Maitland's-Vertebral Manipulation - 7th edition

IllI IllI ..'.f. . I,ff Fig..~ 10.20 Ctf'WOIrotitlOllw.thoutuf/ftO\\/t1lltfl1 understand the l<J.nd of symptoms thai the patient feels and calls 'dIZZiness', it is n«essary ton'late: The symptoms refem>d to in (3) and (4) abO':\" are: 1. ll1ehisloryofdil.llnt'Sslothehistoryofnl'Ck 1. Facialp;lr;teSthesil. symptoms. 2. Dirk'ria. l. Blurring of vision. 2. The presence or aggravation of dizziness by 4. Nausea rnovemt-nts of the head and nl'l:k. S. Vomiting. 6 Unsteadiness. 3. AggravatiOJ'l of diuincss by SUSLlincd 7 Nystagmus. positions of the head and nI'Ck in relation to the body. Initial qutstioning The physical t<-'Sts and the symptoms (abow) both dur- The first step is to qu('Stion the palient effectivdy ing and after treatment a~ now dcscrib<.od \"-llarding any symptoms of diuin!'S6, In order to

C~rvic~1 ,pin~ 247 Physical tests maintained for 10 seconds. Tnesymptomatic responses are SOllght as explained above {Figllrr 10.23). 'The manipulative physiotherapist may need to expand on the procedures giv\"'\" by Cop<> and Ryan If the te5t:;;are positive in the silting position, there (1959).Whenapatientassociatesdizzir>eSSwithquick is no need 10 \"'p<>at them in the lying position. rotary mO\"ementsof the head and neck. lhefollowing However, if this is nol lhecase,lhen the lests must be l'l<;lminationproceduresshouldbep<>r/ormed performed in the lying p<:»ition. This is because a Test I - With the patient standing.. he should be asked to tum his head from side to side S<!wral times lhrough the full range while being as:;esSl-od for dizzi- ness or any o(theseven symptoms listed above Test 2-Todifferentiate the relationship of lhe dizzi- ness felt in test I to neck movements, rather than to disturbance of the vestibular system. ft'p<>at,'<I. neck rotation should be tested while the head is held motionless, thus eliminating the effect of the middle ear.ToachievethismovemenllhepatientsLlndswhile the manipulative physiotherapist, standing in front of him, holds his head in her hands The patient lhen twists his trunk fully from side to side while his fet't and head remain stationary. Thus his trunk rota~ under his head without mO\\'ement of lhe head (Fig\"\" 10.20). Di7.zinessprovoked by lhistesl is nnt caused by vestibular disturbance. When a patienl rornplains of dizl.iness with 'pos- itions' of the head ralher than 'rnoveffi'-'Ol',as well as testingtheposilionshecanquote,lhefollowingk-sts should be performed in lhesitting po<;ilion. Test I-Rotation to each side. With the patient seated, he is asked to tum his head fully to th.., left side. The physiotherapi.t then places h,'T right arm behind the patient's left shouiderso that the right hand is placed over theoccipul. The ldt hand is plac,-ci over thc right zygomatican:hsothatthefmger$exlenduplotheforc- head. l'ressure is then applied and sustained for at least 10 seconds. 'The patient is questioned regarding dizzi~ ness or associated phenom('lla both during the tech- niqueandagainaftertheposilionisrele.lsed,whilealso watching his eye movement:;;. A p<>riod of at leasl 10 sec- ondsshouldbesiventoallowforanylatentrcoponse from the sustained rotation. 'The test is lhen carried out with roLltion to theopp<:»ite side {Fig\"rr 10.21) Test 2-Addingexlension. 'The previous position of rotationisadopted,andthenthepatient'shead,rela- tivetohisneck,ise:<tended and the p<:»ition sustained for 10 seconds or more. AgainaS6CSSment is made of lhe symptoms both during and after the «'sl move- ment allowing time for any Ialent response. The lest is ll'peated wilh rotation plus the eXlension romponent 10 the opposite side {Figure 10.22) Test 3 - Sustained eXlension. The manipulative physiotherapist slands in fronl of lhepatient and asks him to extend his head and n<'Ck as far as possible. Gentle over-pres.ure is applied, and lhe position is

......248 MAiTlAND'S VERTEBRAL MANIPULATION greater range of movement can !IOmctiml.'5 be achic\",xl by ather pain Of Sl1ffnes6. Undl't\" the5e orcum;,lMlCeS. in I)'inl;' Tc:!Il:5 (4H6)are thcn'~ pcrmrm,od w,th tilt ~t of the \\ertebl'Obuil.or syslem CANNOT p\"li,;,ntsupine. DE COMPLETE, 8ECAUSE n IE TEST MOVEM.Er-.'TS Tl'SI4-Sustarnedn)lation,~p\"tio.\"'th~supi\"\" roCAI\\.':\\.'OT BE TAKEN fAR ENOUGH CO\\lPR(). with his head and neckbeyond theendofthecouch. Tho.- MISE THE ARTERY. If there are any positive flJld· manipulah\\'\" physiotheRpist hold,; Ius hciId... ,ttl her Iclt hand ~pporting ouoond the h9d ;met \"\"\" righl ings on examination 1'-SIS, while adopting any hand around the Z)'gornabc an:h. The Iwad is thm stretched in n)la00n 10 the right. and !he polition sus- lreatment tl'Chniq\"\" position, during a t.Ntment tt'Ch- tairll'dbIO~.. _(FlJ\"\"'lOU). Thep\"tol'nl ~~~~;~~~~::~~~a\\m' ....t, m,ll1ipuJalhe pmredures are isqut'SbOncdn:gardmg~orUl)'lI!ISQCIoItrdphr­ nomeN boltld~!heliL'dvliqueandag,altlalWrthe pawbOn \"\" reI.ued. Wlull' in thti pawnon at 5UStalnl'd roca6on,and also in thenal ho-vet poIIbOnS(5n 61. n)~~~M~~~~thep\"~t~ O')~\"\"\"\"'erl'll'nbashe ...... tet.o:sMrnoo\"ingfinsr>'. Tnt S-SOSWll>l!d rotabOn withel<~. ThealJo\"... pawt>o:Wl IS adopRd. and \"\"Ien§ion 01 the hNd on the neck is added and sustarned while as&o::5ISlI1& ')'lllplom!; bolhd~andilftertheproceduf'e(F'SI/\"lO.ZS). Ti'Sl' - Ex!lmSion. The patient loeISUf\"M ,,',lh his head and Ill'Ck exlt\"l>dI'd beyond the end of the couch. The rNnipuJau\\'\" ph)'SIOtheraptSl holds the head In the manncrd,'SCribcd abme, and full \"\"1Cf\\S1On 1$ per- fom'ledanda~(flgu ... l0,26). QUALIfiED ASSESSMENT ClIoreful asses.<;met1t needs to be carri,od Ollt wht~, fllil rotation or e~tefl\"iion of the cervical ~pint> is ....'lil,ictro

CtNkall.pint 249 \\'aluableworkln~areaofde/iningphyskalll'Sts when.>by ce!tam mo\"emenb of the arm (neck and leg) cau5f'neuTallIKl'\\·ementinthe(l.'f'Vicalspineina~imj_ lar manner to neural mo,·....oonts such I1S lho.soc ao:hie\\'ed by straight leg raising in 1M lumbar spine tie has shown quilt' dearly 00 cada\"el'$ at lIutopsy lhal,inadd,!ion to tnO\\'ement of the shoulder, l'J1(l\\'e- ment of the elbow when the shoulder isp06ll'J(1nOO in IIlx1uctioo and \",,!erna.l rotatioo i5 ..cromran...·d by ffiO\\'emmt of nen,'\" roots III IN \"~ral ~anal a..nd inter...ertebral l'ofamlJlll, H.. has shown llbo thai fOO\\e- menl of the left shoulder and Jri'tdbuw CfNll.'5ffiO\\e- ment of the \"\"\".., I't)Ots lind bra.dti.>1 plnU!l on the right5ideofIhe5plne.~test!lII~.\"mportanttNl all physiO!herap;,;15 shoukI M>ow and.- them, \",en III undergradu~ ... I...\"\". 8utlcr(19QI)do>otoibes f\\lrther neurody1\\amic: testmgoftheurP\"\" limboo Qualifoed manipulatiw physiotherapists know th.at some patients han <JIou\\der pain tNt is «'fVica1 in origin. \\\\n..n.a pahent bas such shoukler pam, 11 an fnoquenltybenoproducedb). !heneuu.I_Eht')1100 Butle!- tu,-\" described Some of the tests shaw, by \\ ...1>etherOl\"notthertare.ny~)·mptomsOl\"~Igm;of \\'irtue of the bma.,->OUr of the poIlIl \"\"hen <E'\\'>CiIIl ,-~iLor in$uff~~)', nv.mpuLotion,..a ilUd- fOO\\-emenl:!;lI~coupled...,ththem.th.otthepilllmts dnl lOO>~t ~'md IN poItienf$ coolrol is con- ~Id.... pain must be omic.al in origin A numberof Iramdic.atl'd in e-\"eryt'klefly poIlK'I'It .. ho h.u nvrkd ~1\"~cNngts.T«hn.ique must be limned to lIe;bCMIbe<:al'ril'douL1'heroul1neol~oIthee mobLliziIbonl; used m conlm...l CIlnfU~hon Wllto IISl5i1stifoUows: ob!;en\"ilbon$and qut!Sl><ln$ne!ahc'd IgdiUinl'S~ I. a) The p<llIent l1e supme w,th M IIrm able to be Granl(I~1 haslkuilN a mro.ro-Itgal prollOCOl for \"\"tended~ybeymdtheN&\"oftherouch. nunimum 51andards of \\'ft1ebrobaoSllar al'tlPfy Il\"iIing. \\\\1th Ius ann bytus SKIr. lussOOulderspTlp- toms ilre then ~_ The pn\\\"SXlthl'raptSl lhenabduetshl5arm....,thout.,k.. allOllofthe MOVEMENT IN THE VERTEBRAL CANAL AND shoulder girdle,in a frontal plane pl»lenor to INTERVERTEBRAL FORAMINA the med..... frontal plane until the symplom!l Uppe:r limb neural ttsts (UlNTs) changlt'(Fisu\"IO·2n. b) She !hen releMesthealxluclJOnl\\.'f\\!iion toa Mcthodsfor-l\\.'SIulgfor-lJlO>emm~o(the«r.nl.-.e poslbonJu:st5hortofpnl\\·oIungthesymptom.. She !hen externall) rotiIt~ his urn ..00 rootsortheu\"!Ilee',e5by Mreldling are nol yetclearcut. supinateshis forearm and assesses any changt' in symptoms (f.g..... 10.281. Ne-'ft1I>eIes5,Jwolpful'nformahorllSoftengamedwhen c) She then releases the Llter..l rotIIl.oo toa pas- a pilbent spoo\\.ilno.'OU!oly rommenb that he ach~'e5 itioon jusl shorl o( prm'olung symploms. ..OO rehefofhJ~$ympl<)m$byplacinghishandonlm;tv.-ad thensheextendslu5\"lbowfollowl'dbyh,swrist (olSStImlngthepossib,litythatlhispositioorelie.·e§lhe and fingel'!i to al\\5e5S wl'ol.'1l\",r th,s n.\"nxluce his symptoms (Fig..... 1029), If the shoulder strctehoo the fifth and sixth«'1'\\!ical nel'\"e roots),or by symptoms are provoked by ..\"tension of the supporttng lho:elbow of hill pilinful arm In hisOlher hand in a shng·hke bshion (which pem..ps relieves hand, the SOurce of the symplOms must bt! ,n n -~rt1ch on the -\"l'\\u,th a.1\"\\ic~1 nl'I'\\\"., rool). po!\" structuresothcrthanthcglcnohumcral;oinl. d)lVh,le malnlaln\"'g wnstand finsere~lenslon. ilion!; are sponlaneously adopt~od by pillients wllQ5t' sh.. f1e~~'S his elbow and asscs-;cs lhe pain symptoms and neurological changesal't' in lhe arMS r'l:.'»ponsc(F,gurrlO.30) R'latt'CI to Ihc \"\",ryC roo15stutoo.Cooyersely,stretchcan somet'mesbeincn.'a!il.'CIbyprolractlnr-;thcshoulderand slrelclung the arm aCr0;8 in frunt of thc body. E1ycy (1979), al lhe W~'Slcrn Au,lralian Curlin 2. a) If the pat;ent's ann is th~'JI put into the positlon University of Tedmology. Is conlinuIIlJ:; lhe e~lrcmcly lhat reproduces lhc shoulder pilin Ictus

