Maitland's-Vertebral Manipulation - 7th edition

s/'I~ction of t~rnniqu~ Tabl~ 8.5 Symptoms and signs in h~rniating or h~rniat~d disc, and with intact OUl~r annulus fibrosus i i Inlactoul.,annulu, fib\",'\"'' ~rni'li~g/rddi'\" i i i Loca1i>'l,n Loeal.odvagur l'IusnrM-rool ..fmedsymptom5 0011009 ..f~rrrd poin Forexample,therateofplUgl'-'SSionofthedL<;cdi~ and thesupportivc intel'\\'ertcbral ligaments. However, orderovcrti>cpast4ycaT'jmayt>erapid,yetatlhcprcs- for the purposc of this text, sprain and strain arc coo- enllimcthesymploms (and therefore the disorder) sidel'-od in rela!ion to the ligamentolls-typestructu..,; rnay t>e quite stab1l'. its stability t>eing indicated by the oc'CallSC, frorn the point of vi,-'W ofscJ,-'Clion of tech- lact thai thepaticnt is,forexamp1l',ablc to continue niques, almost the same gllidclineo; app\\y whichever with manual work without worsening the disorder. structure is sprained or strained UnderthcsccirculOslan(esthcpresentingsitualionisa S,,,airr - This occurs /ollowin1'; an incident that stable One and, although the usual (are is taken. firm injurcsbysllddcn movement. In the text of this sec- l<-'Chniqu,-'Swill thercforepmbably ben,-'Cded 10 .lite. tion, the only kind of Inddent that iniuresasa sprain is the situation and encourage \"\"\",very. the Iridal inddent,sllchas tucking the sheets under a mattrcsswhile making a oc'(l, luming suddenly to sce Rf/otionships what calls<'od a sudden noisc, Or an un1';llard,-od typcof Onet' a disc has hemiatro and irrit~tcs or compresses mo,'ement such as the jarring that occurs when walk- the nerY('l'OCIt and theotherpain-S<-'Tlsiti\\\"ecan~lstruc­ ingand not seeing a small downwards slep in the path_ \\1orc major incidelltsand traumas a... not con tu\"-'S, the symptoms and signs can Pl'-'S<-'Tlt in many side,,->dhere dilfe...ntcombinations(1\"bl~8.5). Strai\" -This occurs when a faculty Or part of the The,,-' can be p~in in ,'ariOIlS areas, pain of varying lx>dyiso\\\"ertaxed.ttmaybcduetobadposturalpos- intcnsiti,-'S in the v~rious areas, paracstht'Sia, ncuro- itionsatworkoratrcstaswellastooveruseandabuse in sport or work. logical signs and neurological changcs. There is no one single p.lltem of pain and nctlrological signs for a hcr- rhe sprains referred to arc oot caused by more niakod disc!ne....e-root situation. l\\·lost patients suffer- major trauma. The effects of sprains and Slrains on ingne,,'e·root pain also suff\"r pain roncurrcntly from pcriarticularand ligamentous structures pn.'Sent in olhcrintcrvcrtcbralstructurcs onl>oftwo w ays,andonexaminahon wi!1cxhibitthe following' Examining thc mO\" ..nu.'llts of such patienlscan be ,'err inform.lth'e and important. For example,a palimt with pain in his buttock, posterior thigh and call,and 1. Strctchrcspunsc withlinglingalongthelilteralborderofhisfootandthe all'roducinglocalstretchpulling lateral two toes, musl have in\\'olvement of the first b)l'rodl.lcingpain sacral nel'\\'C root. His histury may dearly indicate disc 2. CompK'SSrespoOS('-painisprovokedduringtcst herniation His muvements may ne,-erthel,-'SS be mO\\'cm,-'Ilts pcrfonned in compressing diK'CIions limitl'd by pain, but this pain may bc onJy buttod pain andnotestmo,ementswiIJreprodu~therestofthe Both ofthealxJ\\'e tend to t>e symptomatic at or near pain o'lXlraesthl>5ia.TIle k'Chniqut'S of treatment and theendofarangeofmovementifchronic.The'stretch' prognosis would bcdiffel'-'Tlt (lhis is discussed laler) if pain and the 'compl\"C'SS' re<ponse may, if of recent his movements were limited by calf pain and increased onset.t\"xhibitapain·through-rangephenomenon tingling in the foot, cspedally if these symptoms ltad a Local pain presentatiansofligaments, capsulor component of lalency or summation (WcbcT. 1994) andchronicdiscagenicdjsord~rs ligamentsandcapsule5 In the early stages of OveruSC types of strain, the Thisaspt.'Ctofintervertebraljointdisordersalsoappli,-'S patient may leel symptoms only intermittently. Under asmuchtothediscasitdoestothezygapophysealjoint thcsc circumslances. although the stretch or comprcss

196 MAITLAND'S VERTEBRAL MANIPULATION phenomena will still be evident on ex~min~tion, the This rel~tionship- that is, the diagn(l!;is/symptomatic test movements th~t will qualify the phenomen~ will presentation ~ is the primary. all-pervading and n~\\'l'r­ need to be combIned mO\\'\"m\"nts, and th\"y will ofl\"n ceasing guide to th~ sl'l('C!ion and modific~tionof t('eh- be associated with lhe functional overused movement niquL'S throughout treatment. Tru~ though this that the patient can demonstrate as being the p~inful ~tatement is,the term 'di~gnosi~'n\",-'ds to bequalified activ'ity. l'atiel1ts having a diagnosis of 'disc herniation with The symptoms resulting from sprain and strain on nerw... root irritation' may have different patterns of th\" intra-articular structu\",-'S (i.e. of the zygapophyseal symptoms ~nd signs. Six e\"\"mples of different joint) are quite different from the above. The symp- patients may help to make this point clear, as it is very toms will indude aching and, on examining move- important whl'Tl rdating the selection of treatm\"nt ments, pain will begin romparati,'ely early in the tL><;hniqul'S to the diagnosis: range and will continue, frequently increasing. until the limit of the rang... is reachl'd. This is th... definition • The first patient may have Pilin radiating from his of the phase 'through-range component' as us<-'\" in lower back to hi<; posterior thigh, while anoth\"r this text. Other aspe<:\\l; of the zygapophyseal joints may have pain radiating down the fullll'ngth of were discussed earlier (Sf>' p. 190). his leg from his lowl'\" b.~ck to his big tlX'. The peri~rticulardisorders usu~lly P\",-\"5l\"Tlt with an • Th~ second patient may have neurological 'endoOf-range' pain, whereas the intra-articular dis- ch~ngcs, while another with simibr symptoms orders, excluding the intrusi\\'e di50rders mentioned, may not present with a ·through-rang\"· pain • Th\" third palil\"Tlt may have markl-d limitation of DIAGNOSIS straight leg rai<;ing ~nd forward nexion with a full pain-f,\",-\"\" r.lnge of exll\"Tlsion, while another may In the pR'Ceding section it has Ix'<'n indicated how the ha,'e a full range of both forward nexion and area and behaviour of a p\"tient's pain can assist in for ~traight leg raising yet ha\"e his mnge of extension mulating a diagnosis in terms of the structures that grossly limitl-d by c~lf pain. may be in\"olved. When patients d\",clup symptoms \"ither spontaneously or folluwing a triv'i~1 incident • The fourth patient m,ly h~ve an ipsibterallist, as (that is, no direct tr~uma has been in\\'ol.-ed). the his-- compared with another who has a contralateral tory of the progll'SSion of the disorth\"r ol'<'r thl' years list also ass;\"ts in formulating a diagnosis; there is ~ char- acteristic history for a postur~1 ligamentous p~in. ~s • The fifth patient may h~\"e symptoms that are there is also for a degenerating, a hemi~ting or a hemi chronic, while another's may be more recent and ~ted inter\\'ertl'bral disc. • The sixth patient may have pain that is morc This pl'Ol;rcssiv'e history over the years also pro- sc\\'cre proximally, while another has the 5<'v'ere v'ides information th~t determines the stage that the pain distally. patient's dIsorder has rNchl'd in rel~tion to the worst possible stag\" of progression of that disorder. This ;5 YET ALL HAVE THE SAME DIAGNOSIS. di1;cussed in Chapter 6 (set PI\" 121-122) Besides h~ving differingdinkal p\"-\"\"'-'Tltations when it The 5ubi<-><;tive and physical ex~mination of the ariSL'S from 'disc hl'TIliation', 'nerve-rout irrit~tion' p~tient CMried out at the time of seeking treatment may ariS(> from other sources. Macnab (1971) reported must also aim at delermining the stability of the dis- having made a diagnosis of disc herniation with order ~t thilt particular time. The dl'gn.>e of stability uf nerve-root irritation demanding surgic~1 intervention thedisorderhasa vcrydecided influence on theselec- in 842 patients Of these', 68 had negati\"e disc findings tion of techniques, and therefore will be discussed at surgf.'r)': the nerve-root irritation al'(l5(> from one later in thischapWr. of fiv'e other sourccs. Although a clinical diagnosis of disc herniation was proven to be wrong in II per cent The sck'etion of technique is guided by the diagno- of cases. Ihis is a very small percentage; howe\"\"r, th\" sis, with particular referel1ce to fact is significant. The point being made hcre about diagnosis ~nd its relation to selection 01 manipulatll'e The p.~thologic~l~nd ml'ehanic~1 changes invoked. t('Chniques is that, \"ven whl\"Tl a di~gnosis of 'disc The mann\"r il1 which the diagn(l!;;S manift'Sts Ill'rniation with nerve-root irritation' is made, it is the itself in terms of the patient's symptoms and presenting symptoms al1d signs. linked with thl' pro- abnormalities of mov~ment. gressi\\\"t' history of the disorder, that guide the sckc- tion of manipulative tL><;hniqu<'S - not the bald title of the diagnosis.

Selection of Itt~niqucs 197 IlislhellrcscnlingsymlltomS3ndsignslinl:cd Wlln dii'C/ner\\'e root group (set' pp. 205-2(6). The lollowing the progres\\ive hislory of the disorder thil! guidcslhe e~ample will h<'lp to clarify the importance. 'oC1e<:!ion of manipulative lechniqu~s rath~rlhan th~ bald tille of the diagno:;lS n..., original cause of II p~tient's pain arising from a lumbar intervertebral disc may ha\"e ~ a \\'ery tri\\'ial It is important to ,,-..:all that rcferl't->d p.lin can arise from incident when he was in his late IeetlS. ll\\e pamb-ponta- othl'T Slmctures than the nervC root (set' pp. 190(192) llt'Ously disappean.od. bul he noticed that O,\"er the ensuing 10 years he had episodes that occurred more Diagnosis is dcfined in BuUerworth's Medical e~sily and ...\",mingly, at times, without any incident Dicrionaryasfollows Gradually his pain sprc~d from being in hisbad: only at first, to being referred into the buttocks al'\\d post\"\"';or TI,earr of al'plyi\"g 5delltiftC m,'tlwds to tlleel\"ddo- Ihigh in later episodes. For noe\"plainable reason he was Iwnofll\",problems prese\"led by a sickpalieul. Tlris then fT<'(' of p<lin for 5 y<,ars. AllL'T a period of unu,ual ,mplies lire roI/eclim, and critica/emluatiOtl ofaltllre and hea,'y worl:, he dl·...e1oped pain that sp~ad to his I't'ide\"ce o/Jta\",oNe from every possi~le s<mrce ond by calf. l'alliati\\\"(~ treatment and di;;continumg his heavy IIIC use ofo\"y \",dl,od 'lffes50ry. FromtlrefoclSSlJ worl: effected romplete fl'lief of pain. Two y.'ars lat~... oblol1led.ru\",bllledwillrakuowlcdScofbasicpri,,- (his pl\"('S('nt episod<,) hl> waket\"-'<l one morning with a Clpl\"\". a crmccpt i5fomte>I o/lIw aetiology./JlllholiJi{iOO dull pain in his calf and tingling along the lateral border If'Sio,,,anddiscrderedfimdiollsu~liclra,,,''ill''etll( of hi,; foot to the two lateral toes Even on persistent \"\"tier'!\"s disease. This \"'JlyCllnble thedu;etlS<' 10 be questionin8- he rould not thin\\( of any rcaSOl\\ for the placediu a certain recoguiuJcalcgorybut,afftlr 0TlS<'t. When he sought !\"-'aOOent he had had the symp- srmlerimporlance, il o/scpravidcs a ,UI'I' basisfor toms for 3 Wl'<'!<s. Following 3 weeks of palli.lli\\\"e trcal- Illl'lrcalmcnlon,lpmg\",:>sisoft/rei\",li•.;;t\"a!palie\"t ment and anti-inflammatory medication. hi!; symptoms were unchangf.'d. He was referred to an orthopaedic This definition. which refers only to pathology. should specialist\" ho recommended manipulative physioth<.'f- be expanded to include similar wording to co'\"er th.. apy. On questioning and e~amination;1was found that purely me<:hank,,1 toint disorders thaI occur These the symptoms w~re st.,bJc and not influenced by activ- pilhents are not skI:, as defined in Th£ COIleis<' Oxford ities. evCfl playing sport (nOfl-rompe1ilive tennis) D~IimlOry. but they a\", in pain and may be disabled To CO,\"Cr the mechamcal disorders. the definition The 'eauS<:\" and 'origin' part of the aetiology of the should bee~panded 10 rC<1d disorder are reasonably recognizable. Tht' 'devel- opment' part of lhe aetiology is also fairly dearly assess- ltolS<lilllp!iest!lcartof°p/'!!Jin~.'M;,cntrfic,nellwds able. But there is a third related component which 10lheducidolionofllreprublfflrspre;enrf'dbya should perhaps be included in the definition of 'aeti- patienl s\"ffrring pain lrom a mechanical di>ord<,r ology', which is, fX'rhaps. even more important, and that is the degree of stability of the disordcr at the time This im,,/irs tllf wllrclim, lind mlica! evol\"1I1wrl of of commencing trcatmcnl. olltllfl'l'ldfllceobtni'Ulblefromeverypossiblewurce and by Ill\" uS/' of an.~ m/'/Iwds ,t/xc>Sllry. From lire This episode began in an unreasonable manner, fi'crssooblmned,combi\"edwitllakllilW/edgeofbasic indicating that care durin!; treatment will be l'SSe\"tial pril1(Jl'les,lIcOIICf'/\"isformrooflllfluliologyol1d if the disc's i\"legrity is to be maintained. The repeated rliSlJrderedfullcliims 11101 constil\"le lire pnlie\"i\"s dis- episodes indicated a progressive detcrioration of the order. Thi,mllye\"lIblel!ledis<>rd<'T ro be placed ina dii'C towards an evenlli.:ll herniation. The current pre- certai\" m:ogni\",dClllcgoryb\"t,offargl'l'flreri\"'porl- sentation indicates that the disc is herniating (if 110t \"\"ce.illlisoprovides\",.\"rebasisforll,elrratme\"t already partially hemiakod) o\"dprognlJ5isoftllCiudividualpatimt However, as previous<,pisodes ha,·c become·symp- 1l>en- is anoll\\er fe~lure 01 diagnosis which i~ impor- tom fn...:, it Can reasonably oc hopt-xl th.lt, with proper tomt Jnd i~ co\\'\"n.xl in th\" definition of ~<'Iiology manipulativc physiotherapy treatment. the same end· \"\",uit may be achieved. Spedal care with treatment AetIOlogy - tile science of llU' invest'gation ofillc and wilh assessment i!; required because of the pro- ca\"se,origina\"ddewlopmmtofV/lalpilmome\"a gressi\\'en<'SSufthedisorder. 11>e imporlance ollhe aetiology component of diagno- PRESENT STABILITY COMPONENT sis is critical in the S<:'k\":lion of manipulative tech- niqu~'5 when tn'ating patients in group (Ii, the The pll'SCnt stagc of Ihe disorder indieatl'5 a stable situation \"'-..:ause the patient is able to play tennis

198 MAITLAND'S VERTEBRAL MANIPULATION without wOnl<'ning his symptoms and, despite the !(>n- ml'lastascsoran inflammatorypro::ess may be invoked nis, his present symptoms have ....mained unch\"ng~'<l lhe problem of incompl~diagnosis can be own.:ume for 3 w~'Ck:;. n,,~rdore. tIXhni'lues may rt-quire firm- by treating the patient with judicious manip,,\"'tiv.. neSs for them to be successful, (Furthe' detc'rioration physiotherapy on thebasb Ih.llthe disorder ha\"at h1>t, may be lessen~'<l by proper t,,,,,tm,,,,t and instruction a mechankal oomponent, Theanalytical assessment will in 'backcdre·.) determine the diagnosis in 1'\\'lrospect Al'liology is also important to the diagnosis of other What information dOl.'S the manipulative physio- disord..rs. but th..re the emphasis lies more in th.. pro- therapist ideally want from the doctor', diagnosis! gressiwnt.'Ss of the disord..r and its origin rath..r than First, she.-' wants to Imow what the doctor thinks is the in its prt'St'nt stability - the exception being. of course, causeofthepatienl'sdisorderandwIMlledhlmtoth<lt the stage of any innammatory destruction dl'Cision. II is often this lalter part, the doctar's reason ing Ihat leads him ta the di<lgnosis, Ill.lt is th.. most TlK'SC expanded definitions m('('\\ th.. rt'<juirements \"aluable for the m<lnipul\"tive physioth~'Tapil;t. Sl..:oodly, of the manipulative physiotherapist. she wants to know what thl' doctur considers is the present stage and likely p~nosi5 of the disorder. The The oonc..pt l'mmciated in Verle/n\"a! Mn\"ipulalion doctor's answers to t~'S<' two questions will provide from tilt' filbt edition has hinged upon the continual all the important inforn'ation that is n~ed. ec·..n if an assessml'nt of the patient's symptoms and signs from informati\"e diagnostic title cannot be given thl' bl-ginning of treatment to the end. This concept has brt'n further emphasiw in succeeding editions. By Th~ most u';l'ful nformation th~ phvsician can gi\"\" i5: basing \\r(>atrnent on symptoms and signs, useful tre~t­ ment may\"\" effected while the medical profession • Th~ca~ofthepatient',di\",rde,andthe and its 5Cientlsls continue to work towards under- ,~a\",ning leading to the diagn\"';s standing more in rt'gard to diagnostic titles. The con- cept has proVl'<l to \"\" accrptable. and has even • The present stage and likely prognosis of th~ di\",rd~r provided manipulative physiotherapis~ with a basis from which tocontribute towards und..rstanding more Theinformation and knowledge that lead the doctor to about diagnosis. It is pleasing therefore to S<.'C the fol- being able to make the diagnosis include 'knowns', lowing definition in Butterworth's Medical Dic/\"\",,,ry 'thought to be knawns'. 'unknowns' and 'sp<.'CU- The bracket is the authur's iru;ert to include m~'Chan· lations' (srepp. 6-7) ;cal disorders,lsexplainoo above. Although the specialist manipulative physiother- DlngnOS<' - To rt'C\"S'\"iZl' ti,e p\",\"\"IICO'ofn dil!ellS<' lor apist is highly skilled in neuromu.sculoskelelal eX,lm- m\"'himica/ dismderllJy nami\"al;rn Qlld lIS.<e5Smffll ination, it is not in the patient's best inte=t for her to of II\", sym/'Ioms \"lid signs take responsibility for areas of diagnosis and medical examination that are beyond her scope of pr\"ctice Although th.. di\"gnosil; iTS defined and its symptomatic This is of particular importat><;.. when manipubtion is p\"-'S'-'nldtion are the primm'}', all-pervading and fll,\\'lT- the treatml'Tll and the diagnosis is in doubt ceasing gUide to the selIXlion and modification of tIXhniques throughout u.,atment, the making of an Selection - diagnosis rnformat\"'ediJl,'TI05is is not alw<lYS po55ible, Twodiffer- ent sitoationscommonlyexisl. With th.. first, although a Ta discuss the sek'Ction of t<)Chniques in relation 10 doctor n;!lerring patients to\" manipulative physiothera- diagnosis it is nec~ry 10 sepdrate patients' disorders pist may not be able to give an infonnativediagnosis, he into lour group5 (Table 8.6). Each of the four groups may be able to say, 'this patient's problem is mU5CU- applies to ail sections of the spine. but some disorders loskelelal\". Such a diagnosis Can be ad<Xjuate. With the are more cammOn in polrticular sections se<:<;lI'ld situ,'lion, although th\" disorder is Ih<>ught to be mechanical, th,'\", rn.1y also l'Xisl the possibility that The discussion regardmg selIXtion of tIXhniqucs in this chapter relates to general principles, Asp<.'Cls of Table 8,6 Aspects af pain that intluenceselectianofa technique i i SELECTIO\"l i i Meehan\"al Ligament' and i Arthritic!osic OiscJn~M blocki\"') ca\"\",l. tygapoptrysealjoint ~,

seloction of tl'Chniqu.:s that Me rele\\',lnl to particular Intervertebrol disc/nelVl': rOOf sections of the ~pine are discussed in their chapters TI'ffo'IrII'Srollpinclud\", those patientswhosesymp- The >amcapplil'S to discussion concl.'Trungthe man- tomsar,S<' from an interverlebraldlsc that isprogres- agl'ment(ascomparL-d with the tl'Chniquesthat might sively dl'lerioratlng, The diagnosis is a confident beo;elected)ofim;tabilityandhypermobilitydisorders. pn'dictionthatthelOter\"ffiebraldiscisbothfauityand juveniledi>cprolapses.primarypostero-Iateralpro- progrt:'SS;,'dy worscning, with lhepossibililyofe\\'(,n- trusionand spondylolisthl'Sis, The four groups are as lual nervc.root involvl'mcnt. Thedisc nuyonlydisturb follows movemenloftheinlcrver!cbraljoint,butatalalcrstage of the disorder, mO\\'ements of the canal structures may Blocking ofjoint movements alsobt'affl\"Cted.Whentheyareaffec!ed,theconductlon oflhencrveroolm,lyalsobecomcaffec!ed.Howc\"er,it 11u'firslgroul' IS affocted by the mechanical blocking of must be reali/-lod that a patient may deveiopseVl't'e interHrtdlral joint mOHmenl. Examples of such radirularpain without any altl'rahon totheconduction ml\"Chanical blocking of movement in peripheral joints area tom and displaced ml-dial meniscus in the knee, of~ne,,'c.Forthl'PUrposcsofthisehaptN,this ora loose body in the knl'e. Mechanical blocking is not group relatl'Sto thcp.ltient whoscpain is scven' and in uncommon in the cervical and lumbar spines. This whom it is known that the intervertebral discisin dan- g<'rofaffecting the intlllrity of tl'.e ncrvc root group,im·oJvingml'Chanicalblocking.h.lsbeengiven many diagnostic titlL'S. many of which areuna<Xl--pl- Stlection-pain able. Wh\"tever the cause of the blocking or locking maybe, the history, symptoms and signs are readily There are many aspects rdalc-d to !\"lin that influ- recognizable and sp<.'Cific tl'Chniqucs are 5Clected to ence the selection of a lechnique and the manner in restore moveml.\"l. Mo,'ement of the inten'l.'Ttebral which the techOlqueis p\"'rfonned (TabIe8.6). In ~ tnt joint is blocked; canal muveml\"'ts are not usually sofar,thekindsofreferredpainha\"clx~statl-d,as affected h<>s becn the diffeft-'1l.ccbetwl'l.'n end-of-range pain and through-.\"nge pain. Howe\"cr, pain may also be lall.\"t and it may have the capacity tosummatc or linger, The Ugomentousondcopsulorstroinorsproin disordercausingthepainmayormaynotbee>..tn.·m<'ly uTilablc(Wp.ll7),AllsuchJS!,,-'Ctsofpainmuslha\\'c Thr Sfwild groul' includ~ patil.\"ts whose symptoms a meaning. and they certainly have an cffect on thc arise from the ligamentous-type stn'ctun.'S that sup- manner in which thl'selected tl\"Chnlqueis performl'd port th\"intc',,·ertebralS<'gmenl.lncludlng the capsule (stl'Cand D, Table 8.3). Thesc asp<>ds are discussed on ofthezygapophyseal joint. Th\"y present in manydif- p.lges2{)}-2{)3 f\"K.\"t forms, but thl~ is always a oompatible relation- ship betWl\"'''' the patten!'s symptoms and either intervertebral joint movement and iispain response, HISTORY. SYMPTOMS AND SIGNS Or mD\\'cment ofpain-;;cn.i\\l\\·e structures in the veri\"\" bral canal and inten'erk'bral foramen and its pain response. The pain ,,-\"ponSl'S with movement may be Thethirdintcgr;mtp\"rt(S<'l'Chapter6)coosistsof, felt only at thcl'ndofa range of mo\\'ement, or they The history. maybefeltthrough~rangeofmovemenluptothe The symptoms -that is, the cirrumstanc.:s undcr end of the range. As has Ix'l.'n ml~'tio\"cd earlier. the which lhc patient fl'els the particular an.'as and !\"linmaylx'localorn'ferred types of symptoms. 3. The signs-that is,themanner in which the patient's symptoms Can bc \"-'Pro<luCt.'<l and Zygapophyseoljointorthritis/orthrosis varlcdbyphysicalc\"aminahon. Thr lI,i,d gmul' includes patients where symptoms HISTORY ariS<'lromthe'arthritkf.uthrosk·zygapophy$ealjoint ,n either the chronic or thc more painfully aculc phase Thcthn.'ClTlainfl'MurL'Sofhistoryare Thl' srmptoms feU by the patient may be local or 1. TheonsetandprogR'SSofthedlSOrder rt'lerred where comparisons wcre made with the 'arthrilic' hlp t>t'ing painless rct causing refl'fl\\.'d pain throughout it,; history. inthelncc

