s..,;s-dlKnl by ton- Io\"'et\" trunk .nd Sim.iJ.rly, ...hm. InSId.-the~GVUlOtbe\"'-C\\.bullht.\")'canbe ~_1hI' \"ertebralcolumn issimiL1r. Until this 'fut>I' U5U'S thumbs to perform rentral PM (mobilizallom in is Ic.med by \"'-'fWt.-d p~, In'alment by tnObIhu· \" postcn>-anl<'rior dlf\"«'tion) on ...., Col, the ~ 01 tionwiUnot be fuUydfectwe. the thwnbs ...ork only ..~lrically ,n tr.m5mI\\ting tho-' With C\\ery technique, it is the ph)'~iolht.\"-\"l'i:>l'S body lh.~t must produce lhe mo,\"em..,,1 n,,~ phr~'''' pres&urc thot produaoothe 1'_-\\ ll1O\\'l'TJ'M'T\\tolC4, the tht.\"-~piSI'5 ltands, Ihumbs or fingers should \",-,,'cr, under ~n)' drcumsl\"n<:eli, be lh\" prime mo,'Crs; their pressure itself ronunjt from lhe m;>n'puLlh,e ph)-sio- mu!lC1eo mus' work l'CCcnlrically, nOI conC'-~llrk,lUy. Whal~'cr llle pari of the arms or body IhJI is Irull,,· lherapist'shod, lilli/inS llle mOV\\'11X'nt to lh<' intcr'Wld,r,,1 joll1b, When usm(o; teehr\\lqlM.\"'o buck a!i o;oen'icallak>nl fk>~, ,I Mlould not be tile Ihumb mUM:lc proJl4J/1~ the ll1O\\'cmenl. thiS pnndpl\" is tlleone mall1 l\"WmC1\\t thai ion, lhc marurul\"li,c ph)\"Siothcr.pisl must hug tile will ......lclc.rning 'feel'pos,sibl\".lnfalt,\"'lhl\"'ery pahent's head bet...\"\"\" her two hands, Iler arm along· ~itk his h\"\"d and her trunk aj;ain.t his head. Her olher arm should hug firmIY.I\\,,,,,,,thcrtrunk,solh.:Jtllle paticn\"sllead and ht... upper body and arrM can be 'ccmcnIL'<l' logclh\"rand will al \"lll,mL'S mo\"casa unil during the Il'Chnique. This hugging principle applil'S <'<luaUr to using ,entr,,1 I'A pl\\.'56lU\\'S in tile «',,-ical ~pinc, bul ,It,,ious1) the mooe is dofferenl- Performing lcchniqu\"\", b) 'rm\\Olc conlrol', so 1o speak (i_e_ the php;'oIhcrapist is .11 ~ d,stdncc from the paltent), produC<'S poor l<.'Chniqul'S dnd poor f..,l. F'>g~.. 1.1 Cut·....... ,.; ... of. m.nWlI9\"\"\"'\"

Princ:ipl6ofkdln\"ll>t5 113 ~1an\\· prupIe!ot'el1\\\\()beIie-~tNl tl'l.'iltmentbY~ rolalton.1ateral f\\t':loon or traction (..nd in a sm;oller 1I'\"t'\"\"\",·eon\"'lInece\",;mlvin'~'·esstretdUng.bulttu\" IT\"tC'asureth'silpphestothcleduuqut'Sln.'ol\\mgpres- surt'Slolhl-'ertt-'br.w).itis~rytoF\"»,tionthe isnotal ..'a)'So,olio\\<.~er,tn',)tmenlisalwa}'Sin\\'Oln'd \",,-'Ckin >OtTtedL-gn.'l'of flexion in ordl\"l'10 g.llllthe \" \" t h m c n · c m l ' n t . . .·..... t l , . , , - i t i s s t n . ' k h m g o r n o t ; 1 > e n c 1 ' - mid·posihonoc'\\..·eeo the limilS of flexion and exten- the Importance of f{'<'ling mmemenl. Almosl all of t..... sIon for the lowl$t ren·ical IIlteI'Vertooral jOlllts. K'ChniquL'S im'oh\"oscillatol')'mo,,,m,,nts, but i(th\" EJc.\\ctlrthesameprindpleappli~lothelechniqu~lJ( rate of oscillation Il> too quick or too slow it will be Iraction. longitudlllal movement ..nd rotation in the impossible tog.lIn allY f\"\"lol n\\()Wmflll at tl1ol'jolnl. lumbitrspine. WhCfJ mrn'ement ~dc:llrod in tIv Io..·t'l' lnsk'ad. the mm'ement will 1m hkeshakingor slretch· IOtnt5thelumbarsp,neshouldb.-posl!lOnedrow.uds IIl& Il\"Spectin.-1} Allhough It would be \"'rung to try 10 fle?tlOn,and when thc upper lumbar Il'U'lS.re bo..'Ulg f'St.:lbIish ..ny <E'I rate. §OfI\"Ie guid,ng figure!leelll rea- moillhzedthcpt:JMttonoithelurnb.lrsptneil5 ....hole JIONblrandtherefonoa ....\",oIh\\'oorlhn-eOlCillatlOnS istov.ardsl'Xte\\Sion pK '«Ond is offf'n\"d as .. guide v.. rialJt:lm from Ihis m)thm .....,dti.cu~ Loler(_p. 176), Thl'impottancr Oinral tip: To pt\"odlltt m...i\",,,,,, mow:IMnt of il oJ. learning to fc<>l mm'ement cannot be emphasizrd norm.. ljointln .. nyonedlm:t'o~whf~ ~ildil-ing.il too much, for without Ihis '(cd' cumilld(lOl1 will be i~ enler to 9oi~ the fulltst rongt'. With lust effort for lessinform..h'·candlrcatmL'fIlt~cf(ecti.-e. thep/1ysiother..po\\I ..~dwithoulslr;li~IOIM\"'odet ifthisjoi~t ispos.\\I01lfC1 as rn:;Iras isilvillilble to the Galnjng'f~I'oftht\",~rntnttstsstntiatinordtrto \"'id·~I_of\"\"sothrr13\"9t5 ptlformat«hnoqueadequattly wtom p\"actis.ng teehmque!; on one otnOther, ph>w- In Chapter'J, ....tching fordisturb.once tn \"'\" normal Ihrrapists!ohouldparattent>onlodetailsolpa;;ition- rhythm oImrn'emenl is em~ 11us IS lfCJw.lly \"'8 and rh}'thm. Once Iw~ theie skills ha\\'t' 10 be Import.ml ,,'hen perionnlllg Ct'l'\\iul and lumb;.. moo:hfoed when applied 10 pal~lls - no 1\"'0 paticn~ rotdti<ln techniques. Dunng t...,.. lmenl, mobih\".,t>on h.we t..... same build. nor do lhey ha\\·et..... !i<lmejoinl isdlnlCkdlothefaultyjoinll'\\·CflthooghthcadfilC\\.'Ilt abnormalities jornlsarealsorolalLod,Therefore,dunnglherQtarymool' liz.llion,distortionoflhemovernenlshouldbewalt:hcd Wh!:n prxt'ling t«flnoquo.altenliool \\houklbl: paId ftx.andiflhefaultyjotntisthccauscofsochdlSlortion. tDmanydeurls-pllSltiol'lmg,mym\",of(tlerrlllYl'lM1\\l theffiO\\'ernenlshouldbeper/onnedoniyuplothb po<ntandnotcarricdbt'yondiL ~9raclill9ofll'lOWe\"ltnt5,,('OI'ltaetoftl\\en~ fIlCldlfial_totlltpatlmt'il.lnlCt~r~etc. T«hrUques tNt in\\'ol\\'~p_\",.gamstS<lrne ~rt oIthe,'rrkbra~l\",sperialCoJ...... nwthumbs,nn- gers or W hand, working ettmtrrill)·.•..., the anI.' To prodUCO' \"\"n,mum mmetnmt of. normal point in medIum through ... hkh the roncentric tl\\O\\'emenl 01 the phyJ>iother..plSl'S bod)' is lr.nsm,lIed to the.ert<>- anyQfledil\\.'Ction\"hcnpract,slnK-itiseas~togain br~ 10 prodUCO' mo,emenl. If the inlnnsic mll>iCb of thehandsareusedloproducelh\"p~ul'<',thet«h­ the fulleslranSe, Wilh INSleffl)l'\\ for the pliyslother- niq\"e will immroiat<:ly become unCQmforl~blebolh 10 ap,.t and Wilho\"t~train to the modd, if thIS joint IS J'Ol',tionedasneara.isa,·ailabl<:IOlhemid·p06ilionof p;!tientand to physiolherapist; the hands wiil bL'Come aU its other ranSt\"!;. A dear example of this is seen in tense and all pos;5iblht)'of'fC'l!ling'themo\\'<'fT\\t'fl1 will be ......t. A.tudy of I\"'\" diagrilIIl> will sho... how the W normal rnetat:..rpophal..ngeal joinl of the mdex shouklersdn!F\"»,t,oned .bo',-\"orbetund the hands. finvt\" If \"'\" ......\"\"\"om distraetlOl\\ mrn'ement with and how thcjointsfrom the~d\",,,\".. .rnJsacl as.~ofsprinp.E'l'r)·effortshouldbe~\"1 w....<Ieffortl5et....rtod,thcsl.1rt,nApo5Ibon$houJd t.. thcbtt;,nninglO~.. thcscpoinb. INdwn belW«'fl It... norm.;al lim,'\" of fk!xion. e<.ten- .......bduct>on. adductiorl and rotation. To put tIv jolntalthclim,!ol;orwQfleoflhcso:rangeswillse-l!T\"eIy When performmg ICClutique tNt tn,·oI,·\" d,n.'d pressun.-onpalp;lblt·parbofanindi,idual,·crtebra, IImJ! tt... rangt'ol distraction n>OH'1I\"-'fII. When .pply- mg rtus pnndple to ,he cenk..l SpIne, it IS c1e.... thai if twob~Sic\"'-'\\sofcil'C1,m,tanccscane~ist the head and .....,.-k \"re kepI in normal alignmf:!nl t~ 10.·..~'StCt'r\\'icalintt!rverld,r,'I;O,nISwillbcmuchnca\"-.,. 1. The It-'Chnique mar beu\",-od in thetrcatmentofa t....~rextended than thcirflcxLod ~ilion.Tht'TCf(W, stiffjoinlwithlheintenlionofinel't'Jsingitsrango' whcnusingthctL'Clutiquesoflonlli!udinalmo\\'t'ml'I1t, Mm'emertt is produ«'<! by thumb p\"'5Sult'SaganlSl