250 MAITLANO'S VERTEBRAL MANIPULATION F\"'9uro:lo.21 (oIA1x1uction;umin lnt IorlohOllIdo'l'I;n.IIllAbductrd Fig,,\",lG.2'~ohbduetion t~_followfdbl\"o;ltfnallOtatiofl

Cervical spine 251 Fig~'c 10.29 Rclca.. ollalc,.1 rOlOli\"\" loHoWM byulension Figurcl0.30 Elbown,,'o\"during wPist.ndfi\"ge,eXlension assume that it is this last step of the test just c) ~ same pain respol\\Sl!S are assessed wilh the d\"\"\",rioc'<l above - he i~ then a~\\«'<l to take hi~ cervical movements of flexion (Figure 10.33) and ear toward~ hi~ painful ~houlderand Ihe physio- rotation towards and away from the side being therapist assesses Ihe changes in his pain testt.'<l (figures 10.34 and 1O.J5}. response, It is vital that the glt'Tlohumeral joint and shoulder girdle be maintained in exactly 3. To add another component to the lension. double the same position throughout Ihe lest of straight leg raising can be included (Figure 10.36) cC\"'ical movt-m\"\"t~. If thi~ is not done wilh Lastly, a further step can be taken by /!Sking the fine judgement, the test becomes invatid patient to nex his chin on to hischesl (figure 10.37). (Figure 10.31) SLUMP TEST b) The next test is for the pMient to take his ear away from hi5 painful shoulder, while again The slump lest, as described on page 144, should be asscs.sing the change in symptom response to incorporated inlO the physical examination when the the movemt'Tlt (Figure ]0,31). The other cervical examination findings of joint movements do not fit the patient's symptoms. movements can be utilized to delennine whether there is a cervical componenl 10 the pahenr~ symptom~

252 MAITLAND'S VERTEBRAL MANIPULATION Ftgu,el0,31 Asse.smentofpain \",s.ponsedu\"n9rntationofthepat,ents hudtowardsshoulder Ftgu,el0,32 Assessmentofp.in responsedurlngrotationofpalientshud awayf,om\"'ould., Ftgurel0.33 Assessm.nlofpain ~ponseduringce\",kalflnion

Cervical 'Pine fI9~~ 10.34 Asst1smcntofP'lin ,c,pon\",dunnglatcralfluionto..ard, shoulder Fi9~~ 10.35 A,<nsmcnlofpai\" rnpon'>l'du,inglatcralfluiona..ay f\"\"\"snoulder Thc~ is anoth~-r as!,,-'C1 of verlebral canal lests, EXCLUDING THE CERVICAL SPINE AS A SOURCE which is parlicularly perlinent in the cervical area. OF SHOULDER SYMPTOMS Breig (1978) has shown dearly 1h.J1 the pain-;;ensitive slruclures in the verl~ral canal can lie in different To be certain that shoulder symptoms are not cervical places when 111e patienl is in di/fermt posilions. For in origin, thn'C other tests are mandatory: example, during cervical lau\"'al flexion 10 Ih~' lefl the pain-sLonsitivestTucture:s will be in a different position 1. The firsl tests lhe physiological movement:s of: if Ihe mo,\"\"m~onl is perform~'<l with the patient silling rolation lowards the p.,inful shoulder; exlension; to thai when he i$ lying on his left side, and will be and the right low cl.\"rvical quadrant. These p0s- dilferent again if he is lying on his right side. There-- itions should be susl<Iined in an over-pressure p0s- fore, if a patient has symptoms and signslhal do not fit ition lor a short lime. II Ihis lest reproduces the in with the common musculoskeletal p.~lIems, such shoulder pain, Ihen Ihe cervical spine is impli- cated. If the t\"\",1 produces local cervical pain, the tests as descrilx>d above should be perlormed. If when test should be repeated to the other side for COm- doing the lateral flexion 10 the left a parli<;ular site of parison, SO as toaUow a decision to be mad£' on the pain is provoked at 20 per cent of Ihe normal range, yet implication of the cervical spin<'. it is full range and pain f\"\", when done in left side lying.. and is mo~ S<1\\'erely provoked with minimal 2. The SL'Cond lest is c<'rvical compr(!S/;ion with th.e lateral flexion to the lelt while lying on the right side, patient's head in slight extension and laleral flex- trn.on there mll~t be some canal stnlctu\", involvement ion lowards Ihe side of pain. If it provokes th~· in lhepalienl'sdisorder shoulder pain, the test is positive. If it produces

254 MAITLAND'S VERTEBRAL MANIPULATION F<9u'~10.36 A5~~nlolsh<l\"ld\"-p;linr..pon... d\",ing Fi9ur~ 10.37 \"=ssment of lhould~r-p;lin ~pon ... during doubleltraigntl~raising doublestraighllegrai,ingwilnnc<:kflo:ion pain cenl~ally(at approximately C6) or slightly lal- fully by palpation. If the c..-rvical spine is involved, e~aUy towards the painful shoulde~, comparison there will be a ma~koo differl'nC\"- belween the should be made by performing lhe lesion the painful shoulder side of Ihe cervical spine rom- opp06ite side. If this lest also provokes lhe previous pared with the opposite side pain, the cervical spine is implicated. However, if the tt'S1 on Ihis opp06ile side produces pain on the PALPATION side of the <;omp~iOll, the decisiOfl ;U; 10 the involvement of the cervical spine rests with the (Adapled from Maitland (t982a), by kind permission quality of pain on each side. If Ihe pain on the of publishers.) symptomatic side is fa~ greater, deeper, or sharper than on the othcrside.the involvement of Ihe cervi- The muhne of palpation examinalion is performed cal spine is heighl~ned. in thefollowingscquence. It is first necessary to ha,·e the patient lying pl'C>ll(> with his forehead resting in one 3. The lasl and most important test is thaI tht\" cervical palm (palms overlapped) and his neck SO posilioned spine from C4-7 should be l'xamint\"d very CMf'-

~rvial 'fl'''' 255 l'igu\",10.38 SofHissIl,polpotioowithth,.. fi\"9\"\" Fogu\", to.39 Soh-li'SU,polpollOflwithlwofillgl:f!O thai there is no 1.:It<:r,,1 fk!xion or roI<Jtion, and so thai th\" spine lies in its neutral mid-f\\e)cioo/edension position Ar~as of sw~atin9 and t~mpc:ratur~ chan9~ The first step should be to I\"'lpal\" the posterior aspect 01 the neck (especially laterally) 10 ascertain the p.-. l'OCC of any sweating or temperature increase, result- ing from an inflammatory disorder or increased sympalhetic outflow. A dl'Crease in temperature may also be d\"tl'C1\"ble in cases of 'old', 'cold', chronic arthriticpalhnlogy. This isasscssed by using the backs olthefingers Soft-tissu~ changes F'!Iu\",10.4O Soh-lisw.palpalioowilho... fi\"'!l\"' To gain the patient's confidence, the\"\"\"\",d step should of lhe articular pmar), from Cl-7 (Figu\", 10.39). The be 10 usc the hands and fingers in a general manner lCChnique involves moving both hands in rhythm with over thoe back of lhe nl'Ck and adjacent supraspinous each other, moving the skin up and down with the f066il area in a soothing circular pc!rissagl'-trIX' mas- pads of the fingers as far it allows, while gently sinking sage, during which a gen<!ral impression can be gained into lhe muscle bellies and other soft tissue. The pur- as to the state of the superficial soft tissues. This r>eed pose is to feci for areas of thickness, swelling and Hght~ notl.. ke longer than a few secunds, and it is invalwblc nl'SS in the soh tissue, and also for abnormalities of the in gaining the ronfidelllX of the ..pprchcnsive patient gene...l bony conlour. Having performed two or UteL\"\" Qrthepaticntwithanextrcmelyt<ndernccl. up and down movements in the uPI\"\"'\" cervical area, the fingcrsshould be made loslidecaudad 2-3<:m and To begin the more positive part of the sofl-tissue the process repeated. This is then continued, moving e...minatioon, the tips of the middle three fingers down the f>I'Ck in approximately four stages, until the (figure 10.38) should palpalc the sub-ocdpital area level of Cl is reached. A partkular level may be from the superior OlJCalline to the alias. To do this, the returned to if an abnormality is felt there. Once lhe pressure of the fingertips should be directed towards general and more gross imprc5$ion has bcc:n gained the patient's eyes and the tissuc palpated by both a through the full pads of the fingers, the procedure medial-lateral movement and a postem-anterior should be repeated but using the lip of the pad of only lTIO\"emet\\1. Palpation continues by noW using the fuJi one finSC'\"ofeach hand (Figure 1O.4O)and emphasizing length of the pads of the middle and index fingers of each hand in the laminar trough area (that is, from the laleml surface of spinous process 10 the lateral margin