200 MAITLAND'S VERTEBRAL MANIPULATION 2. Thtostagi'ofthedisordcratthi.tllTlcwhenthe pain Can be prndoc..d without there hemg any changO'S f\"lllentSl'CQtreatmenl in thi. ann pdin. The ~hruquecho5cn for m,oatment of thi. flJ'l't patient would han- to be a J\"ll'11xIn. and a lI'IO\\.e- 3. The degree of stability of the dl!lOrdcr at the lime ment that relic\\·ed the spnptomll 50 lIS not to damage when ~Si'\\'ks lre.. tment the structures causing hI!! pain: .. here<t5 IJW' 5«O'd f\"ltimt may R.'<lUll\"<' a linn sustaml'.'d t«fuuque that pn>- They apply equally to the rnecn..nicaUy bkxked lI'IO\\'~t and the sprm/str..m dtSOrdcrs of the ,.~ a alcu.latt'd des\"-\" of the sapular ~....ptoms to mlcr'\\mebral joint, ilS they do to the rommonly seen and mon'senous problems of the inten;ertfllral d\"\", inlpfO\\\"t' IJW'ddooier and the pam ,tcal.l§6. md ........·i'1\"O(ll. Wmination of lI'IO\\ement<. ronstS!\" of ~ dB- SYMPTOMS tinctpar1S: 1. EJu,ll\\INltlon ofll1O\\ements at ,·ertel>fal caNol and mteo·ertebralforamINlMTUctul'l\"\"'. The areas and tl'pe of a f\"ltienrs s)·mptoms i1nd the 2. Examrnation of ph}1o,oaogical rr>O\\·emenlS of the ciK\\lll15tances under ..-lurn ~ feeh them can in i1n onteo-ertebral!iegll1t'll15.whichinfl'f'S' unportant wal' mflUl\"T\"lCe the selection o( a treatment a) Rou~ anatomIC..1tnO\\emen\\:s (Oexion.-I'~ten­ tl!(hmquc, For \"\"\"'mpk>, the patient nul' ha.,i' pam in sion,Jater';l/1Jeuon and roIal;on,also..sp\"rtol his low.... back, right bullock and right po6tcrior th'gh, a functiUMlly demonstrated mO\\\"t!mCfl.t). ...~tt.\"/1dmg to h,s knCl'. Hi' rommenhi 1t1.1' the po!>ition b) Expandoo rhl'sioJloglCill mO'o'crnenlS into rom- that prondes hIm \",th greah_'St ea,;o, is to lie on his h-f, binatiolb of movements grouped together in sidl' WIth hIps and kne...'S ne\"•..:! and his right kn~ rest- varil..:!seqU<.'TICelI mg on the bN. Tolil'on his right sid,,;ncINst.'S his but- c) Sostilined positiON, dlStmct,on and compressIon. tock and leg rain. This may indicate thai h(' should be positlon(od Iymg on his left side and that the p<:lvis 3. Examination by palpation Il'l:hniqu('S, which infers: might be rotated towards the left as th\" tl'l:hniq~ a) Assessment for temperature chang~ and sweatingoftheskinsurf..~. Any comments lhe pati(....' mah'S about his symp- b) Soft-tissut' asso.ssment for muscles. toms can only be ust.\":! in the so>lccting of tn.'alm\"nt c) Soft-tissue assess~nl of the interspinous, I.. m- tl'(hniques when the physical ex.ammation findings ina. trough and 7.ygapophyseal joint areas. nuteh the manner In \"hich the patient is ..Ifl'dl\"d by d) ACC'e'I6Of}' ll1O\\·ellll....b in sland.. rd dll'eChons. hl!ldi~ oe) Accessory ll1O\\'l'1TlCfllSll1\\·aned IncliNotions. =- _SIGNS A«e5N;xy ll1O\\-emen\\:s on \\aned incliNti0n5 In different physlOlogw:al pos,tions. The s'gns ref to the physKal exmunatioo finchngs.. Selection of teduuqUC5 l'l'!ak-d iolhe5ernmJX-'le'lSis They inchcall' hethercanal. .......·.........lSilrl' on\\·ol\\ed. l:'OrlSiderro ~y from the poont of ,'iew of \"'1Uch findingbetfilSthepa~I'sd.L5Ofder.lnother ....ords,il whether nen\"t' oonduction· imp<lll'l'd and whether a 'combined' phVSlOlogKaIll'st lnO\\·emmt rompletelv noproducesa f\"lbmt'slocoll symptoms while palpation the spnptonu NH- a stretch or CODlpre'i5 component. and caNI findmg:s i111' ,aSUE', the combined ph)\"S>(>- IogicaIInO\\·ement would be chosen as the treatment and they help IOconfinnthe~of,mtablhtyoi technique ItshDuld bepotnted out, toow..e\\....., lhat canal ll1O\\emmlS, e\\-en who:>n Iound 10 bo- dllKtly relak-d to thedosonier the patient's disorder, should not be used itS a first choicl'butshouktbeuscdaftcrph)'SIOlogKaland .K'Cl'5- Wh,~ d ~ IS alI-unportant, the flWV'Il\"I\" on sory mO\\l'menls han- .'Il\",,·ed thl\"ir usefulness. ,,-hich the pat>ent's symptoms can IX' ,nc......sed or Compontnts of recognizablc rcgular pattcrns dl'Cr'Nlol\"(f ~. eqUillly s.ignificanL With rl'S\"'rd to seI«- At the IX'guming of thIS sccllon on selection of tech· niques, the statement was made thai the greatest hon of tcchniq...., the following I'Qmpk> should advance mad\" in manipulatIve physiother,'py in recent years is in the cl('~re. recognition of p.1ttems of l'''pJa,n the ,mportance of examiNtion findings as pain. pMll'ms 01 movement. and histories. These are detail•..:! On pages 133-136al1d 18S-196. rompall'd WIth the importance of the diagl105is.. lwo palll'l1ts diagncJ5ol'd as ha,·ing 'dis<: henuabOrl \"\"\".1'w,th ner....e-root ,rritation' may left scapulM and arm paon. Howewr. one has Cl'l'\\'ical lIlO\\·l'ml....ts th..11 arc nurkedly restricted by severe inc~ng scapular and arm pain. The other has full movements. but it is found th.1t. if his he..d ..nd neck are s\\l5L~ir.cd in a sln.'\\Chcd position of combined rolation to tN> left plus IMeral f1,,~ion 01 his head to the Idt, only faint scapular

- 1lll.'n',I1t' CftUin history,ympklm_gn p\"\"\"\"'la- malll uUormabOn w,th regard 10 tho-' ~lar pallent bonS tl\\;lt ...........dtly rerogruut>le, and lhcir resporee When trauma is imvhed in the onset of the pall('nl'S 10 polrtlcu.Ur tre;ltment tec:hmqUCli is pn!dirtable- problem. he lJI<1y pteenl \"\"m an historical progreso The hostoo' of tht' dt'gener;1l1ng dISC is reJKlily rtC- Moo 01 his s)·mplolm ..·Iuch ,-rt/y resembll'5 one or ogruut»e, p;lltK\\lwt)' ,f the patient hils had !ie\\'t\"tal more aspects ol a nocognll.able pallt'm; the mo'Iemenl pPi$Odes Theprogre;soonol~dlSCdISOldeTIOprodu­ SIgns found llIleuDU1loillbOO may ..l5ofil part501 OOC'or -\"\".,,\"cmg net'\\l.'-root irritation or (Onlp~on is cqu.ally mort' rrgular patterns. besides tul\\ing !10m(> mo\\e- Whenapalicntp~tswitha~\"IUZ.il.blen.-guL1T menlj which do not filan)' paltern. Ilrian Edwards (pp, 1ll-1J6 ..nd 221-222) deals til pooll,,\", of l'p1SOde!;, and the pauem of symptomatK <kopth wlthaspectsof~ moecharuc.ol rq;uiMpattems. I'I.'Spon5o.' 10 examination mOH'm..\",ts is also of a m\"tdl,ng ~uJ.. r patlem, the two together \"\"\"\"gillen SelECTION - ASPECTS OF THE TECHNIQUE ITSelF t\"\"andronfirmlhepallem Whl'n mOl·...m\"nl p.111~rnS arc rt'gular, the SCll'..:- lion of t,-,<hniqu~ is de\"'''T and the '{'Sponse 10 tre.. l- ment i$ mo\", pn.'<iictable (..... pr- 133-136, by Ilridn We now IK'ed to COf\\Sld...,r \"hal '~k'Ction' aspo.,>:1S £d\"ards) n.'l>\"rding the ,..drni<j\"\" \"\",If require dec;ision (T~~I.. 1llcre will ob.iously be nl.l\"Y lime'!i w~ a 8.3), The aspects arec jUlIen!'s hIStory or IT\\()\\emefll signs only partly fit a I. Mobilizeor m.lrupulate ftSul.ar pattern. thoeYe bemg Ol.her romJ\"O\"E'lllS of tho.- 2. Dift'Cbonof mo\\-emft\\t dliOfd\". thai ~t with ,\"\"Sub. patterns. Under theSl\"mrumstaoces, tlxKlgh the ~IOOof tl'du'uque \"\" ....\"\"\"\"\"J. Po;.lDon In ...-hldl the dll'Kted l'r\"IO'·ftnent ...·ould IJY~ Mdtn'C:\"K'd !O>\\'ards the f'l'lI;u~r m:cgniz3ble p.ol- 4. nw.martI1erofthet«hn\"lUl' un. ~ ~Io tn>almenl \"\"II ob\\iousIy be kss S. 'Jh<>duraDonoithelMiltment pnl'dicWble The hIStory of the \\OO:;;led tnlCf\\'fi\"rtcl>ral joint is ,h.J'.ootho.'T .......mple of .. recognll.....1e histor.-, and on MOBILIZE OR MANIPULA;,;;',;;,' _ l\"..lmll\",hon ;, is found the mOH>mcnl sign.~ ..Iso fil a regular pattern_ Under t~ cin:-urnsl.ances \"gain. ucept in the CaS<.\" of the mechanical blocking or lock- the t~atmenl \"\"\"ponse from a p.lTticul<lr lechnique i~ ing of inlen·\"rt,--bral joint mQ\\emenlS, to mobihze is a predictable. ~ller and wiser sell'Ction than 10 oc'gin lreatment b), Thl-no al1,' many lime< when a patient's hi~l()ry i. not In.1nipulahng. The e\"c'-'Pl1ons to lh;s stat\"nwnl would deMo al\\d under the.><' drcum5tanc(\"Ii th('1'(' i. no rcgu- hi: rMe, II0w\"\"er.;1 is usuall)' \"ec;essary to m;lnipul;llc wh,-'n Ihe inten'ertebral jomt movement is loch-d 1M p.llt..rn. 1I0w..v..r, on e\"am\"\"'t,,,'n the movements may fit a \"'gular pat\"'rn. For e~;lmrll'> Cl·rvi(..ll;lteral fk~ion to the I,'(t and rotillion t\" the k.ft m\"y both In most dinial cr..n it is wtlot to ~In tr~atmcnt \"'Prodoct' the pattenl'. Ieft-O('C~ ram. Bolh of tho...,;\" mouments produce a cJ.o.inIl down o( the left side ol w'fhmobilizingfrchl\\~,aw'thanm;lrupulalJOr\\. the Inh.T\\ertt.-bra1 joint Cen'w;all!')'h;'nSion ah;oc\\o5es Or! 'a~ lICaSIlIm of, lor cumpk. Iodml jotrlt do..'\" the left si<k>ollhejolnt ~)\" Them..... if IIlO'I'mlnlti,!:IM' phy5iotlle-apist.-, progteS to a lhed~hemtheleft-sidedstructuresP\"Steriorlo m;lnlpulalJOnlfmoblllUlJOndol5noIW!llt.m!M thetra{\\§,·er;eu.lSolelltl'nSlOnand\"\"d~also fil$ttrutrMnt~ reprodl.lre<thepatn.thepattrmolmo'l\"E'lTlCOt ..'iUbe\" \"'SU~r ~1T..ab1e pallem. \\'/hefl such .. pat\"\"'l is lrNlt'CI \"\",Ih the !'oelecbon ol techmqlll'5 based 00 the \\\\\"tth d~ other thaI' kxW II1O\\emenl .1 may ~1U7.aNepattern of mm.-emenl findmgs.!be lrNt- beromeob'·ious, ..fter atle...t the first treatment. tn.1 a ml!'nl R'SJXltIS\" should be p,\"('<hctable. If the treatment mampulahoo in the dlll'Clior> of lhe limililOOn may be \"\"p«taticlnisnolachie,'ed.lhe~asonfIXlheirregular \"-'<lUlted. response m<>y lie in the hislory of the palienl·s disorder An irritable joinl di§Ol'def rna)' sometimt\"S be belt..r 'mrlicahng ot\"\"'\" slru<:tures treated by a sing1l'. gCl'tle manipulah\\'c thru.t. Amon).; lhe mechanical disorders there are many hoec.111SC \"--,-,etil;\"\" mobllizatiun rna)' 01'1)' ...,rve to irri· rt.'COgni1.able patt\"rns of ('\"ami\"\"I;on findings. In t.1lethedi.orderfurlher, lhe degl'nt'rallv(' zygapophyseal joml disorders and When a selecled large-amphtude movement is nOl IhediS('(>genicdisorders;tisllx-'hislorylhatgiveslhc bemg as effecl;ve as ('\"peeted. il may be morccff,'CI;\"e

202 MAITLANO'S veRTEBRAL MANIPULATION if precedro by a m... nlpulation. Similarly. when l'lthcr ha'·efaiJedshouldcana1lT1O\\<.'mCflltl!ChmquesN _tilined or intennmeot uacbon is beU\"lg used. ,t mil) u\"ed.'Jlo,rn,\"\"\"6cq>tionslolh.i5ruk-,~\"\"\"thilll D\"\"\"\"\",efferu,,,ifpn.'«'ded b)' a m.rnipulahon. ruk's.. One l\"XCq)tion IS \"hen till' potienn S~'mp­ toms ilrc Iocilllb!d 10 thespmt\"or nNrb~. \",tiler THE DIRECTION OF MOVEMENT OF lhanbemg~\"'lothetimbThisI!o~II~' THE TECHNIQUE sotfthl-svrnpl~iltechronicilndil\"\"mon'ddfi­ cult 10 ,...,-pnxl.- by spinilI mmemenb th.m b) Cilnalmo... _ t S - lhe d'll'CI>On of mo....~mmt, porticularly of\" mob,llz- S. ShouldllpllY\"rok1gJ<'tfl_~forllniCCr'll, 'rtilllm'f'- mg technIque, IS gu,dro by lhe purpa;e of the tt'Ch- nrmtll,ingdirt'Nronltrf,nfhf/lo\",\",rbnJbrsrltrfr/l> nique 1ll.e foUowing li~t indlc.ttes the factors that may The cho~ depends upon ,,'hich of the two pm. ;nOUt'~lhese1,-ction. du<:cd the mO!>t ~ignificant findings, ThaI phy.ic.. 1, SJw\"ld IN aim Ix la \",I<''' (m~ .,idr of 0\", i\"tfTI\",tf'brol 10gic...1 move\"....nl h,ch\"'ques can mal.<' mar~rd slJtU:~~ To do this implies widening Ihe intcr\\'\".tc- changes to the palpation findmgs 'HId Ih\"l acces- br.,1 disc spiKC betw'...·n adj\"\"\"nt vertebrae on the sory mo,'\"m\"nt te<:hniqudo Can cleM physiologic...1 opI-\"Il\\'\\:I side.... nd abo widening lhe inWl'\\eTll'b.al movemenl n.'Strictions must always be l~'Pt in (o.\"men on that SId\" TImes when this might be a mind when rn.al\"'l/; lhese d«isions. choic<.> ... \", when the poticnl has lleI'\\e-fOO! p\"'n 6. Shollid lin tffiNl • ma.u-Io dntTmiM lPIwthtT II ptlr- and marked u ..... l/for.\"\"... ~Jgns on e.... miMtion. lioll<lrp<ti\".fW_...-..tajlltrstnod'''''lI'iudI;'OItjrluit 2. SItouIJ Ihr\",m Ixto:Jl,\"ch ronlTfll;ltIlstrudllfeO /Jlllt 10Mb /u \"\" IlIlft In ordn to .... it ~ 'IS p<tm·f= IIIIt'l' /Iml!oIc \".nfuP When hgammtous-type struc- nuogr' Somt-tm_ .. pot\"-\"\"I boerornt5 symplom fTft tures ue str,,\"W and f<ll>Sot local pain (QO\" \",en with tn'atment. p,'i ~ may be QO\"Ol' ...........iru\"l! ~pilinultlll'l)\"..,doscribedonp,I90)they l'....ltliMIJontl.'StlTlO\\\"l'I1leIltthallSpamful.ltrn.a)' often need tobe~hN.inilcuntrolled 1TIo1Mer, 10 be important to f~ this mo,'emenl of ,ts p<lin in become full ~ilI1ge and poin free. IVhether Itu!; IS., the intt\"l'C5ts uI proph~'IIl>.is. On theOlher hand. the can be detemuned onl,' by perfonrung tho! \"tn.1dl- hi>.toryofthe p.alient'sdJSOnler may indkatt thai it mgk'duuq.... gentJ)\"ilndataoonsLlnI rtoylhn' dur' is highly unli ....l) lhal it could be made p.aln free InS the perfonnlllg of the tl!Chnique. If dbcomfor1 Ies.;cns during the k>chnlq ..... It ~~ Ule corn\"C1 ....~,'C. POSITION OF THE INTERVERTEBRAL JOINT IN WHICH MOVEMENT WIll BE tion. A woroerung p;l'\" responseexlending progn.... PERFORMED si\\'dy over a period \"f 20 wcOfld, of thl- Kl'l\\tlr st\",tchiog technique 5lI~ ·~t<lP'. Ho,,,,\",,,r, the full onswer as to whether the contr<lCtrd struchn't,'\" The answer!; to this aSpt-'Ct of st'lt'Clion al'l.' clearly linked with points I-S '\" the abo\\'e sectiOl'l. The ftll- should be sin'tdwd or 001 can only be made by lowing de5Criptions an' \",lal\\'\\:Ilo that so.'Ction by using the same \"'''erenee numbefli. assessrnentofchan~thatta~placeDsaresullof the t.....atment (Wei\" a 24-hour inter.al. l, ShoulJlltelli\",.'ofi'Oidprotoollgmyrtjtmd,-l1l,or I.T\"opnr_5IIkoflhrml\",-,\",Irfm,I~I,the is iI /lttltT JIIpmmb' IJtt vnys-JlB_nl' \\\\-'hen choice of FUitlOf'l is detenn\"lt\"d b) two factors lhefirstis ....lIlt«llolcno..\"1l~andthe considering tn. app..-t., pn:l\\'Oking rMmi p;tlfl sec:ond IS the p.a11l response felt by the p;lllmt once lS~whentherererrodpainischronic,,,'hen ,Iisunlikelyloberwo·eroolinorigin. .. hendostally he is pb«d in lhe ~ po&IlIOf'I For ~ poin IS not J\"'O''Obd on examiNltion.-' example, 10 open the nghtsideoftheC6/75pD«'tne .. henth.rea..... no5olgJ1!iulneuroIogicaIdeficil. p.tt.....rs 'TM.\"Ckon-trunk' ~tion ..'OUld be a com- 4 ShoIIlJllhrlli\",ktlllftfllYl1llldirrdiotlllwllllOR!Sthr bined po!iItion of f1tuon. latt'fal fle>.1OI1 Iclt and O'lIlI1/ftmlmnt .t,..durn \",I,,\" thim the jIlInl >/fIIC\"- rotation Iefl.llow·C\\tr, the arnount of the flexion\" tllm;7 AI lhe time of the ,rllrial examilUltKln of a Iattral flexion and rotation, or till' emph.lst!l on p.t-tient. sp\",,,1 mowments mily provoke relC\\'ant one of the thrt'l' dll't'CtiOOS, depends 0I'l lhe p;lin n.>ferred pam, and movements of the c... nal Siruc- response d~iR'd. If I.... aim is to a\"oid p.aln. then tures may also pro\"ok~ thes.~merelevant pain. The the amount of f1e>;;0I'l, lal.......1Oexion left and rota· dill.'Ction of mo\"\"ment chOSl'n initi... lly should be rion Ielt is modlfi,>d until lhe pain·fn.\", p'''ition on~ lhal mewcs Ihe foint and leaves thecan... l siruc- is found. To ta~,· this dis<:ussion further. once in tures ...lati,ely undisturtx'\\:l. Only when I~ this posilion, the dl ...-chon of mo....rm.'I\\t sell!Cted

xlmionoflechniqu6 203 (M\"t' aoo.e sectIOnj would be to mobIbze inlo fur- pilin-through-range problem and e>.acerl>abOn IS ther 0..':>.100 01'\" mtilllOO Iftl ~ Literal flexion left. .. lucho-\\erproducedthedeslred~. ' *to be a\"'llde<! at all COlM5. e. Z. Tht _ _ ClIfItIllmIs .\"\"'1 to IIw 'po5lfior\"ng' as .....'\" 2. \\\\'lwther pain IS II ma,or roncem and IS an beenhsh'dfe.·direcbon·\"'!he.00'... 5<'dion. end..of-rangt' problem WIth faulty structureo; ..1uctI can be handled firmly WIthout ~~hniquedirecbOnand thepos'lionmgofthejoint el<M'f'rbation. ~ , .. 0 Stoparale OOnlponenlS. )'1'1 an\" 5ekcted on \"irtu- .11) 'd.....IIc.1 cnleria. If. for ~mple. the .im of thlo \\\\'1ImptmtishJbrnsptdtJllndlltrpmhlmois_titlltrl/fflts tl'Chnique itI10 avoid any pfl)\\·ol.:ml; of disromfort or ~ltrlrl!l'nn\",grorl:>lIp11ut.'lrmtlglr·\"\"''''1Iflr p.o.ln. thm the 'posllion' must be D pam-fTl'l\"position and the ledmiqw mo'·<.'lTIeI1t must boo po\"n free. If the aim is 1. The positinn. in t~a\\'ailablerange, in whICh the to !'.'produce the s)mptoms, then the 'position' Chos..~l tt'Chnique should be performed should be fn..'(' of must cIt)\\<... p\",\\,oke some d\"SR.-'C nf the symptoms or discomfort. put the joint 0' canal structun'S in a position whe!'.' the t«hniqucdlR.-,.,tinn doe!ll'l\"pruducc thesyn,ptoms. 2. The Il.'CMique should b.: '-ery comfortable and comforting An unusual example of 'pos,tlonj,,].;' and 'mm'{'- menl d'l'l.'Ction· will helpdanfy thelr Inte'Tdationship 3 The amplitude should be as large a>; can be A pilt......t .....d right Kapul... paIn. \"'hlCh could be performed provided it i~ froe of any di5<:omforl reproduced on l\"'Qmm\"bOn by the slump tCSI (str whalSOt-\".-er. pp.l+l--l49las ..'ellasbyjolntmmements.Joint m''' .... mmt tl.\"Chniques Irntially produced ,mpfl)\\~t in 4. TheSf>£\"l\"dshouldbe§\\o\" both thl.' p.ltlmt'ssymptorns 'lInd,omt SIgns, but \"'Ith- 5 The rhythm shauld be bmOOIh. out any impto\\'ement IJ\\ th<' slump test s.igns.. At this 6... Theduralionoft.hetedlniqucmustbeshort, Slagt', \"')lnt tedlniqucs' faOOd to gam .....y further dwlg15.lt .. asthendecidedttt ITUtJa.llyuntil.the$hourresponse;\"~ I. 1,;se ea.~ (ncurod)'narruc) ~h\"'que;ba!;ed on It IS in t1tis area lNt grade I and II mO\\emmts are so thee\"\"minahon findmg'! \".I....bJ... As pam~.grade IIIll'\\O\\emmts may be w.ed Point (5) refer\" to tht' rh}'thm of the wdulIque; 2. UM' the 'posItioning' and 'din'etion' 10 I'l\"produce rh)Ittrm' arediscussed m dct.>d on page 176. the symptoms. 1'1'1ww 51iffi-t> is dam\"\",,,'..nJ IIw\"'ulllJ 5tnKfu\"\" IIrt So the slump tl'S1 'posit;un' was adOph.'d. and tho! 0010- pone\"t of Ihe slump tcst tl1M most p,t)\\'oked the \"\"\"ll....unntbyl\",ulllOlordlSt'tl!lr \"\"'pul'>r symptoms was the 'direction' ch\"\"\"\". The end'Of-raoge pooiollion should be chosen. The {a\"curable effl'Ct nf the tech\"'q\"\" waS dramatic The technique ~hould be fIrm. and last\"'s TlIt- poswcm for 1M tl.'Chnlque was sitting The amplitude should be mainl)' small, but WIth l('g'Istretchoed out in front wIth Io.naoo;extended should be i\"tcrspcried witi1 !OOme larger Thl- «'T\\lCal, thoracic and IUmNr 5plf\"lCS ........... held amplitude mo..\"m''fII~, fully f1eM'd, lind the trunL was fle-<ed forward at the ~spcedcanbequickl'r. N!\",unhlast\"\"\".strctch ... fcltby!hepahentinthe The rh),thm n......ods 10 be !IOmewhat staccato. Iwnstnng area. His rightles w..s r~ and held M1p- DIscomfort should be respected, e<;pecially if there por1t'd,nltuto ro'\"non. and k.--fIe:OonJ'f'\"'ented is any indication of summallon of Sympt0m5 dur- ing the pcrformlllg of the tedm'que. 'flwo d\".'.\". fe. the tedtnlqUe ~ was maximum 1.· The duration ea.\" be longer, though actt,'e l\\'lO\\'ementsshould int~ bet-.......... the attlIe d~1ie'Uon. 1lus ntO\\emcnt \"\"Produced h,~ pasIiI'emobiliZolbOn. Kapularp.rn 5e'I~}' Wtth e.::h sTretch. It >!i5Ol\"letimes difficult todoeri<k,ust ......' firml\" the THE MANNER OF THE TECHNIQUE ~ TV l\\'lO\\'emmtshould be performed. ThedCOSKln is based on the l1'i.at>onslup bet-.'een the follow,ng' Two f,'''h'l'1.''S ptay an important p.ut in this cont\"\"t They are • The newness or oldnoss of S(lft-ussue change!l (the olderlhe)'are,thefirmerthep~urej l. Whether the problem is a pain IImiling mo\\'t'lN'nt neM the ocllinlling of rallK\" or • Th\" relationship bet.. ...:\" pam on mO\"'ment and tl1e resistance felt on mo\\'ement (the closer the relatinnsh;p in terms of stn'ngth a\"d posit,oo in ,angl', Ihe firmer the pl'1....surt.'). • The 'irritability' rt.>SpOIlS<l from Ihe previous 1l'1'a1menl (the lcss 'irritable' the responsc. Ihl' firmer lhc prl...surcj,