174 MAITLANO'S VERTEBRAL MANIPULATION ...... ..... F''t''~1.2(l;<l'ctiotlof~reOl'lsplnous~ Fi9u~1_3 R'9\"ttlumb:Ioo,,,,,,,'ac'po,nts the \"ertebrae (S« pp. 155-156), and th\" din..\"Clion chosen should\"\" in th\" direction that is stiff be u,;al to trJnsmil the Pl\"{'Ssur\\' 10 lhe ,·ertebra. 2. \"Thes<-same tl'Clmiques Can blo used in thc treatJt1<.'I1t They a\",: of pain rather than stifflll'!iS. Under these CIrcum· I, ThctIpofthethumb. fhis prodoce!i the small con- tact area neoedt'd to d\"fone clearly the anglt> and the stmc..s, the method is toproduceMlargean amf'li· contocl poult of the tecluuque that relate fin(ltngs tude ofrrun'emmt as is po!i6ible with the gentli'St of pl'i'S!lure and w,thout frehng any degreo- 01 stiff- tothedkonk..... \"\"\"\"\"-If poslt\"ro-antl\"l'1Ol' pft\"l6Ures are.-i on the spinouspl'OC156.a\",mustbe~lQfindthe 2. The pill.....rjoonl of tht'lip of the thumb. If the t«h- nghtposiblw'tfor the wpportmgfingt'l'Sas ....cllas nique P'O\"oke!; Ioarl pain ....hen uwd with ron~ the right dIrection for thl.' arms and thumb; 10 be on potnt number I,contactpoint 2 .....les fnOft w;ed lOp 01. the nlO\\'emeru nus can be libned lQ apph\" the soft p;olmllrjotnl of the tIp of !he thumb, This ing pn'S5Ureon topofOl'l(' 01. a serie5 01. balls set In Ies6enstheJorene!ii!>producedbytht'thumb rubber(Figurr 7.1).lrthedirectiondthe pres.sureor 3. The palmar surfaet' of the central area of the dIStal the point dcontad of the p<\"C5Sure is off-.eentn'. tht' phalanx. The teduuque used an be made mtlOl' lI\\O'\\'ement produced w,1I not be .. pure Jlaot.;,ro- cornfortableshll by using tllu; area. ObVIOusly it is orntenor mon'ment. Dunng pe~ of the noIas informauveaslheothL-r.;.but ,t is (or can be) technique this will be (ell as unl'\\en pressu .... undl.... the best and most comfortable way of IrJn$m,ttmg the thumbs or slidmg on the spmous process the p.1lpatory technique to the vertebra T~atmentte<:hniqunean bl' ustd in two !l;I~c sets of 4 The antl'rior surface of the bas.;, of the Ihumb. The circumstanas: tIM' treatment of ~tirmn... Of of pam llse of this contact point I~ the contact a~a of ,athcrlhan,uiffnr$.Thcme!hodofthercchnrquew,1I the tL-<:hniquc in 1 abm'c. bul is less inform<1twe d'~Mp\"ndingonjlSobJC'CI'~ I should acknowlt'dge lhe ide;o gin'n to me by M.ss The slMlmg fl'O\"'bonll are al:5o lOlportml, 51nce they must allow the pal>n1l 10 n'.'lax oompletely and the .l<'anne-Marie Ganne in 1965 when 1 was preparing a phrs.otheraprst to ....ort< effectixcly with the rmrnmum lecture for the CNrtered Society of Ph)·siot..........py'-l of effort Rebxablw't d the ph}\"SiotheraplSl's ....nds is I966Congre'lts(Ma,tland, 1966, 197\\llo).Onl>ofthf'goab _1LaI. for it is impotosib1c to feel through hands that for the paper was lQ describe the dUferml amplJtude§ .~- d passi\\~ TnO\\'mM!nt treatment thai coukl be used. It \"iIS Mis6G3nne whl!ga,e me the idea of deptcnng the \\'t-'hen us,ng techmques m\\'Ol\\-ing direct J>\"'S'ures original diagram for the diffun!nt grade!l of fnO\\ en>enl. onthepartsofthe,er1ebrat',itisessenlial that they are Manyl101>,cl1lU'l()\\·allOnS ....\\\"ebo!en~50ncethen not performed painfully. Thoen'! is a difference be!>-'cm tho.' techruque being pamnJl and the technique \"'pro- <s« Grie•.-e. 19lIl). but the Ol;'dit for the baSIS d the ducing the local pilin, If thl' pat~nt !cds $Orencsa or superficial pain with th\" technique. Ih~'I1 it is ne«>s- nlO•.-ement grades muSI be Ml5S Ganne's, Sour fllr the contact point of tho.' thumb tll be modifi~-d. ''/hen using Ihl'cen'leal teehruques of lateral \"\"\". fIgure 7.3 shows four Soi'Clions of Ihe thumb thM un ion and rotation, relaxahon and fi\"\"r control will be obtained if the physiotherapist ~radlcs tl><- patient's headIx1\"\"~,,,n her arm and ch\"\"lso thai she hugs it Each of thcsetcchniques, when pracli,;al on tllel1or- mal spine or when used in treatment, can be po.>rform~od in differenl positions in tho.' ra!lSl' as well as using

p,jnciplcsoftechniquu figu,e7.4 O.piclInga,angeglmg\".m.nl figure 1.6 Grades;n a ~ypomobilejolnt.l. Pathological limjt 01 ,ang. (ha'd end-feel) , f'~~ IIIW!=~ f7 :::0 IVB figure7.1 Gradesinrelaliontcahvpe,mobil.,..ymptoma!lC A II rangt.B~ Rang. ofmov.ment beyond nc,mal average rang. N-No,mal hvpefmobil. range Mgu\"1.5 G'aduinano,m.l,angeha\"ingaha,dend-f..1 movements of small Or large amplitude. Applic,'lion of leChniquein lreatment wil1 be discuSSt-'Cl in Chapter g, but for the sake of learning the tl><:hniqul'S on the nor- malspine,thetypcsofmovementaredividedintofour grades Grade I A SJ11iIll-amplitude movement nmr thcstarting :~i~;:n:: [lepicting a soft end-f..l. R-.. Il<-ginning of position of the ran!;c Gmdr II A large-amplitude mo\\'emCl1t that carril'S well into the range. llcan occupy any part of the range that is fl'l'C of any stiffnl>sl> or muscle spasm Grode 111 Al~ a large-amplitude mo\\'ement, but one that docs move intostiffnl'S5 or muscle spasm Grode IV A small-amplitude movement stretching intostjffness or muscle spasm. Thl'Se grades can be depictoo diagrammatically When pathology or a physic...l disorder limits thl' range against a line repl'C\\OCfltinga range of mOl'ement from ofmo,\"ementand thl'end·fcd is hard. the grades are a starting or resting position to the cnd of an ,H\"erage alsorrolJced in range (Figul'l' 7.6). Mrrnal \"nd of range (Figure 7.4). This line can be rep)'(~ A hypermobile rno\\·em\",,!. which ha5 a hard end- seoul(! by any chosen movement, and altholJgh the feel and which is asymptomatic and normal for that end of the range is always the >arne, the starting pos- person, would ha\\'e grades of movement such as those itioncanbcanypositiooofchoiCl'.·l1Je ....asonforthe in Figul'l' 7.7. thickt·,l<XlpointBiscxplairn..,jonpage~53.Forexample. When a hypermobile range is affected by SOme dis- cervical rotation of the supine paHent js most easily order that causes a slight limitation yet still has a hard consjdl'red as starting from the position whl're the nose end-feel, the grades of movement would be repre- faces forwards at right angles to the tnmk. Obviously. SClltedasin Figr\",:7.8. Jtis important to realiz\" that this theend-posjtjon wHi be full rotation with the nose stiffness still pt'rmits a rang\" of movement that;s facing approxirnate1yover the shoulder. beyond the a\\'erage normal range, yel in relation to its Different ~,int mo\\·ernent. ha\\\"{' a different f~lat thf' normal hypermobile range it is still hypomobilc end of range. Forl·x,'mple. elbow \"xtension has a hard As was pointl.,j out earlier, the end-feel may be end·feel and l'lbow flexion h.1S a softer, springy end· softer and \"xt\"nd m\"era part of the range of mo\\'\"menl. f<.'el.lntherepl\\'$Cntationsforthedifferentgrades.a Taking lowe flexion as an e>(ample, the l'l\",islance to hard end-feel has bet.'n assumoo. Th\" arrows, markoo flexion may COmmenCe at Revcn though the end of the for each of the four grades, depict the amplitude of average normal range is slill al B(Fisure 7.9). earn of the movements and the positions th\"Y ocCIJpy Grades lll+ and IV+ under the circumstances of in the range (Figufl' 7.5) softend-k'ClmaybedepictedasinFigurr7.1O. This allows the stronger or gl'ntler techniques th\"t are taken into rl'Sistance to be depicted (Figurr7.11) OiftertntmOYl'mtntdi,...,tion~haveadiffer.nt The soft end-fed al\", provides the opportunity to end-fel'l. to wnictlthe 9r3de~ of movemtnl will be show that grade [[ movements nl'ver ....ach into adaplw rl'Sistance; they are always resistance---frre movements (Figure7.J2)

.., \".Omm n\"rtlC.ll). and ....;os able 10 measure lnO\\'ement ' Fig\",,\" 7.10 G,~d.. IIIJnd flJun<k,~soft ~\"d-f~1 throughout tholl rangt\" more olCCUr\"tely ttwn could be determined by a dwgauge n\"SOl\\ing 100-01 mm. The ., .. plunger \"'''S controlled elecll'Orllilgncti<;ally, SO that Ng\"... 7.11 ~ing!Od'ln\"lllntHtnintorn.rwflttin 9r~ltlJncllVu_JloOhend-~1 mechanicill cu<'!s from strings. weigh'\" or fnetlon \"\"\"'\" avoid..'ll.l(csiSlanre to Ihe plung,-r movelTl'-'fIlcoold ~ _, . , .•..,.,1.1' GradtI_...e\"\".rt.lwr,srMbnCt'-fttt introouc..>d at any point by the eleetromagflt'tlccontrol syslcm (figurt 7.13). Using a ta5k where the tht....-apisl WiL> \"\"'luiA'd 10 detrt:ttheonselofasubUeremstanre{R,)al~point ...,th,nther;lngt'ofItlO\\YIJWJltofthe~theSWld­ .I'd drvi.ation for R, estimabOO by e.:penma'd maropo- Iah,~tt.,,-i1pists .. tiO.16mm Untrolinedsubpectshad astand.1rddc\\-iat>onofO_7'9mm. \\\\'hen ...led to per- form the smallest gnde I O8Cillatllr) m<n~t on the plunger, the mean amplitude of oscillation was 0.02 mm for the c~p'-'lit.'nCed m:Ulipuiahvc therapists, and O.IOmmforunt,a\",..'dsUbj!.'CIS. Althouljll ~ are results from .. pll'hrnirklry in...\",ti- gatiOll,a\"dagrealdcal_n.'S'-'archneedslobedone. ...,-it is obvious that the accuracy thai may be obumed by p.1lpabm and ~\\\"l' mo..........ml h'dutiquo'S is ft'fIWi- LearnIng 10 CQnlro! the gcnl\\eness of gr<1de lmm\"f'- RHYTHM mentsisas Important as leaming tuoontroltne smooth- ness of rh)'thm wilh gradC!i IJ and 111; and all of these The rhylhm of mobilization can be v..\" ..'ll In many need far more emphasis than grade IV.A fitting descnp- ways, ranging frQm a slow g...ntl... movement toa sharp lion for grade I posiero-atlll'rior p~ure on a ~pjnous Slaccalo mO\\\"..,\",.....t O' a sustai...\"j po6itlon without process is to l\"Iy thai if .. fly were betWl...'\" the \\hcr- lip\"'\"''''apist's thumb$; ;rnd the anYlllSCillallonalaH. proce.!i5, il would nQ! Stacc.ato t«hniq..... are used to make a sutJ joint be squashed by tIT,., I«,h'''que Thai such S....tl...- move 10 the limilofii's rna\"\"\"um rangebefln lIS Mgt>- anbeflfO'Ctl,eintreatmenlil;l\\ardlorSOfJ>l'~tQ bowing joints ha\\\"e time to start mO\\ing. It is oM\"lOUS belir\\~.Neo.·~whenpain\"\"\"~ylurutsmm·,,,, thatlD ..... sudl.rttythmthejoinidisordcrmustbe men!.. h'duuqut~Sft'I\\o,>asthis&radell!UmplecMl chronic and not marl<edly painful H the symptoms beeff«b,e frornthejoontarf'uunirnatthespeedoftheSb<'calo In fKl, many people linduding IIlanlplllalcm) do techniquecanboehkcnOOlotheSlattalonoleSprOOuced not appredah' or belie\\'(' that il is J'<'i\",ble to del(,r- On the violin by plucking; if the sympl~ att' moder- rl'UtIe such a r~ deg....... of mO\"'!I'nenl or resistance lit\". thestaa:~tOlt.'Chniquecanboelik\"ned to the Staccato Those who wi;;h 10 be convinced would do wen 10 notes produn'll with the bow on the vioHn \"'ad Eva\"'\" rL-,;earclt findings (Ev.lns. 1982). He state: When a joint disord.... is quite painful, the OliOlla- Thr.'CII'*Y ofptUfJdlio/l, .nd Iltedri~11/1111 tory mO'-ement should be performed smoothly and ....my SO that the moment ..\"hen the OISCillabon ..,wsll'Ibdr , -..... W«JbiJiztllion kdt.. OIn \".. (hangesfrom'p<essu~'to'~'cannotbe - \" \"~\"\"'sli1ln1t~.Ioa/ongbmr determined_ In a r«mt study lu in\"~llgate the attur.tey of pal!,,\"- hon findUlgS {Evans. 19'U),anln5lrumcnl w~madclo R~hm ofmow:....nt van.:sfrom...-Ih gcnlk t«it· '0simulate the movement ,he therapist might expect niql>(Slo~a,p$tacullomCM:mentorto.:wstal~ find wht-'fI using her thumbs On a spmous pl\"Ofi'SS and positionw'IhOiltany.,..jllationaIIII.Thcmythm;, e~amming movement in the postero-anterior dir«- $C1c<:I.ddtpcndingonlhcobjcetivcoftMlc<:hnlll~· lIOn- 1lw irostrum.....t hold a plunger whkh Il\\O\\\"..'ll