256 MAITLAND'S VERTEBRAL MANIPULATION the examination to the areas where discrepancil'S from C2-7 the normal tmve ~n found. The ,pinous processes are unreliable as the sole sourn' A rea:;.onably accurate determination of the site and of information regarding position of the vert..-.'brae type of tissue abnonnality should be made SO lhat a They frequently lie to one side without there being any more detailed determination can b,' made later. rotation of the vertebra, and ab$ence of onl! or olher lerminaltubercle of the bifid spinous process is com- The most common findings at lhis stage of the mOn. However, as they are accessible they arc !\",Ipated examination are: first. If a spinous process is nol cenlral, the arlicular pillar and inlerlaminar s!\"'ce arc then palpaled to 1. Gt-'Tleral tightness of muscle tissue along almost assess if their position indicates any verlebral rotation lhe full length of One side of the cervical spine or lateral flexion. With practice it ;,; also possible tQ appreciale a small loss of the normal cerl\"icallordos;,;, 2. local areas of lhickening imml'<1ialely adjacenllo parlicularly bclwloefl C2 and C5. Similarly, an abnor- one or more Spmous processes. mal closeness (which is a quite COmmOn finding) of Ihe spinQus process of C6 10 C7 is readily palpable 3. Local areas of thickening in Ihe largesl part of Ihe muscle bulk in lhe mid-laminar trough area The arlicular pillar is also palpated laterally, and the Iral\\5verse processes anterolaterally. The age of any 4 Sofl thickening over the posterior articular pillar soft-tissue lhickening found can be as.sesscd by virlue at one or more intervertl'l>rallevcls. of the hardness or softness of its fecI. and zygapophy- seal joinl Hoslo,;escan be clearly fell 5. H.1Td bony Ihickening and prominenceO\\\"er the Jateral and posterulatcralmarginsofthearticular Gauging any anomaly of the position of lhe verle- pillar. bra must be done by a correlation of lhe lhree findings The first is the position of the spinous process, the 6 Tightness of the ligamentum nuchae. or localized ~ond is lhe prominence aod depression of opposite Ihickening of a section of il. articular pillars for lhe same ,\"ertcbra, and lhe third is confirmatioo by X-ray findings. Displacement lalerally Bony changes ilnd position tests of a spinous process wilhout any accom!\",nying rota- lion of the \"ertcbra is common. Bony points and intl!rspinous spaces are palpaled nexl. The lip of the lhumb of each hand is used 10 pal- Thc lhrt.\", mosl common reliable findings are pale the bony oUlline of the spinous processes first. 1. Prominl,\"ce of a spinous process associated with There are 1\\<.·0 importanl plan\"\" in which to aSSCSS limited range of movem\"''Tl1 and p.lin. the posilion of the spinous processes; the first is that they should lie cenlrally in Ihe sagillal plane; and the 2. PTI>minence of a 1C'·cl of lhe articular pillar. sc<:ond is lhat from C2-6 they should lie roughly along 3. An abnormal closeness of lhe spinous process an arc of a single sagillal circle. That is, the spinous processes should change evenly along lh.... normal cer- ofC6--7 \\'icallordotic curve. However, normal variations with regard to Ihe deplh of 0 and the prominence of C6 ExoslO5l.'Sassocialed with the Z}'gapophyscal joinlS arc and C1 should be allowed for when intcrpreting the easy 10 find. Assessing Ihe relatiol\\5hip of the changes positions in lhisplane to lhe patient's disorder dCp'-'Tlds upon Ihe quality of sofllissue around the joinl and also Ihe quality of pain CI-2 that may be provoked by moving the joint during lhe palpation examination. The patil'Tlt iii'S prone and J'l;'Sts his forehead in his palms while Ihe ph}'siolhcrapisl palpates between the PASSIVE ACCESSORY INTERVERTEBRAL spinous process of C2 and the occiput to ascerlain MOVEMENTS (PAIVMs) whether the postcrior tuberde of CI is palpable. From lhis point she !\",Ipates bilalerally through thc relaxed Movement is first aS~s.l'd by mO\\ling quickly up ~nd suboccipital muscles, moving laterally until the tip of the lral\\5\\·ersc process is reached. The relalion$hip lhal downthe~ine,performingtwoorthreeoscijlations each side of Cl bears 10 lhe occiput and 10 C2 should be assessed. This finding i$ a$si$ted by also palpating ~teachlevr:1 with lhe tips of the thumbs ilgilinsl Ihe Ihe lip of CI laterally to assess its rt'lationship 10 the spinousproc=esilnd articular pillar. In lh;swaya anterior aspecl of Ihe mastoid proct'SS. general impressio-n of comparative mobihty Can bl' determined The spinous pT(l('t'SS of C2 varies widely in its shape and lubercles. It may hal'e only one laleraltubl'rcle and thus appear lobe rotated, If rotation is presenl, une artic- ular pillar of C2 will be mo\", promiflCflt than the other. X-rays will also show the shape of a·s $pinou$ process.

Cervical spine 257 <: rFigun: 1O.>lt Unilamal post\"Q-anmiormovem.nts. (a) Medialty (bl Mor.lal.rally Movemenl is assessed by using pressul\\' through the is achilol'oo when thumb pressure is appli<'d in a combinoo unilateral postt-ro-anterior and m<'dial lipsoflhethumbsagainstlh('spinouspnx~firsl. dill'Ction. Thisdircclion of movement produces a maX- imumslidingofthezyg.lpophysealjointimmooialely Twoorthreeoscill,lloryposlero-anleriormO\\'ements under the thumbs. Jfthisdirectionofmovement is per- al\\' pcrfonncd at e\"ell levej in lum, moving fairly formed throughout ilS total range-that is,from max- quicklyupanddownthcspinc,untilagcncralimprl'S- imum foraminal opening {lifting thc n<..:k postcriorly sion ofcomparali\\'c mO\\'cmcnl in both quaJily and and lalerally) to maximum foraminaldosing-a I'ery rangeisdeterminoo valuable assessment of flexibility and quality of move- mentatthezygapophyscaljoinlis rcadilyoblairwd The movements \"realt'd by pm,s.\".., on the &pinous The technique for the lifting component of this move- processes Can beassesscd e\\'en more finelr by varying menl is faciJitat<'d by hooking Ihelittle finger Wlder thedin-..:lionoflhe p,,-'SSures,inc1iningthem Icft, right, lhe patienl'schin (Figu\", 10.42\"). Also, by varying the cephalad and caudad. Combinalions of thl'Se inc1in- hand and finger posilions, Iheseunilateral poslero- alionscan also be u5Cd (Sf\" pp. 157-1(1), Nol only anterior PK'Ssurescan bt>performoo in such a way as should lhe dir1.'Ction of the pressure be ~Jricd, bulJlso 10 produce a rotary movementora lateral flexion thepr1.'Cisepoinlofconlaetonlhoespinousprocess movement ThiswilJ produce a change in Ihe movement occurring at the inten'crtebral joint. Thcsamc procooure is (ar- The movemenl abnormalities that can bt> found are: rioooolO\"l.'rthcarticularpi]laraleJchlevel.oolh limit<'d range or hypomobility; resistanre 10 move- mooiallyandmorelalerallr(figurtlO.41),romparing mentlhroughlherangeduetocrcpitus,sliffnessor 'oolhlherelalivcmovcmcnlofadjaccnllcvc1S,andabo muscle spasm; and differentqualitiesofend-fcel. Ihatfound at onl.'intl.'n'crtebrallevclon lhcleft wilh themov<'ml'Tllatthesamell.'l'elonlhl.'right In makingdetermioations, it is importanl topoinl out thaI a hypomobile joint Or a hypermobilejoint is Variations in inclinalion and poinl ofconlaCi wiU prodUN: a cIlange in the movement occurring at the noln\",,~rilyapainfuljoinl.N<·vertheless,thequalily inle~r\\dlraljointo'l'f9apophVSl:aljoinl of movement and rangeo! movement musl ~appred­ aloo before attempting to relale the abnormalities found to Ihe possible caose of the palient's symptoms. Similarvariationsofdircctionandconl;lclareapplioo Pain response 10 lhe articular p,Uar. Howel'er, one of the most us.eful lest movCII\\enlS in the middle and upp<.'TC<'rvieal spine ThenexlstilgeoflheexaminalionistheaSSt-'SSmenlof pain responses. The above stages of examination are

258 MAITLAND'S VERTEBRAL MANIPULATION Ftgu•• lo.42 Orcipito-all.nUlI ,olatioo.(o)Unilat.,al \"\"st=_ant.,iOf \"\"\"'.....nt<on In. Idt of C2. (bl Hook..tfi\"9\"\" iflC\"'asi\"9 O/C2 rotation Idt carried out withoul asking fo, any comments by the UPPER CERVICAL SPINE pati~'TlI,and in fact it is wise to iostruct the patient to make no comment about SOf\"l\"'C!JS, tend\"m<.'S.S 0' pain For the upper cervical spine, it isimporlant 10 palpate until asked for lall'T in the examination. deeplythesofttissueandth\"capsulara~aofeach occipita-atlantal joint {rom posteromedially to lat- IOl1lO\"itt:aStS,onlyaft.'ti~thict..,i\"9.bony erally.II is po6Sibletodiscemthe d<.'gll'Cofsuchthickm- promjocnttSandClualityand,af19\":of~m'Mh. .a. ingwhL'Tlitisp\"\"\",-'Tl1. b«od\",.rmi~<houldtl\\tpali.otbta<1.dabout any pa,o,.sponsc l'ostel\"O'anteriorpresl>uresshouldbcappli<.'<ialong Iheatlas{rom the midline to the tip of the transvefSC Having made the determinatiorul ~an:1ing tissue prllCt-'S.S. When lhepatK'Tlt'shcad is fully turned toone thickning, bony promincnces, quality o{moveml'flt side, postenrantenor pressu~ is applied to the articu- and range of movement, it ix'comcs llCCCSSary to ~late larprocess of the axis on the side towhi<:h lhepatil'flt's th,' pain Il.'SPOflSlS to these determinatioll.~.Notl)flly is head is turned. 11>c fingers. hooked under his <:hin, il necessary to know which mOVeml'fl!s either provoke can pull and apply opposite rotary movement of the the pain for which trealm~'Tlt issought or produce local occiput and atlas to that producW at C2 by the thumbs pain only, but it isaloonecessary todek-'rminewhether (Figure 10.42). Assessment of the quality and range of the SCf\\Siltioos are fell to bcsupcrficial Or deep. 11 may occipilo-atlant~1atlanta-axial rotationsoproducedcan benec:cssary to apply firm p\"\"\",ure tooblain an accur- be asIil.'S.\"Cd in this position and rompaK\"CI with that ale d\"tcrmination. (H1 the opposite side when the head i.\"tUml.'<i 10 the othe, side. The quality of this allanto--axial movement A stiff joint does oot necessarilycausc pain; it may throughout its range is fully assess<.'<i by positioning bc rcsponsible for an as$Ocial<.'<i joint bt.'COming painful thehe.1dindifferentd\"grecsofrolatjOl\\bef~apply. \",., same applies to thickened tissues. inglhcthumbpTeS5ures(sn.p.277) Having discusso:-'<i the general ex.aminati(H1 pl\"O' With the palil'fll's head still 1utllI-\"CI slightly toone \",-'<iu~ arw:1the possible findings. it is now possible to side, transverse pressure can be applied to the trans- discuss special palpation techniqu<5 and the abnor- verse process of the atlas and a comparison made with maliti<5 that can be found at each of the three sections the mov~-mcnt available on the opposite side (sa pp of the ccrvical spine, and to indicate what ItK.'Sc find- 283-2ll4,f;gllrel0.7T). l1>ese pressures can be varied in ings mean to the manipulativcphysiothe..pist. lheir dill.'CI1011S from posl~'Tior through t,am;verse to antcriorpK'S.SIm'. While performing these movements.