204 MAITlANO·S VERTEBRAL MANiPULATION DURATION DF TREATMENT n:ryspeciocdoosions r<'1\"tmg to selection of torll- n'CIue Can be based 0f1 dlagl1oClSl'S subdi,-ided into the Allhough Mated 10 !hi> ~ of teduuques in tNt four group5suggestcd onp.lges 198-199\"ndsuJlUTU_ rued in Tabk 8.8 below !hI>\"mounlofchangutgtTomonekrlmiqut\"toanolher.s goo.-ernt'd by the amount of lJe\"tmenllhat can be adnun- iSk'n'd it one!leiSlOl'\\. It... duration of trNlmenl is dIS- MECHANICAL BLOCKI;;.NG;;.;... _ C\\ISS£'d moR' fully under 'ipplicition of t«hniques' (_ ,l,.1ectw.ruc31 blocking occur.. most commonly in the p. 219). There I!i ill uptimum amount thai can br ct'OicaI spme. 5OInl'\\'<NI Ie;e; commonI,\" <n the low lumbar 5p'!\"Ol', MId is: uncommon <n the ~ sprne adUeo.ed at one ImiIlment session,. and the l\\\\lJnbetof In SUtlUni.ry. if the mecn.nic..1 blocking occurn:d hme;, i Wdmiquecan be ~Ied at one <c!ioSion may be IimJt~od bythl.-same fiC'lonastl'n.sked in6' and.,. abo'I-e '\"err N'Sily (and has dorw to in the pasl and been fol- SELECTION - RELATED TO DIAGNOSIS Io\"'ed by spontaneous unlockmg). mobilizing tech- AND PRESENTING SYMPTO,,\"\"'S'--_ _ ntques that open the mt..-nertebra.l space on lhe bIocked.sodl'shouldblou.t«l first. Iftheso!-fail,amanipu. ~ lrwtmt.'nl is undertaken, tl>o> manlpubh\\\"t~ ph).,.. lation to open the bllxl.e<J sid.. will be used. iothl...apist must first know the diagnosIS of the p;!lJent's LIGAMENTS AND CAPSULE. AND dl!lOf'd~..., both from lloI'rown knowkodg~and from know- 'ARTH RITlCIARTH RO SI C' ingthen:ft'lTmgdoctor'spmc~ofn:achingthediag- ZYGAPOPHYSEAL JOINT fIO!llS: The second CSS(>flt~al is (or the malllpulativl' phYSlotlwrapJSt to d(-'\\l'rnune exactly all of the details that form th~ examination of the history. th... symptoms and the drcumsLma:s under which the p.~tient feels l1\\\\'oommon presentation of disturoances fitting tile thern,and the signs (th.Jt is. the test mOl'emmtfindings abo\\\".. headings arc often impossible 10 t..ll apart at a n:lating pam n:sponse to range of movement) (TI2/>k B.7). on<:e-only t'JUInunation. The ligamentous and capsular Ob\\'iou,ly, ill other aspects of e~aminatiooto CO\\ (or ron- group, \"\",de symptomatic by minor spr\"in, or strain traindicalio:ln5tolmillmentmustalsobe~bly from !\"ol'W-u\".... misuse, o\\\"eruse, abuse or postuno (as dlStinctfromlTiunullcCaUSl'$l.c\"nbe'end~f_ran..g' ex.tm1.....od.bothsubjocti\\\"clyandph)'5icall\\· problemsOl'\"'pain-througll.ra~·pmblems. The\"p.un- In t\"\" pn.'Wdmg text it has bt.\"·n ('mp~ tNt through-range' ligamentous group uswlly causes ~ln localized 10 the ,.w:uuty 01 the st~ caUSltlg the KCUraleinfOTlno1tJ\\'ediagno&isisoftl'Tl('1{In.'rT1l'lydiffi_ ~Tlll'ptogJ1!SSI'·e·anhrit.s'disorderisalsoUSUolllh i '.~in-through-ringt'· problem. with the main (MIn cull 0I'\"l'\\<'rl impossible to achi<>'e, Rden.'fKt' hoils been being felt locally. m.Jde. too. 10 the fact thlltoften the diagnosis can be made onlv in ret1USJ\"f'd, once the f\"ffto,:t of (Mrticu....r a..nm.n;treiltment proadu..,-.; is ~ the grNt Import.o.~ofana.I)'bcal~I.N\",·t\"rthriese, The ligamentous 'end-of-rillge-(Mtn' group IN)' a~ referred ~in\" but It will be of the ,agut\" kInd. Table 8.1 RdatlOf\\stllp$gOYerningstltctionof decrNsmg in in~t) the further It refers (_ p. 190) technIque Tlll'duunic 'arthrillS' Z)\"gilpophvseal joint dlSOl'dw FWu'-llift.m<-nlThclntiad S«orMI....\"\"..rt-.ot can ...150 prewnt .is ...n 'end-of-rillge- problem ind \"~it'\"\"l:· 'OOniaIpIt'WrlUlIo.f ausereferredpaln.(>«p.I90). lloIgnooUCtt\\e HlSfOty.S'f'OIp\\OIIIS.Sl9nl ~ is one olher presmtation; the p.ltil'nt experi- ences his ~in intennlltentl)' as ... sharp ~in.lSSOd<1ted WIth mo'·emenl. The p.~in IS alw.:lYs a localized pain Table8.8 ~leetionoft~cllniqu~bascdonSllbdjyisionsofdiilgnosis . Liqaments,nd SElECTION capsule M~anicil I blod:.'''S C Mhriticlosic rygipopll'f'ol'lljoint

Sf;l«tionoflKhlliqYn 205 mel Ile'\\'er a R\"Wm.-d pam. The pabenlmay nlM be able Pm,.,.'Thee groupmgs p.1rallcl tho!;e III tIw romparuon book I O l 1 ' J l m d ~ t h e p a m c o n s a s l e n t l y w l t h a p a r t i c.u. .L A-UnrpulolhOll (M;l.lliand., 1990). Bea.1,.l§l' the !ie\\·l'1\"lly oIlocaJ and I\"INrby referred 11'0\\\"\"\"\",,1. s),mptomscan \\'ary 50 .. ldeIy\".t >5 more helpful \"'....... dealmg with thesubj«tolsdect>on of te<:hruque.s if For lhoe ,mt1.1lsekctooo of 1«hniques,«pKificchffer- fl\"b.l1000 as 10 the SOU~ of tlwsymptorns is nlM an lhe \",lecrion is first relaled to thE- two e>;1l'efl'W!i at 1JiOiUl'; nm,'e\\'I'1\", .... hen Impl'O\\'ement Slops or is too 5Io\",diffeTmllaltonisnccessary.l1lete_t tNt follows !ie\\'enty.l1lefi15II'_Il\"l..,.\"elobedescribcd will be the 'pplies 10 pain and shfflleS5aming from ligaments pain-limiting mon,menl al the beginnmg of range of and capsul<->s, Additional comments, whie\" apply to the pain-I\"rough-rangc Situation (group 1), where the more chronic 'arthritic!art\"msie' (t\"at is intra- painis~\\'ereandin\"ibitsthepaticnt'srllO\"eml'll\"'­ articulM) 1.ygapophyseal joint probl,-'JTI5, follow. the ... is no stiffness or muscle spasm limiting mo,'1'- m<->nl. The other extreme is where the patient (Om· SELECTION plaInS of stiffl'le'i6, not pain, although p.1m is pl'O\\'med when the stiff mO\\\"ments are slreld,.~ CKlOUp 3). This The- pa56i'e lnO\\emmllt.'dtniques from wltic\" a.selec- is thoeend..of·rangesitl.lilnon. when!p.1in is minimal tion can be m.adf, m the treatment of inlff\\ertebral GROUP 1 ~ PAIN jotntdJ.SOf'der.;aR'~folk).,$: 11lew pal,ents N\"e <;('\\\"t'Ie p.1m-hm.tmg mon'menl, I. l1le ph)'5ioIog.i<:al mowmcnlS of ratl\\e-rtlunitbc;nghmIl<-'<l by any other fad<>rs. The a) Fle_ionandl')'!<-oru;ion te<:\"niquesthatcanbcuso.odareasfoUows b) Lat.>ralf\\e>;ion. c)ROIation. Acre:ssorymove:mentsin a part of the: range 2. ThcgroupaC«'SSOryn\"\"'\",\",entsof thati~allvfre:cofanypainordiscomfort a) Distraction. b)Comp\",,\"ion Thcjointtobell'\\'at<-'<l must be posillOnl'd ina totally symrtom-fK'C posilion 1_ e\"amp,\"\", below). 1he 3. \"fhl.>localill'dacas.sory'l'w;)\\\"ements,which amplilude of the lJ\\O\\l'IT\\l'f\\t should be the largesl pas- can be prodll«'d by direct pl'l':5Surebemg applied ~Iblc amplitude thoIt Can be ad'oie\\'ed p.1mJ,cs.<;I). To to palpable parts ofa 'l'l'tebraor twoadJoXl\"flt make tlwamplitudfo l.lrge. il ma)' bell('('C§lSary to start ,'('I1<.-brae. from a point well bad.. in the range. The rhythm of the n>O\\emenl mUSI be smooth and sJo.- Thedlrectionsoithoepl'l.'!i5urestNtprodUCl\"these The following e>-amp1O' may 50'1\"\" to male the5e ~·\"\",,·ementsa.n;>: poinlSclear. lfa p.1tic'rol M.s5e\\'{'ft' m,d-eeo'Kal pam • Postero-anlenor ..-entral or uniLaleral 'ertL't.ral and thoe chosen I,..,alment mo\\'emenl is postero-anterior pre!i6Ure!i. rentral \\\"erlebral p,,-'SSure, lhepalienl\"s head and ned should be in a pain-fn.oeposition, This can be ,1(\"ie.ed • Antcropo.slenorcentralorunilalffal\\'ertebral withlhepatienlpronCOI'Sllpinc .p~u,,--s Toachie\\'calargcampliludcfortheposten)-anterior • Transvel'Sl'vertebral PI''-'SSures. mo\\'emcnt,pal'ticularly if the p.1tient is lying prone,il maybel'll'CeSSilrylOliftthoep;1tienl'smod..:ervicalawa lhe direclions of th\" above PN'Mures Ciln be \\'aried by postcrio.-ly with I\"'\" fingt'fS(Figlltr 10,61)50 thai the inclining thedirectiornl of the pressun.-S rnedially, lat· postc~nteriormo'emcnl has its starting potnt fur- l'fally, cephalad and caudad, and alsob\\' .arying the lherbal::kmthf'r.mge poontsofronlactmmimall)'. lflhoepalienthas<;E\"\\en'Ieft\"\"\"kpamINtlSl'asily AU oftlwabo\\'e lJ1O\\emmlScan be used \",d,fferent reprodll«'d byl'JCtens:u-o, rotation left and Jall'f\"al fIe:<- gndes and rtn1turw, and they an be combined 111 1OII1clt then the s,.mptom-free pos,non will be a com- m.Jn, 'aned .5<\"quenn'l',often frilled IOtIw p.1DenI'S b,nalion of f1e>oon (modway brtw...,., erect and full flexion), Ial...al f\\e:l<ion nght (midway between erect functiorwl ~tnlnon or \"'Iurtr>s TJ\\O\\·emml. The and full lateral flexion right) and rotatIon righl (midway betv>',-oen straight and full rolahon right) IIl0\\l.\"\"\"\",tscanbeu!il'dtolrealfj\"egroupsofpresen- Underlh<-~circumstanc<$lhefi15tchoicemaybelou5t' t.Il1onoUlfol\\OWS; postero·ante.;orunilatl'ralpl'l'S/ju~onthcleft,blllthe unilaleral pressun-may need to be inclined latt'ralJ}'1o 1.I'am. 2.Stiffnt'Sli 3 l'ainassocialedwit\"stiffness 4. MomenLlryjabsofpain. S. Di50rde15directlyn-lat<-'dloa.spt'Cificdiagnosl5.

206 MAITLAND'S VERTEBRAL MANIPULATION a\"oid pro\\'okingdISComfort.lfthlSl<'Chniq\",,<:aflflol mo\\'em~nls isd<'Cided by which of th\" two can be per- be performed pilmlessly, trilns\\'~ vertebral pressure form~od with the lal};<'St amplitud.. mOlot comfortably fmm the right s,dl' is usM for the patient Asthl'pat\"-'I'lt'ssymptomsimprQ\\l',sothetreiltml.'fIt The first prog\"'55ion is bemg able to mo,'e the 5iI0\\1' m()\\t'Il\\l'O'Itcanbemo,'edfurthermtothcrafl8<'andthc lechruqUl'altheSilflle speed, but now into\", rontroJll'd FO\"\"ooofthl'patK'l1t'sho;>ild may becarefulty<:hanged degreeofdisromfort, Jfit is tn.,. nf;ht stag.. of tl\\!iltment t\",,'ardstho;>pamfuITGtrw:tion,l1lI't~'Chmql.lem.:lyalso 10 be doing this, the discomforl w,1l ~¥l wh,le the bead\\ancro lOastilgl' \"\",,\", the Ll'l;O\"-dmplitudeIDO\\'e- technique ;\" being performed Thc ..mphtude of the mentista]u,ninloadq;T\\.'i'ofdiloCOmfort. teehniqul.\"maythmbeillom.':lSI'dunllllargt...... mplitude F'tl~iologic,1 movements mm-l'InCfllSan> possible Thenexlprogre56lonislOcl\\an~tn.,.poslhonoflhl' When ph\\'~iologicalIDO\\emerl!S.re U!ied to treat pam. jomt by mming il to..'..\"Js the pamful dul'C1IOO, but tho.» too musl be perfQnrlt'<f \"Ithout pt'O\"oI<ing pam notsofarth.altheJ'OlSitioni~pamfuloralar..g.. mph. tude of t\",atment mm-ement IS not pos.s>ble ordiscomfort_A>.w,ththe~lI'IO\\erncnts,the Theftoisone other method of lrwitlng pa'n. wluch 15 mten'encbral Ie\\-e-I betng treated must be po6lboned pam\\e!;sly ma mid-position for aU other din\"Ctions of described Lall'r,lt tS quite dJffermt m C'OnC'l'ptto tht lI'IO\\~LTh.otis,if\"'teralllexlOfllefti5tobeU§edto fon.-going; fOI' thIS tN50n it IS kq>t !K'p;Ir.. tc tn\"ilt right-si<kd pilm among from the C5/6Ie\\et thm theCS/6jolntshouldbe5Upportedmap\"1Ink:s&pos- GROUP 2 - STIFFNESS 'bon rmdway betw~ the IIm,ts of ,ts fIocxoon/a\"\",,\" soonranges,itsrotlltlOflra.ngesrrud . .· . y b e n o , e e n b l ' m g oompresed m1d d1SlRdled. The bll'r.u fIeloon IrNt- Thi$<:iIliPgo'yreLoleslopallCTllS .. hoseektre.. tmcnt mentD'lO\\oementsbouklbrmthe~dU'l.'Ctlon. beociIltSt' stiffnes:6 hDuts norm.al funmon. or becaU5e\" ,liffjouttisslighdypamfulwhmstn'ichedSln)ngl\\ m1d the large. slow, smooth amplitude m~ end before the omrt of any discomfort. As the patwnr''' They are not seeking treatmenl brocaU5e of 5e\\l'I\\' pam. symptoms and lI'IO\\ements ,mprm..-, the lechniquP butbecaUSOl'theyl\\a\\'edjfficultym~ersmglhf><:iIror may bot to...... inlO a J,;no,.n andwntrolled ~of a.... kl5l:ng their full golf swing. 1'hen' all' milnV Olhrr dilioomfort. Funhrr prosr-on t5 .-cluor\\-ed b~ <:haD- simiLu rin:umstan<:es. When one is l'LImtnmg their ging thI' posilJOnofthehNdand ned. m ..-hM;;hthe mon....ents. aU mmements a .... nslri<:tl'd_ When their ph~1 rno\\\"('fl1mt 15 pel\"fl)l'lTWdunlo! full range lJ\\O\\'ements aTe sln-'lched. they ..ret\"lthl'r pa,n-frceor rmnim.illypainful. isJ'OS'ible mall pos.Ibons. TheseleetionoflOOuuq0t'5 f..... such pn:Olern5 L510 When the patienl's mOU'Plen15 a.... IfloiIrlo.edly A3tnCIt'd by bilateral or('ft'ltral pam, theamphtudt-of use two kinds of strrtdting 1nO\\............ts. alh'mdlmg tIw tn... tmenl lnO\\t'UWnt Inily ...., .. to be e:>:!ll'TllI'ly from one 10 tIw other. Aftft' so-lKbon of the pnm.uy small to avOId d,sromfort. Welah\"8 this to USUlg lateral lnO\\'emenlneroinglobesln\"lChed(e,g_C('nic..lrolahon flexionorrotatiorl,themm-l'nll'nlwouldbea,'ery5low, nght because the patienl hoosdifjicultv'*\"I\"lng when> hi' smooth, gt-'I'ltle. OICillatory 1TIO\\t'men1 from approlci- is going wht.'I'l \"-....ersing the<:ilr).the first kind of mm't'- mately 5\" Iat'-'ral fk>.uonlcltlo5\"lat=a1 Raoon right, or ment is the ph}'siologic:aJ m<:n-cment of nomcal rolahon S\"rotalJon Jeft loS\"roialloo nght_l..ongJtud'niIl fl1O\\-e- nght as an oscil.liItory stretdung lTIO\\('ffi('flt al the Iomlt of the range. Thill should be pt-'rfonncd for \"pproM- ment. ..lthoo.ifth no! truly a 'physiological r1lOV<'lT'lCrl.t' as matelya minute or so, varyingbctw....'I'l strong and gmt- defined m tIu:. te)!t, would 300 be a useful tlldullque Ier strengths. 1be ....,ond kind of fl1O\\'emo...t In,'ol\\\"t~ undl\"r ~<:irt'Umstan<:es, It would bell'llually smooth, a<:<:e5/iOl1'fl1O\\emetlls(againstn.'!dungandOSClllatory ~low,~ma.llandgt.'fltk> As the pati~... t's symptoms and J1\\O\\'~m\"\"t signs mO\\'{'rl\\l'fl!S of 'arymg stn.'Ilgths} whIle thl' cl'.... oc,};1 spine isp06,ti,-\"\",-'(j at thl'hmitofthl' ran!!\" of ro\\.iIhon improve, SO t~ tre\"tm~nt mO\\'~m\"\"t Can be taken fur- tht.'T into thl' Tangeand thl'amphtudeof the mo~~m\",,1 Tight. All dinxtions of JeCCS50ry nlO,cm~'Ilt ~hould bl.\" thereby increased, A lat~'r progll-\"ISion, as mL'fltioned utiliz.<)(!.Foliowingthl'aCCl'SSl1l)'mo'~'fll''''I.'i,therolil_ abo\\'l.\",isthatt~mO\\·l'm\"nl<:anbetakefliflloaCOl1_ :~:~~~~:t:~~;j~~~=~~:~~~~I,:':t~h:t7~:'I~~~troll~od degn.... of discomfort. the physiological raogcwith the pTimary ph.rsiolog,cJI Progression mo\\'l.\"ITICr1l.lhc Solm\" prindpk'S<:an be Ulil-od In conlul\"\" Thl' imtiill <:hoicl' bl.\"tween ~k'Ction of on~ of the tiO~:~i~~;;/:;:2,~h~~~lo;,~~:1~:-;~~':::d range a<:<:essory mo\"~mcnt.~ and OIl(' of lhoe ph),,>iological ofmo\"ement, wlwrethe r(>!ttriction iscau5l-od byonc

parlicuJaraC<:c5.-<;orymovcmcolrathcrlhanlhephysi~ point of onset of the pain in therange.md lhe limil of logical movemenl ilself. This is delermioed during th<, thC'a'-ailablerange.Thl'rCshouldbea'matching'com- e~aminat;on, when the rang~'S of acCl.'SSOry mO\\'~~ pari\",n belw\"\",n the symptoms of whkh the palo<,nt menlsareasSCSS<'dalthelimiloflheSliffmovemenl complains and the findings on e~amining his spinal On such examination. the particular accessory mov~\" movemC1lts. Palients having con.slant symploms will ment will be found to be sliffer than the remainder, have IMin commencing early ina ranb't' of movement, and if all are stretched equally slrongly the primary and lh<'pain will continu\" and incll'aseuntil thl>limit acr~'S>orymo,'cmentwillnotonlybeJess'gi\\'ing'but ofth\" range is rcached (i.e. a pain-through-rangeSltu- will aJsocaus<> gn.-at<'1\" discomfort. ation). With the majority of disorders thai cause\" The following points should be taken intoconsider- p,'licnl 10 ha\\'e pain only on movement, he will have alion whcn performing the techniques this pain provoked at lheend olthea\\'a~ablerange 01 1 The biomechanics of the intervert~>braJ joints arc an appropriate movement (i.e. an end-{)f·range-pain such th\"tJateraJ Ilexionand rot\"lion can OC<:'Ur siluation) togelher.Th<'n.>fol'l\"inthatpartofthespinebctw~\",n C2 and C7, when One is performing rotation right. il In addition to lhepatient having through-range may be neccssary .. lso toslretch lhe he\"d and neck p.,inorcnd-of-rangep.,in, lh\"nl IS anolher featurc 10 bedarified_ With the patient who worst'nswlth pam al in thl'di=tion of the coronal plane-that is,strL'Ich the end of range, it isnl'C'CSSilrytodClerminewhelher the palient's chin towaNs his right shoulder al lhe the rL'Striction of the movenlertl is the dominant factor or whether pain IS more dominant s<,m\" lim\" The use of th\" mO\"ement diagram (S<'t' App\"ndix 1) 2. \\\\'herc,lsthcacrcssorymovemenlofpostero-anlerior explain~ lhisdearly, unilaler,,1 \\'erl~>bral presSUT<' may need lobe indin~>d When IMin is the dominant factor, PI will starl laterally when lreating pain; when treating stiff- bt'fon' R, and even if it is R1 lhal limits movement, l\" nessitwiU net'd lobe dircclcd ml>dially. ('P prime', prime being an engin\"\",ring and mathemat- J. In lrcatingpain, lhe techniqucs an' performed gen- ic.. lterm)will be \\'cry high on the R1Lwrticailine lly, slowJy and smoothly. In lreatingsliffness, the abovE'L accessory mo\\'ementsshould,forpartofthetot.,l trcatmenttime,bep<'rformedinaslaccatomanner Whl-n stiffness is the dominanl c!emC1lt, 1', may so a;; to emphasize the impetus of the mo\\'ement to start beforc R\" after R\" or al the same poinl in the th<,o,,<,inteT'\\'<,rtebralle\\'el range as RI, bUI R:/ will be the factor that Iimi15the a\\'ailablerange,whileP'willbealallyle\\'elonlheR1L 4. Th\" strclching technique can be expected 10 cause vertical line above L, well below Rl _ HowE'ver, thE' more dominant the stiffness factor, the lower P' will be sorrness, but thissorenl...siseasilyresolvedby p<'r- On the R2Lverticai line. forming the same mm'emenl(s) as large-amplitude Whenpainisbyfarthemoredominanteiement,the movemC1ltsin thes<lmedirL\"CtionsasthoscuS<'d choice of techniques will be idenlical wilh thai already during lrc.'hnC1lt but this time performed justnudg- descrioc-d above for'pain'. ingal,orjuslshortof,lhelimiloftherange,until Wilhin lhis'pain wilh stiffness' grouping there is lhesorcn\"\",sgoes another method oftl'l\"atingpain, which wasrefeHl-d 10 With this groupofpatienb,themanipulali,'e physio- on page 206-207 bul not dl'SCrioc-d lhere oc'<:au\"\" of its therapislofll-n fails oc\"Cause she is not prepared lobe differcnlconcept.lt is only appHcable when a patienfs firm enough with hcr mobili7.alion techniques painisdirectlyrclaledtolhE'sliffn<'SS,and,tin\\'olves pushing into the resistance until thedesirL-d degree of painisprovoked.lnthede;criptionoflhemcthodlherc GROUP 3 - PAIN WITH STIFFNESS willbcS<lmereaders,indudingexpcriC1lccdpractition- ers,whowill s.ay,'Bullhat is treating stiffncss, not pain'. liavingdbcusst'd the two extrcmesofpresenlation- This is inmrrecl,becau,;e lhC' inlention is 10 provoke a all pain .. nd no stiffness, and all stiffness and nopain- cakulak-d symptomatic \"'\"poost' and the mOVl-ment is we now come 10 th\",third group of patients, where taken into the rL'Sistancc until this Tl'Sponse is achieved. pain and stiffness occur together. This is tm, larg~'St The lreatment movement is notlimiled or conlrolled by group and the most challenging 10 treat. Th<'5<' palien15 lhercsist,lrtcc;iliscontrolled by the pain response. The will na\\·cp.,in,eitm,rasaconstantsymptomorasa following is an example of 1rl'QlillSpaitl by pu,hinglhe pain on movement. In both examples the movements selectl\"dt{\"Chniquefirmlyintothestiffn~'SS. will ha\"e an eleml'nl of stiffness, On l'Xamining thc A man had left suboccipilal pain, whkh <;Quid m\"\"l-ments,lhercwill bea relalionshipbctw\"\",n lhe develop inlo left~idcd headaches. On examination he

208 MAITLANO'S VERHIIRAl MANIPULATION ....as found 10 have marked IImitalion of allanlo-nial be hurt in a rontrol~ rna,,\",\" 10 set the ......Iing rotatlOl1 10 lhe left, and J1'lO',.,mrol In this d'r«loon pr0ces6e5 Ul mot..,... l'erhaJl'l thl5 fact bean 5<>rJW \"'Produced lIwlet\"lsuboc:cipir.olp.oin. '!'hein,rYltn.>al- ....lationstup!Otheml'Ch.ornca1~~tom ment ~ used teduu'!Ul'S described aoo-'e under orderlOstimulalC'uruonin un-urutlllg~Whm lIw ....adingoftreohng 'p.om'. but theydid not: .111'l\"lIw such .. lK:hni<jue OJ being perfunned, tho.patift-ot will piltlenl'~ ~ymptolm 01'\" lTlO\\-ftTorrll signs The d«isio-> oftm sponttneouslv 5.lI\\. 'II'~ hurting bul it's ... na ..'~~ ~1D'lrNtpamb)'tnO\\~,nllnt,ffnt-w' hurt'. Sud> .. rommenl ...........Iy \"'....)\"'5 lIIO'IOl\\S thatlhe The pilrt>c'uLar \"arirty of tec:1Iniq.... dOt\"'J not matln.l rightd>oictoofla:hruquehasb.>orn~,bulproollio!ic th..sw~,~IOSilytNt'I\"~\"smllhimphtudt', inllw~t,OIhe-rp.oonfuJ.~decidedIy ~,OiaI\"torystretch.loo:mz..dto.tl.anto-..ari.llrotil­ ot:;.dtobeinghurt.lfllwfirst5k'f-lJl~\"\"\"1o lion lQ lIw left. The poant of ImpotU~ IS tNt. choose ICdlniquefor IlWtmg 'p.om' do:-;;cri>ed o:a.-bft. .althouW1.~ofstret<h.. ~.pplil'd,I.... ~th arid III pmgn$S to tJwIling pain only by usmg .. Hh- ofllwtll'duuqut'w.llSgw<mttd/lyllwin!enlk,Jst\"\\ ....I). ruquethatJ'l'O''Okap.om.lll;described ~·f',no ..TOt'I8 quabt> and S111t of pain bmlg produad. II w~ not sIe(IS ..·illbO'tabn..~\",norrwth<dofdetennirung ruloob) lIwstrmglhofllwresostanef'm.ny ..•..y.I.11. .........\".1Iw pal......t'S dJflOtder requIre; to be hurilD The goal of lIw treatmenl tedulI'!.... 15 to ehmm.. le rnau;lhell,04hertharltOU!lethf'techniquepn;nolong thai SOl\"\\'enl)-, quallty and 51le of pam so th.lt II \".annol minimaldJ«omfort for \"\"ery britf time arid then 10 bel'l'J\"'l'duced'~neof ...hathappen5lollw ~'t!lefFect(»·t'I\"2\"hours.'t'heref\"..\"thisme..nsthal -\"~ whenfi~U5lJlg.teehnlquethalpro\\okesloo:alpain, When shfffll'liS and pain are l'<Jually domln..nt, il 1. Thed'lICOR1forl musl bekpl at .. minimum. IS ,mportant for Ihl' less experit!nced practitioners ah...·aY'\" 10 IIm,tlhc initialla:hni,!Ul'S 10 lhose already 2. The teehni'!.... must be po....-formed slowly and dl'>Cri!>..'<I fOl'\" lrealmg 'pa,n', It is only wl\\o:.'11 1I\\l'5e fail smoothly with the patient lotaIlYlI'la~ed. to impro.'f' the patienl's symploms or h.. tL\",t mOve- 3. During thc firsl fcw OKiUallons of Ihe technique, ments 11\\.~1 USing techniq\"es for 1~,'ti\"8 st,«(ne.s should beconsidered. When sliffne5$;S by (\"Ihe mo~ perfonnedalaCQllSlanlrhylhmandposHioninlhe range, lhc ITUlnipulati\\'e ph)'liintherapisl must know dominant element. Ihe tec:hniqUl' will be 1M s.'me as .. I If the hurl is onl)' slighl .nd in rhythm wilh the has b..'l'fl dl'SCribed. abo\"\" for 'sl,ff.-'. The onl)' dif- fen'llre'i will be the following' !edmique, in wtuch case the tec:hnique ;s ron- tinued for another 10 S«Onds; if the hurt in 1. IllJli..lly/lfllyl.... ~or phfSiol~l move- rhythm is incrnsing. STOP, ..-.b will be used, not both,f',therbro;c..uw the ..mounl of trealmmtst.>uld blo hrmlo. t thebegm- bl Ifllwlll'chniqut\"isca\"\"\",&anache,inespecli\\eci Jl1ll8.or!M)~toma~~tofl ul.... of whll'thl\"riti~.lsocaUSlng... hllrtinrh,-thm.-STOf' lIwrdlll.~~lIIOn'rff«I...f' c) Th.1ll1wtec:hniqul:itronlm.-1onJyifllwhurt decrnso..'SOI'M11<l'llSuncha\"8'\"d 2.ltl5~r)\"todecidt-whethc-rllwll105tpamful <&. ThI: leduuque G ~furmo.>d. only for a maxunum _ _1 of half .. rrunul\" briO<\\' ni'~g the pabl-..t'. and_~{U:,prirnary)a<n55OI)' oe..r{notatllhelunilofthf'prirnaryphysiologlaJ 5}-mptorns.OO 1IgN. n n p ~ b e ~ O I '. .' h e t h e r t h e l n 0 5 l S.llisimportant!O~thatltlSboItlerllldoonlv piluUul and n'StJicted (iz. pnmary) ph~ _ _a~tdeln'atml'nlandmalo.euseof1lw2-l-Mur ~I\"\"\"\"ldbe~ mentand find thaI nothIng hasOOf'n g;uned, than It 3 Tlwfirrnnessandmythmoftheteduuquesmay ISlodo.httJoolDOmucnand find la!<'r the patient: JlI'lodtob..modJ6edm~!O~the ..~ much wur.;e N.lf an how\" after trwtmenl. dl5o:\"\",fort fell dunrl& lIw kduuque. The dtSCOm- It is lIw 2....hour penod thai is the _ informall.,f' fon feltdunng the perform\",&of the Ieduu,!uc.llt.ll andusefuloflhetypcsofa~t. roostitnt mythm and position in lIw range should GROUP 4 - MOMENTARY PAIN Itos..en. or allNst remain unchangt\"d; Il must not be ..llCM l-d to rontlllue wonet\\lJll; 4. In,\"all\\', a slrelching techniqUl' should nol \"'Pro- This palienl e~po..'1l1\"1\"1Ct'5his pain as a sudden momen- ducea pahent's ....ferred pain. tary jab, which occurs u''C>.po..'Cll-dly. II i$ alw..)'5 assa- riMed ,,·ith moveml.\"t. although Ihe m\",·eml'flt may ClilUCal experience shows lhal .orne struc\"'res lhal besominimallhallhcpaIM.'flli.\"\"ta\",,,,,,thalll\\Cf\\1 ha<'cbeensprainooorstrain<'Cl Il<'l'<l,alsomeslage,to has been a mO\\'Cml'l11