Prlntiplesof ttthniques Figu,e7.1J l'alp.atjon !-k,lIlo-(lI) Plunge, arid \",,,ording equipment lbl M••suring inw\"ment5 Using the simile of Ihe violin ag.1in, Ihe violin lsi can There are three e~ceptions to this general nIle of p,,-'Ssure-.onbcingfastcrthanprcssure-.off, playa prolonged note in such a manner that if th\" lis- !l:nl'r doses her C)'cs, ~he is unable to tell wh\"n the I When pain is e~pcricnced as a consequence 01 bow changes from the up-stroke to the down-;;troke movern\"nt in a rel\"aslng dir<'t:tion. '5Also, the speed of the forward direction the same as 2. When th\" spinous process is abnormally de,-\"p set and painful when posterc>-anlerior pressure Is !ll<' s~ of the backward dire<:tion. Under nearly all applied. Under both of these circumstances the other Circumstances. the cornparativ\" sp<'<'<! in each 'prcssure-.off· part of the oscillation should be dis- direction is different. The forward direction (pressure- tinctly faster than the ·pN$Sure-on'. 01'1) is always faster. even if only fractionally so. than thl' backward dim:tion (prcssure-.off). It is a valuable 3. The third exception is when a t,-'Chnique is US'-'<l as e:<pcnence for every practising manipulative physic>- a slowly increasing sustained pressure into either lhcrapist to h.we performed an oscillatory cervical muscle spasm or strong resistance. when the pain rotahOn 01 3W amplitude performed on her, first provoked by the pressure isquite inlt'n\".,. Whil\" the t,-'Chnique is pcrfonned at the moment when applied with the rotation movemL\"Tlt faster than the the pain is about to increase suddenly and sharply. dc-mtat'on. and then with the dc-rotation faster than the mtation. In this way she can feel the difference bctwCl\"I1th\"m

lhe pressure should be instanlly released, e>\"en if only (using the tim\"\" aspect already mentioned) the release by a mi1lillK'bl', so as 10 avoid thl· sharp incn\\lse. pain can hi, useful as an aSSCSSml'Il1 guide Or asterisk This new position is then held for as long as f<-\",ls rea- indicaling improvemenl or wo~ning !;OJtilble for !he inlefl'>ity to ha,-e wbsidcd. 1bc manipulalin! physioth.!rapisl det\"rmines this by If the relea;;c pain inlensity is lesscning e\"en though closelycommunicahng with the patil\"tlt. IVheretlpon the I'A pressure is being sustained for the same length th<: mOVl'llK'fll is !hen slowly taken furth''T inlo the of time, Ihe patient's as~risk mowment will show range untillhe next ~mall 'backing off' L~ l'1!'luire<! improvem''TI1 Another facet is that it is possible, by altering the TREATING PAIN-THROUGH-RANGE rhythm. 10 I\",at \"'ith anleroposlerior mo\\'em'onts by applying postero-anlerior pressUT'CS. This is achi,'ved by When lreating pain (Ihal is, treating a pain-Ihrough- pulting Ihe emphasis of the 05CillalOry movcment on range situation with grade II movements), the ampli- the release of Ihe pressure-off rather than on the po,;- tude of the movemenl must bc as larg\" as the symptom tero-anterior diK'Ction itself. In olh,'T words, the sp\"-\"--d \"\"'pon\"\" will allow; th\" grealer lhe pain, the slower of the \",lease of the p\"-\"i6ure-on (i.c. pTCS5unx>ff) is and smoother should be the rhythm. The changes that f.1Ster than lheslow. delibcraleaPl,licahml of Ihe posh.'ro- can be made to advance Ihis tl'Chnique (wilhout alter· antcrior pr.:ssurc (i.e. pK'SSuK--on). This particular ing Ihe palient's position) arc to: rhythm IS also us<'''Cl when a patient's pain response is felt on the release component of postern-anlerior pres- Mak\" lhe amplitude larger. sure mO\\\"emenls. In other words, the s)X'cd of the Take the movement into a degret' of diswmfort releas.c of the prcs.sure-on (i.e. prcs.sun--off) is faster th.m lnm,ase the sfX\"-\"Cl of the oscillation while still the slow, deliberate application of lhe poslero-anterior relainingilssmoothness pressure (Le. pn'Ssurc--on). This particular Iilythm is 4 Mak.· Ihe oscillation slightly staccato. a!sousedwhenu,ingpressu\",mm'em,-'TIts TREATING END-OF-RANGE PAIN RELEASE PAIN Whm treating pain Ihat is pK'SCnt only al Ihe end of Pain experi'\"Jln..J as a \",suit of this pressu\",-offsitu- range, or when lreating stiffness, Ihe technique should ation can be ref\"rTl\"d loas release pain. Thiscan beexpoc- be a smilil-amplitude slaccato mo'-emenl at the limit of rienced aethely, as when an arthritic joint is moved to the range. The treatment movement slrelches Ihe joint its hmit and then released from the limit. slructoK'S 10 the Iimil of their rang\", and is held Ihere finnly by Ihe manipulati\"e physiotherapisl for as The\", arc three aspects 10 this. and th\" fin;t iJl\\'ol\\',-'S long as 5 minUles. The slaCCillo small-amplitude o\"er· lime. The amount of linle that the limit of the mov... presSU\"'-'8 are applil..J for a t'me and at a strength dic- menl is sustained will influ\"\"\"\" the intefl'>'ty of Ihe tatlxl by how chronic the disorder is and th\" dcg\"'\" of release pain. Secondly, lhe range of mOvement in discomfort mtend,xllo be produced by lhe slrelch the releasing direclion can alter lhe pain response For e\"ample, if the neck is turned to Ihe left and the The pressures referred to above arc not performl-d releasing movement involves d,-rolation to neulr\"l on only Ihe one vertebra, even if it is only movement of but without stopping lhe movem\"nl is conlinued to that single vertebra that reproduces Ihe patienl's inmlve some rotalion, the right pain may be \"xperi· symploms. If T8 is the vertebra al fault and postero- ClloCt\"d after the Iwutral position has \\x-(,n passed. Thirdly, ant\"rior pressure is Ihe oscillatory lreatment lechnique, Ihe sfX\"-'<l of Ihe releasing movement can influence the the treatm\"nt movements wOl1ld, at leaSI, be applied to rain experience. The more quickly the mo'-ement is 17 and 1'9 as well. This is only a general rule, and ;s done, lhe more pain can be felt. The relalive speeds of open to wide variatiofl'>. Ilowever, when the pressun\"> the 'pn.'S/;ul\"\\~n', 'pressure-off' are dictated by the are used 10 treal a som<'whatsliffT8, the rhythm of the paIn response intended. Usually, Ihe fmlher lhe !t-'Chniquc would besimilar to the following: fomoscil- 'pressure...,n' is taken inlo Ihe range, and alSQ the fasler lalions on TS, four on 17, then foor on 1\"8, Ihen four on the'pl'CS'iure-off'isperformed,thegreaterislhepain 1\"9,T8,T7,and500n sopro'·oked TREATING MUSClE SPASM Releas.c pain can similarly be experienced asa ,,-,,>ull of passive movemenI Whe\" using a t'-'Chnique th.,1 is a painful movement proll'Cted by musclesp.lsm, th\" rhythm is mainly a As a trealmenl technique, a poslern-anterior pre>- sure may cause pain and by sustaining that pressure

§ust~lncd position r\"tho.-r than an oscill~hon.The t«h- STACCATO RHYTHMS roque is ~owly taken in to thl' pornt wht'n' pain islclt and muscle spasm n$StS further m(rI·ernent. nus Staccato techniques (1m be used as a broken mythm; tmuuqut\" posltlon is then held shll. waiting for t.... IN.los. a sequence of four 5ta«oIto mQ\\ements can be Ir\\e'ofpalntolessef,toallowthespasmto~, follo....ed. after a small ret. by two lnO\\-ernents. then The ... a,ling tJ.mecan bEoask>ng as I mmuto:-, but IS usu- fi\\e, thenOlll', then thr1't'and $0 on. This provides 1Iw aU\\ in the onk-'!\" of 1()-20 <;<<<In<ls. The t«hruque is malllpulali'·... phrsiotheraptst with a pId 'feel' of 1Iw then nudgro a fraction further and hekI at tNt p<l&\" u...mm·ement. and iI\\'OIds iln\\\" anticipation by patient ,bOn to \"'all agaUl for pain and spasm to allow further lI'kJ\\emerll Dunng t1us slow process. 5OO'Il' tiny 5oIow Il§ to when the mmernml ~ gou>g to be appbcd ~ thU!i O§Cillatory m(rI't-'ment 15 Ul~; no ~ than l,aidIng any 'm.-w hokhng' II1reo.' or lour (llj01L.>hons at a lime. and ....,thout much olani~mJMIn Foreum.ple, if the tre.atrnenl teclu\\iqueofchoicEo is lumbar roI.iIlion done in side I)·ing. the b.-'dmique may \\Vhen SJM~m hrft.lts the a\\·ai.lable r.mgt\" of m()\\('- be doneas a IV to treat end-of-rang... softnfss. and this menlthe myllun of the tcchniqUl' used '5 II \\'(-\")' slowly mayea~_ pain. By intt\"l'TUpling thoom)'thm ...·ith applied p\"-\"SSUrf' and lhere is no oscillation other than a III of large amplitude, he Cilnno1 pll'dict the chang<' • liny ...1\"aSO' rompont-'nt ....hen the spasm mmutely '\" m)thm and amplitude of lI'IO\\'ftT\\Cfll. and Ihis inter- but sharply 'l'Cl'CaSt'5. Thisp.-essure issustilincd ....ith rnptstus atternpts to 'help' sucnprt-'ooecontrollhat thepali('r1t hasconfidt.'I\\C'('in MANIPULATIONS m., mdnipulali\\e physiOlht.-rapist's skill in predictln8 th... mom\"nt to reiNS(> tm. pressure dnd in kno.... ing Khythm i'j al50 important in relation to manipulative how slowly to ll>Creds(> the 'prcssure-on', II also l'1,,~bICll t\"\"hniques. Qb\"iously manipulative t~'Chniquesart' P'-\"- folllled with speed, but \",'m though the ~ond'posiliort Ihe pati\"nt to gathl'r str...ngth lor the n\"xt sustained of the manipulalive movcm\\.'nt is constant for a par- tkuL~r ~t of conditlom, tIw stdrting position may vary. P\"-'SSu,.., Onee the posilion to perform the manipul\"tion has t:--n adopted. and it is detl'TlTlined that the desill'd LATENT PAIN RES;;.'.;;ON\",'.;;' _ symptom responsoe is felt when the 5111'tdl position of the tl'ChniqU\" is tested, the strt'lched position can be When a p.:i1i('r1t, during the physical examinatKlIl, is eased. The decision i then ~ .os 10 whether the found to ha\\e a lat('r1t pain ~ponse (SO'f p, 63), the manipuliltion is performed from the strt'lCh pa;ltion or from a position where tIw sl~ch!\\as bo:'en sbghtl)· but durabOnofsustlininga tcchnique is frequently direct'y ~gruflantl)'reIeascd.\\\\'tuche\\('rischo6en.themanipu­ proport,onal to t.... timing of IN.t lat('r1t pam re.ponSO' laboo is taken to lhe !IoImt' end·pos.tlion. From lhe The ~1t till.e to plU\\'oleSrmptom!lOlllfustamtng strdChposition the;amplitudol't'ihny;from thereloeased • test mm'efT\"M'nt ,\"\",th firm 0\\·t\"l'-p\"\"\"'U11' at the IImli of or ...ased pa;ition the ampt,tuM b larger. but ooly ttw ral'lg1\". the longer I.... lIeatmenl leduuqUl\" should beca~ it is startmg from a posill()n further back in the ranp'\"o not beause illS gomg furtho.-r into lhe range besusto,otd. Thrs \"an,,,,pomml,..,.,.,,,,. CHANGING DEPTHS OF RHYTHM _ SMOOTH RHYTHMS ~am)thm~bel-'nchosen,iteanbeperformcdat RHYTHM/SYMPTOM RESPONSE d,fferenl lkpth>. Ul a rang.... The depth of a smooth. Follo....ing e\"\",mmalion and a5St'5!imertt, a particubr f'\\'l'fl mylhm u-cd 10 lreat pain is changed in response techruque may be dlo:o;o,n With the deliberate mtention to pam fl.\"lt durlllg lhe lechnique; lhal is. t.... technique lhal il should reprodUC'l.' I cakubled degree of local is 1Tl(l\\et! back in t.... range-to avoid JMin. Similar'y, If it discomfort. nus may be the eho~ for two rcasort5 lli tnlendl-d lhat the Il'chniqu... should be perforrn..'d as cloo;.e as possible to Ihe- point in the range ....hl'n pain 1. It is anlicipatro thai the symptoms will d{'Crease as begins. il is n~ry occa\"onally loearry themrthm thc t{'ChniquC' is continued, and that they maycom- a FraClion (urther inlothe range to S{'l-' thaI thl' posilion plctclydisappcar. If thisdo..'S occur during the pcr' of th... oo>cillalion iscor...'CI, Illhet\"\"hnique issu«ess- formanceof the technique, the patit.'nl's mOVCml'flts fully ch~nglng tht' symptoms and signs, th... pain may and symploms should sho.... Impro\"ement .... hen recede, allowing the rhylhm 10 be tah\", dl--\"pl.'r into reassessed. the railS\\.' by increasing the range of movement.