CeMalI SfliM 259 not only is it pcw>ible lQ_tIw! ql.llliityci the move- toone 5idc in relation \\Q theoocipuL BeforeaccqXUlg.. ment and ib ...n~, but it is also poIi5iblrlQ_ the from tlwpaJpation findings,. an interprrtation 01 being ql.llll.tyol tIw soft ~ immediately S\\lJTOUoding this iUN,.whichi5frequently~uniliIIleRl.ly. displaced looneside.thenKlioklgical viewsshouldbe ~.ThisisMcauseitisnot~forthe Difffftntiation of symptoms arising from 0-3 traR'i~~oIlhrat1astobrsrnallerononeside or C1-2 apophyseal joints thantlw<>thn-. Tho= is ~ particularly important lest prooedun' Todelennine wl1fthera poosilional abrKwmaloty is Ihat isU!:ll\"d whm it is nerellSiIry tode!lennine wlrtheor a old or new, the X-rays must br viewed IQ see if bony pa!icnl'••ymplorns arise from a disorder 01 the Cl...J adap\"'ticn;tothechan&edpoositionhavetakenp~ apoph)'!ll'.ll joint or the CI-2 apophr-JNl joinL WIth the If the positional abnonnahty .. old, the bone will NV'\" paticnlproncandtheheadinlhctll.'tJlralposition, slightly changed illl shape 10 accommodate 10 the postt.'I'O-llfltcrior Pl1'$ute;lin: llpplil:d, forcxamplt!, to adoptcdposition. the Icft articular pillarofCl SOilS tu move it ina posten:.- anlcriorditeetion. llle quality and rangt\" of mm''-'fTlL'flt, A palpable rotary anomaly isonlyofclinicalrele- and the ;ocoompanying pain ~ , are COlJlpan,d WIth tIw same featun's whm the p06tl.:ro-antcrior prc5'\" vancctothep~lingsymplOm!lifdcrotalionby sun'iIapplicdwilhthes'llneSln--ngthtoC2.butlhislunl: palpation provokes dct'P local pain or n-prodl.lre5 Wlthtlwpatient'$Modrota!l.'d\"'PP\"'J'ima\"\"r:.l)-4tJ\"1Q the patimt's symptoms. This principle applies to any the left. If thl'pain response isgn.oater with tIw '-d roliIlOOlNnitiswiththehcadstralght.thedi:sorderisat palpable anomaly. WOC\"\" very strong palpation p\"\" IheO-2joirLlfthepainresponselSgreatel\"wilhthe sores prod........ only a small dcgfl'e of derot>l1On and only local pain. tIw poiWtional change IS pmNbly \"-dstnlght.thmlhc~i5attheCl...JjoinL longstanding. Thecorn..-..findingsare.follows.. MoYr1nt'nlobnormolirks Suboccipiutarea The mo&t common ~t frnding thai a.n br Soh-rissuf!chon~ dl'terminedbypalp;ltionisadi~inthel'illnge of moo.'emml prodoced by posI8O-iIInl£rior prelSOn'! Two particularly important findinK\" in the sub-«tipilal 0'0''-'\" the articular pillaf at cach Icvel. Stiffne!laal one areaan'gt,,\",-\"ralizOOthickmingandtightt-rungofth.e level should berompared WIth theothed\"\"e!sancl the suboccipital strudun'S O\\IerlyinK the atlas, and, ,-'Ven same level on the oppositc side. IJlQmpartieularly.lyingbctweenthcatl...~andocciput. II is IIlOl'Crommon for this tighlness to lie in the mo:dial Movement abnormalities have more signiflcan((' tw.....thirds of thea\"\"\"',but vet'}'OC'C.>Sknallyit isfclt 10 thandothemoll'fixedpositionalchange5.Thecasit... it be in the btera.1 half only, and '<>II:ly on one side. is In push inlQlhestiffr<lngcand producemovt'lT1ent the t'aSiCT il will be to I'\\$lore thc range. However, it is The:l«Ond common fonding is marked thi<:kening important thai the improvement in rangc must be of the aopsule and S\\lJTOUodUlg tlS6llC of one or both accompanied by a roncurn:nt improvcmmt in the pain atbnl(H)lXipilal joints.. The ttucket\" and harder the m- I'l..\"Sp(>nSeduring the rnovemcnt. suesare(itSCOfllparedwithbringspongie-r),theolder Atlanto-axial 0-3 aru\"'-' _ ..,,~ Soft-r~r:hanf}ts The relevance ol the findings to the p.ltient'ssymp- toms <Wpends IIport two things. The fint i5 the agn.oe- Soft-lissuechanges in tlwCI-21aminar trough an'! less ment betwt\"en the chronicity of the history and common lhan eIsewherc, although it is not ~ symptorM 01 tlwdisorderand theol<ir>ess of the tissuc to find thickening ol the soft ~ immediately ad~ changn found on palpation 6llminatioo. The S«Ond IS the n:-productionofthep;lticnt'srefcrred pain or the centloonesideolthe5plnous~oftlw..,.i5.For provocationofadcgfl'eof d<\"l'plyfelt local pain <:Onl- thisfindingtobcp..rtlflenttoapatient'suppercerv~al patiblc with the paticnt's symptQn'lll when the tissues arc palpated firmly. symplOm!l. firm palp;ltion must provoke deep Ioml or refCfTl\"d pain. As \",\"-'fltioned above, the hardness or Bonyanomolif!S spongincss of thesoft fuooluesguides the inlerpn.'13tion The oommon bony abflOl'1llilJiticsof the atlas are that it oftheoldnl'SSorncwncssofthechangcsandthcircon- isof\"-'flfeltlQbeslighUyrotatcdorslightlydispla<'l:'d ~uentll'versibility. l'rominence and Ihickening around the articular pillar of the 0-3 apophyseal !oint is a rommon find- ing. p.~rticularly in palk'flb suffering from cervical headaches.. It i5 pos.sible 10 diffc....,tiale hetwl'l'll

260 MAITLAND'S VERTEBRAL MANIPULATION =0 'old'.nd 'new' in relation 10 thesofl hssue(as explained .Ixr.,..j.\"nd IoreLotethem loostooarthrilk (-u;icjeXOSI05t5. n.... oomparabiJily belw....... the palpation findmgs ..nd the pabenl'~symptoms isaSSCSSlld by \"\"Lalmg: I. 1lw: pa.... ~ whiJt' ..pplymg pressure 2. 1lw: In'ngth of the pressure required 10 pn:l\\'ok the potm n.'Sf'Cl\"S\"'. 3. 1lw: oIdnes or .......- . - of the ti56ue d'Iotnges. Bony onomo/its Htw 011 old softtluul VwyolcllOfttilsw c~(althrOCic) Oslt'Oolrthntic(-(J5jcj~oslosesarereadll)·palpable.1 .....cNn!I\"(r-.:~~) the 0-3 apophyl§O:'al joinl. The... reIe\\'anct' 10 a \\/ Harll,lNlhery pahmt'lsymplomsis .... part indicated by lhesharp- .-01 the margins of the \"\"ostoses. II lhey are nol ~/ sh<irp or bony,beingco\\\"er..d by otll<-'I\" solt-tiS5ue thick- enmg..lheyaremorelikelyloberelalOOloprcs..'1llmg If tht- poslem-anterioo\" It\\(l\\'emenl applied mer thP symptoms. articular pilLar is dil'l.'dcd Tl'M'liyU)·. the common find· ing is .. not>rell~ lad. of rmgeas5OClolted \"\"th The absence or smallness of one of lhe prQC<'S6<!Sof molrlced diKomfort and pool'\" q.....Jity of mm·emenl thc bifid spinous pl'l)C(>SS of thc aJus is common, ,IS is throughrange(fip\"' lO.U) deviation of thl'_ptnoUS process fnml tl1l'nwdi,1n sagittal plane.l1te only importance relatt'd ttl such Differentiating bet\",~ p.lln ..rising from tht- 0-3 findings when they exist alone is tltal' and tht-\"t!.antl)o-ilxial jooInt5 has bem described alxr.·e. • There must be a !\\SIson for lhe spinous proo::ess Indirotionoffindings bemgshapedthus II isirnportanl todl>termine, when p.1lpating o\\'er the • ltindicateslht!prcscoceolanas)mmetrical CZ-3 apophyseal to.nt area, Iht- quality of the lissues. func:tional difference, of some kind, al th~ Hard bony promlnl'f\"lCeS, Indicating Oliteoarthrilic cer\\ialle\\el eXQl;tose>, are common. When 1 ' - bony promin- et1CesJrenotcm·crL'd by sofl spongy hssue, lheinler· Such bony abnormillibcs do nol of them;..to4,es ClUSo!' prelat;on is Ihalal1hough they indicatcosleoarthritic symptoms. bul they do ,ndICa'\" thai the joint may (-<:I5ic) changes in the apophyseal joint, the arthritic be d~\\\"an\"'ged il subp-cted 10 an asymmetrical pruccssiscurTCTltlyinacllveandnulasour«ofp.1in unguardl'dlTlO\\emenl, However, when the lissucovcrlying thecxoslO5CS is Mol.T~ntabnorma/rties n.ethickened, lhe interpretation is quite different With a potltil\"Tl1 ...·ho ....Hers from ceJ\\'wl heacIactM':s. thickening varies bt'twt'en twoextrcmes, from being like lough dry leather to being ,·cry sofl and spongy. po5lftO-antenorpn'!l6ureonthe~inousr~of o rnchnedcepltalad isfn.oquenllyutrernelypamful Ioullydeoeply,and\"\",yreprod~theheadaches. It IS surpns....gly uncommon for Iht- aILant~a)l1011 joInltobehmllOOin rangcwhen comparL'Clwrththc frequency of limilation ofmO\"l'menl and poorqualoly of movement al 0-3. Occurrrng concu='IlUy wrth this poor 0-3 mon~ mCTlI IS lhe common finding of a promin~'1l1 'pinous proccssofC3,whichisreadilypalpablt', Thecommon pain response isunt' of local d~\"I!p Pilin felt with moverno:.nl of the C2-3 joint by Presl>u~ ditl'Cl~'Cl poslel'()-anlenorly over the C3 spinou~ pro<:l.'S8 and al thc articular plilM