Selection ofk<:hniqu~s 209 The selection of t<,<:hnique under these circum· ceased to produ-ce an acceptable rail' of progress, the .tances is entirely dependent upon the examination techniqueselecled must move tnezygapophyseal joint defining the movement(s) Ihal provoke this pain. The through a large amplilude while its opposing surfaces movemenl is usually a rombin~'d movement and pas- ~re comprcsst.'d logethlOJ', During the performance of ihoo, which includes an aclX'ssory mo,'em,,\"t involv- the I<'<:hnique, if the righl sclL'Ction has been made, the ing din.-et contaci with a palpable part of the ,'er1rora. patienl will be aware of local discomfort. A validating The tn·atment IL,<:hniqUe 5Ck'<:tL'<l is the acc<'Ssory examination procL'<lu~ is that, if the mOVeml'llt is coo- mov~\"TTlenl in the combined position that reproduces tinul>d bUlthecompre:;sioo is gradually reduced until the 'momentary pain'. The te-chnique is nearly always minimal di.traclion is applied, the local diBromfort a slrong grade IV movemenl followed by gentle grade goes (MaitJand, ]980) lIJ movements 10 reHeve any treatment soren\",s A simple example whkh explains lhe features described i, thai of the elderly palil.'llt with left-sid~>d GROUP 5 - ARTHRITIC/ARTHROSIC occipital headaches in conjunclion w;lh marl:L-d ZYGAPOPHY$EAl JOINT 'arthrilic/arthrosic' changes of the left atlanto-axial joint. The ph)\"\"iotherapist, slanding behind the seated The definitions of arthritis, arthrosis, spondylitis and patient, cups herdasped hands o\"\"r Ihe pallent's head spondylosis appear to vary. Synovitis Or any intra- and supporls his back with 1><', thorax. She is Ihm in a articular mechanical innammatory proct.'Ss will pm;- position to rotate his head to Mt and righl (through an ent as a polin-Ihrough-range situation, and if it is to b<' arc of 25· 10 each side) and at the ..,me time gradmllly treatL-d by passive movement lechniques ralher than increase the p,,-'SSure on the crown of his head. olher melhods of orthopaedic medicine, lhe ;,,;1;\"1 selection of lechniques and progression of I\",alment This P,\",-'SSu\", should be gradually increased, unlil are identical wilh those aiready de5Cribed in detail the patient is awa~ of Icft-sidL-d suboccipital discom under the heading of treating 'pain' (p. 205) fort and perhaps even a reprodu-ction of Ihe occipital pain. If the 50\" roLltion is conlinued and the com pre;- The zygapophyscal joint can b<.' responsible for sion through Ihe-crown of the head gradually rt\"leased, Ihe p,'lienl's left suboccipital discomforl and Ihe occip- p\"tehes of referred pain without there b<'ing any pain in ital paio will decrease and disappear. the I'icinity of tho.- L}'gapophysca! joint. In the examin- ation of an arthritic hip that is causing refem.-d Imcc One may liken Ihe zygapophyscal joint 10 Ill<-' fNlin, it will be painfuJ locally ilstress<.-d,and fn.\"luL'fltfy osteoarthritic hip in that it can Prc:sL'fl1 as a very will reproduce the knee pain. Similarly, if the arthritic paioful disorder, having boll. local and refern.-d pain, zygapophyscal joint th.lt is responsible for a patch of Or it -can pres-ent as a stiff joinl which, if subjected to a rt>lelTl'd palO \" stn.'SSt\"d, it will be pamiul locally and sustained and progressing stretch, will dL'ltlonstrate sometimes reproduces the referred pain. SeIL'Ction and pf'O!VCSSion of tl'Chniques art! identic\"! with those lhe rough bone-on-bone 'chinking' noise so typicai of dl>Scrib.'d lor treating the pain-with-stiffness group Ihe -chronic ostl\"Oarthritic hip. Huwever, within \\his category of disorder, there are Iwo further ways in which te<\"hniqul.'S may be advan-ct'd In the laller group, imprm'emenl in functional 'angecaooflenbcachievediflhetl'Chniqueisdirectl-d at strel-crung the din'Clion of movement -causing the functiolMlloss. First way of progressing In the furmer group, where the pain is the problem, selection follows Ihe same pattern as Ihat described for When mobilization has \",ached the limit of its effc-el- Irealingpaitl(p.205) ivenl'S~, manipulalion of the kind that is localized or ernpha~zedattheOf\\Cfaultyinlervertroralle\"l'lshould OISC/NERVE\"RO:;O:.;.T _ beseleck-'d. It must strel-ch the zygapophyseal joint, and should be followed by a repe,'l of Iheend--of-r.lnge When the intervcrtebral disc is responsible for ~:~~~~~n, u,ing both small- and largL~(,mplilude repeated episodes of symptoms, the slate of the disc can progressi,-cly worsen in or>e of two bask patterns 5c:cond way of progressing (stl' p. 194). The first is Ihat it progressively degener- ates and causes symptoms from its own structure, and When the symptoms are believed to be arising from an beocause of Siresses it places on other structures associ- intra-artkular disorder yet there is nO synovitis, the ated wilh the mechanics of the intervertebral joint. The inWa1progression of leochniques is the same as refem.\"d Sl'Cood is that il progresses and herniates inlO the ver- to abo\\'e. Ilowe\\'e', when such mobilization has tebral canal Or foramen and irritatl'S orcomprcsSl'S the

210 MAITLAND'S VERTE8RAl MANIPULATION neural slruCturt$, u<&nR rclerred !\"'In into ttM- And so the lreillment t«hmques are modifM'd and hmb, usually accom!\"'nll'd try' neurological signs and change!>. ad,·anced. Such p.1-h•'.Jl1s would ..oo be tiled 10 aoJopt \",.-enthe p<l5lbon many limes during the d...\" and 1hen'aK'threePn'!iel1latl()ll;,; .asked to atlcmpt some IItO\\ cment Similar 10 tt... mobil- ......en.-1. uw;l disablms srmptoms suffi<:icnt to izingtechnique, ...·,th the Instruction th.lt It !ohouldbe stopped when and if p.1-in is pl'O\\'oled. m(hcate that surg<'n.- 15 contemplated 2. lcssse-'''''''spnptomswhlCh, though .......\"',do An example altt... second Jl'O!SIhon IS b (,,110\\<.·5. A similar patient ma)' not be able to find a $ufh':M\"f'lII) oolpn\"'mtconhnuInRhghtwork- sUCC'eSSful posItion for pam relief, and the~Jonof 3. Chronic remnant!> of l'll'1'\\e-root symptoms. technique under these circums~ may ....ell be to d\"\"\"\"\" \"I!f)' g'-'f'ltk,o traction. He may be reaso.Mbl) SEVERE AND DISABLING SYMPTOMS comfortable lying supIne on thctre,ltmef\\tCOlXh \\\\ith SUFFICIENT TO INDICATE THAT SURGERY his hips and knl'eS supported in f1l'~ion; thl''''' by IS CONTEMPLATED addingthcgcntlcstoflongiludinaltraction,hissymp- toms may befurtlwr n,'lie\"ed (this I\\'S~ may ~an Suchasltuationcan~('xpCdedtoexhibitthefollow­ indication for his t~Mm'-'TIt being constant ho6pJtal- InRfeatuA'S ized traction; <Itt T' 388). The traction. distraction, IongJtudinal rnowm'-'f'lt (or whatl'\\\"\" word is U>.ed to I. Thcpatient's!\",mwillbeworvwithronlinued describe il) is an II<Cl$5Ory lItO\\'ement pos,tion. .100 wcightbearing. cMmOl al...a)s be adequately perlormed by the p.1lient twru.clf 2. Tlw!Y may be an Krompanying defomul)' or h5t. 3. \\i\"\"'mlefltswill rro-'oL,o limb pain uw;l piI\"\"\"'- ....Thede-;cripbonal~lmentb)' traction ~decribt-d the!wt, and U - ma~' summate or 5UIl>f'. in the reIe\\'ant chapW'rS ronceming the \"f'CtKn> of the 4. ~patientlNly\"\".ep.1-ine\\'enwhenlp~bul PoslllorungaOO traction il!i discussed hc-ftoarecur· tM-can prob.tbI~'adort some' position!; tNt a\", ~ rmtly going through a phase of bang rcfem:od 10 lIS p.mfuIthan~,..... mifth\",rel.ieflastsonly. 'three-dlme05ioNltraction' shonhme 5. Then- ...·illpmbablybe.ssoci.1tedneurolOJ;lCal ~igns and neurologic.1 manges. In \",lation to the select10n of tcdu1Jque<, the t«hmquc LESS SEVERE SYMPTOMS WHICH, THOUGH obl'lously must not irTltJte the eX15ting symptom, SEVERE, 00 NOT PREVENT THE CONTINUING This means that a po\"ition ha, to be \"..1,-'(lLod that OF LIGHT WORK rl'hcves the symptoms. and ttM- movement clll)!;<'n must furthcr N!lievc the ,ymptoms Th\" l'SSO-'JltJill f\"\"tures areas follows: Tbc 'position' mal be on'-' th., patient can adopt I. 11>e palient is able to be ambulant for all or most hUTlself. or il may be. f'<)'iit;on that heca.nnotadopl of the da) himsclf. An examp~ofea~h will serve to explain what ;sll1oC'anl, 2. Then-WlllbeccrtallllltO\\cmeI\\tsorpos'tlon;.that poSIb,elyU\"lCl'Ca5ehisrck.-neds)·mptotn&.and ~l\"XiImprol thefirslp05ltionlSapilbent w,tha odrt$th.ltless<Ylthem. left 51 ne1>'e--ruat p.1-tn. Be may be able to relic-\\'e his calf p.1-IIl Wld IaIl'R.I foot tlfl&lmg b)'lying on hIS right 3. Thene It\\lly be no KrompanringdcfonnJt\\ on Ideo WIth both hips and knees flexed. but with his left standing or trunk It'lO\\'ements lnce\"-\"'>Unf':onthebcd.Onc-eheisinthispa>lbOn.w ... lhough It'lO\\'ements rna) prm'oli>,..(erred ,..4toct>on aI the trealmentl«hniquewill be found try S}'mptoms. tIw)· ....ill not tun\" a latent qUollih,or. them.tnlpulati\\'eph)'~pislperformingslow, ifprl'5en!. will be of short duratIOn and not ...... \"\"\" m;oU-amphlude rno\"emcnls m,wy, a rotary dir«llon. 5. Thenema)beassociat<\"dneurologw:alslgns cndca\"ounng to increa\"\" the mon\"n\"\",ts without pro-- without neurological changes volung any discomfort III !he leg. Toaclueve this, small Selection of l,-ochniquoi$, as duectcd by thIS I<md of adJl-,s'menlsmayneoedto~madetothcanglco(thc pre:>en\\;ltion,muslallbea~iated(allcastinitially) mlilliOTl,incorporaling lalcral flexion Or f1l'xion/\"\"ten- with posilillns, diTo->ctions of mOl'ement andqualilyof sinn, It may be found th;;lt rotalioncannot bepl'r- mOl'emenl lhat a\"oid pain. They shmlld prod~lCl' an formed painl~\"SSly, and under these c;rcumstanc,-\"S a impro'·\"mentinthepallenl'ssymptomsandreo;tricted lateral flexion, f1\"\"ion or extension movcm\"nt may be mo..emenlS of both cilnal and inl\"r\\'l'rt<'l,ral joint thcpilln-freernlJ\\·ementthatcanbegraduallyino::reased. structures.. Exilml\"\"tion of spinal mO\\eml\"f\\ts, making

SeIe<:liGnofte<:hniquts 211 p.>rt,cuLu usoe of combining mo,'\"'''''''''' in various Tl\\t,otheressenhalf\\-atun.'Sarelhat; ...a)·~. forms. \\-il.1ll p.>rt in ~la:ling the la:hniq~ thai n.eshould be usro, For example. if a palioentin thl$cal- n.s ..egoo 4, referred pain.l.'\\·1\"I'I wllh ~ dlSl.1Il right di5cogen-ic C7 l>el'e--rvoI disonler. il dennat<lrJW. is rninor.o:lot5not reslrictiKb\\,I>e;. ..nd b<lsic..llyisof·nuJS,;l~\\alue· onl) mII)·befoundthatwhilehei51yingsupine.ifhishNd S. oaminatKln lflO\\\"emmb WIll pl'O\\.ol,e ilny of the andned.aneflc~edfJJ'.LlterallyflexedlotheleftJ(l\" ....ferred symptc:>m5 only if the I1eSI l11oO\\'f'ments aJ!' performed w,th finn O\\l.'l\"p\"-'\"\"'Ure\",nds-usl.\",ned MId muled 10 the left • his righl forNnn s)'m~0m5 6.lfcanaJlJlIJ\\·.,.\".,.,lSa.... ~.tlwYill\\\" dccre_. II(1l\\M'Ct'. if the position is maintainl.'d. the restricted bysttffne!i6 lOIthet-thanby pam. ~'mplomsdo not further decrease, While maintainIng 7. Anyprotecti\\'e'-I\\-pedeformJlies,whid>maybe th~ rommned Jl'OSlt>Ol\\. the manipulalm~physKlItwf'- mcn:_apl5l should gently e.>ch dira1ion of the rom- seen on stand'ngor dunng mo••t'InCI'It. nhibl.1 S1,ffness\",'henrorn'Cled ..nddonotC.lUSl.'an\\' bull'd po!S1tKlf\\. and find the one she should use 11.5 the mobdizahon technique ~pain. MobolL7~ngmtothepall1\"\"\"\"din.ctions\"'IIS1! l e l h e first choice. H(W,'M\"'-, there a.... lirnoeswhen ltus Under these ciJ'cum5tilllCt'S, tIK- skllloo mampulali\\e approadldoesnolproducelhedeSlJed prognsos, Under JW1Y»lotherapistselectstl.'<:hruqut'Sth.llrcproducethe these Clr<:un\\St.ilOCtS,the tedmique5houldbechango.>d pa.li\"\"t'ssrmptorru.. Imt1ool1ly, thoe5e Will be,mnl mo\\e-- lOoneth.llcanbeconlroliedtoprO'..o!.ean ble men-IS, as d~lmet from ,-QI1III mon'111enlS. and will bc minlln.11 d~I\\.'eof discomfort. \\Vhco such an approach detenninro by ......aminatwn mO\\'emenlS thai incorp- is ~1l.'Ck'd. liltle should be performed at the first se.;s;oo or..le various l1Jmbinahons of Iht.- physiological and OOc,lu~lt is the 24-hour rl.'SpOnSethatpro\\'idesthl' i1ccessorymo\"em\\'Iltll, inforn1.1lion upon which adjustments to the t~'Chniq~lc If such tl.'<:hniquesarepcrformedand progll'Ssedto soscl~'Ctroshouldbcmade. being firm in th\" position thai most produces the When Iheso:: approaches fail. thc n\"xt choice should symptoms, dnd yet «,aSI'\" 10 impro\\'e or is still too include moving the Colnal struclull'S. This may be ~low. the tedmiques should be chang\\-'<l to those that ach,C\\'oo III conjunction with moving the intervert~ mo\\e tht.-canalslruclures (asdlshnrl from thcioml) bral joInt. or may be performed with the joint stabil- aodrcproducethepati\"\"I'ssymptoms. ized m a pain-free posItion. The firsl application of the Neurological ch.1nges are nOI. of t1>1:\"1nsd\\'es, .IS leol:h\"'que should pl'O\\'ok\" only the most 10m,mal of some woukl h.l\\-e usbelie\\'e, a COIltr.\"ndicahon to referred symptoms fora \"ery limitro 1I1TW. and an I...... tment by ma.nipuLllion. f'\\;evertheles6, they shoukI ~mt'Ilt after 24 hours then prO\\ide'< the (\";\"\",\",tlal ptm'ide diagnostic informatton, wtuch then p'ems .monI'liltlOl'ltoguLde progression ofthi' t\"\"hniq...... If t..... seIechonofilUlhedetilJls~gthetechruque the d~er has \"\"onene<! in any .....y. the I«:hnique chosen lo....,..tthem. m\"\"tbedlSCOflbnlM'd SUMMARY OF SELECTION CHRONIC REMNANTS OF NERVE-ROOT ~ ill\\\" Ihre.o associated ~uiremenlS for selecting SYMPTOMS Il\"duUques in tre.. lrncnL The first IS\"S follows. llusstalc is not d .....m.iLtr 1m lenns of ....,.. trnenl sdK- A decision regarthng 1iI'k'ctJng the initi.alledutiq.... tionl to reft'fn'd pains ofotherorigins in thespine,bul cannot be made until ~ follo\"\"ng information has with one .....,tial pronso. The chronic disc/nef\\t\"- been dctennined from the eumin.aIiOll of the patient rooIS,lUlIliond h.a\\·eadamagoointen..ert..braldisc as its 50tH'ct'. and h.ls neo'e-rvol involvemenl t'\"\\'en in I. Thediagnos~. the ab<cncc of !jC\\en' nef\\e--root pain. neurological 2. TheprognoslS SIgns or rocurologkal ch.anges_ll istl>erefOll' nc·C'l.'SSary 3. The present deg~ of stab,lIty of t..... disorder. to know th,ll; 4, The manner in which tht.- disorder aff~'Cls the Thchistoryisina,tablcands.lfephasc. pali~'rlt and his daily llCli\"ltK'S. The current behaviour of symptoms shows Ihat S The site of the symptoms and the symptomatic the prl.\"\"'nt.ta\"e is totallyslable, 3. If thcrc are any neurological signs or changes, that \"-'5ponscsassociateLiwitnr\"ngl'Sofmovemenl' theyarcold.,tilbleandcertainlyloiallyunHkdy a)'End-of-range'or·through-range·pa.in. tod\"I\"rioratt' b) So;-\\'\"n:-or 'nuis.mcc·\\-aluc:' symploms. c) Reccnlorchronic. d) MO\\·cmenlsprod~onlylocalpainl·\\'~'Ilinthe presct\"lC('ofrefcrrl.'lJsymplo.\"\"

Tablt 8.9 Principlts of trtatmtnt associat~d with difkr~nt diagnosis I I DIAGNOSIS I ugam(ntsand Mrcl1anical II Inte~rtrl>f:otedi~ capsule blod:.ing Zygapoph\\'S(3ljoint n.~root 'arthritic/osi.' e) Mo\"\"m~ntsproduce rd~r,,-od symptoms lO.shouldthetl\"(hniquebeapalpatoryacc\"\",sory indicating th~slru.tu\",alfaull and its de!;\"\"'\" movement? Should it be performed in conjunction of damage wilh a ph}'siological mo\\'emcnt or position? 6 All 01\"'-\" imporl<lnt ~xamination findings II. Should Ihc tcchnique be prilThuily a ph}'siological associaled with conlraindications, cautions and movemenl,citherin50looroonjunctirlllwith nervecondUClion-takcn as read. olherph}'siological movemcnlSand positions? The ~{>f'ld requirement is to know that Ihe mail! 12 Should the pain-scMitive struclures in the '·ertroralc.. nalandinterverlebr..lforaml.... be BAStC joint techniques are rotatiun. lalcral flexion, movl'<linsleadoftheilltervt'r1roraljoint.orin conjuncHonwilh,,,, intcrvertd\",,1 joinl palpation techniqUl'S and longiludinal mo\"ement ma,,,(which indudl'S traclion), and Ihe lechniquc? IVhat should the pain response be BASIC canal during tru. k'Chnique? techniqucsare str,'ight leg raising and 'slump' tcch- niques, and ULNTs(s«pp. 144and 24<)). Th\"lhird requirement is a dear understanding of Afterlhe initial technique hasbet.'1\\ sclecllod,the the principles of treatmcnt associated with Ihe differ- possible Cffl'Ct it should have on Ihe patient's symp- toms and signs, both during and after lhelcchniquc, cntdiagoos<-'S(Table8.9),which arcdescribcd on pages n\",st becakul\"led_lflht'rcsponsc is not as expt.'Cted, 192-197 the technique should be rcpcatl'<l and,iftheantici' patl'<l rcsponsc i5still notachievoo, lhen an assessml'f1t From a fr.tmcwork ooso-'<l upon the above thrr\"'arcas needs to be made as to why il failed. What wa> Ihe par' ofknowllodge,lh~folluwinglistofthoughtsi5Clln.sid­ e\"-'<l so as to arri\\'e al thescll'Chon of the techniques 1. Howmuchgentlene:;s(Le.relMedtOlhe licular aspt.'C1 of the pati~nt's symptoms and signs that symplOms, the diagnosis and Ih~ ~xamination faik'<l to impro\\-e? Pcrhaps the technique should be findings)muslbec\"crci\",-'<l? rcpeated bUI the pooilion changed. Perhaps lhesamt' 2. Ismobilizingtobelhefirstchoke.orshouldlhe questions listed above should bercexaminl-d,and the joint be manipulated asin mechanical blocking? nextll'Chnique dl'Cid~'<l upon for selecled reasons 3. Is Ihejoinl to be trcatcd firsl,or lhc\\'crlcbral E\\'CTytl'Chniqueusedmustl:>esclecledforaparticu· canallintcrverlroralforaminaslructu~? lar re..son, and Ihe selected tcchnique must be expected 10 produce cerlain chang~':S. If the expect- 4. Islhe problem a pain-limiting movemcnl carly in rangc'lhrough-rangcpain',an'end-of-range' alionsarenotachieved,thereasoncouldbethat pain'problem or momcntarypain? The lechnique was ineffech\"ely pcrformed. 5. Should'opening'theinlerverlroraljoinlbeafirsl The reason behind the scll\"(lion was wmng The communication channels are nol open ~ Ihis consideration? could be the reason why thetl'Chniqul'was 6. shouldlheiniliallechniquesbedirectedlowards ineffl'Cti\\'ely pcrforml'<l Or the rcil$Oning was wrong (refer to Chapter 3) trealing'pain'orlreating'stiffnl'Ss'?(theelcmenls 4. The disorder i5 too stable lobe affecled by the describe<! under'lhe manner of thc Il'Chnique' On particularlechniqueselected,andanothershould p.203). be chosen. 7.Shouldthc~itiOflingandlechniquebeina 'symptomrclieving'direction? 8 shouldthctechniqueprovokelocalsymptomsor rcferrcdsymptoms? When prog= in the p.. tient's symptoms and IJl his 9. Should the lechniquebe de\\'ised around the mo\\'ement signs ceases, a reappraisal of Ihe whole position in which the paticnl Can rclievehis probll'm should be made and the rcasoning behind a symploms, or should il be devised around the new selcclion of tl'Chniquc rCCQru;idcred-and so lhe end-o(-r.. ngeor momentary pain position and processcontinucs unlil a final conclusion regarding movemt'1\\t th.ll provokl'S his pain? thev\"lueofthelrcalmentisreached.