180 MAITlANO'S VERTEBRAL MANIPULATION 2. It provides further vaJuable object;\"e examination symptoms and indica ling 10 Ihe physiotherapist information to know the effect of reJ'C\"tcd move- incorrectly. 111..11 postero-anterior mo,-ement is not the mCf\\t in a particular direction that is painful. For righltffhni'lueloU5C example, if a particular mO\"emCf\\t is performed with a consla\"t rhythm \"\"d the movcmCf\\t is pai,,- From all that .....sbee1'said sofar.;tshould bec1ear 1CS'> at first but a\" ache develops a\"d worsens OVl~r that performing a technique well is more than jUSlcarry. a period of say 20 seconds. it IS obvIOUS that the ing oot a mar.oeuvo:' with t1>e<:hankal ex~llenre. like statl' of that joint disordl'r is worse than if the the soloist plaYing her part in, say, a violm CO\"\"\"rIo, the movement had cauS<.>d di5C{)mfort at the begi\"ning manipulator \",-'Cds to bed'-\"-'Ply. totally and <'motioOilUy but had become pamJess wiUun 20 Sl'Conds invoked in the tcchni'lue she is p<.orforrning. WhCfl she mobtlizl'S a joint by a partie\"iar manoeuvre, she \",-,,-xls Itisimportanllhat.wilh~ryt~chniqur,thr to block out from her mind all other distracting influ· manii>'Jlati\"\"pflY'ioth~rapistmustbtfully.w.\"'.t ffiCl.'S- she \",-,,-'CIs to try to put herself inside the joint all timts ofthrrff~t th~ ttthniqu~ is having (Ill th~ structu= she is moving and f<~i a part of them. patirnl'l <ymptoms wltilrtltrt«It\",'qurisl>cing ~rform~d MANIPULATION R'-'garding IIsing f\"O'tem-a\"lerior movements on a The point h.,s \"lready been made tnal a mob,lizatiOl', spinous pl\"lX'eSS (say U) that IS prominent and painful, even lhough it maybe done finnly, docs not cons,st 0/ a the rhythm of the techni'lue should be adjusted to sudden movement. A sudden movement or thrw;t con- reduce the ~in. This may be achieved in a variety stitutes a manipulation_ l1>cre are two types of m.1nip- of war-; ulativt\" t,-'Chni'lu,-'S: those that are the 5<lme as the mobiliLations already described but p<.orfonned much 1 The rhythm may be tiny in amplitude so th.t the more rapidly; and those that localize the manipulation movement through range, being small\"r, will as much .s is possible to one intervertebral joinl to f\"\"\" not provoke as much ·through-range pain'. The its range of mov\"\"\",,,!. Whatever type is uS'-od, it is 'through-r.'ngl' pain' will be f,lr less, though m<Jl..· illwar-; a quick movement of very sm,,11 amplitude mml of the joint, which is an l.\"SSCnti.11 part of the Strong traction is unnecessary and, in some instances. is trNtffiL'rlt, will slill be taking pl\"\"e. a distinct disadvant\"ge. If it is \"pplied strongly, it lessens the range availabJe for the manipulation_Some 2. The sfX,,-'d of tlw oscillation should be reduced to a mml;pulolor'J; beliroe il prol',,u.,, 0 saJcty!oclrn, This is jolw: sfX,,-'d of approximatdy one O'lCiliation per 2 sec- sajetyisprovidedbygrIldIUllprogresslOtlr:flkslre..gthr:flhe onds. This will also lessen the \"mounl of pain wilh techmquecoul,ledwirhcor,'immlosstSOmrnl the treatment t,-'Chni'lue !>e<;au5O; it is n.'dudng Ihe :i:,:,nt of movement of the joint of a llnit period of TYPE 1 3. Be<:ause the amplitude is tiny and the s!\"-,,-od of During treatment by mobilimtion, the improvement oscillation is slow, the pain will be k-ss and the rate may slow down even though the early mobiliza patient will be abll' to ,,-'lax mOre readily and theR~ tions were methodically increased ill depth and pro- fore the t,-'Chnique will be able to be taken dC'Cpcr duced ad'-'<]uate progress. Under these circumstances it into the range. m\"y be necessary to alter Ihe technique to include a sudden movement near the limit of the range. Such an 4 By being able to go deeper into the range, the tech- over-pressure is usually only necessary in the mobiliz· nique will be more effective in producing improve- ing techni'lUesof f\"O'lcro-anterior unilateral vertebral ment, and in fact it will be \"\",ticW during the pressure in the thoradc region; post,'ro-anterior central application of the tffhni'luc th.ll the physiotherapist vertebral pressure in Ihelhora,i, and lumbar regions; will be able, quite 'luickly, to go mOt\"e dl.\"-V1y into and rotation in the cervical and lumbar regions. the range without provoking any Increase in pam TYPE 2 The reverse would happen if a larger amplitude were u5ed and the rate of oscillation were two 01' three oscil- WheY'<' an almost painless limitation of m\"\"eOlent, lations per second. If the amplitude is too big and the which is presuOl'-od tobethecauseofa patient'ssymp- speed too great. thl'rl the ;oint will \"\"'COme more SOre toms, c,mnot be sufficiently improved by mobiliz,'lion with the treatment, thus aggravating the pati'-'Tlt\"s

Prindpitsofttthniquts 181 or the maoipulath'e techniques descrilx-d ab.,,\"e, the Care must be laken not to manipulate under anaes- maoipulatioo must be localin'<l to the one joint, This thesia too vigorol.lsly. Rather than trying to achieve a manipulatioo alms at directly restoring movement to full range of mO\\'emCllt in one manipulation, it is often the faulty inter-vertebral segment. better to manipulate more gently on two or more occa- sions.ln a s<-'COnd artide (Bremner and Simpson, 1959), MANIPULATION UNDER ANAESTHESIA (MUA) Bremner advocates 'follow-l.lp' ph)'siotherapy after an MUA hasht-'Cn (arried out Following the issue of the third ~'<lition of Vertebrat Mallipldatioll,a veryconstructi\\'e l't-oview was published The degl\"<)C of success of an MUA will be known which emphasized the importance of MUA. In that within 2 or 3 days. If the patient gains complete relief review, and in subsequ~'llt correspondence with the from his symptoms, follow-up treatment is unne<',,:'!- author, the reviewer advocated acknowll'<lgemenl in sary. However, if the symptoms do not improve the te~t of the existence of 'manipulation under anaes- sufficiently, passi,'\" mobilization will be required thesia' (MUA) as it is used widely by doctors and by When radiological evidence of ;olOt cluln8cs (which some physiotherapists, and with this view the author account forsomeo/ the stiffness) is present. the palient heartily COnCurs. should be taught to perform daily mobilizing ,.,,{.']\"_ dses. When there is instability, stabilizing exercises Bn>mner (I958) provides Hidence of the effective- shouldbeperforml.'ddaily. ness of MUA in the tn>atment of lumbosacral strain Probably the same applies to any local pain and stiff- It is important to bear in mind that follow-l.lp treal- ness of spinal origin; it certaimy dOl'S in the cervical ment ShOllid only be given seIL..,tive1y and not rou- spine. Cyriax {1980} sets out clearly the indications and tinclyfl.lrallpat;\"nlS. contraindications for MUA and the same for manipu- lation (Cyria~ and Cyriax, 1993). Where manipulation of the con>eious patient has faik'<l, MUA may be succes.>fuL The com'erst' is also A patient's condition may be improv~'<l initially by true. Sometimes, as evidenced by the reviewer. patients mobilization and manipulation, but a stage may be may requi\"\" a balance of both reach<xl where the rate of progreu stops. MUA llliIy tIl<!1l be indicat~'<l, The build of the patk'llt, or a degree SUMMARY of,'oluntary mU5Cle contraction that prevents manipu- lation while a palient is conscious, may well make To Sl.lmmariz.e the need for manipulations as means of MUA the treatment of choice. The reviewer rightly quick thrust techniques or manipulations under anaes- asserts that in 'delermining management of difficult thesia in dinkal situations, my dinical experience has and unre;ponsi\"e cases it pro,·.... \"ery profitable for taught me that whe\"\"as a d''Glde Or SO ago I con- the doctor and physiotherapisttooonfer'. sidered that of the patients who did rcs!X'nd to passive movement m'atmenl 85 per C~'lll only \"-'ql.lired mobil- If a patient can relaxcompletely,thf'end-feelo/the il.Mioo and 15 per cenl rt.'quir~'<l manipulation, now range of movement being manipl.lIJted is the ,,'me th•.,., perc''lltag.'S have changed to 98-99 per cent and whether he is manipulated consciously or under 1-2 perct'llt rt.'Sp<.'Cti\\'e1y. anaesthesia

Chapter 8 Selection of techniques CHAPTER CONTENTS • Position of tile inttM'rtebraljoint in which movement will ~ ~rformed 202 • Selection - general a~ped~ for ~electing technique~ 185 • The manncrofthett'chniquc: 203 • Duration of treatment 204 • Current knowledge of pathological • ~Icction- related to diagnosis and prcSf:nling disorders 187 Movements 187 symptoms 204 Pain-sensitive structure~and their pain • Mt'chanical blocking 204 patterns 189 • Ligaments and capsule, and 'arthritic/arthrosic' Pain-~en~itive structures in the vertebral canal and foramina 192 zygapophyscaljoint 204 Pathlliogicaldisordcrsandinjury 192 Sel~tjon 205 Group 1 - pain 205 • Diagnosis 196 Group 2 -stiffness 206 f'rcscnt slability component 197 Group3-painwithstiffness 207 Group 4 - momentary pain 208 • Hi~tory. ~ymptoms and signs 199 Gf()up5-arthriticlarthrmiczygapoph~al History 199 joint 209 Symptoms 200 • Disc/nerve root 209 Signs 200 Sevcrcanddi~blingsymplomssufficicntto indicate that sur~wy is contemplated 210 • Selection - aspccts of the technique Lcssscvcrcsymptomswhich,thoughsevcrC,do itself 201 not prevent the continuing of light work 210 • Mobilize or manipulate 201 Chronicrcmnanlsofncrvc-rootsymptoms 211 • The direction of movement of the • Summary of sdcction 211 tcchnique 202 Patients \",fern.od for or seeking manipulative physio- a car Or turning sharply. p\"tienls in the second group tlx'rapy are considered in two distinct groups_ First, have symptoms. signs and histories that arc readily there are thQ5C who han' suffen.\":! an injury of some recognizable. Patients of the first group nave had kind, wht'lher due to a fall, dire<:t blow or the post- injury to normal tissues and can present with aoy coo- surgical ~jtuation. ThO' second group includes patients figurJtion of symptona and signs; however, some of \".hose symptoms have appean..:! spontaneously or fol- their symptoms ;md signs may fit parts of the patterns lowing a trivial incident such as lifting a suitcascout of of the second group. It is to this second group - where