C~rvical \",in. 261 Figu•• 10.44 Unilot~\",1 P\"'iSu,~ post.\",-onl.,i\", wilh mffiiol indinotionon C2. III. 10) N.ut.alstarting position. (b) Fully liflffi and o~n position. leI Fully CIORd post••o-anWiof mov.m.nt m.dially«C2.1111 The mon' lealhery il is Ihe lC$$li~ly il is 10 be causing In r<'!lation to prominence of the spinous pl\"ll«\"SS of olker Ikan mild local symploms, wken'as Ike sofler il C3, lhe goal is to improve the quality of the movement is the more likdy il is to be of recent origin and associ- in its postern-anterior direction, to decrease its prom- alN! wilh recenl symploms (Figure 10.43). inence, and to eliminate any decp pain response thai may accompany Ihe movement (n terms of treatmenl, the somewhal harder thick- MID-CERVICAL SPINE ening demands firmer tn'almenl. Also, manipulation may n~d 10 be introduced more quickly. The goal of There are two special aspects of the palpation examin- treatmL'Tl1 is to (\"liminate totally any soft spongy tissue ation for this:;;ectiQfl of the spine. Firsl. TT\"-odially directed changes, to lessen the tkick~ of Ihe harder sofl lis- unilateral postern-anterior pressure is particularly sue or, under ideal circumstances, to eliminate lhe relevanl. The second is Ihat postero-anterior pressures tkickening, leaving 'clean' bony exostoses which are painless if pushed

262 MAITLAND'S VERTEBRAL MANIPULATION Figuf't 10.45 f';l1p3tion b(tw~n spinous pr0C\\'M<'5 ~nd b'fid F'9u~ 10.46 Me~h.11y dit«ted p>1p3tion 01 posterior int~\"\"jllOlr§'f'3ct P'~ This palpation i.\" Ihen continued in lhe interlami~ on the spinous pl'Ol:.'tSSeS n~,<-\"ll, at times, to be per- nar lrough area, continuing laterally to the artku- fonnL-d through their maximum range. This requin;s lar piJlar (figuTl\"IO.4S) that wIK\", performing lhe Jl'O!'lero-anterior move-- Bony anomalies ments the fingers should lift the patk'nt's ned so lhat The common bony anomalies that can be found are of the movement begins from the maximum anlero- two kinds. The firsl is a promirocnce of the spinous posterior position (figul1! 1O.44b). process of 0 (associated with headache symptoms), a Soft-tissue changes n.., most common findings in this section of lhe Cl'r- vical spine are Ihickening of soft tissue immediately adjacent 10 a spinous process or between adjacent spinous processes, and poslerolall'raJly over the articu- lar pillar. \"fh(, tedm..ique for the inlL=pinous palpation is as follows: 1. Palpalion using the very tipof one thumb is carried oul between adjacent spinous processes, first cen- trally (with ligamentum nuchae pushL\"ll oul of the way) thL'{l belween adjacenl bifid p~~ (f'iguTl' 10.45). 2. Palpation is carried oul bctwa-n adjacent bifid pnlCCS/;CS bullhis lime palpating m~'Clial1y against the lateral and po6terolatera1 surfaC<.... {figun' 10.46). 3. Following lhe side of the spinous process the pal~ palion isstill direclL-d medially, changing more and more anteriorly ontil the muscles p,,-ovcnt inter- spinous contact (figun' 10.47). 4. The final step is to direct the palpating p,,-\"SSu,,-... medially, but now from beneath (anterior to) Ihe muscle belly, and still into the inlL'l\"Spinous area

Cervical5flinc: 263 SOft-tissucchilngtS _ Soft-tissue cn..nges !hat can be found in the bnunar trough and over the articular pillar can .readily be detem1inroat Ihe level ofCS. If thepaUenI IS ofa long,. sk'ndcrbuild, tht-'n iI is equally easy 10 feel thechangCll at the C6 level and SOD\"ll'limes at Cl. However, with the majority of pt.oople it b«omc; more diffICUlt to dif- fen.'I1ti.ak the findings the further down lhe spine the arne.\"\"Ipation is carned. 1lw soft-bs8ue cn..nges tNt can be dett-':nnined are the !how de5cribed above fOl\"themiddlecervieilspinr. Soft-tissue thic:kmingaround the·OOw. . .·shump· isroonnal,yet it IS of ,mportance ,fthe Ihid<ftUng_ ~vl'anclisabnorrnallypainfulwilhsudltedt­ niquei as skin rolling or '-U'1J1l.\"ctive tIlIrSuI: lJlilS\\SiIge. 8onyanomalies _ Although the prominence of the spinous pn>Ct'SfiofCS fi9u~ 10..48 Pllpll\"'9 aIltmar ID 1M fI\\UKle body lor 1M has~describedabove.ilisextremelydiffK'Ultal intmponous_ontCfb\",_'I*\" !lInC!II1o~whetheriti5thelJOUKl'ofscapubr or fUpntsapWar symptoms. Most commonly the cs.source is C6, wha~C1 is more common than is The ~ofthespinouspml.\"l\"$5o(C3;oa:om~ differenhahng f;oetOl\"$ an' first theexlcnt of the booy bya promincn<X'ollhespinousJ7\"O\"f\"\"\"0fC4 (usually aroomall('S,llndseroodlylhepainresponselopo!ilcro- rdated to mid~ical \"\"in) and, IeiilI <:ommonly, a anterior ffiO\\'CITll..'I11S. The bony anomaly that occun; prominenceoflhe spinouspl'lX'l'!!lllofCS (usually aSllO- moslcommonly is thatlhe tipo( thtl spinous proo.:e;s of datlod with mid- or 10wcr-ct'rvicaJ symplom.~). C6lil's vcryd05<: 10 that ofCl, This Icaves3 larger~ap between lhespinoU5 pf1.lCC:;$C5 ofCSand C6, and 8've!i n.c second common finding is the exo:o;tO'l<-'S illIIlO- rlall'd with arthritk change in lhe xygapophyseal a ft.<cling of promil'll'OC'e of CS. The pain ~ is joinlS. l\"he;.e may be felt over the atticu1a.r pUbr post- decribO:'d briow. eriorIyor por;terobtera1ly. Moomnent itbnormalitits Mo'i'tm(nt abnof\",:_~lit~\",-- _ AlIi has been mentJonrd above, lhemediallydiredcd ~withthe~ofthespinousproce8lof willateralpori~lI!riorpl\"l'll5Uresare'\"l'I'}'valu­ C6-7 dcscn~ above. the movemenl a~\"ty is that there is a distinct restriction of movement with able. L..- of range of movemenl and poor- quality of poslt.'ro\"lIlll!rior pl'l'S5ure applied 10 the spillOU!i tygapophyseal ioint movement's readily discernible pr0c:e56 of C6. The pain response associated with this by lhilltl'Clmique. movement (and lhe movement may need to be applied I.olrge-amplitude porilero-anlerior pressure on lhe spioous~whentheseareprominentreadily quile firmly) is one 01 deeply felt pain (somcti~ dclcribcd by the patient. a 'nicf, hurt'}. There may shows up their relevance to a \"\"tient's symptoms by a\\sQ be a spread of pain inlothellCilpulararea.(lrPlen virtued. ttIIII\" range of movement available and the \"\"in ~feltwhenthismov~tispusbrdlolhe a bita\\lCl\"ll sp<Nd. When Cli5 the 1OUKl' of the symp- Iilnitof its range. PiLin ollwO bnds will be proyok«l. tom!Ii.lhepainresponseisthesamell$that~\"bed 1lw first and common CKIl' is a wrp pain. and the for C6; when C5 is the 5OUlU' of symptoms. pre!ii6U\", !IIl\"t'OI>disadeeplyrellsensation. on ,Is spinous proce6, though still provoking a dfq>ly felt pain. Ies5 m,qumtly rclers pain inlo the supras- capular a\",a. Transverse pressures ag<ilnst lhe spinous LOWER CERVICAL SPINE ~~::~~~~dd~r:~~:;:~~~I~\":~~;;::~: ~arenospcciala.spo!CtSlQthepalpationexamin. ofsymptOlTlS ationofthissectionolthespine. How~er,lhecommon I'ostL'fO-antcriorprese;ureappliedunilalerallyover findings are important theartlCUlar pillar will frequently provoUasignificant