\", Chapter 9 Application of techniques B. C.(with a contribution by Edwards, DAM, BSc(Anat), BApp5ci(Physio), Grad Dip Manip Th, MMPAA FACP Hon DSc (Curtin) (Specialist Manipulative Physiotherapist)) CHAPTER CONTENTS • Movcmcnlpattuns 221 Stlcclionofll\"chniquc 221 • Treatmentasscssmcnt 214 Stqucnccofobtaininglhcdircction 221 Deformity 216 Forrcgularpaltcrns 222 Movements 216 219 Fmirrcgularpattcrns 222 f\"athology 211 • Contraindications 222 • Dr:pthofmobilizations 217 Ncurologlcalchangcs 223 Pain 218 Radiologicalchangcs 223 RcsislanCl' 21B Vertigo 224 Spasm 218 Hypcrmobility 224 • Ourationandfrcqucncyoftrcatmt>nt • Recording 225 • Mobilizationv. manipulation 220 Manipulil1ivephysicthcraP\"l't~nlqu\\'Sarcooly\\'3luablc done at Ihewrong deplh or rhythm. Thechoiceofa naformoftfc3tmcnlifacrompaniedbyaccurate technique and the changing from Otl(l lechnique 10 repeated assessment In t~i~ way the COrfel:t choice of anolher is detcrmined byn.'pCated accuratea5St-'S5ml'Ot tc<:hnique direl:tlon,gradc,sp«d,rhythm and duration of lhc palicnfs symptoms and signs before, during and will lIc madc. Furthe,more,uperiencc in prcdicting aflereach applicati<.m ofa k'Chnique, and from In'al- t~ep\"',ibleOlJtcomeoftreatmentwillllcgained. The ment to treatment. This routine muSI be rigidly a:;scssment shoold take placc lIcfore, during and afw adhen'dtoifthetreatmentistobeobjcctiveandsafeal eaeh ttthnique I~ pc,formed all times. Howcvcr,sarety\"md guidanccforchanging from onc technique 10 anolher are not the only reasons /o.l,lnyproplebeliC\\'elhallousemanipulalion aSa form for rontinually aSS<.'SSing s)'mptomsand signs; il is by oflft','tmL-ntrL'quirL'Sonlyth<.leamingoftechniques this meanS thai the manipulator gaios L'Xperience in Th~i,odo'lgerol<, rnistakP.ot!dCOI</d'lotbl'furtlierfrom prcdi<:tingthcpossiblcoulcomeoflrealmenl tlU't,Ij/IJ. This s.aml,thought is also, unfortunate1y, car- riedmtosoml'ofthecoul'S<.'Sonmanipulaticm-lhisi> When a parlicular lechnique dOL'S not produce any deplorable. Obviously it is importanl that the tcch- change it should berep\"'ated perhaps more finnly.and niquCli musl administer movement properiy, bul C\\'en a ifit slill fails to product' any change Ihen Ihelechnique technique pcrfonned well may do h.um Or fail com- shouldbediscardro. When a palientsayshissymp- pletely if the wrong mOVl'ment is selected or if it i> tomshllveimproved asa result of tn., treatmcnt, or if any of the signs show improvement, Ihe same Ic<:h- niqueshould be repeated, Rcpehlionwould beindi· caledifonlyoneoflhesignshadshownlmprovement,

214 MAITLAND'S VERTEBRAL MANIPULATION pm' Id~od of COul\"(' that JlOIl(' of the ~m\":lIod('f h.ld whcthcr the progn'S!o is Iikel)' 10 be slow [f qUkl been nude \"'on<>, \\-\\1len the S\\\"mplorns 0' ~;lI;ns are progress is p<JS5ible, changl'\" from on<.' techniqUl.' hI INde ...·01\"5(' by a tlrlutique, 'I should not be I\\'fl':'atoo ..nothet- can be made mon' r\"pidl,'. Fore>.ilmp...., ,,'hen Ilmo.(\"\\eI\", ,t may boeallcmploo agam at .. 1a1('F >.bb~of a techniqUl.' is producing ,mptmC'mmt, If il is thought In:oatmenl (mon- gently pem.:.p!i) ...hen. prondro then- thaI W rate of imprm'ement is ~kM'er than mi#lt M poo;sibk',acha'Woracld,bonolllrluuquema~lIloC:n_ n.s been.m I1terat>on lf\\ joult SIgns. il may be w;clul Ca\"'ooOOsl(lboet.th!ninasscssingsym~boeause the r..te of progress. W\"\"\" 11 i~ I..nown that imrro-e- a p;l1>t'f11 IN\\ SoJ)' In..l hi!; symploms.\". \"\"OI\"§C.' when ment \"iii bo'!io\\o1.ol. ,t m.l' bt- .. rung lod\\.mgf'from~ In f.act thto pilin miI\\ be cl a dif~1 .... tUR'. bern\" a m,,\" ,.tedlniqUf'unhlll~bf'mU5o'dlor two or more trolIl- ment ->om. fkll 1«1<,,'9\"\" ~ \"\"hi pron'II reo;ponseto5ln'tdungra~thana\"\"Of\"o\"Ilingofllv ~g <;nnptoms. Furtheo\"quesl1<lrUng ..bout WOfl§O.'t to/lrirtrlfrr:t;<>r_t do/I\"'('''i' tllcl\"'...... , _nd'li\"'P\" of the \"'OOlm,ng s\\mptoms and lht- an',) and bdlll\\' tom:o:Jat-T1>'-\"-.If. iourol t~~ymploms;\"uTlportolnt ('ft\"Chapl~\"\" 6. pp The quostion IS, ho.- mueh unptm'ement In ~ lOll, 120). In such Col5e'5 It is unhkclv th.J1 the ~rmp­ pal.....I·§ signs is t\"ROOgh to Jusbl) ronhnulOg 10 use ~ toms ha\\\" been mad.. w~ if there is no aMOCla\\('(j particular mol\"l~tlon teehmque7 1lus is diffICUlt to d<'ll'OOl\"allOl'l in t\"\"sigm..1t can be thallhen' ..'as .... Ie.1mf'J<cl'pI throush proKtlCal <,xpencnceb.:ased on con- cho>l\\jo;c In symptoms foiklYl'ing the p\"'\" I(JUS I...... tm\"'\" tinu..1 asscssrn<'nt of ct\"Il1!1CS prodU<:ed by til<' tl'Ch- for 2 da~.i1nd 00 the third day win tensity lr1(rea~. It u....ruq.... und\"r vanous conditions. 5ubtl~ du\",\" from must be clarified as to wheth<.>r lhe intenSity ho'i wors- pilhentcanlx'u..,...fu[ h<.'fC too: 'I don'l t1unk thaI \"\"'nip.... l>ned Ill' the arN of .ymptorru. ha\" sprt';ld pt'ripherally. [,ltion you did LIst hme has help<.od my p.. in', Or 'I don't In the c.lst' of ncrYL~rool (or radiculJr) symptoms, the f~~l any bo:tt<,rbutlthinl you',... hitth\" splIl, amI ifyO\\l pal,,,,,t may p...rceiv,; a wor~ning Ix....~u... Ih... inkn- push .. bit hMder I think IhM's what it nl'('(b' sill' h~, incre~>(od ~llhough Ihe pt.\"riph...ral ,ymptoms llwthl'rapislcan.llsocxplo.... thcllody·scapacityto h~\"l' in f.lel di\"'1pP\"~Rod. So we know that Ih~ an.' inform by asking the JMIlent di\"\",tly wh\"lh...r .... signs of n,·wlution. On Ihe 01\"\". hand, if On the th,rd Ihinks a partICular ll.'Chniquc '5 makong him b<.11f'r ror day the Int...n>!t}' IIlcre~sed. further qlle'otioning of example, O!-' may s.,y' 'IthlOk the first thing you did to 'wh) du you thlOk It got worse?' or 'what hapJX-nN m... will gd me bett...r quick...r Ih,lIl lhe \"'-'l:ond t('eh- around thilt tim... for it 10 gel w~r mal\" I\\:...'.al that nique-. Obviou~ly S()rTIl' pali~'Ilts will show .. g..... t... the pat,,~nt performed an unlJsual ...sk/~Mi\\ill prior rate of chanKe than othcn;. 11 has bf'm found to W wor<cning of their symptoms ('ta,t1~nd. 1957) that as pain \"n.-f..'1T\\'Cl inCTNSongl\\ Tlw ph\\'~lothl'fapi5t must d.., f'1op to!-' ~bthl)' to further from lh<' WUm', lreatment tales longer ..nd is a~>4...\",.nd ..·...igh up the ...·.-idencr\"'-n..~td) Ics.s likely to \"'\" s~fuIIT\"\"'\"9.1}. As tJw sun .... summanz..d in thi!. ...blco rons,~tf'd of 220 patients pw- Sf'1ected b) medlC~1 pracl,IMlrlCr!> il c.nnot bf'e>.pectf'd TREATMENT ASSESSMENT 10 be pr<'ciS<\". and II is not IN. aulhor's wish tNt 'I should Ix- acceptf'd as olrIl thIng mon.' than an \"ppro\"'. mate guide kause IN. ~lb from tn'lItmmt of Cl\"l'- Ifrapoclim~I\"'~rdduring~in,ual ,ic..1 snwtrorne-. follow a <orTWWhal -'<imila. pattern. aMI\" ....\\IOfla>'dtn:atmcnt,~changcfrv\"l_ the sun~' an \"'-~p the 'hKlenl 10 know t.o\", mud! tf'C!'l\"~tolllOtMra\"Mmadf:_qlllddy.lf trealmf'f'llaparticularpat .......llTIillnet\"d The rouhlM' of tre.. t\"...,..,t is ..,. follo..-s: w.. iIn~1 osnptdrd.it-.IdMWftIIIg 10 cftang~ frv\"I_ Irdl\",qlJ~ to afl(lthcr unt,1 it is dur I_ Thepat\"\"\"t\"firsla~forlu$resp<>Il5\"lothe th((rdl\"lItuo:isnoIMing~~ p\",,'ious I\"'almenl ~'SSion. The que<tiOl1ing '\" nol as easy to carry out eff~'C11' \"I\" as :son'e m\"\" thinl... Great care must be \",M.'O to a\"Old mlslOt'-\"'PrctlOg Although II has oo,n suggested that Iwo ~ppl~atil)f\\S the patient's words ~nd it is esscnll~llo l,.-, critial of ~ mobilizing t~hnique are suffkien! hI shO\\, the of one's 101\"rpR't,ltIOllS. C/O (compl.. ins of) ~,t...• isk.<; should l,.-, used ,\" ronhn\\l~I ..'alu~tion of the value of a It.'l:hniqUl', this is nul alwa}'s so The whul\" po1li.:nt's symptoms and hiS p\"TC<'l\\\"-..J dis.1bi!ity. point of a~\",-'SslOg between tl\"ChOlqUl'S is to ha'·... a m...~ns wh\"Il.-'by th\"ir effect can Ix· mC,lM'Il.od. Dunng 2. Th\" second asS\\.ossm,'nt COlls;sts of comparing In... the inillal ...x~mln<1tion of a p~tient. thl· phy,ioth\"rapi,t importJnt mon'ment signs with those Ihat were ~hould ns\"'..,, wht.'lhl'r it will bc p',.\"ibl... t\" bring \"\"idl·\"t before, Thcsc findlOgs are rc«>rd,od as s<'! ..l>....... \" ..;d,;.. ,t..,,..\"·,,\",,'i.. \"\"'I\"\"';\"\"\"~\"><\".I; ....... .,,. O<Jt in T.NW-' 9.:J O'/r \"s~~l..sl.

hble9.1 Results of trcatmcnt =Application of tWlniqu<'S 21 ~ Symptom. ~ti~n\" f~li~d A~~rag~ I~ngth of :lUcceuful (percentage) treatmcnt.(dal\"l Back pain: 96 4.5 Withoutprot~etivc=lio.i. 91 6 With protcdi~. scolios;s 95 5.7 Back to b<lttod pain 95 11 Witho\"tprotcdivcscolio~s Withprotcdi•• scolio.i. 96 60 8;ldto lnu Pi',n' Witho\"tprotcetivcscoliosis 9\\ Withprotc<:ti.eacoli~is 50 8;ld< to foot Pi'in: Without protecti>'C scohosi, Withprotc<:ti.escoliosis P'ainwitnneurologlc.lch.nge.· ·Pain.withn.urolO'J.,.ldl.ng.....fcf3bl.toth.thi,dlumbo'n• .....,'ootw~'\"_diffi<ullto ..Ii\"\"\" than ttlo5< fromth. sacr.I\"...... ,oots.nd both of th ... w.\" mo\"diffi<u\\t to r.I' .... th.n w....11 oth.\" of lumbar origin Table9.2 Symbols I Centr3lpomro-.ntcriorpr=u.. (PA.I/wlth.CDindin.tion I Centr31 anteropo.teriorl\"5SUrn (APs) r Unilate,.IPAsonCD -::::: wilh.medi.lincHn.tion L Unilate,.1 APs on the CD T,.nw.rscp\"\"'U\"lowa,ckCD :J A013l>on ofh.ad,thor.xo, pelvIS tOwards (J:) Late,.IIItJ(iontoward.<D i !.Dngitudin.lmo.ement(st3tecephalado\"audad] UniI8ter3IPA,s8Iangleof@2ndrib j Furth., latcr.lly on ® 2nd rib UnilaterllIAf';on® I .J Ce\",iC3ltr.lctionlnn.ut'311~tting) Sitting cr/ lying cr' Intermittent ~ari8blc ,eNlc.1 I ....tion in lOme d~gfC~ of neck flexion, the Nn' Wenglh of pull bcing 10 kg with a J-scrond tIold pe'iod. no,.\"period,fo, Nn/ a t\",atm.nt time I.st,ng 15mlnut5 lumbo'troction 1VCT/IOl/{l\\5 lumba, tr.lction.th. w.ngth of pull bcing JOkg fo,a t\",atm.nt tim. of 15minu'''' n LT30/15 Lumbar tl'3Ction wilh hips and lne... fl~x~d; 15k9 to' 5 minutes LT,rtl5,'S Intermiltentvori.bl.l\"mbart...:tion,th.str.ngthofpuilbcing50kg,w'th MT500/010 no hold pcriOOand no,...tperiod,for.t\",.tmenttimel.sting 10 minute.

216 MAITLAND'S VERTEBRAL MANIPULATION 3. Followingtheassessrnent,at~'l:hniqueischoset1for changl'Sshuuld nUl bcexpl'l:lro in Il'SSthan hvoor reaSOns that should be slated and rt-'l:ord~>d Ihree se,sions. The minimum impro\"em\",'ts that jus tifyrepeatingatechniqueareincreasesof2.5cm{linch) 4. The technique is Ihen performed, and any of forward fll'xion in lheslandingposition.S·ofstraig.h1 favourable Or unlallourabll'symptomatic rt-'Sponsc Il1; raising Or 5-10\" of trunk ur cervical rotalion. during ils pcrformance should bcnot~>d, lfnc<:es- s<lry, the technique wi1l be adapted to the response There are many pointers Ihat may be found on 01 the patient. examinaliontoindkalelhata slow rateofprogresscan beanlicipak-d,andlh~'Sl'mayapp\"arsinglyorincom­ 5. Following Ihe treatment technique, the palient's binalion. The pointers cao be consid\"n>d under the symptoms and signs must be reasSl-'SSl->d in a way headingsdefonnily, movements, and pathology, that will endeavour to prove Ihe value of Ihe tc<:h- niquethathasjust~nused.lftheimprovement DEFORMITY isadequale Ihetcchnique is repeated, but if there is nOladl'quateimprovcmenlthenachangeinlech- The.ea'~Cl'rtainprot<'CliVl'deformities.pam.nsof nique is made. TI1e new technique is applied for movement restridion and 'ecognilable pathologies Iherequirt->dtimeandanotheras~mentmade which, in gener.ll, ,esp<Jnd more §Iowly to treatm~nl Unless Ihe patient's symptoms are minimal the number of mobilizations between assessml'nts is The four points given here relate mainly 10 low lumbar Iimik>d 10 appro\"imntdy four per \",-'SSion, each discogenicdisordl'rs, but can belhought of at other lasting anything from 8 seconds to2+ minules levds of discogenic problems. If the amount of impr<wem~nt f,om a particular se~on 1. Apalienlwhosepainradialestoonelegand who is<:xe«dinglyfayoorabl~ !7$p<:rC'Cnto' bette.], the.e also has a prol<JCtive list displadng hisshoutders is only one inherent danger; the thOllght proC'CSslends towards lhe side of pain (ipsilaleral list)isccrlain 10 tempi the the.apist into doing the same l<'Chnique to be much slower in his response 10 conservalive somewhat more st.ongly or for a longe.time. Howo:vcr, Irealmentlhanifhehadacontralalerallisl whf:npainislhepatienl'smainromplainl,soch cllangessllOllld NOT be made. It isrn.belte,todo 2. A palient who has a prol~'l:ti\\'<-~Iyp\" list Ihal aller- nolhing fo.r48 hours tOStt if the imp,ovcment is nates from side to side is always diffkult to help reta,\"ed[orifoNffimoreimprovementoccu~inwhirn The more easily Ihe sroHosis can be changed, lhe ca5ol'defe.thf:I.~atmenluntilil.eact1esaplatuul.The harder it is to helphirn. othf:. alte.nati\"\"isto rep<:at the treatment without any et>ange to strength or dUr.ltion ofl<'Chnique.or.ep<:al 3 When a p.ltient with low tx>ck pain exttibi!s marh-d lhe t<'Chniquebut fo. 1= time and with I=strenglh sp.,smoflheextensorrnuscl~'SlolimitlhernO\\·emenl of forward Oexion, his c<mdition can he expected 10 It is important to rememM lhatlhere is an optimum be difficult to help. This lordotic type of muscle amount of improvement thai can bc al'hievl-d in any sp.\"m can be bilateral or unilaleral. Clo:asionallya one day. II is thl'refore necessary to realize that the patient is!iel'l1 who has an ipsilateral list combined amounloftrt.'atmenl lhal can be given nt any One S<-'S- with a unilateral lordotic type of muscle spasm sion is limited, and Ihelreatment must lhe.eforebc Whcn these two factors arecombincd. the response balanced if the oplimum advantage is to be gained totll'almenl is likely to bc even more difficult. from changes in technique. This clinical knowlL-dge Can only bl.o leamed by practice under sUp\"rvision. 4. Apalient who has a lumbar kyphosis is usually fairly easy 10 help with mobilization unless lhe Although it is possible to ha\\'e some idea of whether degl'l'l' of kyphosis is in l'xcessofJOO. Under these a quick or slow progress with treatml'nt might be circumstancl'S it is almOSI impossible to help him achie\\'ed,itisnl'«'SS3rytogivesomee\"\"mplesofwhal COrlSCrvativdy unless rest is part of the lreatment can constilule adequate improwment of signs with the successful application ofa Icchnique.1lle following MOVEMENTS figu,,-'Sarenot intende<l lobetaken too literally, and are oifered only asa guide. With a patient who can be t Whl'na patient wilh pain in his back and leg has a hdfX'd quickly thesechang~'Sshouldbe ''''p'-'l:t~-d afler marked ,,-'Strktion of forward Oexion and straighl each k'l:hnique. but with slower examples the same

Awliutiollof ted>lliqUfS 211 k-g raising on the painful side, he is likely to bedif· 3 Palients whose symptoms arise from an unstable ficult la help (Chamley, 1951) spondylolysis or spondylolisthesis arc alwa~~ diffi- cult to help with mobilization. Also, their response 2. A palienl mayha\\'e limb pain, and exlension of his to treatment is not as complete as that of patients n~'C\\..arb<>ckmay ....prod\\lcesomeoflhislimbpain with similar symptoms from otIK.,. sources. flowel'er, if lhe range of extension is mark~odly Functional postural modes must be taught, and limiled and lhismovemcnl reproduces the distal exerci:;esare essenlial. are\"ofthepain,lhef,lhcpalient'sdisorderislikely labt> very difficult to help 4 Patients whose symptoms arise directly from trauma are always more difficult to help oc'Cause 3. Wh~'Tla palient'smovcmenlS in all directions are the extent of damage is grcaler. A parlkular form verylimil<-'<l and lhese mOl'ements produce sharp of trauma thaI should also be included in this cal- pain, then lhe degret' of s.e\\'erity and re>triction egory is lhe posl-surgkal patient who has not respondcdaswelltosurgeryaswasexpected. indical('Stheslown~'SSwithwhichthepatienlcan 5. One particular group of patients is always diffi· beeXpecledtoR'Spondtotrcalmenl cult to help due 10 the type or l.'~tcnt of pathology in\\·olved. Any young p;lIient,adoll.'SceTlt orjuven- ~. A patient Wilh lhoracic or lumbar pain may ha\\'e ile. who has not recovered from his symptoms lhe sign wherc passi\\'e neck flexion is very Iimitcd wilhoUl requiring t,,-\"'tmenl,will always bc diffi- while reproducing Ihe thoracic or lumbJr symp- culttohclp_ Young people have extremcly good loms. The- more the movemenl is R'Stricled by pain. powers of R'Covery, and thercforcalmosl withoul lhc morcdifficull it is 10 relic\\'e his symptoms exception any junior who has pain that lasts long enough far him to have been lhrough medical S. [I is common forpalients wilh gross arlhrilic or channels 10 lhe manipulative physiolh\\'rapist is spondyliticch1lJlgesloha\\·elocaliz<-'<laching.Their likcly to be fJrslower in his R'Sponsc 10 treatment movements, although generally stiff, are nol lhan his adull conlemporary wilh similar signs painfully~trictedbythisaching,Thesepalil.·nts If young pil1ients have any neurological cnanges. are reasonably easy to help. Ilowner, if lhc p.1tienl the therapist should monitor these over a long with these radiological cnanges has a localized period. joint I<-'Sion of COmpara lively \"-'\\:'ent origin, !hen he i.certaintobeslawinhisre!iponsetatrcalment DEPTH OF MOBILIZATIONS 6. A patil'lll having bilaterallydistribul<-'<l pain from hislo,,\"erbackinlobothlegsafsymmetricaldistri· bution and equal Sl.'\\'erity provoked by minimal cXlensionisccrtaintobcdifficultlohclp PATHOLOGY ThfdeplhofthemoOilizationtfehniquewill~ drtcrmint!lbypain,mu!>Clrspasmand'cs4llallCr.and lClin.icalti~:.DUfin9tfea!mfnt,,,,,,,,,,,eneNr.rootpain thfirrrialionshiptoonranolhrr mav\"malnlhr~mcforsevcraldaysbrfo\"lhf pallfnt nOllccs any rt!luctiQfl in his symptoms Al first it is difficult 10 know how firmly mobilizations should be done. Any l\"\",hnique useci for the first time 1. Severe nen·e·root pain is always a canccm in its should be performed gently, SO Ihat the movement responsetotreatment.lnitiallyilrnaybe7-10days produced at the inlervertebraljoint seems too small bcforcthelMtienlisawareofanyk'SSeningoflhe to Cause any change in the p<1tienl's symplomsor pain, lroctolal trealment lime i. langerlhan lhal signs. Genlle technique is particularly important in for referred pain from other sources, Thelll are the prescnce of se\\'ere pain, neurological changes or lhrre \"\"rve roots that 5<'em 10 respond lessrcadily muscle spasm. The- filCtors thai guide the depth at loconscrvalivemcasu\"-'Sthanothe.,;:1.3,whichis which a lechniq\"e i. performed arc the irrilability harder to hclp than S2; and in thecen'ical arca,C8. ofthedisorder,lhe increase in pain with test move- ment. mu..:le spasm. and pathological conlraindi- 2. A primary posterolateral protrusion is always cations. The severity and rclalive position of lhl'S(' slower in its resulls, although it can usually be factors in lhe range of movement are lhe important helped(Cyriax,I982). guides

......218 MAITLAND'S VERTEBRAl MANIPUlATION PAIN RESISTANCE I'''in on movement is perhaps the m051 important IVhenaresislancecanbefellthechoicl'willbelx1wren guide to how deeply a technique should be performed. a largl\"- or a small·amplitude moveml\"Tlt (grade 111 and and pain Ihat is localized to Ihe vicinity of the joint IV, see p. 175). The small-amplitude .trong\"r movc- must be co\"\"idered separalely from ~ferred pain ments are used in the treatment of l'lld-of-range palO Whl\"fl the pain is localized 10 the joint. the mobiliza- They tl'Tld to producl' local soren('S.S. but though this tion should be don(> in the range that i. pain fr\"., but grade of movemenl may be ncceosary. larger ampli the movement should be carried up to the point where tude movements willlcsscn thesorencss. Large-ampli· pain begins. Where pain is felt al the beginning of the tude movements are ust.'<l when pain is felt through a range. the mobilizalion must be performed with \"cry large part of the available range and if pain is felt small rhythmi<;al movement. (grade t set' pp. 174-175) through range while Ihe l'Ild of rangl' may accl'pt >orne As this technique increases the rangl' of p,'in-fn\", O\\'er-pR'SSure without discomfort. movement, the mobilization Can be performl'<l further into the range (grade II). A .tage may be reached when Small-amplitud~ m~m~nts will IX u~d in th~ il is necess<lry to carry the mo,'ement into the pain to tr~atm~nt of ~nd-of-rang~ p.ain. Som~tim\\\"S tr~atm~nt reach the resistance. This is nL'CL\"\"\"y when progrt.'SS ~n=can IXI~n~d by 13'9\" amplitud~ ~m~nts with this lL'Chnique has .Iowed down and changes of tcchnique have nol effccted progress Car~ m~st IX gi~n wh~n a mobilization t~chniqu~ Whm a patil'J1t has pain in an arc of movement, or if it produ= a pain that is ref~rring \",to a d,stant ~m~fil i. a cal<:hing pain. the mobili7.ation chosen should be and a~Sl'~~m~nt m~~t IX scrupulously rel'l\"at~d performl-d in a large amplitude (gradL'1I or Ill). Greatl'r caR>;s necess.uy when a mobilizing tl'Chnique To summarize, severe pain must be handled gently produCl'S pain that is referrt.'<l into a distal segment. To and movements must be small, without provoking begin with the mO\"emenl musl be performed in the extra discomfort - usually grade I. WIlL'I1 the\", is very painless pari of the range, and a ver)' careful aSSl.'Ss- little pain but there is restriction of mov\"ment, I;rade ml....t should be made of its dk'Cl immL>diatdy follow- IV movement. can be used and in fact are frequently ing Ih\" tL'Chnique and 24 hour. lat\"r. Prodded the the only mo' ..menls thai will hdp. Gl'ntler grade III symptoms or signs have not oc,('11 made WOThe. th.. mO\"emL'I1ts will \",Iieve any local soreness produced tl'Chnique can be repeated. It TTh~y L·VL.... be nL'CCSSilry to by the grade IV mo\"\"ment. increase the movement minimally to Ihe point where discomforl in the refl'T1'ed area can be fdt. Assessment SPASM must be scrupulously \"-'P'-'\"tOO. While performing a mobili7~llion Ihal does cause distal discomfort, the There are many varieties of muscle SP.1Sm. but the 0\"'\" physiotherapist mw.1 continue the technique at a fixed referred to here comes into cffl'Ct in rl'Sponse to pain amplitude and position in the range whilst as-SCS5ing When a mobili7.ation produces a 'luick musclecontrac_ anychangc in discomforl.1f rcfl'1'1'\\'d symptoms increase tion, the technique mu.t bt' perfomled mort' slowly without any increase in technique, the amplitude and and at a depth that avoids the spasm. If pain is used as p<\"'ition in the range of the mobilizalion musl be the guide to the deplh for performing the lechniqul', ,,->duced. Assessm\"nt o'-er 24 hours. or on Ihe day fol- spasm will be avoided because pain starts earlier in the lowing a furlher b....ntle mobilization in the saml' range. range than Ihe spasm. As the sig\"\" improve, the depth will ell'arly show whL1her the llXhnique should becon- at which the mobilization is performed may need to be tinUL-d. Frt.'<)uently it is ncce>sary to provoke discomfort increased to a point in the range that fails to provoke \"ery gently to producl' an improvement in movements spa.m. Because mobilization can dfc<:t prompl improve- and subst.'<)uent lLosSO-'Tling of symptom •. mmt, an occasional oscillation .hould be laken further into range to elicit spasm to en.ure Ih.'tthe technique Wh\"n pain is found 10 be in the last quarter of the is being performed deeply enough. Careful technique range of the mobilization it is likely that the tl'Chnique in this way can be eXp'-'Clcd to produce quite rapid can be taken through pain, whether it is a local pain or increases in the range of spasm-ffl\"l' movement. The a referrro pain, up to the limit of the r\"ngeor up to any presence of such spasm in a patient i. not a contraindi- physical resistance that may be restricting mO\"ement cation to mobili7.ation, and in facl the opposite is true; Ihe tcchnique to choosc is the one Ihat would cause the protective spasm if done too strongly.