Table B.l Sequence of selection of techniques Bilc~ral -,-uniJ'ffllJ symptoms I I I'osttro-ant.rio,unila,.,al\"\"rt.b,al I'ost.m·anltrio,ctntral.tn.b,al P'6~u~:I::tat;on I Posttro-anlt,:J::t.r1Il \"\"ntbfal P,.S>Uft 125idts) lawai f1t>:lon or l,ans\"\"rst I \"\"rttbr1llprtssu,t lon9Jtud;n~l_mtnl I T.-.etilln I Rot\",\"\" uniJl\"fflJ1 Bil}tt'fI1J symptoms symptoms f'ost.ro.ant'fio,lc.nlr1llv.\"tb,al pr.\"ure Posl'fo-~nttrio,lc.nlr.>1 ••\".b,al I pr.\"ure Tr~nsvtrst vt\"tb,~1 pr=ure I I Tr1Insv.rst ....rt.b.. lp'csw'.12Sldts) Posttfo-~nttnor unil~t'r1Il vt\".b,~1 I prtssu,t Tr1Icti\"\" Tr.JjOn I I 8i1ote'al Unilateral symptoms sympfCm<; I'osI.ro.antt\"or1ctntr1ll\"\"rttb,al pressure I AGutlon - f'ost.,o-~nt'fior ctnt,al\"\"rttbral I pressure I AGt!tion I Upt1C,Jum(:lCl( I Upperlumbor I towerlumbo' r~rOll LowtrLmbor rt9('\" reg,,,,, I \"\"00 T\",nsvtrst Tr.>d~ Tfansvtrst T.Jlion \"\"rt.b,~1 pftSSU\" longiJU(Hn~1 \"\"\".brolprcswre I T~lon T'.~ion lon9itudin~1 In .~,II '<g,on th. ord., m~y be oh~rIgt(l by remo\";n9 trod\",n from il< dtsignalt<ll\"\"'lIOn~'\" p1ac,n9 it ~nywhere '1'1 \"\"IUtn\"\". Tht rem~,n,ng ltohn'qutso .. tOtnu..o in\"'\" sam.I>I'<It1~,,\",,...ninlhi.t.blt

xl«tionoftcchnjqu~ '5<!\"'ction'and'prediction'areclearcst-thattht ...'hQIe 2. Thell-\"COg\"itionofthediffen...\"t t)\"pcsofJX1in,arid ofthiscMp...... l$applit'd dlfft\"renl pallems of bcMviour of thaI palO Man,pu~tNtptlysiolhcr.lpyil;nolontyamlltICfof (Butlcr,lm). lca\"\"\"llalldilptl!y>nglcduuqua..lti§i1 .....I1Cfof ~ Prroictablel'1'5JlOfl5C5. ~\"'w/lcnilndlW1llltlollSCwIlidItcdullquc.how 4.Refineml'ntolasscssmcntsIuJJs..~analyIicaJ toodopl!hclccM'CIlICtOthcpilfticulilfSlWill*lof !hcpl!lCf't ~tof~51\"\"q ....htyandbeha,·iourof the pat>enra potin plL.lli the concurrent rcrogmhon of the ncuro-mU!lC\\lIoeil<eletoll stNctu1\"C5 11I,0hfd are ..reolSolimportotnlgrowth. 'SeIection',tidi!icusliedlnth15cN~.i5d,v>dedinlo lneul.eTl'dltlQnliofthi5bool< twotilbles ...'ere pro- thefolloooing: .ided.uguidelinefforthe~tionoftn>atmentteel\\­ I.Gcncr\"'asped5for~l«hruqU(' 2. Aspemofthcbechnique,tself Nquei. One t.lble liskd a Sf'ql.lt'J\"lCe of 5elechon bMcd 3, The re.... tion of selection 10 ~ dJilgTlO5<Jl and on ... hen the JX1loml'ssymptoms .. ered.stribuled uni- Ia~ally or bIlalffally (TRIM 8.1), and the second tlbJe presmll1lg symptoms and tlp. mau.>d specifIC techniques to their pnmary uses in each§l'Ctloo of the SpU'l' (TRI1kS.l). Thesc.-tabll'Sare Auscful<tdditionalrck'ft'l\"l(eto~ll'Ctionoftechniql.lC.'5 appcarsin Magarey{19l:I61. usefulasanovcfS'mphfi~>dba,isfo.scJcctionult~'Ch· nique!l. TolM'1 down, in writK'\" fonn, guidelines for the selection of t<'Chniqucs is difficult. Thl' subfl'Ct 's ,\\Ot SelECTION - GENERAL ASPECTS FOR m('T('ly a mattc.ofd...,idingwh\"\"tosek'C1 a particular SELECTING TECHNIOUES mob,li7~'tionorm,ln;pulation.o...\"enwhL.\"tochang\" from one tl'Chnique to another; it alS<) indudt..'S dl'Ci- S'OOSl\\'gardlOl;thcrhythm,amplitudeandwcngthof I'resuming one knows all lhe ki\"ds of Il'Chniques thai the technique and thcposition inrangein,,'hich the are a,·ailable for use in treatment (sa romml'flt on technique should be performed. Finally, there is of pageS, and the t('St related to t~'(hniqu\" inClulpler 7), roursc thfo durlllion of application of the tedmique(s) thc,..lectionofapa.lic;ulartec-hniq.... isb.ascdupon (summari7.ed in TI/b'\" 8.3). thcfolJowingthrecintegratcdpam; Item Din TI/11k8.J-lhe m,\"mc. arid durallon 01 the 1. Cllnml /mou~td~fJ/\",,'hoIogilwl d,sordn-s lind mjllry m::hmqut'-refI'l'!lIO' uf IN T'rTItbr41 ooIl1l11n. thIS kncMlcdg<: Inclodes 1. TheflO'oit>oninthea\"ailablcrangt'olm<J\\cmmts known and prm'en facts, rcahzlng IMt there is inwtuehthct«hnlqucshouldbc~ much shU unl<no\\o.·n, Of greatest Importance is 2. Thefinnnes5orgcnIJcneo;.softlwf1\"OO\\-rment. knowing the structures IMI GIn cau.sc pain..oo thr 3. ~ ..mplotudc of the f1\"OO\\·emcnt. differcnt JX1l1erns of paIn rcsponsethat<:anOttUl' dunng test mmemcnts. .. ThespccdofthcTnO\\ement_ 5. The rhythm of the f1\"OO\\'emcnt, ranging fmrn 2. ~. The diagnosti( IIUe is importotnt. but 'VOtlo>'to'$Uol'CaIo' ooedslobcdo!;clyrelatcdtolheh~orywhcnccn­ 6.. Thedcslrt'dpa.'n....sponsc,orabsenct>ol~ 5ideringtheselcclionoftechruqucs(p.l96}. dunng the perlomung of the technique 3. HIStory. Symph>m5l1nd 5l.~1IS (pp. 19'J-200). i. Thelro~thoftlmethemovementshouldbc a} With regard to the tus.tory, and knmo,'ins the conhm.1fti diagnosisoftheJX1t't'flI'sd.rsordcr,theil5f\"'<-\"b Q\\--er the Iobt 10 or more fears, the s...Us a!i6OClOItcd di~y..-riatcdw,ththeselectionofthe with theseleclionolridprost'-\"55ionoflechniql.lC.'5MVe tre.-.tmcnl techniqucaR' the onset and p~ grown UX'lCurrcntly w,th the growth of Imowlcd~ m ofthedisorder;lhestagcofthedisorderwhcn a.....lom)\". ncuroph)'5iology, biomechani<$, pathQlogy and diagnosis. logclher with refined examination and lhe patient seeks lfl'alment; thcdegret' of stabLl- assessment ~kiUs, Probably the grealest gruwth MS ity of the disordL\"r al the lime\"'\" _kslrcatment; o«urrcd in Ihe follow,ng four areas' and thc irrilab,lity or s-e\\\"t!rily of the diso.der. b) Tht! 5ymptof1\\$ include the areas and types of pain of which the patient complains. the 1 Thecleafl'r Ti.'Cogmlion and inlerprel-ation of ciTUJmslanc~ under which h<;J feels them and diffl'rentpattern$ofpalicnts'symptoms,signs l!lc way it may limit h,m 10 PUfSUC ach\\\"ihcs of andhist\"ri(>S his life

186 MAITLAND'S VERTEBRAL MANIPULATION bolt 8.2 Mobilizing ted1niqul:S3ndth~1rUlon Mltf0P051triorunilllltf1lvtrtt~lpre.sure \",,\".,~ !Iou!>on \"'\"\"\"\"\"\"'\"~oI ..,...... ~oIa~~1V T...roo.inflt:lcioll \"\"trmitt~t~lI'Kt*\\ llattniIIylJlSlributtd~8otIyd\\ltlgc5\"\"\"'alIta115ft,. .~. . . . . . . . NlltfotV¥t~\"\"\"\"\"\"\" Un~lttrJllVdlSl:ribultdsytl'lpt<lf'l'lSlIIrtltVilrly,frnoddltll<u~tt'Ni..a.I orig.... (~lhtpushclowftwardsOl'lthtsocltofpai~1 Unillltfllllyd ....ribllttd'Y\"'ptOlftl,.lIonyma\"9t'm.mal1au'\"-IO\"mtllt pu!ihlowlflhlhtwcltofpa,n) Un;I'tt<lllydj\"';bul~Sj'lTlpla.ms.(D,t«1I~tP\"S1'onHltsHjtof~,n) Mostvllulble·u~IIVlh.~tltl«nnjqUtultd.Unillttr31Iydjlt'ibut~ symptoms. (Ro\\.illt Ihthud',wlV from tht Sod't ofpainj Unil'ttrillyd'ill\"buttdsympta.ms.Ott.nU1(d'10 rnl\"\"\"olat>on,(fltx.WIV frotrIthtwcltofpainJ M'_S'fI\"IPtorM ... lhtprtSt~of\"'tt'Utrttbrll\"txionrnlr'i(l>on N\"/ttMQltof><litioP-,.....,..,\"Iftpa\"'wthmantdlyij.,.ltdlltd_nllO Uppt1ttrw:altorlCl,t_ l - . ttMol to'Id,tJOr\\S Groosradocllogla1clt9m'=lwdlMlJtS \"\"\"\"\"\"\"\"\"'\"u.ually\\lltf~\\tdI\"\"It>tlrltd.a.llIltrlllydlSUi:outtdSV\"'p\\OIIlS;u\"'laltnl\\' dlWhrttd\"\"'l'l.... ifl\"\"'r!Y~lI<wolnprucl UnilltMIIyG~;bultdsym~IOlrtttthtpuslllowanhtht . . oIpa... ,nd moblHlCIl'«'\\lrib] Un,I\"t~d.w,bIlttd .,...,pIOms. lOu,tel lilt push <lown...rds on tht sick of ar.pa,n,nd\"'Obill/.tIClJaetntn\"b) Widtlydj\",ibul~sympt\"\"\" ..ptci'llyifrad\"'I\"!liulldtgtntr.lli.. cl1'''9.. pftStnl;whtnpaini,not'9Qrav.ltdb'ylct,.. \"\"\"\",menu '''''~ Bllalerlli'; dimibllted symptoms. (Eq ...1'nu)tful ...... witll rolahon] Bonv rhlngtS from all a\"\"\" 'Mtrm'U~lwariabltlractlOl'l S\\r;\"'lht-l~r.I~n'l lJro'latt1lllydistributtd\"\",ptomspart....I'..... if \",iddltOf upptr_barin ~ong'n.(Olr~ttht~downw'rds\"\"th.t. . ofpa~] lJrolatl'flllydostnbultd S'J\"\"IltOfl'l5. MortIlWfuI fotUllPl'fI..~sp.f'It tIIIn _ _ (D<t«1lhtpusll~tht\"'oI\"\"'l 0l'ttf\\tht~~utl>Wd.~tr.I'1y4rwJllut~'Y\"'4'C_(Aoutttl>t pt'-isf!;nqrdsontht ... oIpa<n] ''''''~lloIattralJyoflStribllt\"'''Y'''PI_oIlDwtr ...mba<ong''. Orltql)o'lMt<al1ylhstnllc.t\",,~oIlDwtrlulntl¥origjn BilMt<lllydiurillul\"\"Slpmp_of't!lroIIlc,.,t..~inthtprtometofnv...... -~Grld~1 onstl of symptoms. Whl'fl ~in is 1101 agg.......l~ by ICtiYt _mtnts G'ossrld~ogi('I~\"\"fat\"\"'d'oIn9t' Un;I'teral\"\"'illl\"\",ofst,,jght-Jtgrai~ngw'lnoutextmntpa;n fo.-S'/mplomsof,c\"'Gnico,stable naturellis;ng from lhcn.\"\", 1001. (Tht t«~n,qut Is nOI ustd IS a first 1«~n,q..eJ