264 MAITLAND'S VERTEBRAL MANIPULATION pain ne!i~,allhough ~Iative InO\\'t'mentll ..t C6 rnd Occipito-atlantal joint (lateral f1e~ion) C7 a~ much han:lef\" 10 detenmne than is the s.>ntC mo\\'emenl al CS. NC\\'crtht'Icss. they should form part Starting position of I..... c\",\"mm.alion procedu~ for symptOnl$ a......ng from the lo\\..t'\\'\" reo·k..1 spine, despl.... the fld lhal In this e><arninilbon. the paloertt lies supine \",th the more luTlt' is required 10 disa= the findings at this crown of his hcild pro;ecllng be)ond the end of the le...e1. It is !iOflletirnt'!i nece!iIS<Iry to i1pply these un,\\iit- much. Standmg al the hNd of the rooch. the phnio- \\!rlol ~nkrior pressure; through t~ m~'\" lherapist crildle:s the patoertl' oceipul in her left hand belly, while 101 other tirnt'!i OOIl'l\" infom\\llllon is glollwd lond grasps the forcheild in her righl hand ..·ith the fin- if the mu.<;c1es ..no pushed OUI of the w ..y 50 m..1 lhe gCl'S pointing towards the right and the thumb IortlCUlilr pillilr. particu..1ilrtr thai of C7, can be palpated too.,..rds the left. \\\\lule the hp of the left thumb i5 in a dll1'Ctly. position to palpal\" deeply bet..een the left trans\\·ft'SO! process of the firsta'f\\'ic..l n:rtd>r.. .and the.t)acft>t Aspt\"C1s that .. re of special significance fO<\" the 10........ m..stoid procO!SS, the fmst'r'!> reach be)-ond the nudhflO! cervicalspu-.earec to the right occipllill.are... \\''''Y slIghl pressuno is thm applied to thecro...nofthep.1tienfsh9cIbythO!phys- The deep loe..1pilin referred to above. iothet\"apist's abdomen 10 &S>o1S1 in stead)'ing head Ttwo common reproduction of rclerred pilin. mo...ement dunng miNllion (F'gw\" 10.49). The dear asSOCiation of the pilin n$ponse when pressUIl' is applied to l!w soft·tissue changes at Method the spinous processes and articular pillar. Although the I'alk-nt's hc\"d must be I\"l\"rally n,,~ed \\Q PASSIVE RANGE OF PHYSIOLOGICAL the right, the crown of the !wad is moved and not lhe MOVEMENTS OF SINGLE INTERVERTEBRAL neel<. To do this, lhe physiolh..rapist's hands combil\\l' JOINTS IPPIVMs) with a swaying movement of her pekis to tilt the head When lhc upper neck is fullyslretched inlat..ralf1ex· The (ollowingall' the «dmique;used k... a$~lng t..... ion, lhe position of the phySioth..rapist's left lhumb, rilOgd ofl1el<ion, \"\"tension, lal<,>nl fle1tion.no.! rota- between lhe trans\"cl'lll' p~ and the mastoid bon for NCh 1t\"\\e1 of I..... cc,.,..ical spine proc~, must be d'k-'Ch'd. Call' must be laken wtM'n producing the lat.......1nex'Dn mQ\\'emenllo ensure m..1 it is a '!wad on neck' mQ\\etl'M-'IIl.ll is so easy to be mis- led into performing lo\\.·er reoical mm-ement without any occipito--allanlil) lnO\\·nnenl

Cervical spine 265 As the h,,~d ~nd n~'Ck ~ ..... mov<\"d back and forth in Mt:thod Ihe inn\"r on~~lhird (approximalely 15°) of the lateral fle\"ion range, lhe Ihumb\"'n fed lhe OJX'ning and dos- When the patient's head has been turned fully 10 Ihe ing of Ihe g~p betwe,-,\" the Iwo bony poinls and Ih(' right the position of the tip of Ihe Jdt thumb belwt\",-'n resulting chang~ in tension of the lisso~'S the left mastoid pl\"OCt'SS and the left traru;ver>e proce5S of Cl must be checked. The patient's head is then Ocripito-atlantal joint (rotation) rol~lt.xl back and forth in the inner one-Ihird of the range (approximately 20\") hefon\" maximum rotatiOfl is The starting position is ideollcal with thai described approachtxl. when lhe transverse process is felt to for t\"\"ting lateral flexiOl' (Figure 10.50). dr~w ne~IL'\" 10 Ihe mastoid process. As the he..d is broughl back towards midlin(', Ih(' Iransverse process m\",\"cs away from the mastoid process. Occipito-atlanlal joint (flcxion/extcnsion) Starting position There is a small amount of movement in Ihl:' nodding movement of the head To ft'C1 Ihis, the pa!il:'nl lies \",pine with his head extending beyond Ihe end of Ihe coucl1. The physiotherapist cradles the patient's head in her lap, holding his occiput in both hands and pla- cing lho' tip, of her thumbs in ront..ct with the lip of each laleral mass of Cl and the antcro-infcrior border of the masloid process (Figl'rc 10.51) Figu,. to.50 Occipil<>-.t1.Malm\"\"\"m<ntlrm.tionj Mt:thod The physioth~'rapist rocks the base of the palien!\"s skull back and forth through approximately 20\", repro-- ducing the nodding movement. The crown of the head remains comparatively still. With 1m, tips of m,r Figurt 10.51 Occipito_31lantal m\"\"\"mcnt (fluion-c'ltn,io\")

dlair ;md the physiotherapist stands sllghlly behind the left ~. She pbces her left hand over the crown of Ius heOld, WIth the little finger .nd thumb ~,ngowrtheright.ndleft~a~~ h'~y;md the mnIIllUI'lg ~ sprea<hng bM:kWollrds 0Vl\"I\" theoccipul. 'The hand s)o\"ld bespmlld 10 the m:u:.imum so that. with her left roreann pomtu1g ,'em- cally, the phyWotherapist has full control 01 the patient's head. With her right hand she gnosps lhe spinous procl'S5 of C2 In a pincer grip (riK\"\" 10.5211) bt.otwecn the lip of lhe Index fingt-'I\" and thumb. lhe paravcrl~>bral mu~k$ lie within the ('In::le formed by the finger and thumb (ri.~\"\"' 10.511». Mrthod Having bh'!1 up the position prior to lcSIing the rotary movemenl betw,-Ul CI and C2, the physiother.lpist should, w,lII her left hand, perfurm small Ialf!nl 10$.flexion movernerrts of the head on the neck through OIpproxima~y '111' (10\" 10 eKh side). bps the patiom'shead Iothelcft,tohes)o\"ldfueitheSf'U-'s proce!ll'> of 0 mo>'e to the nght. Similarly, lIS • lat- enlIyfbeshosheadtolherighl,tohewill ftoeIlhesptn\"\" OU!I......-ofOln(lWlOthelcft. Br_ingtm. movement. tohe shouki s.top OIt the poont where the spinous pl'OC'elB of 0 is in the midhrw. She then rotaleS the paIR'!1I'. head back ;md forth from the cent\", 10 the lefl up to the point where the spinous n.epl'OCeS5 is fell to move. Lamina of 0 on the koft is feillomoverockwardsagainst her thumb, and the right tater'll surface or this spinous proc~'SS moves against the pad of her index finger. On<:c Ihis point has lx'(.'l1 ~. the pallt.'!1t's head is held still and lherangeof rno>'emcnl asseiK'd. Although the rutation to the right can be asses&'d by mo._ly turning the piltM..nt's head the other way, it is br more accurate tochangesides 10 repeal the led>nique to the righl (1-2 (roation) =\"''''pin(''--- _ Stortingpo5ltJOtl thumbs, ...... ~ the §milll movement between the lhepaticnllies.supinew,thhisheade.:tendro b..-y....J two bony poonts on each ~ide. the ft>d of the coucf> ;md cradled in the physiothcr;>-- pist's righl arm (for rotation 10 the righl). Wilh her Iefl CI-2 (rotation) in sitting SfClrting position hand,sheclaspslhespinouspl\"OCCSSOro III much the TOl'Xlminc the range of roIiItion 10 the lefl betw~~~, Ihe same pincer grip as lho>l in Fig..'\" J0.5211 (Fig''''' 10.53) fin;1 and S<-'COnd <:crvkal vcrl~>brac, the patient sib in a Mrthod Starting with the patient's head in the straiW\"I:u.ilion, thephysiolhcr;lpisl~lowlyOllCinatehsill ht\\'ld III robtion

Cervialspi~ 261 k1~nghl whiJc..wnWningthcgra$poiC2'sspinous ~8yinl:n.'a:singtherangecl'-d~1 w,thfullrangr,thepoinlwhcnC2star1slorotaiecanboo fcltthroughhrtrightthumbandindrxfingel\",thero!by enablinghcl'\"lo~lhcrangeorCl-2rot.ation. 0-7 (flexion) 5tortingposifion The palimllic!l supine with Ius head bqond the end ofthecouch,whilethcphysKllhcraplStcrouchesallhol h.-'ltdl'l'\\dcltheroudloc-lowthe1eYeiofthepalK-\"I1l. She holds the patimt'socciput near the \"\"-'el of her right hand, while the fingms and thumb point for- wardsOVft'lhecrownoi thehead.11er left hand ilIu-. ~ apmst lho.lo.ftsodeofthepatiml'sned<., with the bpoithe thwnbbctwft'n theMdesoftwospir-.s ~andthetipoltheindrx..ndmiddlefmgers reKtunsaroo.mdlheleft~musdetolhe performedattheinIL'f....min;or ..~oralthezyS\"po­ UlIcnor5U~oltheno:rvio:'i>ltnlnsyersept0ress('5.1f physNljolntpo6kriorly movement iii to be~ betw~ o and Ct, the thumb ill placed laterally between the tips of lhespin- Method OIlS processoes of these vert.obrile ..nd the index and mKldlc fingers are placed over thc ..nlcrior surface of The palient's head is passively flexed by ltlt' ph~ the left transverse Pmre5/l of Col and CS (Figurt 10.54). therapist's right t.and with a 'dUn mto chest' aetion, If Ihc ligamrolum nuchae proVE'll an obstacle to NSy while with tht! lip of h\\... left thumb she feels bclw~'Cf> palpation,thc lip ofthc thumb is movlod a little away Ihe\"Pinousp~'llfortheamountofopeningand from the Ct.'fll\"\" line to palpate adjacent spinous ckll'iing tnat tak0.5 place ;\\8 the head is man-d bad- p~ (rom the sid... This palpation can also be wards and forwanis through a rangt' of movement of

MAITLAND'S VERTURAL MANIPULATION Hgu..,lD.55 Il'!nwno:btlol_~LO-1(b;1\"l('tltl1lc.­ _otm5iotl~loIPin«r9np,.(tlI.(dand(dIPirftrgnpappbod alstarWWlpos.l_ IS-:ZO- To prod\"\"\" tht ma\",mum men'metl beh\\'l'l'!l lllO\\.·ement IS produced ;al the ~-e1 being leslo:'d, ;and a;andC\",lt..-fourth~·ic;aI\\cr\\('braandthosebeklw thai the lTIO\\\"emcnl is the maximum available it are Sl>!l>ili;red by pressure agatnst thean!eriorsurface ,,f their left transv~ processes. The position oflt..- '111' ;aICofoscillatiof\\withintN-fuUrangeofforwardnel'<ion C2-7 (bilal~ral f1~xi=:'\"c.:\"\",\"\",\"::::ion,,-J _ \"ark'S with lhe joint beinK e~amjllt.'d: toexamine move- ment belwecn C6 and C7 lhc oscillation is performed ThisisauSl'f\"ltI'Chniql,,,because,withlhepmcergrip nCar the limit of forward ne~io\" rallKt', wht~as move- on earn sid\" of the nec;k al lhe one intervertl'l>r,tl Ic\\'el ffi('f\\! betweenC2 and C3 muSl be sought in thefirsl small varia lions from lhe normal ran~ of movement partoilN-rang\",C\"\",mUSlbeex~>rci\",-'dtoCflSurelhal can be finelyappR.'Ciah.'d