=AppliationofttcllniqufS 219 Musck-spasm t1wt lirrub. r;u'l;lIof m(n\"l!IJ>mt and is andsigns ..\",not-W\\-.,re,muchmorecanbedonl'tIwn .J.. n!lf\"l'Sl\"'I ..tthatpomtmtherMlgC.no ......tterhow if the ~ene is tilt- ColSe It should be rernt'mbercd, smtl,ar~-lytheu:duuqul'isJll-\"l'furmed.isspa5ffiot holO'I\"\"'-l\"I',thatlt1en'lSitlophmumthatcanbeachle\\-ed OlOOlher land fmm t1wt de5cribOO ......, T<rllniques in ..t itly one Im1lmrnt, and to contInue mobLl17..Lng a lINiment an 1M' done as de5cribOO abm..\" up to the joIntbto)\"OndacefUU\\lengthoftunewillcaU!le<f'lCTN5l'd poinl\"'~spasm begins. r.;..tu....Uy .1l5f\"'S\"' mUSI be ~imd \"'Sressoon_Ob\\oousJy thisopbmum will re;pec1ed.butlhlS\"\"nel}... tuchissostrongtlwtfuT· '-ary wlU1 d,fferentlOlnt conditlOflS, but the.rnount of tlrr 1TlO\\-emerl1 IS preo.mted. must ne\\er 1M' forced_lk Im1tment IS ..pproximately thM' or four moblh.7.aborl!> spMm described In the foresooos pa....graph. oo..·e-er. of a joott lasbng approumatcly JO -..is each W,th an 1M' \"\"oldl'd If ItK\" techniq..... is done mort' slowly or ClCtrcmclypainfuljolntrooditionsthisshouldbehahcd. g.·... tly.Noatl~'lTlptshould\"'erlM'mi\\{Il'withanyto:h­ ~nd when symptoms and signs are mmimal It c~n be roque to force .. w~y through 8piI,m, Thi\" can 1M' con- Increased fusl'dw,ththepatirnt'silCt;ve'holding'orre>islinga Tre,1tment must beM,ffidently frequent to be able to mo\\'em~'Ilt 1x'C~usc of p~in. In this sitWltion, k<'l.l' the aSSl'Sschangcs Il.'Sultinjo;from thl.-' tl'l'alml'llt so as to mobilil.illK!lhort of pain and occasionally in<:rcasc thc a\\'nidthec()mplk~tionscreatedbythepatie-nt'5intcr­ depth of the tcchniq\"\" to test whcn.' p\"on begins. ve-ningact;\\';t;<.... Forthisl'l\"aloOn,iflhcp\"tirntask$ 'Should I continue !;Ik'ng m,. tablets?' or 'Should I cui All ~ ~utcml during a ~_nt muo;tbo: dO\"'n on my actl\\Ihe.7\", the physiotheraplM should ~~, hil'ldkd gmtlyand _bo:fotm SiI)'. 'In the inihal st.a~cs of treatment I wanl tn aSSol'SS, l5e\"\"\",I,..\" leaR. thecffuct of my trc..trnent. With thlli thought m mind, ronhnue domg what\",-.\". ~'OU ha,t' been doing sotlwt I will ha, ... a better rn.nc..of N'lhng DURATION AND fREQUENCY Of that ..hait\"\\-er changcs take place olre due to what' am TREATMENT d<>mg and not 10 whal you hi'·... changed doing or not domg..as the C.i!iemay bco' n.e amount of t\",.lInent that ca.n bo-' g...en 00 the fir<t Ifln:at_ntispl'rJl(tUlhngjoonI5On:nes50f,fthen: d.lvshouldbecons>dered!it'J'i'ralcl)'fmmthatoisu~ isnoimprovt:_ntovt'anumbc,oft'Ciltmcnl ~sion~then\"~i1tlll(ntmlghtbcdiscont'nued qut....t t,,-,atment sessions. On the first day, a fulll'Xam- t~mpo<a,ily in order to decide whethe, l,eiltm~nt is hilvmgilnylong-te,m eff~ctso,nol in.ltion of the p\"lirnt and any treatmt.'Ilt given ..dds 10 thelo.ldbo.'mgl\"\"erteduponwh.1tI5presumablyafuult), ,truct\"I\\', Abo, the first stretchm,.:; of a jomt ~ppear5 to cause more reaction than !lubwqUCllt stretchl'S Tile du,ation of tilt: fint lJutm~ntscwon 5hould bo: Fl'\\'Cluentl)'\" stage may be reached in treatment when it isd,fflCUlt 10 tell whcther It should bo-'contonueaor Iesthan~ttmot~lS.~tllcfint!>tn:tclling stopped._ The difficulty of ol$SeSSlTIl\"Tlt may be becaUSl\" ofajoontaPPfil\",to<:au5l'mon:n:ae:toonttlan sub5tqUoCftts~u:t~WilhUlis\"m\"'1.l.adtq. . . t ( tll'atrnent is perpetuatmg jolnl 5Of'\\.'f>l!SS, or \" IN)' be _m'ng of, tmoporoory~_In symptolllS5houkl b«'aUSoeasta.gehasbeenrcached ..'henassessmenl bfpntothl:P\"'!loentafte-tl'IefitstfJratlMrlt~ from treatment 5eS6ion to treatment -.ion does not 1 M d u. .t_oftln~tatwb5tqUoCftt~ cunfy the effecti\",,'rle;6 of the treiltmt'flt techmques. ~OI'\\'~lotl'lePft\"l'lOllStn:alfM<'ll Under \",!her of these CIINI'I\\StUIn5, ImiItment mig.hl weUbcdisrontlnuea tcmponrily ..nd .. ~I 1l'Il\" n!'!ol davs tre.. tment therefore should Ix- less In mad... on 7-14 dOl).,., Drpendlng on whether the SIgns n;ogard to tht- number of mob,h7.ahOr\\S glH'Il. ,\\1 the ha,~ sno..'Il further ,mpll)\\ement, m-.tmerot mayor end ot this first lreatrnent thef'i'tlrnt should be gi'-rn maynotneedlobere-instotutl-d ad{'(juatl'wamingofthet\"mporaryin<:reaseofsymp- There is one fi....1point lhat occurs qUIte commonly loms that m~y follow, to allay (e,lrs thaI can arise (rom ~n uncxp<,'Ch.-d increase in paUl. Th... number of mobil- and should not be forgolt<..\". A pallent m~y be treated izatioll5lhatcanbegi\\'rninsubscqurntlreatments 0\\,('1' 10-14 days without producing ..ny nohccable dcpends on the reaction to thl.-' p\"-\"'ious sessions. If thl.-'re is no I-\",due rea.ction ..nd the piltlcnt\"S symptoms chanKc in symptoms or signs. A 2-w<.-ek br...ak from treatment is then ad\\\"iSilblc, lx'Cause there arc tim5 when th.,impro\\'em<''f1lisc\\'idenlinthcthirdwcel. This h.1PP'-\"-'S sufficiently often th.. t ib poss,bihty should not be forgottom. The pallent should thcre-fol'l\"

220 MAITLANO'S VERTEBRAL MANIPULATION beasl.edtole!q>honea\"dreporlanvcl\",nge.othilt In\"\"\"td,nicalcirro\"\"llfItt$,symptOlMonM ~\"I'It and ad\\ke can be formulah:.'d. With lhis ,dicvcdby mobil,ution w,thOUI ~tng lo~ to thoughl in mInd, it is a good policy for reft.'lTing doc· .....nipulottion lor.;lo\"\"\"_p;>llents2weeksafrertreatmmlends. Such llmltlgs\"esa mon\"aceuralt' iIS5t'!i6fll(\"t oflhe eff\"\"'t 01 the lreumenl II is 001 at\"\"iI}'\" pa!i6iblc. nor IS It nece5Wnh ....1\\ ....:Iblc to ..im for n5to.-ation of iI full range ollllO\\ ement. For MOBILIZATION V. MANIPULATION ex;ornplc, in the p~ of deg~..b\\e or ..rthnoc changes or when;odaploH' IShortcningh.b taken place Man,pulotl>On ft rardy dIcMn 111M begtMtng of In~topostur ..l~ormit~,itwil1beimpo:>osoi- lruttntnt, _and~,nly' _ in ~ of a wry bIelUl'f'gIin the full rang... (l/mo mml that ..·oukl ellist in ..n unaffcet<'d sp''''', Alto bmttahonof 1J'lO\\~ Pf,~MjoontOf~~ ment rna) be present to prolO!(\\ an <Jtheno...... unstable ItftIOIll<nal\"'kno:Yl:l' to Ihn.r.;t forciblythrougtl lnteo·ertcbral;Oinl.llisnot ..lwa)\"Sinthebcstinlerests of the ~lient to continu... m.Jnipulall\\{' treatmenll prol~M~ mobiluahOn or TNmpulahoo te<:hmques ,I' an t'ffort to produce a full ranJlc of mo,·ement beyond the stage TlW' qu~tlOll now ariS<'S as 10 wIlL'\" mob,hL1llon '5 where syrnptnms h....c been .....hc\\'ed, In priKticc, uSl.odand wht..'\" lllilnipulahon is used. Man'pulalion is appm~imate1y Il5 per <'Cnl of pallents succes.fully ra\",lychu!.enatthe~inningoftrcalml..\"I'It,andccr· treated will \"\"'jX,nd to moo,l'/.ation. I\"a\\,,,,g 15 per tainly nen\"r in tht'prcsen<:eola very pamlul to,ntora ccntrcquiringthcstrong,,\"manipolah\"l·\",,,hniqu~. jooint whose mo\"ement i. protO'>Cted by muscle spasm. I f m \" b l l i 7 . a l i o n i S b c i l \\ ! \\ u . . .'dsuc~fullyi\"tf'Cal­ On\"ofthccardinalrulesoftrcatmcntofpa~.,ven'O\\·e· ment, Ih\" patil'l1t should shnw marked impro\\'ement mcnt is that a movement must ne\\'erbc forcibly thru,t within4-5day5.llowe'·...r,ifthcrehasb.'Cnprogn.'S5 through pTote.:h\\c'pasm. Manipulations are usuallj bUlithas\"otMnasgl't!atase~pect,'d,thenmanipu­ progI'CSS,ons from mobilization. that have i!lCr('a<;l'd in lation ,hould prob;ably form pilrt of the lreatment. 5lrength and shown clearly that further incn.·a>c lS ....'.U'§- Und...r these circumstallC'ei thoc treatment would rom- ha\"\"sary. Gradl'Sof mobili:tahOll5 meJ'lC\\\"with mobihzahoo, ,,'hid, would be followed by been discussed (Itt maIUpulation and then completed by more mobiliza- p, 175),ao<l a marupulation is similar toa grade IV mob,Ii7..bon in amplitude and J'O\"'!Jon in the r..ngc; it hon.Similarly. man'pulatoon might bcuS<..'dasa fore- difftlS only in speed. A grade IV mobdlZallon is an numer prior to thl- admtntSlr.ll;on of traction. Un<Icr OKilLiotory 1nO\\'.......\"t that lhepa\"\"\"'l(oUt p.....,\"\"t if he the;ecircumstal\"lCellll5lnlendcdthatthe~ choose todo~, ... hcreasthe lnO\\'m-omtoftheTNflIpu' O1O\\ement obtai\",..:! by the mampulallon \"'ouJd asIIl5t tlw efftocti\\·cnes5 of the lracloon. So 'I can bf'set'll th.u LiotionissoqulCk,tcannotl:ocrrl\"\\'ent,..:!bythe~hent. marnpulation TN) be ~ 5l':'p;&ralcl)· or in ronju\",,\" S«:.louse then' is thIS linlbetwl'ft'l tlw lwO~utt\"J. itisperlwpsanad,-antagelUconsiderTNrupulation. lion with mobilization. ag~Vll\"lO\\emmL Manipulatiort differs fTom mobilizatiort in its effl'd on oUt inlerwrtebr;ol ;omt. If ,t IS done \\igomusty. It A man pulilllon ~\\I\"\"liIr 10 ilgrack NrnobiJ'U!lOIllR must \",,\"'e \"iOlT>e trauTNItc ~ The!ls<5Ue rPaction amllhllolkand~llOIljnQ.l . . ~cl'~rtnctlltS fromthelTauma infIuenreslheltwlTnl'ntplan.-\"1udl ,nIMi9t'tcl nonn.aIlyaims.tprodudngthequicl.cstrcsultJ'05&iblc wlthlhcmtrnmumdlSOOmfoo1tothepa\"\"\"'I.AsajoUtt should not be mafllpulated unltl;o\\lSOf\"-'OCSISfrorn I'f'\" vious man,pulahonshas gone,lI may not bcpossible to One of thoe ocrasiOll5 when manipulation might be manopuJateunt,12-3da)\"!'lafl...rthefirslmanopulatlOn. u.c.\":! early In tre~tment IS when ~ stiff and almost pain- ThissorerM!SS tends to iocll'aSl', and ,tcan rL'Sultmil le-<sjooonti.responsibleformmor.ymptom•. llowe\\'l.'f, b~akof4-5 dars bcfore the third manipulation and whcthcr manipulatIon is used Or not w,ll depend another:;-7da)'5bcfon.·lhe fourth manipulation can be partly on whdher it isbclie\\·ed that an allempt must g'~l\"O. Howe\"\"r, ,t should 1'01 take more than four or be made to incwa-e forcibly th... ran8l' of mOH'ment of five manipul\"hotl5 to flam the maximum possible the joinl. In most circumstanel'S, the ~ympwmscan bt> ;mpro\\'ement in Ihe range of mo,·\"mcnt of a jooint. By relie\\'ed by mobili1.atio\" without ha\"ing 10 n.'SOrt to allowingtheson.-ncsstosubside,progrcssmaybemore manipulation. accurat...lya_ _odAhhollghsymptom••houldbethc

AjlpliUlionoflt'dlniqun 221 ultimal\" guide 10 I\"\"alment. intervertebral mO\\'t\"I1K'Ilt 1Il the symptoms may appear in an appan-ndy random 5hould be ch«ked each tlII'l<' for imprm,emmt. 'asluon. Crxk-like 50UndS coming from joints of the spine When choosing the teclmiqU<', care must be t.11cen may be ~ard dunng marupulation, but they art' only thatlhl' correct grade of ll'lO\\'ement IS chosm in rria- of 5l.gmfic~ In truotment when the joint is being marupulated 10 ft'StOft' ,ts ll'lO\\'emenl When then' is tionto~..\"roducbonofpa\"\"spasmorft'Strictionof almost no ll'lO\\erner'lt in an inkn-ertl'bral joint, early mo'..ement (_ Chapter 8) attempts 10 manipulate it will po56ibly produce lillk mon'thana forri~stR\"tchon lhI'joinl ~er. MCJSI examm.at>ons of ~ (ftV1Ql. thoracic ;on,d \"'hen the ll'lO\\·~thas imprm-ed a little, the marupu- lumbar sptnal joints ..re c.uned out U\\ the upright po5i- Iabon is ~ likely to produce a 'crack', wtueh md,- han. Howe'l~ most ire.1tment IKhniques a.., done catl5an ,1'lCf'NSl'd rangeofll'lO\\ement_lluscrack is WIth the pabent prone,suptne or III side 1Y\"'@;.Becauw difft'T\"l\"nt from the tearing sound associ.ated w,th of the a1ten.d ...\"'-ght drstribu!JOrl and posibon of c........ lUplunngadhe!i1OM. structure ..'hen .dopbng the posotions of su~. prone or side l}'ing. there may be lIOl\"l\"W alterabon II\"l the MOVEMENT PATTERNS pam response when the wme fflO\\·enwnts are com- pared with those in the upright po!\"hOn. It is impor- by B. C Edwards, DAM, 8Sc (Anat), BAppSd (I'hysio), tant.lhef\"efore, that if the h.-.:luuquellitObotchosenthat Grad Dip Manip Th, MMI'AA, FACI', Hon DSc produces partkular symptoms III the upright position. (Curtin) (Spedali.,t Manipulative l'hysiotherapist) the treatment position adopted must bot adjusted to produce Ihe sam... signs and ->·mptoms. Within the palterns of mon'ments describ<.od above, parts of pattems call be p,,-'so,nl. For example, im.'gul;lr T1Iftl' a\",two alll.'mahn'S: patterns of movement, whkh may be the result of 1. Examine far pallems af m(.... elllent in the position trauma, m.1Y h.lve regular paltems or 1\"\"\"\" parts of \"'gu- in which the treatment is to be carried out lar pilttems of mo,e~t pn'sent. This ml.\"alI$ th.:Iteven 2. Perfo\"\" the t..,atment in the upright position. when imogular patterns of mo,\",,,nenl a.., found during eununat,on of a paloenl's DlOVl\"lIlmls, thought must SELECTION Of TECHNIQUE be glH'Il to deciding wht.other they han, an)· It'8uiar pattern components that ll1ily be forminl; par1 of the There a.., basically two tyre' of pas.!'i'·e mo'-ement trregUlarpattemand thereby indicating a ~I<! ~ular romponcntto par1 of lhI' patient's Wsordt'!\"_ tecluUqucs; ph)\">iological and accessory. r-.OI only may The I\"t'COgJ\\IUng of ddterent p.lttcms 01 mm'('Tll('Il1 the physiological lIlO\\emcn15 be rombined, bUI also canllSSl5lmpredining' the accessory lI'lO\\·emm15 may be done III a rombmed phY~lOlogical J'OSII>on. It IS us~11O find With regular • The ft'Sult of m?atment pallernS that the accessory pro«<lure of,say. p0stero- • The manner In wtueh the S}-mptoms and move- anterior unilateral \\,ertebral pn!Sl!iure will bot found 10 produce most symptoms when performed In the com- n'Il'nt sop may imprme. bined position that produces the lI'lCrNSol'd symptoms than \"'hen done in the IlC\\Itral pos<UOn- Hm.......... \"ith Regular p.alll'-rTllo of mol-..mmt lend to rt'Sfl'Ond 10 Irregular p.lllems this may not be the case treatmenl In such a ,,·ay that the least pamful ll'lO\\'('- Thc rocognition of regular (or Irn-gular) patterns of ment ,,·illlJl1rl'(l\\ebeforethe most painful. Foc~mple, mo'..ement can help III the se!«hon of tecluUque_ The if nghl lateral fleXIOn of the cervical SpUll' in neutral asp«t of Irrltni<jue in whw:h rombmahons of D1O\\-e- produce the patient's right suprascapular 'ossa p.ain and th,~ pain Is made worse when the lIlO\\'ement ill menl~are, done in e>;tension, tllt'fl right lateral flexion in neutral will Impro'·e before right lateral flexion in ext~'IlSion. I. The seqUl'l\"\\C(.\"of obt.;:umng the dll'KIlon 2. The direction One can also eXpec1that the t..,atment t~\"Chnique of rightlat\",a] nexion done in nexion (found on examin- SEQUENCE OF OBTAINING THE DIRECTION ation 10 be the painl~'SS position) is unlikely to make the symplOm~ worse II is important to assess accurately whIch mo\\'ementof the examining mo\\'emellts is the significant mO\"l.\"menl The .-.sportS(' in the case of irn'gular patterns of either in reducing or in inc~aslng the symptoms. This movement i5 not as prcdicl-'lble, and the impro\"em~'Ilt can beconsiderft1 the prImary movement of the exam- ination. For eumple, i' the patient complains of left

Icgpain l'xtending down tothl'calf,thl'calfpain ls on the righl side of, say, the C4!5 interlaminar joint increaSt-od when the patiL'Tlt extends thl' lumbar spine, will produ\"\" maximum symptoms when the cl'rvical ilnd other mo,\"ements of the lumbar spine do not alter spine is put in th\" position of right lateral fl<'xi\"nand the calf symptoms, then exlL'Tlsion may be considenxl rightrotation.lfth\"unila~ralpostero-anteriormoH~ to be the primary mO\\'ement of the examination. When menton th<:>right is the primary finding it would be using combined movl'ments, one l'xamines thl' df('(t used as the treatmenl technique, starting by perform· of lateral flexion to the right and left pcrformLod in ing the t<-chnique in neutral and progressinS 10 th<, extension. If,forexample, left lateral flexion done in mOO;lpainfulcombinL'dposition. extension incrl.'asesthe left calf pain. it isnccess.uy to asSt-'SS thl' effl.'Ct of doing left lateral nexion first and FOR IRREGULAR PATTERNS thl'n performing l'xtension. and COmparl.' this with doing extension and adding in left lateral nexion.The Thedire<:lion of movement chQ5en for irregular P.1t· differcn\"\" in the S('(jurnC(' of thl' mO\\'ements may be terns of movement would similarly be the most important in terms of the rl.'production of the patient's painful dirl.'Ction of movement donI.' in thl' least symptoms, The technique of extension may be per- painful way, or, If lhedisorder is one of extrl.'me pain formed in left lateral flexion, or the ll.'Chnique of left or high irrHability. the least painful direclion of mo\\'e· latl.'l'al fk'xion may be performed in extension ment would be used as the ll.'Chnique in the least painfulcombinlod position. !lowever. if combining of Similarly, in thl'cervical spine if flexion is thL· pri- movements is not pdrt of any obvious pallern, the mary movement producing, say, right suprascapular chosendlrl.'Ctionforlhetrcalmenttechniquewouldbe pain and this same pain is incrl.'ased when left rotahon in the least pamful dirl.'Chon. Fore~ample,onexami­ is addLod,it isnL\"Cessary toaSSL'SS the effL\"Ct of perform- nahon right lateral flexion produc.... right supr\"scapu· ingflexion first and then adding rotation. and compare lar pain and lhbpain iseas..od when done in fll'xion this with thedfl.'Ct of performing ldt rotation firsland The chos.:n dirl.'Clion is right lateral flexion donI.' in then adding in flexion extension, However. the resp\"nse to treatment will not beaspnxlictable The direction Performing the technique in theleasl painful pos- Thedirl.'Ction of mO\"l'ment refers 10 thedirl.'Clion in ition may improve the most p.linful ex~mination which the oscillatory procLodure of mobilizing or the m\"\"emenl-rightlat\"ral n\"xiondon\" in flex;\"n, On thrnst of manipulating is pcrformed,and it ili the last the other hand,the mOVemL'TIt of right lateral flexion movemenloflherombination done in extension mar deteriorate. In other words theremaybearandomresponSL'tolhet('(hnique FOR REGULAR PATTERNS When a patient pfCS('nts with regular pallenlS of CONTRAINDICATIONS mo\\'ement. the tl.'ChniquechoSL.... is usually the One that is found on examination tobc the most painful din\"Clion of mo\"ement. but ilisperformLod in the least Iti,a cardinal rule that movements muSl never be painful way. For example, a patient has right supras- forclblvtnrustth'oognprote<:ti.espayn cdpular p.1in and on examination right IiIteral flexion of thecef\\'ical spine rl.'produceslhe rightsuprascapu· lar fossa pain; this pain is made worse when the mO\"l~ The possibility of serious damage !'bulting from mentofrightlateral flexion is done in extension and manipulation. particularly cl'rvical marupulation, IS cased when it is done in flexion. Similarly, if right lat- often emphasized when this form of treatm<'nt is dis- eral flexion is sustained while producing the right cus>ed. Although dealhs have occorrlod (Smith and suprascapular pain. then the pain eases when fle~ion Estridge,I%2),itmustbert'ali~edthatifthenumtx>r isaddl'dandmcreaSC5whene~tensionisaddl.'d.When ofmanipulationscarriedould\"i1ybylaymanipulatoTS each of thL'Se mm'ements is done in extensi\"n th\"pain is rumparLod with the mortality rate, the danger is isworseb\\'titiseasedwhenfle~ionorrlghtrotationis extrl.'mely small (Brewerton, 1%4). Coupled with this performedinfle~ion,andisprogressedtoperforming is the fact (Liss, 1%5) that similar damage resulting in the mo,'emenl in extension. death Ciln occur with daily activiti<.,;. V\\'ith cart' of Similar principles can apply when usingacee..sory applicationandtheconlinualasses,mentofthepdhenl's movements. Considt-ring thcs<~me exampt~a, above. il symptoms and signsadvocak'd in lhisbook \"\"rious will bcfound that unilateral postero-anteriorprcssuR' damage is almost impossible. especially ifit IS realil.l.'d

Al'l'lk~tion of technIques 223 that patien15 with 5Crious pathologkal cooditions are two nerve roots, but in the cervic,>l spine only one excluded from manipulative treatmt'nls by the med- ncn'e root can Ix- involv<.xl. Theref~, a patient with kal practitioner. ann pain and neurological sig\"\"attributed to two \",,\"\"'e roots has a pathology that is a contraindication to manip- Tncmanipul~ti~physiothcrapistshouldalwaysask ulation. Disturbances of bladder or bowel function or perineal an,'esthesia are similarly contraindications. thequcs\\ion,'Canldoharmrlhroughoulthc e~~miniltion ilnd trcatment process Cord signs are also a contraindication to ,>ny form of fOlU'ful manipulation. Very g<''f1tle mobilizing nlay There are many considerations influencing contraindi- be quite sail'. but it is unlikely to be of any \"alue calions to manipulations. For eX<1mple, some medical (('tvical traction is quite safe also, and although it is conditions may be conside,,-od contraindicatioos occasioMlly prcscrilxxl it is difficult to see how iI can lx\"Cause manipulation is pok'Tltially harmfut while effL\"Ct a favourable change in the cord signs. Gentle other cooditions may be conside,,->d contraindkaHons t<.\"Chniqucs may be used to treat int..rvertebral joint in the SCrl5C that the conditions arc unsuited to or pain when this exists with cord signs, but il gentle tL..:h- unlikely to be affect(od by the trcatm('nl. On thes<:' niqllt'S fail, forceful measures must not beemployed grounds, the doctor will exclude such conditions as Paget's disease, rheum\"toid arthritis, osteomyelitis, RADIOLOGICAL CHANGES ankylosing spondylitis, malignancy, cord and cauda equina syndromcs, and vertebral ,lTteryinvolvement Osteoporosis and rheumatoid arthritis art:! two condi- tions that should preclude forceful manipulation, yet Somc conditions may be eontraindieabons 10 both condition, can be p\",scnt in a patient who has manipulation,butnolnN.'eSSarilytomobilizations pain that can be \",licv~xl by mobilization. Both condi- tions present sItuations where the safety measures Another consid('ration is that some conditions may be dctai[(-d in this book ,>re not enough to prL\",,,nt fr\",- contraindoealions to the more forceful manipulations, turcor serious damage if forceful proc~-dures are uS«! }'et they may not be contraindications to the mobiliza- There a\", no sign:; to warn the physiotherapist that an tions described in this book. In fact, one of the import- osteoporotk bon.. or diseased Iig\"ment is about togi\\'<\" ant fac<'ts ofmobilizatioo is that, by itsgentlcnessand way under the strain; there/ore, fOKible manipulation with careful assessment most of the possible dangers must nel't'r be used. However, it is wrong to p,,-..:Iude arc eliminat~xl and the trcatmmt can be applied mort:! gentle mobilization widdy. Neurological and radiologkal changes cover two groups of conditio\"\" that rna} be contrailldica- Two tt<:hlliqucsthat should be perfOfmed with g\",at tions toany but the gL'Tltle techniqul'5 carc ~\"'ce<Vical rotation in the presence of ma,.rd rhcumatoid arthritischang.s, and rib p....\"'rc in thc p,cSl'nceof~t~osis NEUROLOGICAL CHANGES Two techniques \"-'<;Juirc particular care. Cervical rota- tion in the presence of marked rheumatoid arthritic Pain associated with disturb,>nces of reflex activity, changes can rupture the transverse and alar ligaments, muscle power or sensation due to nerve-root comp\"-,,,- and ca\\lSl.° atlanto-axial dislocation. Rib pr<'5sures used sion are frequently cited as contraindications to manip- to manipulate the costovertebral joints may fracturea\" ulation Patients having thl.\".. signs c<'rtainly should ostcoporoticrib. not Ix- manipulak'l:! vigorously at the commencement of treatmL'flt. I-Iowever, provided the proper care is !.:Iken Diffe\"-'Tltia\\ diagnosis can be difficult, and in the and the nature of the complaint is appreciated, the early stages of a disease a patient may ha\"e symptoms gentler mobilizing techniquC5 can be used from the and ,igns that are believed to bt' skeletal in origin. This beginning. It may even prove nl'Cessary, as treatml'flt patient may be referrL'I:! for manipulative therapy, Pn:.>gresses,tostrengthcnand/orsus!.:linthetechniqucs, Howe\"cr, if thl' signs do nut follow the usual patterns and e\"entually but rart'ly manipulation may Ix- or if the patient does not improve during trt:!atment, he indkated should bt.- reflornxl back to the doctor. Treatment nlust not be continu<.'Cl for prolonged periods when only l-It'miatLxl disc material at one intervertL.(,ral level minimal improvement is being gained. Ocdpital in the lumbar spinL' can \"\"use comp,,-\"Ssive sig\"\" in headachcsand neck stiffnesS,e\"en a wry neck,canbe