SelcctiOf1 ofttthniques 187 Tablt 8.3 Guidelines for the selection of technique -.....,i.~, I ...... d The ~gns refer 10 tht- rompJmo ph)'Sica1 e>.am- and .straIght Il'g r.using. Each of the jouu 1llO\\eme\\1s inabOn finding5. but tht- ....~ most important 10 the scll.'Ction of ll.'Chrtiques ~ the rn.Jnnef in C..\" be performed while the joInl is p\\*tlOnfd in ....ti- .... Iuch the p;lll.mt·ssymptomo;can he \"-l'rodun'l1 ous lkgl\"l\"eS oflater..ll\\e:(Ol ..nd rotation_ AddJtJonalIy. longlludinal l1lO\\·cmenl an ;ili.o be petfonned with 1»-and \"~ncd !hee-o;..nunahon lesIlTI()\\·...menl~of the JOInt pa'litioned to \" .. nous ~ret'5 of flexion and cxten:o;ion (plus dcgrocsof IateroLl flexion and rotiItion). the struc::Iu~S)<:allS,\"g the p.1tient·ssymplc.m>S. Similarly. the rTlO\\·emenls of fle>clOO:and exlen:o;ion c..n Before rel~hng the Sl:'liXllOl'I of parhcular leo::hmques 10 be perfonncd in vatious po5ltlOOS of longitudinal ~ lh,,-'e ,\"l~'gral p~rts, it ~ ne<;CS;5ary 10 discuss NoCh of them in depth, To some r\\\"~dl'T'S thiS may set'm O1O\\\"m...,nt ..ilher cephalad orCillidad tKllOUS and to oth...,rs unniXcssary, but as the authors belie,\"c thatlhc whol... P1'OO'SS of lreMm...nt is b.~St\"d on In most levt\"ls of the spine lhe gross mO\\\"ement of 'cJlISl:'and effect'. th..., import~nce and inflll...,nce\\>i or th.. inl(>gr~l p.~rts must be lhoroughly understood. A dis- I\"ter~l flexion iI'lcllldcs a compont'Ot or rotation, and ClI55ion of Sl:'lecting tt'Chmqut'S will follow similarly the moveml'nl or 1'f,l11l1;On includes a rom- CURRENT KNOWLEDGE OF PATHOLOGICAL DISORDERS ponenl of laleral fleJ<ion (While and ranjabi, 1978). For example. II is believed that if the oormallumbar spin,;, n-c:arethree:aspectstoooosider: is pa'lition<.'<1 in fleJ<ion and Is lhen lalC'ral1y flexed to 1. MO\\<.>mcnts:andlherel.Jtcdr~'W'/pill\"response 2. P\"II'l-wnslh''''S1RKtureo. ..ndtheirpallem«of the left. the laleral flexion will incJud.... degree or rota- tIOn to Iht\" I...fl. Similarly. if the oonnallumbar spine is ,.~ po>itioned in extension, the l1lO\\'emcnt oflatC'ral f\\e:x- 1. The pathologK..I d..-deB ..nd illfUl'}; Ion 10 tl'K-1eft is combined WIth rotatlOO to the nght.1f these Iwo 5ta1emen1s are CQI'1'ed. then there must, of MOVEMENTS llC\"Ce$ISlly', be a po!iJllOO between lumbir f1erion and ...xtenslon when l.1t.......1 fleXion to the Il'ft ..'ill not Physiological mo~ment considerations tndude any roI.illIon. H\"\"'-t'\\,...... in this fIeIUon/v:ten- sinn ~tion. the av-..ilable rangeofblt't\"al flexion WIll ~ lTI()\\'mM'\\'lt!; I\\~ 10 include lTI()\\'cmcnts of the be more lmuted INn if the poIoIbon of fIexioon/6~­ \\-mror\"\" and ltM>Ir functJOnal structures. mo'-mwnl!l of sOon ...........llef\"ed so as toall(lw rotation 10 tne pbre. lhe .sIructu~ In the \\\"t'I\"k'bral canal and mlt'r\\o\"rt\\.--bral I\" the a-oial spine (C--C7), Iatenl Raion and rota· b'amtn.1, ..nd mQ\\ emcnts of all the neural compon<.'Ots. tion OCCur tolhc same.sidto regardles&ofthe ....-mt of MO\\'l\"IJ\"Il'fIts 01 the ,C1'tt'bra,;, includl.' l1lO\\ernt.'f\\ts of the fleJ<1on and extension. inll.'r,\"CI1eb..1.l dISC, the neurocenlr~l pints of Lu..;chka iIld the Z)'gJpophyst.'a1 jOU1lS. while moH\"nt\"ts or the The Ir.Ins,·..-rsea>.i5 ..round wluch flexion and \"\"len- foraminal and c.. nal Slruc::lure; iI'lclude mo,\"..'ffit'f\\t~ or sOl tale pla<:e, liko.tl'K-Solgiltal:axis for Iat......1 f1erion llrspm.~lcord, thed\\lr~, the vessels, lhe nerve rools and lheirduralhwt'l;tlllt-nb(B....ig.l978j and the longiludinal .....1S for rotalJOn,. 15 not in il smgIe fixed pa'lirion; th<=;s ..n 'instantanoous' axis of r0ta- TIwI.....st CQmpllcat..'<l gross movem\"nts are fle~iOll, tion for eoch phase of a mo\"emcnl, These '\"arymg axes exten,lon and longiludinal movement cephalad and ill1' discuss..'<l in depth by White and I'.ln\",bi (1978). caudad (Ihat is,long·aJ<~\"J<tension or aJ<ial eJ<tension), There must also be a difference as 10 what takes place in the intervertebral jolOt when lat...ral f1...xion (My of the lumbar spirle) is perfonne<! from above downwards (th~t is, asking the patil'Ot 10 bend his trunk to the right), rompal\\'d with being pcrf\"rmt\"<l from below upwards (asking the pat;~'Ot to hitch his tight hip upwards towards his tighl shoulder; 5(Y p. 3-49 and Figu,,\" /1.6). Tbcrc must be a difference, beea~

lBB MAiTlAND'S VERTEBRAL MANIPULATION pi'hents fNql.M'lltl)' hone different polm R'5flO\"5'1'S buliystructu'\" Fort'Umple\"fthepatlC1llhaJpi'lnon depending on ..·hether the lllO\\-ement IS nmcd out the nght side 01 lheno-T12 area, ttus pam may be fn:,m thetopdown ....rWlorthebottorn upw..rds,. pro....ked by !;olenl fII.\"-rion!() the nght, whICh would be;ocompressi\\\"t,typeoipain~,or1tma}'bor 'The~b.'~stn>clureliinthe.'m..br ..l~.\"\",l p\"\"·oledby!;otenln...oo..lothelocft.wludl ..'ooldbor ..ndml1l!n-..rtebr;olfor.min.lc;onMmm·edin ... ther;o Istretehresponse,II\"\"'·........,underthewt..... on:um- ~ or nuda<! dlf\"('(bon. Also, the nrW stn>c- Slilnl'o'thepabC1lllNyfuelth.atthel\"CSf'O'*' just. ture!i Ciln M mo....<1 or .ppro>UfNl!Jlod tow;ords ;ony strctchingfl.\"cling..orhenwyfl.\"clililli\"PI\"',\\\\\"~ deslredsurfaa-oithe~;1Nl,eiu.\".bysW>dingorl)'ing forehawthl\"<'l'end-of-rangep.1in~~ tlw poltJcnl in d~l posilioM (for \"\"\"mple, I)';ng him on ltisleflorrighlsidl',proneorsupi.....);orby End-of-rongeorfbroIl9h-ron9~pain pos,lioning the intl\"r\\'ertebral joints in f1exion,e.ll'I1· sion,lJteral flexion or rot<ltlon whi\\(, producmg lhe l1\\ese d\"scnptl\\·I.\"l1lles are S('lf-cxpla\"\"tory, A patienl cephalad or caudad movemenl of the canal SlruCIUrt..\" will feel pain only whC'll hcmovcs the part at fault to Thissubja'iisdealt wilh fully by Breig(J978) the end of'b ranKe ofmovemc-n\\. TI'e pain may occur only in on\" diR-'Ction of mOVentC1lt, in many diffenml \"IbIs for the paino!l('nsith'c ncural elemenlS from di~tions,oronll,nnncdiroclionthatisacombined the CNS (rentrallK'TVouJ system) to the IX'riphcry mm'ement - ,u<:h as cmnbined ext\"flSion plus later;ol ....Iyon mo,'ernenl tt.'!its!range/pain-l'C\"porIS<o man- ne\"ionlolhtor1ghtandr()btiontothelcft(ils.altheend QeUVR-'5, as do 'joints', bul dw skills ..re different. The of the s,,\"'s (nr I nght-handcd golfer). two main phys>othe'raf>lS1S to \",\"plore thisC'Ofltmumg su~,R.EJ\"'''Y{I'erth.\\\\estemAu.str.ili.J.l.mdD.Buu.... A lhruugh-r.angt' polin is commonI)' .lSISOClolted w,th (Adelat<W, South A~r;ol... ), ha,~ ~'oh'ed pr<Xl-dUI'\\'!li ~ympllXJ1!i that aft' felt constantl}' by the polben.l. On m the fw.1d of ~t>on and lINiment by p.iS6oI'\" _~.toonoilherl'l(l\\..-.n.mts.painisfdtwe!lbefon> theendoither;on~oIthe_mlJ\\'emml.andthepain rr\\O\\·~tToundeostindandleunfromthcir((lnlri­ I8>ds 10 ir>creilse m mtet\\Sl.l)' as the rr\\O\\'cmenllS rar- rirdfurtherinlora\"8E',An~.aoran:oipi'inor.n.ache bunon 'I IS.......-es.ory to ~ Ehey's.rtJcles l ..n;olsoberonSKIl\"n'dtobethrough-Rng'-\"mnaturl' and Bulle's book (Bu~, 1991). Lorol ond ~(~rmJ poin There ~ _dc5Igna!t'd for ~t pcnpho.--nl .........'t'S (Butler, 1991), Thee p\\e the elUffiincr the When a pat,c-nl has rcfe'lT1!d pi'in,lhe pam n..;ponsclo meiIIns 01 dUfermt\\,)tlng between I radiculM pll\\Il ICliI mm'(''Il1C1ltsof the ,ntervertebral joint, thec;onall referredpi'm.mdlhepi'mfrornlperipheralncur.' foramina or neural structures is ext .........\"ly important. p;oin(intraneural,po-nneura\\'cxtl'3neural) The rain rc:;ponSl\"ll that a..., ofgreate!il significance in theS<'ll'Ction ofl<.'Chniqu\"\" area~ follows Ringe/pain response: to movem_,\"_'_ _ I. Tl.\"St movcm,>nts, en>n if restricted, may pro\"ol.J\" This is determin,-d by th{' many test movements of Ihe only local spm.al pain without malo.ing an)· differ- JOINTS and the CANAl IFORA\\-1JNA and \"cur,,1 encetotheref.-'l'ft'dpamcither;otthet,...... oIthel~ 5IruCluI'\\'S. There;o ... thrt.,,'eoR-~idl.\"rations: mm·ementsOl'llS;o!;otmtpain~.Tlusmo ...~.. mentrespons.eranbehandlcd fi.nnJywlth&;lf~' I. Stretchmg or comp.--,ng pam. 2. 'The pain mar presenl .a pam-thmugh-range 2. Test mlJ\\'ements may p\"\"'oU;on iKhe,. W>cinat- ing p;oin. or tinglina: in the refwred ~rN, Sud>;o situalion.andl'nd-ol-r.angt'S1tuationora respon5oO' derNndi rlSpKI. .md p\"\"olmg the combinaboflolbolh. TI5f'OI'SCSshouldbea\\1:lOd<odduringNrtylr1'.at- 3. Wlwn;opabmlhasliopl\"\",lpolm.and~polm, ment and d~lly Kfl\\,be!>- movemmb ......y pl\"O\\·okfo ttw-Ionl pam. the lriem'dpain.orboth 3. Test 1t>O\\'C1lll>nts \"\"\"y pl'Q\\'oIoa> d,stally re-fenl!d symptorm as \"n ,mmedLate response to thetnO\\'c- SrrrtC'hing Of romprosing poin menl wllhout pm\\'Ol<lng any SJ>1nal p.>,n, Though it maybe f>l\"CCS6;Iryto pl'Q\\'okthtofMlnsJightly W\"rtll ~ lebng lhe!'e 1ft thnor pa5loMo Md-of-rangl: with a IrNtmC1ll,it should be done only ,f t..... pain pi,\"~.;orom~fffiil1g,.aslR1dl I'('\\'crtslo its priorl\",'~l on releasmg thl.\" tcchnoqm' f~h\"9Of;offfhngofpiirl 4. Whcnl\\:fcm.'<lp.~inlSprovokedby;ot\"\"tnlQ'·c'\"'-\"'t, Whe!'pai\"ofinl\"r\\'l'rt<-'lnallointoriginisfdtlocally thl.\" pain may~tarldi,lally and sp\",ad pro~imajJr, yclunilaterally.\"xamination movements may repro- ducl.\" this pain by t'ilhcr stretch,ng or compR-ossing Ih\"