Ce\",ie~1 spine 269 ftgure 10.55 (rontd)lrlFlexion.II1Extrnsion Starting position non-p.~lpating hand, she givl'S support under his occiput. When the lower cervical movements are tested. The patient lies .upine with his head extending beyond this support extt'flds under his neck (Figure 10.56) the l>J1d of the (Ouch and supported in the physiother- apist's lap. With the pincer grip (Fig\"re TO.55a) she Mtthod graspsbehv\"\"n adjacent transverse P~'S with her thumb tip medial to the stemomastoid anteriorly. and ik'ing careful to t'fIsure that intervertebral movement the tip of her index finger at the same int\"rvl'rtroral can befl'lt, and not just the head on the neck. the physiO- level on the articular pill.. r ~teriorly. therapist fi!\"5t laterally flexes the joint frICtionally away from her palpating finger then pi!rforrm the lat- Method eral flexion towams her palpating finger and asseslit'S the move.......,t at the interlaminar space. The opposite The physiotherapist raises and lowers the height of her movement is then pi!rfOTrn'->d to aSSeSS the dosing lap (by extending and flexing her Im~) and thereby capacity of the space. By this means the excU!\"5ion of lat- flexes and extends the patienfs h('ad and thus the eral flexion at that level on that side can dearlybeevalu- neck. producing movement down to (and not beyond) atoo. TIle palpating fingertip must remain motionless in the le\"d of her pincer grip. In this way she can f\",,1 the thcspace; thuscarc must bcexerciR>d when that hand is rmge of movement available. used to produce the lateral flexion of the neck C2-7 (lateral flexion, closing) C2-7 (laltral fltxion, o~ning) Starting position Srllrtingposition This is the same as for the 'dosing' test position The patient lies supine with his head \"-'Sting on the (FiguTl'lO.57). table {'On a pillow or in the ph~iotherapisrs lap ~ preferably the latter. The position chosen should facili- Mtthod tate relaxation, and support the head and neck mid- way between flexion and extension for the joint being With the patient's head cradlro in the phySiotherapist's examinro. In this position. both lateral flexion and lap, she pivots her body (especially her pelvis) on her rotationarefff'l'St. fcetto produ,e the head and head-neo;k movement The physiotherapist plact'S the tip of ht-r index finger !rre;pt'diveoftheint{'rvertl'brall\"velbL-ingaSSl\"SSCd. ink> the inter laminar space d\"\"Ply enough to palpate the movem~>J1t startsasa movement of the head, which adjacent lamill3C. With both hands. p.utkularly the

210 MAITLANO'S VERTEBRAL MANIPULATION F;gurt:1Q.561nt~~I.O-ll~\"\"'­ \"\"'I. ~ nght wkl. lal 5arUng \"\"\",1-,\"\"\"\"kf3l nr-. ............101dt.11ll~lMlpItirog.r.. fo,O-JMltIts.Qr1Jng,,,,,,,~ kl .......lJtIg ..to:nl~\"\"'t~dclwng.O-Jatltlt islN.,., contmued down IOmovementoi theneck at the theinde.; fin8t-'f\"palpal\"tht·marginolthezygapoptoy- Ievdlx..ng~. sealjoint{fig\"... I0.58}. C2-7 (rotation) M~thod Sfortingposifion The head is pivol~\"j, away rrom the side of palpation. aroundanimaginaryC{'l\\lrala~ispassinglhro\"ghlhl' The 'starting position' is idenlical with that dcscribal joinllx.-ing tested. The physiotherapist's hands p..... rorlatcral ne\"ion, \"\"cept for the palpating finger. This duce the movement in II Slcady oscillatory rashion. isC\".rril.od a fractiofl laterally, and a slightly bruadcr giving movement down to the jllint but not beyond il. conlact is made. 1lIe tip and ad~ollaIL..al margin or

C~rvic~llpinc 271 'I FigY\",10.56 (ronl<l) (a) C5~6 31th. 'taning p\"'itioo (c)CS-6allhcdOS<ngpos;tion.(flC!;-6atlhcopenin9 p\"'ilioo Her palpating fin~r follows Ihe movement of the stands ncar his head, supporting under the patient's joint, as~sing the extent of sliding or opening head and neck down to the level of the joint being Ix-tween the two adjacent articular pl'OC'<.'SS<.'S. It is not lest~>d. She places the lip of both index fmgers into the possible 10 assess the rotation towards Ihe palpating inlerlaminaf spa~o\"each side, as described abo,'\" for finger. because the muscles obstruct the palpation laleral flexion (figure 10.59) OccipLll-C7 (~xtension) Ml\"thod Starting position Tne physiotherapist extends the patient's head and nl'Ck down to the le>'el being examined, by lifting TIll' patirnllics supine with hi5 head re:;ting OIl the <;OU<;h under his neck. At the same lime, she palpates fordos--- or in the physiothlJTapist's lap_ The physiotherapist ing down of the interlaminar space with her fingertips

Figu'el0.S7 Inle~'lebralme\"\"menlC2-7(1aler1llfiexion, Idl,opening right sidd. 101 Slarting pos;lion, hnd str1lightand cr1ldl.d in hand. and lap. First mO'o'.m.nt is small lat('al fiel<ion te the righl. (b) Slew os<:illatery lateral f1exien to left. palp.lIing movement on righl. Approprial••nd offing. forC2-3 and C3-4.kIApl\"opriateendotrang.forC4-5,C5-6andC6 EXAMINATION AND TREATMENT MOBILIZATION TECHNIQUES longitudinal movc\",m,,,,',--'-'--'-- _ Any e~aminationproc~-durecan},., used as a treatment Starting position !t'chnique, and S(lme such techniques have been d~'SCriocod on pages 2:W--271. The \\('~hniques that The patient lies supine with his neck le,\"el with the end are now described are al50 used as examination of the couch. His head, supported in the physiothera procedures. espoxially th~ technique; im\"olving pist's hands, rests with the joint being treated in a palpation neutral po>ition, approximately midway betw~\",n full

Cer.riulspine 273 flexion and full edension (or as nl'ar to it as pain lhemetacarpophalangeal joint of the indl'x finger lies over the superior nuchal line. This lhen gives a good pt.\"nruts) grasp of lheoccipital area of lhehead. If the lower Thl'physiotherapiststandsat the head of the couch cervkalspineislheonly~ionrequiringmobiljzation, with the back of the patienfs head cradled in her right hand so thai the ftngers are spread over the left side of lherighl hand grasps around the neckimmediatl'!y the palient's occiput to bt:>hind the lefl ear, while the above the levI'! being lreated. The physiotherapist thumbispJaced behind the right ear. The palm oflhe comfortably grasps the patient's chin with hl'T Jeft righlhand is so positioned lhatlhepalmarsurfaceof hand from the left side, beingcarefuJ 10 avoid any

= 274 MAITLAND'S VERTEBRAL MANIPULATION Prtcoutions l'aincanocproduccd in the mid-thoracic spinc, but this only occurs If the pulJ isstrongorifitiscarri'-odout with the spine in too much cxtension. This over-extended posilion must IX' avoided ifthep.atient hasan abnormal kyphosis. and considl.'Tation must IX' gi\\\"-'fl to thesefac- Iorswhenpositioningthepatienl.ASlrOngpulicanirTi- late an existing thoracic condition, and may in fact causcthoracic p.ain in a previously p.1in-freeaJ'l.'a. Fogure 10,60 longiludlfl~1 movementl ......... 1 This procedure is of particular valu\" in gaining the confidence of the patient. By the assessment of the pressure on the thro.~t. The left forearm lies along the patient's symptoms and signs afterwards, it can serv\" left side of the patient's face. aSa uscful guide as to whether or not it will oceasy 10 relie,-\" the symptoms. Those patiomts whose symp- The physiotherapist, with her fert in a position toms or signs impl'l}\\e marhodly with this procedul'l! as if walking and her anns flexed at the elbows, are likely to K'Spond easily and quickly. It will effect crouches over the patient's head to hold the crown initial improvement in a ne<:k exhibiting a protcctive of his head against the front of her left shoulder deformity such as a wry fl'-'Ck, when the technique (Figlll1!1O.6O). should be pt\"rformed initially in line with lheddorm- ityforbesteffects. Mtthod ExamplC5 of treatment include pain simulating The oscillatory movement, elongating the patient's migraine, page 424; cervical joint locking, page 428; n'-'Ck,isproducedattheintl.'rvertebraljointsbyagen- and5hootingoccipitalpain,page429 tie longitudinal pulling through the physiotherapist's forearms combined with a slight backward mO\"ement Posttro-antcriorcentralvcrtcbralprcssurc: of her body, followed by an equally controlled relax- ation to theslarting position. lhis is repeated continu- Startingpasitian ously toprodure the oscillation The patient lies face downwards. It is usually s.~tisfac­ As the technique is gentle, friction ocn.''-'''n the tory for him to K'S1 his foreh\"ad in the palms of his patient and couch issufficienttopreventanyslidingof hands, but it may be ne<:essary for the chin to be the patient's body. lucked weH in. This is particularly necessary for mobil- iLation of the first and third cervical vertcbraebecause Loco/variations of their relatl\"e inaccessibility. Whcn a patient hasa limited range of extension or the mov\"ment is painful, IVhen this K'Chnique is used in lrcatmcnt of the lowest an altemati\"e 5tarting position is for him to cradle his cervicalintcrverlebrallevels,thcne<:kshouldocpos- forehead in his palms with the armspartialJy under itloned in approximately 3O\"0f flexion. Mid-cervical thechcsl. treatment \"-><juil'e!la ne<;k posilionapproximately in line with the body. Foruppt\"rcervical problems, it is The physiotherapist stands at the head of the thehead-ncck relationship rather than the angle of the pati\"nt with her thumbs held in opposition and back neck that is importanl.Again, the position must IX' toback,with the tips of the thumb pads on the spinous midwayl>etweenflexionandextcnsion process of the vertebra to be mobilized. The fingers straddle the sides of the pati'-'Tlt's ncck and head Balancc and steadin'-'SS of the physiotherapisfs thumbs are gained through the finger position, but it is unnec- essary for the finger5 to grip firmly. If too much of the pad is uscd,the localizing ability will IX' lost bccausc the spinous prOCt'SS<-'S are so5mall However, with strong pl\"C'SSure the bon;>-to-bonecon- tact may oc uncomforlable, and il is then ad>'jSo1ble to use morcof the pad of the thumb near the tip.