Appli~ationofteehniqun 225 flexion/extffiSion (set Chapter 12) indicates how the shortest possible time, Th(' best way 10 learn from lumbar spine can be tested in such a manner as to manipulative treatment is to record accurately the \",,·ealinstabHityinaparticulJrintervertcllTalioinl. cause and effect of all that occurs during and following lrealment. This writl('f1 record should includ(' all of th(' Instability folluwingelem('nts,inthesuggestedsequ('!lCl' Any patient wHh symptoms arising from either a Writing down the t'tatmenl plan facilitaltsclta,.\" thin~ingand htlpsthtthtrapisttolcam from the hypcrmobileiointoran unstableiointcanbetreated trcatmtnt,tslJlts by mobilizing techniques, and the dfect of such treat- menta$S<\"S5oedasde5CribedinChapter4.Oncethejuint 1. It should begin with a summary of the pati<'nt's has been made symptom free, the patient must be accountofchangesthalhave resulted from the pre- shown exercises to strengthen the muscular support vioustr.... tment.['e~livequestioningmaybe around the hypcrmobile or unstable ioint in an required to obtain the relevant infonnation, and when recording the inionnation it is wise to endea\\'our to add greater support for that ioint. If pain indudea dill.\"Ctquolation from the patient, using is not rt:!iie\\',->d readily, then stabilizing exercises should his own language and quotation marks. Thisinior- be added or substituted early in treatment. lfpain is m\"tionmust beacomparison. not just a statem('nt of aggravated by mobilizing exercises, they should be fact» discontinuedandst<lbilizingexercisessubstiluted,The addition of supports to make the an'a more stable 2 The record should then indicate changes in the should also be considered. It should also be pointed Import.1nt signs from physical e\"amination per- outlK-re that hypcrmobility does not directly relate to formcdthroughouttreatment. theorthop<ledicdi<lgnosisof'instability'. 3 Next. today's trealment is plann<->d. The advantage Clearly. the dangers of manipulation increase as the ufawriltenplanningstageinrt:!lationtotheeX3m- strength of the t<-\"Chnique increases. Safety measut\"t'S inationofa patient isespecially important,i1nd it is taken with manipulali\\'e treatment must be ,-'mpha- even more \"aluable when \"-,,,ording treatment sized if the medical proft.'SSion is to understand and Oncethechang,-'Sthathaveresultedfrompre\\'ious ha\"econfidence in its use. E\\\"ery effort has been made treatment have b<'en aSSf--ssed,the physiotherapist in this book to emphasize the importance placed on mustchoo:se whether to continue with the same gentleness, with techniques Ihat are only increilSed in technique. and she musl know clearly why she ha.s madesuchadecision.lishechl>US<-':Stochangetoa strength as therontinual aSseisment of signs indicates particular t,-\"Chnique, she must know why she has then,-'Cd for increase. E\\'en then, no atlempt is ever chosen thatparlicular technique. Wriling this pJan down fadlitatesclearer thinking and encourages made to thrust furcibly through muscle spasm. consideriltion of the next day's treatment Some prople be/In'!' Ih\", \",,,Inillillmg ~tnms t,,,ctum wlrilepcrjwmingn'roical\"'ldllw,,,cicmarripllllltwnis,,,,sr,,· tiJ>/forSilfrty·tmlliriscllllsnl'lluplrysioll!rrapiSlllfi>/se smsrofsrcllrlty.lfpai\"\"'ldspasma\",igllon'drecallsrlra.:- tionlsbri\"S\"w\"kmg<'TSwllIsllllexisl.G:lrealld\"ssrss- atmenl, logellm will! hlawledge J'lltlJO/ogy. prouide Sllfety. RECORDING 4. Treatment is recorded by naming the technique used. stating the grade in which it was uscd,and Accurate rcoording i~ ~ vi:;ualiution oftht manipulatM, notlllg ulIy<jfed illwd oll/lre pal!l'fft\"~ symploms while physiother.lpl~t'~ logital. methodital tv~luallon of the illl.,sbeillgcarrle.loul caust and tffectof all thatOtturs btfo'e. during and afttrtrcatment.ln thi~ wav~ht can Itarn Iht fint' 5. Following tM Il.\",ord o{the techniqUt\" and sepa- rated from il bya clear and thick vertical line, a pointsofe)«lminatlon,trtatmtntanda~sm.nl record is made both of the asS<-'$Sment of what the pali'-\"Tltfeclshashappcnedasaresultofthelilst Manipulalive techniques and the indications for their treatment. and also oflhe physiotherapist'sass<-'SS- use can be taught, but this is notenollgh. Experience ment of Ihe changcs lhill havc taken place in the withanalyticala~mentteacheslhefinerpointsof fMlient'siointsigns. In:<ltment SO that the best result is pruduced in the 6. \\'/hen the treatm('nt has been completed. the m,lnipulati.-ephysiothcrapist will ha\\\"emade many judgements related to what she particularly wants

226 MAITLAND'S VERTEBRAL MANIPULATION Table9.3 Record during the treatment C/O - Subjcaiv<: ~'Qt:!i\",,~nt: .\"\"\"\",~nt of what Ih~ pat\",nt says [Ulot quomlOnS) ha, h.pptntd \"' ...\",It oflh~ la,lt..atm\"t l<:omp~risonsnot 't3I~m~nts) prog\"'\"C!I~d on any a,leri~rd poinls. With p.ti~nl' wh_ can b( e'pttltd 10 b( 'l<Iw. ma~e Ih~ comparison <:I'Jtr a wee~ ,al\"\" than <:I'Jt. 2~ hou\", DIE _ Obj~cli\"\" a~,m~nl: pIlysioth~.. pi,r, a~~nl of ch;lngts in ~nyof !h~ ,ig~ rtsul\\lng from the la'tlf~atment (Ast~ri,,~d ,ign..) Plan - St3le which technlque is to bt u:ltd and wl!y. P,P. - Presenlp.in. R rh~t\"\"l~nl I '\"0/' [i) Stale the techniqu~ u:ltd [iii Th~g'ade u:ltd (iii) Th~I~latwhichilwa,done (iv] Th~numbt.oftimtsilwa,done (v) ffiE EFFECT IT HAD WHILE BEING PERFORMED - Slate reason /0, any possible treatm~nt change .nd not~ anv remind~\" for n<X1 t,~alment Tab[e 9.4 Pattern for the mental and physical p'(K;ess~sata treatment session qo Rx 4: [m~~ning thi, is Ihe ~Ih t,eatmenl StsSIon of 1M 91h day from Ih~ initial ron,ullabonl m 'Ith'\" ,mp\"\"\",d,in\"\" I I.,t saw yI'lu b(c.Ulot I c.n tum ove' in 'I' btd w,thout pain now' P1~n:do \"Y~ because pq' No pain with coughing now' ,,,pp{presentpa,n) C/O did __.. PIE (withoutp~in) Nowni,worth'''''\"iIllJIO~if.bytakinglhet«hnique inlo a\"\"alldcgfttofdiscomforl,lhe bthaviou, of pain b(yondPha,cnangtd did __.• (into s1. disromfO<tl linmythml \",,, 10 as5'-'SS, and 10 what she feels she may ch()(ll;e 10 In the learning .1'IlL'S, and fordarifying whatlhe men- use in lre.lment al the \",-\",I session. These should tal pl\"OCC5scsduring a In!almL'flISL'SSion a,..\" the wriltl\"fl be ,,\"'Corded. Table 9.3 sumrn.rizL'S.U of th\" \"bove notes from olher Ihan Ih\" inilial consultation would elements follow a paltern something like that shown in Tabl~9,4.

APflliclt;Drlof tKhniqU<:$ T~b1( 9.5 wmpl( of writing up ~ tr(~tm(nt Wl'>t1l ~di\"'llf(~tm(nl, it is tsStflul to 'nduck ~ ~t1to:mmlofhow1M pat,.... t ftds dunngthe C}O-·IrIIoW'9_frto:ly.but\"\",\",badpain· ~ofthetnltIMIIlt«:h1lJClUf' OIf--F~\"\"l\",~butle.opa,nand~w \"'.y~ 'in' and thr 'did' (indid) is BuI,\"\"'5 excellenl ~lD~_'IftWI\"'·;\"l8ctt~'l5Q of ~ the wrilJn& up of the IreiltmenlledvuqUl', ... -SligM~--.s'\" but 'I also I'll\"«i5 to include • sUotemenl to ~be I1l-)xUSN \",I'I,lIt thi' patienl fftk DURI~ mE n\\tE ntE TECH.X'QUE is being perfonnecl. The e:qntinalion \",\"..Hop. findings will \",,·N.lJX'SIti0n5ofromfortorpo!>ihOnS \".,-fItpot~.beuw:\"'JIfDW\"I\"\"tis~( thaI incn!.He the symptOll\\5 The fmd,\"~ will .Iso l'C\\~al the m<)\\'emcnts that promle the.sympt0m5and C/O· I.....,· the ones thalles.sen them. n-th,rdcomponenl ,S, is,t O/Ef I/3.lnsliSl I \"\" \"\"_IfI'lOl~i....,.......do; ... LT

228 MAITLANO'S VERTEBRAL MANIPULATION better 10 do the mo\\'ement from the top end or from 1966.) From thL'S<! basic syrnbols innumerable variations the bottom up? With this information in mind, all can be made, but thc esscnce of thc symbols should be otherinflu,:,ncing factors will help in making thl'dl\"Ci- that th,'y tell,at a glance, what they mean withouthav- Slonsconcemlllg ing toleam th\"m. Gri\"ve (1988,59) give:5 many such variations.lfthenum~roftimesate<:hniqu\"isusedis 1. Th,:,position in which the patient isplaclod. wrillcn in numbcrsand grades are rL\"Corded in Roman 2. The mo\\'ement technique that will be performed. numerals. the whole procedure can be vcry quickly recorrkod oncc the habit iSl'Stablished. Then. it mu,1 provoke or lessen the symptoms, whichev,:,rth,:,c1iniciandl.'Cides. Tocnableeasyreferencetopreviou~treatmentand quick retrieval of informalion, it is suggested th.lteach On,:, of the main complaints made about re<:ording treatment should bewritlen up as shown in Tablr 9.5 treatmentinthiswayisthatHistootimeconsuming; Only by this means can a ml'!hodical treatment be this is quite wmng. Abbreviations will make the task given and the steps taken bcclearly understood. This quicker and encourage the omission ofunnecessi\\ry will avoid unnecessary waste of treatment lime result- words. Tablr 9.2 offers descriptive symbols thai might ingfromfalseimpfC'>,.~ions. be used to describe each of the tl.'Chniques (Full credit for the origin of th<-'St! symbols musl be given 10 Miss Figure 9.2 is an example of the brevity that canbc Margaret Jenkinson. MCSI', of King's College Hospital, \"mploy<-od to record verydetaikod information of the London. and agret'ment on their identification was examination and treatmcntofa patient witha lumoor reached by a group of physiothcrapists in England in disorder

Chapter 10 Cervical spine CHAPTER CONTENTS Movement in theverteblOIl canal and intervertebral foramina 249 • Introduction 229 Slump tea 251 • Subjtctivcuamination Excluding the cervical spine as a source of shoulder symptoms 253 'Kind'ofdisordcr 230 Palpation 254 Arcaofsymptoms 231 l'assiveaccessoryintervertebralmovements Bchaviourofsymploms 232 (PAIVMs) 256 S~cialqu~tions 232 Upper cervical spine 258 History 232 Mid-cervicalspine 261 • Planningtht physical uarnination Lower cervical spine 263 • Ph~icaluamination 234 Passive range of physiological movements of ObSl'rvalion 234 single intervertebral joints (PPlVMs) 264 Functionaldcmonstf<ltion 234 • Examinationandtreatmenttechniques 272 Brief appraisal 234 • Mobilization 272 Whtnapplicabltlests 237 Cervical traction 288 Sc:qucncesofcombining movements 239 Grad('Vmanipulation 293 Vcrtcbrollasilarartcrytcsting 242 Qualified aSSC'SSffitnt 248 INTRODUCTION the lower cervical spine (C5-C7); and the area of OWT- lap. Ihe mid-cervical spine (CJ..C5) Disorders oflhe \"ppeTcervical spine frequently For cll3min.ation .md treatment pU~.lht ~rvical result in head<1ches The high cervical spine does nOI SllintCOln~subdivide<lintohUdonnc<:k(~ppcr in\\'oh'einleTvert~-bTaldiscs,whert'astheuppercervical ccrvical}.ncdonncck(midccrvical),i1ndncckon lrunk(lowcrttrviul) spine also includcs theC2-3 interverlebraljoint where there isan inler....ertC'bral disc. which n<'ft1s to be tak~.\" intoaccOUflI. The reason for subdividing the high cervi- cal spine from the upper cervic<11 spine is so that one 1heccryical spinc(FigUff 10.1) is best considered in particular part of the palpation e\"amination can be lhl'l)C§l'Ctiom;: lhc upper cervical spine (occipUI toO), emphasized. The lower cervical spine involves syn- whichindudeslhehighc~·r\"icalspine(\".:cipult()C2); ovialjoint structUTl.'S and theinterverlebral disc.

230 MAITLAND'S VERTEBRAL MANIPULATION c.,·rvlc~1 discogcnic disord\"rs (which m~y ~Iso Invoke Tabk 10.1 Subjttlivetxaminalion 1l('T\\'croots)occurmost(rl'Clumt1yin lhelow\"rccr\\'lcdl SpUle. J)I\"orders 01 the lllJd<l'rviGlI SPIllC ~n.' moe;t ·Ki.... of d\"\",*, commonly synovi~1;oint typc disord\"r5, ~nd pol'\" from Establ~ ..\"'~p;I~l~bftn~IorOf\"\"\"'lht thelell\"\\els maybe l'l'k'rn.'l1 UpWdrdS or downwdrd_ tJntmmt: 1. f'aifl•.tiffnm,. -atnm. onsllllobl¥ 11C. The calldl Mruclun5, dural attachments an..! cery- 2-Aa.«:0fl5tl. icalnerwroolSarealsopotentidlSOUl\"Cl.\"Sofs,'mptoms andfunclionalreslriclioninthis....,;ion .......3.I'Ost--wrgial.~/olt.IA.~uaetilIn,l1C. SUBJECTIVE EXAMINATION IltttntandlftWlll'bft'HoUor(bcIoo<l TIltV10l\"E't§outtJ..._·~lioopaltem.buICl/'l'Uin ....~of~ltloutMtoryaoobt_ potnlSnoqu'l1\"P'CP\"nsIon. Isthedi:5ordtrOlltdplOll.SldMm,~~ttr> 1lt<.'ord000the'bodydlal'l' PatJtnts ... ltlnNl'OmUS(U~I~ofll\\( 1.k'nanddtpdldS¥'\"'j)tOlMiNoatonglllllil'latNSand n«t~com.plainof~lfIl1SwdlllSnsooalcd \\lati\"9~dSJf\"IPI_ ~ptomssuc/lilSstJffnas.~aclacMOfd,ni~Tho: 2_~/lGa.fI(I~ S1t~.ndclncriphonofll\\(svmptOlMoft~~lpsto ]. Q1rctlor'Y\"'otOfM.II01ntrlSl«l.I\"\".~fl.,i.~.: ~Ubl~IMSOUftt (.JolhnftttrlKall~u; 'KINO' OF OISOROER (bJjO,\"ts~a\"dbelo.. t\"\"d'Sl>fWr; (clol\"'r~l....antjointJ. lhe answer to 'Questlon \"esl~blishcs lhe 'lind' of disorder the m~nipul~li\\c phy~iolhl'T~pist is dc~ling Behaviour of~I\"\"Ptom~ with. This forms thc b~sis for the l'l\"t of the c~m\"in­ Gtr>cral ahona\"dtrc~tmentoptions. 1. Whtn a~ tht¥ prtStnt or wht\" do they nu<:tultt \"\"d wh¥ The '''ind' of disorder in the ccnical 'pirll' is u\"o- (loc.landrt~\"rill ally OIl<' of p~j\". This may range from he\"d\",hcs. 10 •. £fftctof~stonthtloclllndrcfcrrtdsymptom, (.\"\"\"i.tt/di-.sodatt with llao(s aclivitit's: p;llowsizt/ ronttnLinflammlll101l) CorrIpn\"\"\",pIOff!SOIIrisonglfltht'\"Ofl\\J\"'I\"\";lhmdol6ay. 3.Palftandst,ffMSSon~ng;duralionof, 4 Hfn:tolKlivil06(btginnintoibyton'lp;lml ...,lIotnd ofdayJ h\"\"\"\" I. What\"\"\"\"\"\"\"''''''''*'''''-whal~~Iy- irrilabili'YI~ 2.Arr,susta~posol>Oftl~l'f\"'II_l 1- ~.-.--..cs f*\"Im,~ SpetialquatlOflS 1. llont!lrpllllmihawarty-..ttddiu.- I\"«rtrlnlMkry)1 2 llont!lr/llt>tnlhawbdatt'fllt.ngi...... handsandlor fM.Of....,9\";tdist\"\"-nkanl~l 1.I3mtralhtl1l1o.nd~lMinl~>gIItlosstf'l>td'lQI\"\"'toryl. 4. Whattabll1s.~bto\"9Ul.~fortMandothe<toIIl!ItJDM Io<tt<>porosisfromott_strtOidthtr.P'!'l' ~ tt1ftrn:<:nlradiographsbt<entaketl? Hislorf 1. Ofthis.tt3cl. 2. Ofp\"~io;r)lttlds.orof\"SOf;I.to:d'i'f'llptoms J.Afttht'i'flllPtoms~ingor.mprovingr 4. Priorlr•• lmtnllnditsdftct. 5.Socio-~nomichlStory'5.pplk.blt HIGHUGHI MAIN fiNDINGS WITH ASTERISKS Planningt\"'obj«Ii'tl:u.min.lio\"

C~rvical ,pin~ 231 local nl\"Ck pain. and associatl..:l scapula, shoulder and ann pam. A consistent link betw\"\"n the pain and activili<'S involving the nt.'Ck should beestablished. for example, Ill<' patient may say 'Every time 1look over my shoul· dcr I gel a sharp pain in my shoulder blade. My arm mm\"emcntsSC'Cmfine' Occ<15ionally. the p..tienfs m,';n complaint may not be pain. He may han' set'n the doctor because of d;7,Z;- ness, for \",,'mple. TIll' manipulative physiotherapist should establish w~thcr tlKore isa relationship between the behaviour or onset of nl'Ck symptoms and dizzino..'SS. The manipulative physiother,'pist should also be aware that. on oa:a.ions. the patient may complain of ne<:k pain in the absence of any comparable signs in thenl'Ck.lnsuchcils<-'Sitis likely that the pain isbe;ng refer~ from l'lsewhl're. such as thl' shoulder, thoracic .pineOr,olseNa AREA OF SYMPTOMS Uppc:rce:rvical spine: Fi9ur~ 10.2 DistributIOn of ~'n of low~r cc\",ic~1 originlC:'-l1 When a patient complains of suboccipital pain, the site must be dctermin,--d with accuracy because it helps Figur~ to.3 OiSlribution of ~in of upper thor~cic origin d<'lennine whelher the cause is likely to have arisen (T1-2) from theoccipilu.all.lIltal area,theatlantu.axial area. or the area betWl\"''' C2 and C3. TIll' most p,,-'Cisc way of determining this site is to: 1 Ask the p.llie\"tto pointt.., the arc\"..,f p;,in with one finger. Replace his finger with yOUTS. Apply p\",ssurc and ask, 'Do you mean here?'. If he says 'Yes', the next step should be to vary the angle of the p~ure,and also vary the points of ronlaclwilhthefingeruntiltht'exactpo;ntis dl\"Cided upon. T,'diuusas this may sound. it sa,'l'S considerable time in othl.,. aspects of ex.lmination; it e\\'l'Tl diTl'C15 the path the physical examination mayuke Lowe:rce:rvicalspine: A Sffond a\",a of pain of cervical origin that is worthy of dL'iCu5:\\ion;s pain fell across the suprascapular area ThIs is a common site of pain. which may arise from the lo,wr cervical spine or the upper thoracic spine The most helpful informalion is obtained by dcterm;n' ing whelher the symptoms 1. Start in the lowercer...;cal spine and then spread downwards and laterally to the shoulders (Figurr 10.1) 2 Sprc••d from shoulder to shoulder across (appro\"imatelylthc 1'211'''<'1 with..,,,t spreading into the n<)Ck at all (Figllre 10.3).

232 MAITLAND'S VERTEBRAL MANIPULATION ~t~~=:= .Iowtrctrvicaldi:lo ~/toInCiow3nl,R.B. tIWilt~of~ISO. 1052·6oI, 1II_~ ....tIIor puIlIisI\\m.l This gives a guide 105 10 whether lhe symploms ari5C follow fairly n'SulM pattems and are ,\",'Orsened by from CS-7 or from Tl-2. acl;vity and by cervical movements. 1hc palil'T1ts m.- II i5 important to know lhal both lower Kap\"IM al'(';l 5ymplon~ and vague TJ-7 symptoms may ari!\\\\' \"ul'llily waken wilh h:mporary n.,.,k 5t.iffncss, e\"en from the IOWl\" cervical SPIIlC (figurtS 10.4 QmllO.5). To though their p\"in is k'Sli_ Patients who have ba'T1 the dinician al leasl, U - symptonu ma)' relale 10 in\\\"olvroinana«idenlwillnolha'\"el'\\)\\ularpatt~ those areas 01 pain discussed by Cloward (1959). of beha\"iour of the symptOll\\5. When the p\"lient hasstated whl>re hi~ problrol hes, When symplom& .'\" ~ggra.... loo by nlQ'-emo.>nts, the exact mm'CJnen15 mu~l be det\"\"\"inrd, If symp- w mampulah.\" physiotherapist should 'l......lioI'l hun loms an> WO<lle on wakening.. the heigtll and conlenl of lhe pillow should boo <JetermlMd Is« Appendix -I). • 5 to whnher he has symptoms in any 01'- .. \"\"as SPECIAL QUESTIONS associaledw,ththe~lspine.lfU-an:chc!c~ Certainquestionsmustbe~lodetenrunr ...hethet- and fOWld to be ~~'mptomalic, the me':ant an'a on thespinalron:land\\·~lars)\"5tem,)n>bl.clylo the body dl..Jrt..oouJd be bcUd_ To do this ' - 1W0 b r i n. .o I \\ ~ i n t l v d ~ n - a , . . , l f i w d i n T \" \" ' I O . 1 putposeJ. The first i~ that it ~ t1w~m\"w.. a\")\" \"\",,'e-\"er, dizztfl<':!!l5 reqUlre5 <p«ial ronsideration,. oul ihed>e<::lung.and the second is that shc then has and~discul6edon~ge2-l2. proof lnat he did not na• ., symptom& on a tic:kd ....... whmslwforstasl<edlum. HISTORY She must ..00 <let.......... the ~1AIN a..... of the Fo<pancn15w\",*\" preoenl~5Cd.. beganWlthoul symptoms u..I _<>I'd them as ~ ''MAI;'\\i' on the incident, the de-'elopmcnt of the symptoms mU5t be bod) chart. detemtincd in detail from the I1me when they wen> first fell. II is only b) ,,-~attnK thi5 10 any pasl lustory Toadd 10!lus. Dwyerrt Ill. (1990}and OreyfII,.rt.t lhatlhelilelyeffccl of treatment Can boodelC'mllnro (1994) na• .,(2l'ried QUI , ..luab'\" \"\"\"'..tch. \"\"tuch has and the fulure prognosis tshmatW. On the other hand, M1pN lhe manipulatin, physiotheraPbl to id\"nufy when a patit'<1t ha5 bt'l_'T1 in\"Oh-l-d in lri1uma the direc- poterInalsourcesofreferredpaillonthecerv~..lreglOll lion and force of lhat lraumn (e_g. lhe exlenl and sit\"\"f (f'KunIO.N;ln<! IO_lib) lhe damage to lh.. car i~a guIde) ~hould bcdclC1\"mm,'<l BEHAVIOUR OF SYMPTOMS As symptoms a\", ra\"\"lyconstaJ1t and unvarying for 2~ hours of the day e·...\"y day of Ihe week, the\" behav. lour must be established. 1hc COmmon cervical mus- culos~detal symploms, ha\"ing a .p<>nt,\"'l'QuS ons<.1,