~1«tionoftfchniqyt'S 189 Or vier t'l'rsa. Neitherisa favourablerc5poru;<' to The periosteum. fascia. tet\"dons and aponeu!'O'>CS. movement. and should bcavoidL'd The arteries and arterioles. The epidural and paravertt'bral veins (points 2~7 5. A test movement may need to be sustained befo~ Wykc, 1976). therclerred pain is provoked. 1fthelate'lltperioo is long and the symptoms chronic, the t~atmenl The particulM p.lin-sensitive structures in the verte- techniqucshould be sustained. 1f thc symptoms oral CANAL and intervL-rlL'bral FORAMINA refetTl.'d areacutt'. provoking should be avoided. to in this texl are: 6. 1hc refcm.od pain provok<-'d by a test mO\\'cmcnt may • Thedura lingcrC\\'cnafterthetcsthasbcencompld<-'<I.orit • The nerve root sleeve may disappt.'ar immediately on completion of the • ThcnL\"Tvel'OOtsandtheirrootlets(Macnab, 1989; Iestmovcmcn\\.Lingcringrcfcrn'<lpainrc.-quircsron- siderablcres]X\"Ct,whereasimmedialelossofpainon personal communication) releasing the t<.\"Chniquc permits firmer tcdmiqUL'S When any of the ahove structures (excluding the 7. A test movt-mentmay be painless,ycl once it is ncryerootoritsslt'e\\'l')causepain,thatpainmaybefelt complt'tedthepalientmayexperiencetherdt'Il'L'<I locally but may also be fe1t in a refern'<l area, However, pain as an aftcr-dfl\"Ct from the tcsts movement the referred p.linhasdiffercntcharacteristicsfor50me Such a response demands gentlenL'SS of IL'Chnique, of the different struetutcS. 11le local and rcfetTl.'d pain short treatmentS<'Ssions followed bya restpt'riod from the joint and canal strnctures arc as follows and very careful a'sessment ovcr each 24-ho\\>r- pt.'liodfollowingtreatmentifworseningofthedis- Thcintcrvcrtcbraljointst.ucturcs order is to beavoidoo. Thcintcrvcrtcbraldisc With.effrrfd pain. special attention needs to b<: g;ven to the pain rfspon~ during tt'St mOVl'menu b<:fore (St'e: Kdlgren, 1939; Inman and Saunder.;, 1944; theapplicationoftrtatmenttecnniquts Sindairrlal., 1948; Hirsch rl 111_, 1963; Mooney and Robertson, 1976; Glover, 1977; Bogduk, 198Oa, 198Ob; PAIN-SENSITIVE STRUCTURES AND Grieve, 1988; Groen et 111.,1990; Bogduk and Twomey, THEIR PAIN PATIERNS 199I;Kakamurarllll., 1996.) The following is an endea\\-ourtQ relate the pain that a Pain from disorders of the intervertcbral disc isoom- I\"'lient may cxpt'rience to the pain-sensitive structures monlydistributed inbfOildal'e.1SWithill-dcfined mar- 01 the intervertebral segment. The lIsts that follow gins (Hirsch etaJ., 1963). In the lumbarspinc it may be a must NOT be seen as being infallible, complete or broad b.md i'CfOSS the back,or it may rul\\'e an ill-defined e:cact. There is still much that is unknown about pain, gluteald;\"tributioo to which the patient isooly able to andmanyexistingthooriesintheexpcrimentsdirected pointbyusinghiswholehandoverthebullock.lfqucs- towardsrelatingarcasofrcferredpaintopain-sensitive tioned, he is unable to palpate a particular spot to spinal structures are still contl'StOO. demonstrate the d;\"tributioo. This pain may also spread intotheupperposteriororposterolateralthighandlower In the intervertebral sc:-gmcnt, thecommonstruchlres abdomen. In tlll' cervical spine the pain arca isal50broad that cause symptoms can bedivid<-'<I into two main andvague,eitheracrossthesuprascapularareasorover groups, First, there are tht'jointsand their supportive anill-deftnedareaofooescapula(Cloward,I959).Such Wuctures; and secondly then' are the pain-sensitive pain may also spread vaguely into tlll' upper arm. 1he structure;intile\\'ertebraJcanalandintervl'Tld>ralforam- dislributiooofdiscogcnkpainmaybecentral,unilateral, ina and the \"\"ural disorders. bilateral symmetrically Or bilateral asymmetrically. l11e mtervertebral JOINT strnctur<$ are: Pain or aching arising from a discogenicdi50rder within an inlact outer annulus fibl'05us (with the 1. Theintervertcbraldi.,c(Bogduk,-tal., 1982). exception of symptoms that have been mild over a 2. The ligamentous structures between adjacent longcontinuouspt'riodwilhoutchange)hasaquality about il that makL'S it mOre difficult to bear than pain vertcbr~e and the capsule of the zygapophyseal Or aching arising from ligamentous disorders. This joint,~ndtheintrinsicmu5CleattachmL'TIts. discogenic pain is commonly more distreS05ing, wear- 3_ The zyg~pophysealjoint. ing, sickening and depn'Ssing. 4. The bones. Thc inte\",-ertcbral discd0C5 not usually Tl'fersymp- toms into the distal parto/a limb unless other pain- scnsiti\\'estrncturesarcalso involved incausing the pain.

190 MAITLANO'S VERTEBRAL MANIPULATION Di.>cogenicpainofK'«!nloriginorrecentexacerba- subjecl to Ihe same dl.~ng~'S as any syno\\-ial joiol lion has two features. The first ~ Ihat the symploms There are. for example, the oslt'<)<lrlhrilic Iype dis- arefcltlobedeepand poorly loca1i7-ed and often cause orders (Harris and Marnab. 1954; Figun'II.1)-degcn- a sickening or nauseous Il-'Sponsc. The patienl can erati\\·.... posl-lraumalic,non-inffft;vedisordcrs-and increase. dffreasc or eliminale Ihe symploms b)' mechanical disorders from intrusion ofstruclun.\"S into adopting certain postUll-os. Wht'Tl a patient adopls a thejoinlsuch as exislwilha looseboxly,a rneni<;cus position that puts the intervertebraljoinl towards lhe entrapment and synovial membrane entr,'pmeol limit of one range of movemt'Tlt and sustains this pos-. (FigureS.I) ition for some time, he will find thai 10 reverse il will lIO;' difficulland require time (a few seconds); he will nol Though there may be radiological c\\'idence of be able to change position sharply (e.g,standingerfft ostt\"Oolrthrilicjoinlchangl\"S.lhejointcanbequilcpain after a prolonged intt\"I'\\'al of slumped silting) free or il may be extremely painful. The \",,,tent of radio- lo!;ical change i,; nO iodicalion of the amounl of pain The second feature is thai, even when mo\\'emt'Tlts The arlhritic hip can cause rcl\"erred pain in Ihe kncc arereslricled by disrogenic pain. lhepoint in the range wilhout Ihcr<! being any pain in the area of the hip or at which Ihis pain ~ fell will vary dt'J'Cnding upon the lhigh. The zygapophys.eal joints have these $<Ime three speed of the movement. Linked with th~ feature are similarpropcrlics. thefaclSlhaltherewillbeapain-lhmugh-rangecom- ponenl 10 Ihe symploms and Iht-re may be a summa- Pain from the zygapophys.eal joint can Iherefore lionofpain,areHefofpain,orlatentp.~inlhatfollows p\"\"\",ot(l) in an aClllc phase whco the pain, which is a SUSlained position. Although lhese fealures may alwaysfeltlocallyandmayspread,isquilescvere;(2) ocrurwilhotherSlnlclureslhanlhcdisc,lhcqualities in a pain-IIl-'C phasc; Or (3) ina chronic phase when' of the di!iCogenic fealuresare characleristically more theremaybenolocaJpain,yetn'ferredpainmaybo: unpkasant. slower to occur and more lingering fell in a dislant localized an'a (Dwyer rI al.• 1990). An exampl(' \"f this is a patch ofalxlominal pain, which Disrogenic pain may be pro\\'okro either by m,'y anse from Iheappmpriale thoracic zygapophy- stn>tcrnng movements or by compressing mo\"ements \"Cal joinl {Lcwillrl nl., 1951; Bogduk, 1978). (s«plSS). Rtftrrtdpain Th~ Jigom~ntQUSand QUf~r capsular strucfurrs Pain from ligamentous and cap,;ularstructure5 as welJ l'ain is almost always fdl locally al the site of Ihe faully asfmmlhezygapophysealjoiolscanbereferll-'<l inlo struclure, and can usually be specifically pointed 10 by areasdistaolfromlheirsource Ihepatient.Areasofrderll-'<l pain from Ihesestruc· luft-OS are poorly defined. Allhough 1111' rderred pain Slructuresthatarcwelldistanlfromlhenef\\-eroot can spread inlO the distal area of a limb, this dislal can CilUS<'this somalic rderred pain when injt-'cled referral is ALWAYS of less inten.ity than the more with an irritanl (Kellgren. 193'1; Inman and 5.1Unden;. proximally referred area of pain. II is uncommon 10 be 1'144; Sinc1air rI ai\" 1948; Feinstein elal.. l'154· able to provoke Ihe referred pain during a con,;ultalion Hock<ldayandWhitty, 1%7; Mooney and RoberlSQn, by any particular position or mO\\'emenl 1'176; McCall <'l ai., 1979) Local symploms <lrising from lhese slruclures can When Ihespace in IhcvCrlcbralcanalaod intef\\'er- always be provoked by movement inonc oflhe fol- tcbral foramina is ,,--'\\'c\"'ly narrowt'<l,thepain'S<-'TlSiti\"e lowing threc ways strllcturesare far more easily compromi>ed and tl1ey then cau\"\" referred radicular pain, wllh or withoul 1 A movemenl that strctches lhestruclure may neurological signs or changes provoke a sharp pain. Tile disc il,.,lfCi!o cause refern.'<l pain, ancAample 2. Amo'-ementlhalstrelcl1esthe,;lrucluremay being lhe rcferrcd pain felt by p<llients duringdiscog- caus.eapullingslrelchingfeelingJlthesileofthe raphy. This can occur e,\"en whcn the discogram does ,;ymploms nOlindicatea\"yfiS5ureexlendinginlolheoulerlayen; of Ihe anoulus fibrosus. A,,)' damaged disc Can 3. Siretching movements may be painlcss, but a impinge against the posterior longitudinal ligamenlor movemenl Illal comprcs.ses lhe slructure may Ihc dura and Ihcwby cause wfcrred pain. Also lhe reproducclhelocalsymploms(st'f'p.tSS). disc, as it is hernialing or when it herniates. C,lO impinge upon Ihronef\\'c-roolsl\"\"\"c, Ihe ner\"e root or Thtzygapoph~raljoint Ihlorootll'ls. and cause referred pain. Thecharacteris- lie;; of Ih\" \",fern.'<l pain from th~'SCdiffereol Sourct':s The zygapophys.eal joinl should be thought of in two ha,'ebeenslalroabo\"e calegories, intra-articular and periarlicular. The joint is

s,,1~ction of techniques Figu\", 8.1 (0)\"\" inferio,~nlc\"l.. f~cct from'lhi'dlumbarvc'teb,• ..no...ing. f''5urcfraeturc,unningacrossthcinfe'ior pole oflhe facet. IbI Ocnlt.dhe,ioM in. p\"'tt'iorjoint.Thtspccimtn ....s phOl\"'lf3phcd from bchind.nd lhc lips of tht po,ttriorh..... bccn opcned a, f., a, po,sible. ,ho ...ing.denst mass of adhtsioos pass,ng f'om ont.ni\"ul., suffa'\" to theothe,. (<!Ocgtne'ativcchangtsin lhcposttnGr joints. tal A post~rior Jo,nl ,ho...'\",! .1\"\"\", ~~n~~i~~~~~c~~:,h:a~~~':fi~~:::rlbt~;.t. abow: issho...n bclo... the loolt body lying bctwccnlhcanicul. r suff.ccs(llcpm<luctd from Harri', RI. and M.cnab.l. (19~) Journal of&ntond)o;ntSufg\"'Y, 368.304-322.... ith kind pcrmis,;\"n of aUlhotS and publiShttS.1 Discogenic/nC'rve-root referred JXIin has thrce clin· locally, followed a few sccondslatC'r by a sprcad of icalfeaturl.'S: the pain into the nearbyart!a of referral and,ifsus- laincd longcr,sprcad throughout the full arca ofthc l.ltcanbealancinatingpainfcltthroughnulthc rcferral. This order may be in Ihc \"'\\leT\"SC5Cquence full Icngthof the refeTreddistribulionand lasling 3. Following movemenls of Ihe \\crtebral column in only a fraction ofa secol1d one or more directions, a surge of pain is fclt by l If a particular wcight-bearing posilion of the spine the patient 10 build upin the \",ferred area of pain is adopted and sustain<--d,p.lin may first appear distribution.