Ccrviralsplnc 2JJ . . figure 10.5 l),~iotpai\",!~ IIcftmdI\"Or\"PCl>tcro\"tc~...rf;tee\"'<C'fYOIdi5a.I/:IIRcfcrrnll\"Or\"cmllalch::fI4lI:urcs {Ikproduttd\"-Clow..... R.I.!19S9)\"-'sofSU'9C'Y. I !oO.I(I5,2-64....thl:&nd\"\",...\"...... \"'.uthor.ndpubl.wr..l IOcnableammloll ....-lu .... ofthelorce!l'n'·oho!'dlo from I sudden mo-ol'ml'l'11lhatsp1\"aim StrueNre5 in the splJ\\C.Howt\"·er,withasprlinlhepahentclnlnitillly \"\"~- rrtum hishcad lothe-nonnal polSiliOfl,t\"'en if I wry \"\"\"kpo»itionde,-elopsloter. Wry Md' >S In W/mmctrial ned postlirC accomp<HIlfll by pail'l.lnd tM pain fslgtmlllfll by Alhird \"ar1etyo/w'Y \"\"\"kocrul'iw\\w..\" lhep;:tllenl walens with his head stuck IOOr\\E' sIde, Thf. importanl Inltlemptt(l~tt>ep'OI«t~<kfOl'lllltv difference between lhisdisoorderand a locled,ointis lhat the p\"hent wakens wllh 11, asrompared wIth. n,., wry nn:k. aSa dlSQrdcr, is a Sp<.'Clal ~\"\"ll)' In the locle<! joint (Matlland, 1978), whIch wakens lhe cl'n'ical,plne, and can have many Cau5l\", Th~ firsl i~ palit:nlwhcnilo<:cur!l-- whl'f1 a sudden IOOVeml'f1t luis la~~'f1 plac.: and the palJenliJiunableto ....turnthcll<:adtolhcoriginal II is also esscntial 10 know the effect of any treo>t- forward·facingposlliOfl.ThediSo.>rderisCOInnlOflI}· menl Ihe pallent has had preo.'lously, the presenl referredinasa'iockcdjnint' Awrynl!Ckc.,nalsoarise degn.'C of stabilily of the di50rder, and whcth~r II is worscnlng O' not

234 MAITLAND'S VERTEBRAL MANIPULATION PLANNING THE PHYSICAL EXAMINATION lfadearSll~\\·epictu.... lw:>~0;!5tablishOO.lhl­ physical6dminaliorl is much\"\"\"\",, straightfono\"ard\" By astuteobser... tion,.an'ppraosalnnbrmadeol~lmd \"'_~tion-thatl5,tht\",gourol~~bor1­ and Ihl-kirt0d5ol\\lc§l mon:'menb that \"\"II bl-used WhentheS)'Tl'IJ*lII'lS'~5l.\"\\-en\"orthed~i:5uTi· tat>w,l__ p lI7).oril~his«x) lndi<:ate..~d\"'\" oroer (__ pLlnning shirt. TIII/Jk 6J). the 1eot mo'oemenlS should bete>tred up to Ihc' pomt ..'here J'ilin begins. lio>o'Il\"'-n;. w\"\"\"lhc'di5ordl.'r isdu....uc.nd pam ismod· eo-ate,tesllJV\\~t5a.... talo.enlOthelimitoitherange\" TftW 102 is a gwde for the ph)\"'OCll aamination.. PHYSICAL EXAMINATION _ OBSERVATION ~.Jb The ph),ical e>amnl.ti,m should begin with obs<-I\"\\'a· tion. The patimt's PRESENT PAIN should al50 be dClcrmin<-'I:l.SubtlccluI'SSuch as poslural alignment faults, protecti\"e ddormitiN (and the effects of corR.\"Ctingando\\-'<-..-com.oclingthcm)andlong'lt,lnding musclc wasting will help to dt'tl'rmine lhc s.oun;:e, con- tribuling factors and slage of the pati\"\"t·~ disorder. FUNCTIONAL DEMONSTRATION ~-~ Analysi'l ol the dcrnonstrali(W1 by the patient of Ius \"Ft!ill\"~ 10.6 I\"\"~, function,ollimitahon willll'5tablish lhedegree10 whKh plll~ .... I..ptOdllttd from the cervical ~PU\"It' is mnlh'oo Whem.er possible, du· pi'\"I) c.,rvi<1ol ryglpop/lY'\"'lljo'~1 ferenti.ahon ol the functional demonstrat>on will hclp OWYC'''-Apr,IIC.~\"lN,II990I«rvi<1olrygapophysell loconfirmthesoul'«'olttwpallent'ssymptoms. jO,ntpl;nplll~ms I,. Mu,;yin normal \"\",lunl...rsSjl,nt lSI') For aarnplit. a patient demonstrate that rNcNng lugh aoo..., his he.d ..'ith Ius nghl arm n,>roduce'!i the .53~.51 .. i,n kind p\",m'ssionof,htautho' and publiP,t,j.nd pain m thc b.lH:k 01 hIS shoulder. Whilst this position is n-Wnlainl'd by the lI'IoiIrupulalt\\·.. phySODlherapist. the bIAU.n'o\"ocdpitll.ndll'C,.IIUlnlo-uilljOin'pllnpaUtms patient \"asle<! lo tal.. h15 neck mlomore~ rightsideflexton.nd right rotatiorl(lo>o·erCll\"l\"\\ic.1 (Rcp'oduct;lf,omD'''fIu<sP.clal(I99.).''tlanto-o<:t:ipital.nd quadranl).lfthepalntnh15shoulder~the{('f· latt,.I.t1.n'o-...i.ljo,nlp;o;npmCfn~5jlin.19(1011125-1IJl ,\"ical spine is the tilely SOUKe.espcd.lly iffurthert\"le- wOlnkindp.\"\"iosiOflOf,M,ulno,and\"\"bl,p,.,.) ,·ationolhisarmdoesnolchan~~hispain BRIEF APPRAISAL Briel appraisill of neck mo\"{'flll'Ttb and palpation of th\"clTVical spin\" for t\"ndem\"ss mar be of value at this ~L~~'\" 10 confirm tho.' rl<-...<d for further examination oftheccrvkalspine.Q\\lickacHvct~'SL'olth.,thoradc spinc, shouJder,dbow and wrb;tandhand would also l'Stabli5h thedegR.'e to which tht-sc an:as an: in\\\"olvcd

C....icalspiM 235 \"'''-p,..Figu,. 10.6 1\"\"\".011 (<'I Addi\",! su~ 10 tt\",loal n~.ion. (Ill-(~ $how ~xam~\" of adding Ovt'-P'\"S\"~!<I tt\",ical aeti~ \"\"'vtm~nl<. (al Adding ovtr_~,. to o~\",i\",1 ~xt.n~\"n 113'~ \",,.,). lei Adding Ovtf'PI<SS\",~ 10 \"Moallar.131 fIt.ion Idt (slf\",ch o~n th~ joint'; and WUCl\"r~s on the fightl-I~ Adding Ovt,-p~Ufe to \"Meal ,\",\",ion Active movements 1l\\e physiological mOVl'nWflts are usually ll'Sll..,J Ii\",t All cervical mll\\'~rnents shllUld be watched carefully C1in\",allip:Fo'c:onllstencyinr~a=smcnt.itis from the front, as each can .c\".cal \"\"\"ful infor\"\",li\"\" imp<lrtanttorcas~sthcactivcm<>vcmcnt';ofthc (Figure 10.6 C-F); the ronlOu. of lhe llt.'Ck when fully ~rvicalsplnc(fan9c,svmptoml\"p<lnSl:andqualityof m\",ementl in thc Silmc Ofdcr each timc nexed isbesl\"\"\"\" frorn bchind or abO\\'e. Care is requ;red wh..'fl applying O\\'''''''pn..,;o;urc to cerlain mn'\"l'IIll'flls. With~r\"icaltxtension, whcthl'f'lheprcssure isapphed by lifting under lhe chin Of pressmg againsllhe forehead,

236 MAITLAND'S VERTEBRAL MANIPULATION SYpine N.u,ological.xaminalion (>calp \",nsalionl Table 10.2 Cervical spine. Physical e~amination c:.nalles1sasapplicabl. Slalic tes\" for muscl. pain ClIlwrvation PPtVM-F,E.LF,llol' f'ostu~ ....illing!ltS$ lO fnC/V't he~ and ned lendern6S F;rstrib swelling l'assMperiph.raljointte:sts Briefappro;YI PTon. 'Polpal;on' M\"\"\"\"\",nt.illing Tempt'.alu,e and sweating Otherjoinll(quidtests) Soft-ti\"\". palpation (muscl., art,rularpillar! Positionofv.rt.b'ae Mo~top;inor~tolimit l'assi•• aC«SWryintervtrt.bralmovtm.nt(PAIVM) F(fl.xion).E(ntens\"'n),LF([Iand<Rl(lal.rolfln\"'n 101.ftandrightlandinFII'dERol\"([Iand((tl OreiputlOCJ i\"\"lr<>---- (rollliontol.ftandrightandinFandEp;in C2 loTI and AI t\"\"lr---\\,/L.J anditsbeh;w;our.rang.....unleringprot~i\"'\" dd\"ormity,localizing,ovt,-press\\l,e.int.rvtrteb,al Comb,n«iPl\\lVMwithp~logicalmo...,menlpos;tions rtlIM'\"\",nt(~ptoaltdmovtmenlandiOCf.ased Checl'·.... notts'for'.portsof~l...anttests(X-ra'fS, \"\"\" bloodlt1ts) Wh.nappliubl•. ~tling INSTRUCTIONsrOPATIENT Differ.ntiatingbel e.:nuppto'andlo....'''''rvical. 1 Warning of possiblee..\"\"rtlation s.uslaifltdE,LFlo anhpain.llol\"lowar(!spain[wn.n 2 Aequt1ttorepo,ld.tails \"\"\"\",yryto,.produ\"\"rtferr.dp;in) 3.lnstructionsin'ba<:kcare·ifr.quir.d a.upperandIOflow.r,and~Slain.dlifF,E.LFand Ror'ar.negati....) Compression in slighl Lflowanh p;inand minimal E [whtnntttSSarylo~prod\"\"\"r.f.rrtdpain) Distra<;tion [ifF.E. LFand ROI\" and Oare n.gative) Com~fItd_\"\",nltests SYstain.dRot\".achsi~.ndForO(\"\"'rt.bral\"rt.ryJ O1hc:''''''rttbralart.rytesll Passi\"\",physiologicalint.rvtrtebralmov.m.ntIPP1VM) CI/2Aol\" Activtpenph.raljoinlle:sll careshouldbeex~rci5edtopreventitbcingamO\\'~ment Theover·pressurewithcervicallaleralflex;oncanbe merelyone of trachoo orrompression respoctivdy. perform<-'d in\"\"\"oopposile ways. If the pressure is being applied to]ate.al fle~ion to the left, it can be u5ed to: Wh\"npain is produced on only one of \"ither flex· ion or.xtension movem\"nts of the neck,it i5pos5ible I. Streich opt-'n lhe joints and Slrudu\"\", on tm, nght. todifferentiat~betwel\"f1an uppt'rand lower cervical 2. Squ~zetogetll'-'rt\"\"iointsandstructuresonthe dJ>orderby extending the uppt'rcervical spine while flexing the low~.., cervical 5pine. lbi5 movement left is achieved by asldng the patient to poke the chin By \"arying the place of thc ulnar bord\"r of the hand, forward and applying over-pres5ure (Figure 10.7). the tL'Slcan be emphasized at any intervertebral level Similarly, by retracting the head, the upper cervical between the occiput and Cl. Jfthe 10We5t level5are to SpilW can be flexed while the lower spine ise~lend~'d. be te51~'d. the phy5iotherapi51's hand po'lilion. are Over·pressure is applied at the end of thc range (Figure quitedifferenl.lnlateralflexiontotheleftshep]aces 10.8). Comparisofl of pain caused by these two move- her right h\"ndagain5t the patienrs right parietal area ments with that produced by the normal f1e~ionand and her left hand over theacromiocla\"icular area, and e~tension tests can indicate whether il isthc upper or th\"n she applies tm, stretch. The appearance of the hcad---n<X:k-trunk relationship is quite dilfcrenl too, lower joinls causing pain.

: FigUrl:l0.7 U~ctrvalt.i<ttnsionlndlowt'ctf\\'iall f1tJUOft.(lIl\"\"anaetiw_~nL[b1I'miIia<lof,,\"nch..nd let poloitiDn of Irlt fOltarm to.,pplving lIYtt-prt5SU,t WIth the hNd-<Jn-fleCk position being different from An auxiliary lest that 11\\011 ~icil joint signs when ..etWI the M(k-on-lrunk positJon (rip\" 10.9). lnO\\·l':IN'flll<5bl'olJo.,.·edbY~\\\"I'\",,·er-prt'56Ut'l'vr ~O\\~l\"e!II5Ure\"l'lth~;uJ rot.lion is de5cribedmChapterllr.ip.lnofddlcrcntiaborlofthe JNuUeY is the mO\"l~mml of combmed l'lOtensiofl lat- c~\",>C;l1 MId thonOc spov Ul rotatIOn.. er.Il fIeoxion and rotatJon tawards the side of !Mit\\, The rochrnque for l@StIng the Iowa cerviclll spiM In thIS WHEN APPLICABLE TESTS 'qu;odr;lnf posItion ,-;anes.ppnriably from thai used f~lheuppercervicalspUle ThtctMCll\"qlladranlS'amllltMrc:ombon~ lowertervicalquad.ant m<M:m~nlS I,e usdul when trying to reproduct Toteslthelo.....t'Tc\\'TVicalspmeforright-sidedpain.lhe miM' symptoms origin~ting f.om the cervical sp,ne, neckislilt(.,jbackintolherightcomeruntillheJowcr cervical spine is fully extended and Lalerally flexed 10 11lemptingtoucludclheccfVitalspineasaso.m:~r lheright(f;gJl~10.1O). Withexlensionandleftlal~ ..;tl f1e>:ion held in this rombuwd position, roblion to the of symptOllli, Of as part of ~1.bI,~mg I faYOllrable righl side i:sadded. trut~ntdin:dion

238 MAITLANO'S VERTEBRAL MANIPULATION Figu,\" to.8 Upp'\" «\",i~al f1uion and low~, nntical ~.t.n5io\". (al A<; an a<b,~ m~m\"\"t.11Jl Polition of hands. Ie) PosilionofldtfO'~;l,m UppC'r~rvkal quadrant spine with the head held in extension, Whil\" h\"ad extension is maintained. rotalion to the right isaddl'(l To lest the left quadrallt for the right side of the IJpper nw a~is of rotation has changed from th\" ,-\"rtical cervical spine. the physiotherapist stands by the right when the \"\"ad is in lhe upright position to almost hori- side of the patient and guides his head inlo Htension zontal when the head is in full \".lension. 1t is the head and applies pressure to locaHz\" thi' movem\"nt to the ttmt is tuml-d, and the ll><:hnique is to produce o5CiJla- upper cervical joints. This is done by grasping th\" tory movements SO that the limit of the rotatory mnge patitont's chin from undt'mcath in the right harn:l and can be felt. When the head is fully turned towards the his forehead in the left, At the same time his trunk phy.ioth~rapi.t, .he then add. the lateral flexion com- should be stabilized by the physiotherapist's arm from pon\"nt. The lateral flexion movement involvl'S tilti\"l> behirn:l alld her side from ill frollt, while applying th\"crown of th\" paticnl's h\"ad towards heralld his pressu,\"\" through ru:,r halld. 10 flex Ih\" low\"r cervical

...C~Nicalspin( 239 ,., Figu,el0.9 Ctrvicallateralflexion.(<l)Neutralpos;tion (b1H(ad-oo-.....,klal.ral~\"\"'.(cINrrl-oo-trunklamalfl(..ion (hin away from her. This movement;s also performed For example. the patil.'T\\fs head can beheld in rot.:llion in an osdllatoryfashion until the limit of the range is to the left, to which can be addt-d flexion or ext'msion \".acht-d (Figll\" 10.11). This is a very difficult It'S! of the head and th<!n lateral flexion of thl' head to movcmenl 10 carry oul ac,;;uralely, and much practice left or right. (It should be pointed out that if,forexam- is n<.'«'SSilry 10 perform it well p1e, after adopting a position of full rotalion to the left, lateral flexion of the head to the Icfl is addro, Ihis lat- SEQUENCES OF COMBINING MOVEMENTS eral flexion of the head is nota lateral flexion of eiKh cervical intervertebral segment; for example the As well as quadrant movements. any otht'Trombin- Cl/n joint would be extending rather than laterally ationofmovementscanbeuscdinancfforttofindlt'St flexing.) mO\\'cmcnlsoompar\"blcwith the p.ltient'sdisorder. l'here is anothcr \"ery;mportanl point that must be remembered during the testing of combined movements

..l:. MAITLA~D'S VERHBRAL MANIPULATION J FiguftlO.l0 lowt,,,,,,,,icalquad,.ntposition starting from a neutral position (Figure 10,11). The Figur<10.13 '><qu.n«l,stcpl.full,otation,ighl.Rot'$ paticnl'~h\".d is His h<,ad and neckwillbein. parlicular position and 1. l'ullyrm\"ledtotheright(Figul\"/'lO.IJ)andthen, h.,\"\" a particular pain response. However, if the while in that position; ~uenceoflhelhreemo'·eme\"ts(thelhl\"l't'SI.·ps)lS chan);oo(tol,J,2:or2,J,I;or2.1,3;orJ,1.2;orJ,2, 2. HislK'<;ki.slaterallyne~ed tu the right (chin to l),lheend-posilionand pain response will bed;ffen-nt shoulder}, whkhisaf1e~ionofhisheadun his neck(FiguI'I'10.14)andlhen; Threesequenc\"5 lhal differ from thc figuT<'S of the f;r:;t !'equencesdc:o;cribcd aoo'·call' 3.2. 1 (i,e. F+ LF 3. His neck is flexed,which is lateral flexion of his head on his neck,and fl\",xion of his n,-\",k on his ® + Rot iE - Figu ... 10.16]; 2, 3, 1 (i.c. LF<8:+F+ trunk{Figu .... 1O,J5) Rot®-FigurelO,17);andl,3,2(Le.Rot®lFl

.. Figu\", 10.1. Stq\"\"n« 1. ~l~p 2. Suptl\"m~ lattral fluion Figu,t 10.1S StqutrlC't I. sttpJ.Suptnmpost<lIItDOllof Gf n«k to oghll~l is. eII;n 10 right \"-Iok<or f\\oion of h9d ntd (11111 is, l1lt~ tIwon nl)hl of htad on ntd pl\", lIwon of lIII nm.plllSllIt~lfkJuOl\\oflWdon trullk}.llot\" 1t..-lf ~ r>m.onUlHlk).Rot''JtH.FII. +f LF ;g - figu\" 10.18). DTawings for lhol other tv.'O should press her chin agamsttne dorsum 01 her hands SO as 10 help apply lherompl'l'SSi\\'e pressu\",\" {Figurt' IO.l9l. possible scquena'S of the s.~me romhiniltions - Lf ®l Rot ®IF (2, L 3) and FIRot QtI1LF ,t{! MNhod (3. I, 2) - h.l\"\" not been included. lWl:ognh:ing 1h.11 \\\\'hil<\"mthispo5ltion: these six 5t\"quel1Cl'S ilil end in the same 'romer po$\" 1. lhethenpistapplie5ana)'l.Ilrom~sustalJl­ .bOn', the tnnUII>l'rable cumbiNti0n5 an! ot..'iou5J\\ ing il as a gr..de IV+ 'pressure' f\\7l' approxilTUllely mternun.Jble; after all, rompr\"eS6lOfl and dIStraction 10 seconds, waiting to a5Certain if there is any mdi- ltIO\\\"emmts han.' not been lnclude<l. nor NHl palp'\" cation of relevanl S<'nsalions being provoked. This llOnlechniques. axial pressure can then be ll'iCiJlak-d as a grade IV + mO'.-emenl. agam asking about responses The ~ason for th... diffc....1xe8 is Ihat as!iOOIl as one (Flgurt' 10.7% and 1O.19r). mon'menl is la1«.., to the end Ilf its range. It imm~'<li· .tely limits the available movement in e,,~ other 2. She thm ~Ins the rompn'SSion and tilts the head d>roction. The exarruneF 5houJd be prepiln.-d to ex.lm- on the neck. OKillahng it from SIde to side in lhe lnl' any rombiNIion of mo....!o\"\"\"ls, in any Sol'qUmCt', lateral t1exion d,,'l'CIlOn through aboutlS~ approx- In an effort 10 find 'romPMable joint signs' imately six times. This mm'ement in\\'olvl'S con~id· I'rableatlanto-axial rotaliOl\\ (Figurt' 10.191> and h) Companson hal. been mentioned in ....lalion 10 Nr- rowing the inIL'r\\\"omebr,d foramina, bul rompl'e55ion 3. She thm returns to neutr..l reLuning the oompres- on also be anoth\"r of the mon~mC'lllscombined with SKIn,.and toClIlf'5 the patient's head 10 each SIdE- other phySIological movements. II is of 8\",at\",,' value in ('L1lT\\imng the upper <:en'kill spine n>o\\emenlll in 4. From ..pprw;IIl\\.;I.teIy IS oi high cel\":K.J1 fle>;ion., a p.Jllef\\ls suffering stubborn Cft'\\\"lCal headache.. ne..ion-exttT\\Sion mon~menl (under compression) of 31)-40. should be performed. nus direc1JOI\\ is ~nts undtr romprtsSion more difficult to isolate to the high cervical spine than lateral t1exion. Storting position 5. If lhe pahenl'5 head is placed centrally.and under The physiothe..-apisl stands behind the SCJ!<.'<l patienl, rompress>on,asharpflKklTlO\\~tm\"\"yoithe CIlpsher hnkd handsO\\·.... thecrownand p\",ielal areas 01 his skull. His thorax must be stabili7.t:'d by her ~chcstandnwdi.a15ldeoiher~She

,., Fi!lu,el0.16 ~quer'lC<2.(aIS\\.p,.Fullfl.xi\"n;f.(b)St.p2. Su~rimp\"\"'dI3t.ralfl.xion'i9ht:F+lf®.{clSI'P3. Su~,imp\"\"'d rotation ,;g,l; F+ IRl + Aot\"@ directiOllsmay reveal a pain responsee.....n when R\"f,,~nce has already been made 10 the testing of movements (IH3) are symptom fK'e Ihe vertcbrobasilar system (p. 118). Vertebrobasilar VERTEBROBASILAR ARTERY TESTING insufficiency is One of the contraindication:; 10 cervi- cal manipulation, and therefore qu...,lions regarding \\kn~brobasilar;nsuffici~ncyMlI) is one I;Onlraindica- di7..ziness(espeo:iallydiainessassociatedwitheithet lion 10 ttrviC<lI mani~lition. R~m~m~r that o~rnal­ neck movements or n~\"Ck positions) should be a r<)U- tine pari of the inilial invl'5tigation, The importance of OU51~I;n9forVBlcanalsot)l,acauSl':of~nebral examiningfor\"ertebrobasilarinsufficicncycannolbe an~ry compromisc_ Note thallhe evid~nc~ for and over-.cmphasized,becauseit isan unfortunate fact that a9a;nstph~;C<lltestin9forUBlr~ma;nsconftiC1in9 evcnwh<m all of the physical tests are n;:-gati,'c, during lreatmcnt of the cervical spine lhcsystcm maybesuf- ficicntly compromised tocau:;e symptoms.

CervialspiM 243 O .. R!lUf1'lO.17 Stquena:l.(IllSt~pl.Lalmlfluoonrigl1l: Lf(B}(blStep2.Suptflmpostdflu,o\":Lf(!>+F.kIStcpl. Supe,imptM<!,,\"ationrigl1l:Lf'1f'-t-F-t-Rol'1l' ~ \"I\\' many ~olromplicationsfollo\\.l.- zyg.apophyseal joinlli and me<hally to the neurocmtroll1 mga-n'iaol manipulabon referTtd to in medw:all'!era- joints of Lusdtl... 5cheenann 111. (1969) demonstl'ilted tul\\' IPntl-1homas and Bergn. 19-17; Sdl\"'\"rn: and anglOgr..phialllytNtdistorbonofthe,·ertebr..larte'}' ~.I956;Greenand}o)...t.I959;Bladinand\"~, 1975; KNeg.... and Ol<azaki,. 19t1O;Shellhasdti.. 1980). WolS possible by Cl\"rIiciiI1 osteophytes, and l'Xll\"n§OOfI and rotalion of the head increased rompres.'5ion of the Ol\"K1eynand Nieuwenhuyse (1927) ...e\". the first arteryonthesidetowh,chthelK....d ...asrotatoo.6ralfl to demonstrate tluil lhe '·ert..-bTal artery OO\\Ild be obSlr\\lctro M Ihc alias and aX'5 levels by rotalion and and Willinson (1%7) showed thai rotatioo of the head e>.lension of the head. The \"ert<\"bral artery i'l'\\lcrs the rnay cause cornpn.'SSion of the'\"erld>ral artery as;1 cervical spine at t.... level ofC6 and passes through pasSt'lilhrough Ihc lraru;,\"erse proce.;sof the atlas on a foramenalt-ac:hollhetrans'·ersepl'OCe:'llSe5, ... here the side away from which tl1e head is rotated For this .1 is ca.--ly apprownat«l posteroIaterillly 10 the reason, when a p;!ticnl rompLuflS of dizziness, sus- tuned rotation mUSI br assessed to both sida

~ 10.11 ~\"\".IIIlStqllllolOltJonnghl.llotJlA 100Sttp2-Suptf\"\"lIO'§otdl\\woft;llor\" Ji.+f{dStql3. Supt>'l~bt~f1O*1\"ght.Rot\"J\\.. ... f---LFE \"fht, p~ of athftomatous and artmosclerotlC should not mampulate tilt> «'r\\'ical 5ptne u~ an changeli oomplicate5 the SituatIon, as do marked X-ray has been 1<110.'<1 and \\iewed criticalJ) Tulsi and Pem.'tt (1975) hal''' shown l\"I'idl\"rln' of t.\"I'OSlon u!\"Kf'!1('l1It,,'e changes in the cervical spine. II IS ilnd indentation of tilt> po!dide of C4, which they Important to qucstion thoroughly asjX'Cts of the state as being the most common lelel when compared p<ihent', hi~tory, which may Include onset of dizziness with other lewis bet\"\"\\,,,, C2 and C6, \"fht, phernr due to changes in position of head, neek or whole menon milY be pathological or del'elopmt'ntal, and it may be symptomatic or asymptomatic. The manipu- body. In particular, middle-aged and elderly patients Iiltive physiotherapist must n.'SJX\"Ct its preseN:e m\"Sl be carefully ilsS\\'Ssed both by the referring whether it is dt'I'l'lopmental and asymptomatic phySidan and by the manipulatil'ephysiothel1lpist for Or not. conditio\", such as hypertension or \\'asculard,seaSt' before cen-kal manipulation is carried oul. One

f9nlo.19 ~lIWftts\\lftCkttoll'prnsoon.lllI~UJal~(IIICom~wi!tlmcillatNlllkraltIrxionoftM hndon-=\"tot~ltft.(de-prmioolwi!tlll'rilbIHIaI~flWonoftMllradonMdtolhtrigttlldl~witll \",Uloontol!lr!rlt Signs of ,,,rtebrobasilar IIwol,,,mefll in a paH.....t 3. Symptoms (listed below) provoked during who has symptoms of dizziness should be aSS<\"SSl'd in fourstilges ormobiliUltion or m.lnipulation the l. Initulquestl0mng. «'rvicalspine. 2. 1'h)·sicaltests{s«p.U7). ;I. Symptoms(lisl<'dbelow)foIlowingsuch pron'd-