192 MAITLAND'S VERTEBRAL MANIPULATION Surge af~1II - Little or no p~in m~y be fell during PATHOLOGICAL DISOROERS AND INJURY c,,~mination 01 lest mO\"cmcnls, but \"'ilhin 4-5 sec- onds after completing t~ movements. the p~lient The lotallext relating to the sclcction of tcchniqucs is divided into two parts. Thefirsl,which appcars in lhis l\"'p\"riencesaninlcnsc5urgcofpainwhichmaylasl~s chapter, is related to patil'Tlts having the palhological disorders and injuries that are common and a,,-'SCl'Tl long as 10 scronds bcforeshowing signs of subsiding, frequently. The \"-'Tllaining parts appcar in thechaptfls and taking another 4 seconds to rctum to normal. dedicated to each individual section of the spine PAIN-SENSITIVE STRUCTURES IN THE In thischapler, the disorders {both pathological and VERTEBRAL CANAL AND FORAMINA injury) are related to· Thcstructures referrro toin this tc\"t are thc dura. the I, The commonly seen disc disordt'rs. both Whl'Tl the nerv{\"-rootsleeve.thenerverootanditsassoci\"tlod disccauSl'Ssymptorm;andwhen;lcauses symptoms in conjunction with the pain-S<'J1Sili\\'e struclure in thc vertcbr~1 cilnal ~nd intcrvcrtcbr~1 foramina Th~ dura and n~rv~-rool sleeve 2. The commonly SC<-'Tllig,lmentous and capsular The site of pain from these stmctur\"L'S dl'JX'l1ds upon 3 prcscnlations~ullin8fromspr\"inandslrain whichSl'<.1ionisatfault.lfthemid-linepartoflhedur~ The zygapophySl'al joints with theIr prescntations of'arthritic/arthrosic' and capsul~rdisorders. ant\"riorlyisaffected,thepainwillprob<oblybeft'hren· trally.lftht'lat\"rale\"Il'lltofth\"nen'l~rootslee,\"ecaus<-'S p~jn. there may also be vagut' referral of symptoms 10 The herniating or herniated disc ~n~reasimilartotheOTl\"towhichthenerveroot,.,.hich Thl'disc it embraces, would wfer (Edgar and Park. 1974) Howl\"·er.thedistalpainiSI...verg...~t\"rthanlh,,pmx­ The inten'erk-bral disc continually undergoes changc imalp~in.l'ainarisingfromthenen'e--rootslee\\'('isnot throughoutlifcasanorrt1<llprocess.ltchal\\gesfroma referred into the fOOl. Paraesthesia is never p\"-'SeTl1. strong.. mob~e. R'Silient structure in e~r1y life to ~ f~r Icssmobilestructult',whichhaslittleornolt'CUpcrativc The nerve rool and associaled nerves powers when damaged (Dl.' Palma and Rothman, 1970) The normal age ch~ngcs can be distorted by such Thc symptoms arc oftcn fl.'ltonly in the distal part of influcnccs as sustained end-of-range positions both at the dermatome. Allowing for pre- ~nd post-fixed work and at home, exn'SSil'l'. heavy or jarring plexu>l'S and for neural anomalies (Angoli, 1976; demands on the disc, ~nd unguarded movcmenls. Fig,,\" 8.1), each ner...e ha~ specific areaS of symptoms Thl' common sitting position of sustain<-od lumbar (supp.I08-109;Et:helbcrgand Riishcde, 1952; Kcon- flexion is one such bad influ<-'Tlce;butwhenthc~ddcd Cohen. 1968; Nathan and Feuerstein, 1970; Bernini insult of the joggling or vertical vibralion thatoccursin rIal., 1980). aCM,busortractorissup<.-rimpos<-od,theinfluenceis The mam1eT in which the pain disturbs or disrupts even greater, These are influences thai plague all mod- the patient's rest and acti,'itics and the mannl-r in em socit'ties (Kelst\"y and Hardy, 1975; Troup, 1975; which the pain is changed by the physical examination Frymoyer el al., 1980; Twomey and Taylor, 1994). tcst mO\\'emenlS also add to lhe inform~tion l\"C<luircd Tht're are two furthl-r influenn'S that modify Ihe to m~kl' a diagnosis. For example, a man may have otheT\\'l'ist\" normal disc changes. The first of lhese is the pam in his lowt--r back radiating inlo his right bUllock, damage that accompanies the knocks. bumps, falls th'gh, calf and foot in a distribution lhat suggests that and injuries that take place in our youth,bul which are tht'nen'erootanditssl~\\'einvt'Stmentaretheorigin soon forgotten becausc any damage that does occur of his pain. On examination of lhis palient'S movt-~ repairs \"ery quickly. The damage. howe\\'cr, lea\"csits ml'Tll5,lumbare-xtl'nsioninitiallycausesbackandbut- scars and we~kn<-'S'>\"5and predisposes to more rapid tock pain; howe\",r, if the position is suslained for 15 disc degeneration or intradiscal fissuring. Structural seconds the pain gr~dually spreads down hisll'gand anomalies (e.g. spondylolysis) or asymmetries (1',8 into his foot. Such a beha\\'iour of pain can be inter- altematingtropismslcancompoundtheabovecff<-'Cts. preted diagnostically as incriminating the interwrte- The intervcrt<--bral disc changes lhat take place as braldisc, as the disc is probably the only struclure that described abo\"t' can occur asymptomatically. They can move in such a waya5 to produ<:ctrns kind of may. however, ,,-'Suit in a 'we~k link', which can give latenlp~in~poll5e w~ywhenplacedunderloadorstress

~I«tionoft~hniqun 193 ~,~ :ry ,., Fogu,. 8.2 Anom~li'l ofth< pattern of lumbol.a•••1neM' 'oots. (01 Cornmon o.igln SI-52; (b! COmmon ull 51-52; lel Y-s/l~pe{j dM\"'onl5-51;lollr.\"s~,s.erouruL4:(dlnlc\".diC\\lI .. ro'l'tttionsrR.producedftOm Agnoli. A.L (1916IJourno!ofNcu.oIogy. 211, 211-28, with kind \"\",mil'>ion Qf~\"tnor.nli publishers.)

194 MAITLANO'S VERTEBRAL MANIPULATION lIy following 1I~ po'th'mS of symptoms th.,t O<.'CUr Tablc8A from Iinw to time. §OI'lle a~ment of what;\" happer>\" HERNIATING/EOOlSC ingin tht- inll..... ertdmlldisecan bemade.1l is P'J'S6ib1e 10 rl_ _-LI- - - I <k-tennlne who.'tho-'1' tho;> inten~'1'k.rol disc i5 progn'S- Loal Ind vag... P1U\\M.....-lOOt siH'ly degeno.-...atmg withoulany bkelihood oIl...·O;\", rom- but long mtrrcd5'l'l\"ptO)lM promismg tnc \"ertroral caNI or inll'n·t'l'tebTaJ for..~ or whether II 15 progressmg ~,..rd an C\\-entual mler- rmrmlpa'\" ferencE' with the elI\",,1 or mmi\"\"l stn>ctuAS.. ~..~th the fonner,each~i5acmmpaniedbypaininroughly thesamf'areaeachtuJ'I('.and the pam does not spn.'ad If !he hemiallng progreo;ses 10 a /'lemioihon - INI IS. furtnl'rCin tht'ClI5('oltht'llUTIWrandcell'icalsplJ1l.\")lhan tht'buttod<orteapub. \\\\\"1th the lalter, hc:M'e\\\"(!r, progrcs- !he disc matenall'Jl\"trudf$ (and rna, '.....n bc>rornl' sequestr..led)inlo thec..\",,1 I\"\" foramen - bothea,..l si'-e~ausrpamd\\atspn.>Mlsfurthlofandfurthlof mtotht'lunb.llusmayo«urO'l·ertwoorlttreeeplSOdes, andfora~anbecomt\"_>enOUsl'·'n'·oh·ed \\'/hen prolap>ed material bq;rns 10 compll'55 a ru\\'(' O\\-er~er;a]~,ordlU1ngasmgJe.\"isode. Wjtht!l('rrog~~('etwlgestilk.ll>gplKt'l/\\tIw root, examining stra.ghtlcg rarsong w,ll show lim'b- mlt'nertEbral m,c thene ;o.re acmmpanymg changes l/\\ lion of range. and d;,otaJ dennatomaJ par.l(~lhco;;,a may tht' zyppoph)'Se'.1J joInb and thesupport:ing \"g.omenl· bepresenl,l1n~sta~tshouldnotbt>interrretedlO ous structu!'t'S. all 01 whICh can ause pa'n and GIn,. m mean lhal limited straighl kog rai\",ng only impllOIte the n........e root; MooneY and Robf:rtson(l975lha, .. part. b(' I'l5f'B\"'SIblf, for I'('('\\lna>t (>J'I..odC!I 01 pam. de;orly shown IhclCff«t the lest has on the zn;apoph\"- It.lStheseh>oklndsoldl$:d~lhal.. re!iO common m OUr l1'I(ld('m SOC.ches. and ,115 m their con- sea.ljoinLNeuroIogoldlangesmdudl'k0s5olseosa- \"\",II.bon,.mU5(!(''''·l'a~andI1!fll'JI\"ch.mgl5.Ahll'mialed §f'n,..b,(' IYYnolIgcmcnllhal the marupulali'-c pnys>o- dis<: in,-m-ing the ........'.. root if ,t also m\"ohe lheraptsthas50muchtooffcrl\"hed~on 5ri0cb0noltedmi<jueswdlbed,n\"CkdoilU-h>O ott....- pain--sensiti,.. stl'UCtun>s. eaUS(' pam throughoul d ~ onh. but It .IS roecessa'1' 10 menbon otlw1- I\"'\" hmb and may tndude neurologlC;oJ $IgrtS or changes. TNodistaJlyl'l'fermdpa.,nlSolk'nolg~l('r ~S1tUo1lKlnSthalal1'notuncornmon. intl'nsitylhan thepro\",imaJ pam (Tabk8,4) AdlSCcoinll.lplul1'fornoob-.iousn\"<l5On,.ca~ suddm'lC\"\\'flt\"pam_ ThcdiscGlnabobe mf..ctro,caki- fled, or present with a \"'OJum phenomenon Among Rauofprogf('SSion other inlt'ncrl..oral dL';C d.-dom; are the IU' l\"Rile dISC, Ar.rpid.rdalivdy('asilyprogr('UIngdl!oOllkrmjlllfe \"ft\"-the hemiabon of dis<: mater\\ioJ into the body of tht' af('in;r.;~ntano:t~aUl\\('llI lebra and the pnrnary poslcrobtl'l'al protrusion. There \"\"\" 00cn a 'ast 1l'IC''NS(' 10 the undcTsbnding of dISC palhology and rc«'art\"h 0\".... recenl Y\"\"\"'. It is ,mportlnl 10 beabll' l0n:'OlgniJ... lne mttT\\ ..rteOraJ Keepmg up w,lh lhis gn....th ~IU'Mi leeping up with discdisorderlhali:!;lik..lytoprogresslo\",.. rd!ilncnlla_ OJrrcnllitl.... lul'\\' lion wilh a passibl.. final m,'ol\\\"Cmcnt of lhe 001'1«'\"1 Tllchcrniotingcmdhcrniatcddisc nt'Ural.,ll'mCTlts. When Ih,s Cond,tion is n:-cogniu'(\\ by thehisloryofthepaticnt\"srompIJtnt.ll~tho.'n~ilallo Once the J.nnulu~ fibl'O:'lu IS '.,eak\"ned or contains be able to asscss thc rat\"andeawwlth whICh Ih,spro- d~X'p fissu ....\"'. the out.... \"\"all of the .. nnuluscan bulge gres.s;on is uking pi\",... Ob',ously. Ill(> more rJpldly aoo inwrf....,w,th theMll.Ielul'l.'5 In the vertl'braJ can.ill .. ndltw>mo~easiIYllisprog,,-'SSing.thcmorecare;s and mt\"ncr...'bral foranu.'Tl. A bUlgmg diS( will prob- reoquil'l'din trealml'ntandofaS5l\"S5mCnl(snoh'Slory, abl}llOtmt\"rlcre\"',lhlhell<:'r...crootunlcss(..\"\"lstrn- pp.1I8-121). osl5cxistsal Ihal I.......J. 1l'lIS bulging or hemiahng disc wiHcau$(' symploms lhal a....• ill dclinl-d.yct ....gudy Srabilityafrlledisorder match parts of all of a dermatome, How fdr the pain is rderrcd inlOlhe 11Inbd..pends upon lh\" d,·grt.'\\' of Irri- Th~ ~t~bility of th(' alsordtf has an ,nflll~n<:t on Iht l..lion pro\"uk,-d in lhe SIn>elurcs in th\" canal and fora' inltnsity of aS5('SSmtnl and trtalmtnl mcn.Jtisimporlanllorccalllhallhepain('xpericncro in this dl'tal S<'gm('nt of th\"dl'rmalome will nol be grealCTlhan ll\\alcxperic\"c,'(lmorcpro~imallyunlcss II is important 10 knowhow slJblclhed;sordcrof the disc is when the pall('nl ~tlcnds for tl'llalm\"nl. Ihcll<:'r\",nllllisdin.'Ctlyin,oh'ed(~\"pp.l89-J90)