C~rv;CiI spin~ 275 figu\", 10.61 PoS\\~\"Of-lnl~riOfvort.brall'r.ssu\", (1) muscles and IigilmCt1ts. Thl' third cervical vertebl'il is often difficult to palpate owing to the large and some- The bt.~t position is to have the lhumbs in conlact times overllangmg spmous pl'lXeSS 01 the second wilh t'Kh other On lhe bpof the sam\" spinous p~ cervical ,·ertebra. Palpation 01 the two \"erlebrae is A method using one thumb to reinforc\" the other c~n mhanad b}' asbng the pat.ent to tuck his heiid into be u!M'd, bUllhis le,.as to make a very genII\" technique s1ighliy~f\\elOOn. difficult to achieve and certainly detracts from the ability 10 f~'C1 small mo,\",~ments. In the cast' of the As \"-as mmboned Ul C~pter 6 (_ pp. 157-159), 5«Ond Cl'f\\'ical 't'I1ebra, tht\" thumbs can be> p1.:lced on tIw- dinrtion 01 the central p~ CiIn be> angled the upper and 10000er m\"rgtrlS of its SPIllO\\lS procewl towards the heiid or Io\\0o- ards the feet. Such changes in (figvn\" 10_61) d1l1\"Cbonmayberequ,redduelo~orsti£fnes6 found with thee lnO\\ements. The thumbs do not always IY\\e to Irarl5nut the pressure ,.... their lips, nor do the mt'tiIGIrpopha- Iangeal jomtsalwafS ~ve to bedo5e londl other. For example, more of the pad of the thumb other than the tip can be theconlact potnt onexh of thrblfid spinous p~ (Fig..... 10 fl2ll). This IS ~Itie...ed by widely !il'parating the mt'tacarpoph.,langeal joints. .\",..., prL'SSUI'l' producing the movement may be delivered through more of the p<!d of iust one thumb while the other thumb stabili7.<-'S its ~itLon on either the one bifid process, or more brOildly across lhe cen· tral hne to transmit the pressure through both bifid proct'S.St'S(FlgU\"\" 1O.61b) Postero-anttrior central 'nrltbral pressure as a 'combined'techniqut Thl' following description is pre;.ented as an l'XillJIpJe of postel'&\"\"nterior mO\\ement pcrlonned with the Sp\"lOIl5 pn:x::ess mobilized WIth the joml m a position of rombined.lateral flexion to thr nght WIth extension. Mrthod Srartingposition Elltrmlely gentle pre!'iU~...11 prodllC'l' a definite keI- The patient lies prone and the phys>otherapist pas- ibons his heiid (and thll5ltw intl'l'\\ertebr.alle':l'i to be mgolII'll)\\-ement,buIW~al,.·arslStousetoo mobilizcd) in ltw degJft of lateral flexion and exten-- mud'lp~~ Slort reqUI1'l'd. She then pbcn the tip6 01 her thumb pads on the spinous pmcP;6(f.gun\" 10.63) The altematmg p~ shouJd be applied by the arms combmed ...ith the trunk. It is impo!itiible to any M~thod out W tKtuUque ~ or comfortably by the aetoonol the U'i1nn$OC hand mU'idl5.1l1he pabent has The 06dllatory postero-anterior pn's..sull' '5 applied to the spinous process in the same manner as hasbt.>en considerable~thll5makingthis\\ll'dmtqUrd,fficult descrihedabove. IOperfonn.wpalmarsurfllOl'501thepadsoithefin~ canbeuscdtoliftWr>eckinloadegreeolflexion.ThlS ~coutions ....u mak.e W t«hniqUl' possible in a pain-fnoerange Mobilizing in the region of the first Dnd St'COnd cer- vical vertebral', if Vl'Ty e~ct'Ss,,·e both with regard 10 /.oro/variations the length of lime and tm- streng!h of the pressure, can produce a feeling of nausea_ .\",..., It'Chnique must never The degrt.<e of pressure required to f('('! mo'·em\"n! in be u!M'dif it causes 19ddllless. the mid-cervical are.' is much less than that n.'Cluimd at either the second or the St-,tTlth cervical v\"rtebra. The fin;t cervicill vertebr~ Ciln rarely be> palp~!cd in lhe midline as a bony surface; however, it is possibl\" to produce mo,ement by pressure through the o·..erlying

216 MAITLAND'S VERTEBRAL MANIPULATION Figu,e 10.62 Poltero-anmiof ~nt,al .\"tcb,al ple'lW'c. [0) Inc,.a~ed a,ea 01 thumb contact. (b] U\";ng Onc tnumb to tran,mit tne p,es~u,. wnile the other tnumb,tabilizc.ill!K\"ition Figur. 10.63 Post.ro-a\"tc~or«nt,al .... rtcbral pr.lSur. with Poslero-anteriorcentral vertebral pr1'SSureisof tnepatienf~hcad.ndnedinlhecombi\"\"d !K\"itionoflate,al most benefit to those patients whose srmptoms of eec- ~«iOf1 to tne rigMt with extcn.ion vicalorigin.resituat~-deitherinthemidlineordistrib­ utedevenlytoeaehsideofthehead,neck,arm,Of\" U5~5 upper trunk Sueha technique would probabtybe used mainlyasa This technique is valuable for pati~.\"ts who have gr<ldeIVtechniquetocieartheremainingjoiI\"ltmove- ment signs. However, ther(>;s no l'I.'aSOTl whr it cannot considerable bony degencrativechanges in theeer· be used either as a verygentlegradelVwhen themO\\'e- viealspine,ic~pech\\'eofthean'atowhichthepainof ment is painful,or as a grade JI when treating pain ct'rvical origin is referred. While carrying out this pro- cedureonth~'SCpatients.however,thedeg,,--eofmO\\·e­ ment fdt is noticeably less tlmn that felt in the normal eervicalspine The technique is of p.1Tticular value when pK'SS\",\", over the vertrorae produces ~\"\"en small amounts of mus<:le spasm. Under these circumstances, the pressure used and the depth of mobilization produced should be just k'SSthan that which causes spasm. Aftec using this technique, it will be noticed that a greater depth of pressureean beappHed before spasm reappears. WhentheQ-3Ievt'listhesourceofheadaches,C3 will be found to be both prominent (that is, caslly palpat<--d) and proportionally painful.C4 and CSare eommon levcls to give riSoC 10 mideervical symptoms, and they too are usually prominent and painful at this tim.,. C6,when it is the source of pain in the upper ttlor- acic or scapular area. is usually found to have its spin- ous proa.\":SSc1osc toC7, with muehthickening filling the interspinousspaee, Firm mobili7.aHon ofC6 wUl eauSoCpain, which is felt to be very do;-eply situated.

RgoI~ 10.$4 Pt:>-t........a~l(IlOI U~'~tflill \"'frtfbnolprnsll'f Loc:olvoriotions ljl WhenmobilizingthefirsicerviaJ\\·~thephysi&­ Ex.tm~ of t....am.ent include pain simuLahng theraptst needs 10 lean o':t\"l\" the pabe'lt', hNd 50 as 1l\\IgnlrM', page 42-1; and shooting occipital pall\\. 10 direct the line of her thumb!; lo\\.o>·Mtb the pat1ml's eye.lntheJoo,.·t\"l\"crn-iGlliItN.thelineisdu-eded~ page4..~ CiludilUy. Postero-anterior unilateral vertebral pressure \"1 The second, thIrd and fourth arbc'ulat pl\"OC('Ml'S a\"-\" fartaSier to feel a<XUl\"iltely th.an iI\"\" the remainder The Storting position firsl cen.·jal \\·ertebra un be felt 4teralJy, and the low..r articular pl'OC'l5SC5 can be felt if the thumbs aT\\' The patienl lies prone with his forehead resting com· brought in under the lal.::ral border of the trapezius. fortably on his hands. The ph~iotht'rapist stands towards the side of the patienrs head. She plan's the \"1The symbol indicJtes that the unilateral pres- lips ofller thumb pads. held back to back and in oppos- ition, on the poslerior surfan' of lhe arhcular pTQ('{'SS sureQn thevcrlcbra isdi ...'.Ctly poslero-anterior. There to be mobilized. Her arms sl\\OUld be directed 30\" are two common \\'JriJtions to this direction th<tt are med.i.lIy to pl'l\"l'enl lhe lhumbi from slipping off the usN in treatmt'nl. Under circumstances wJ-.en, pain is articul.u plOCl'56. The finger5 of the uppermost hand quite5e\\'ere, the din.'Ction \"ilngled slightly away from n$liIoCTOS6thebad:;ofthe pat1Cl\\l\"sneck and those of the other hand rest ilround the piltient's ned:: towards \"1potilt\"ro-antt'rior as \",dic..ted by the symbol his throal. Most of the contact is fell with the under- ne;>ththumb (Figurr 10.64). The seoond \\'3riation. used when the joint is still .nd pilin is 11UlUD\\lI1, is to ..ngJe the pR'5Sure I'nOn' medi.l.1ly, M~thod endea\",uring 10 incmlSe the range The angle is Indi- cated by the symbol ......., and the Il'Chmque 1$ OIiaI\"torypret5un'dlrectedposteru-anleriorlYil~inst de!;crilied on pilge5 257-258; II IS a \"ery important e:uminiltion procedure, especially for the uppercrn i- an artlC\\lLar prtX't'5S if done \\-cry gently wiD produce a cal...pine. ~nll of Inowmenl, bullo pre...ent any Ialeral sliding at the poinl of rontaet a gentle roru>tanl pressu.... Also. as W\"S menlioned m Chapter 6, these direc· di~ medially musl be maintained. If lhe mo\"e- tions can be '-ilrit'Cl shll further by inclirung them 1t1<-'n1 is produced CDm'CIly, there will be small nod- cq>halad and caudad as inchcatl'd by the ~u,,,,,menl5 ding movements of the head but no rOlary Or laleral ofpainorsliffness. nexionnHwemenl Preroutions As with other techruqUCli Involving pressure through the thurn~. this movem(.'nt must nol be pro- The only pn'Caution is 10 perfonn the techniques vel')' duad by intrinsic muscle action. gently, especially in the upper Ct\"rvical \"-\"gion.ll is sel- dom realized how erfKti...e these lechniqut'5 can be while still being perfonnt>d \"ery gently. Usn Applvtton of thiS tedmtque is thes.ameasfor the p...... \"lOllS tKtuuque, ex«'pI that it is used for wuLuenl symptom!.on the~ofthepilin. The mediallydtredt'd ta:hruqueisanespoci.illyirnportanttedu'uqueforupper nonicaldisordefs,particulariywt..en..rn-tatrestonns 11 fulll\"ilJ1gt\"ofpa.m-freell'lO\\·ementstopl'l\"l·t'ntor~ recurrt\"t'lCe5. When po>lero-anterior unilill.::ral verlebral pressure is applied to C2 WIth the pJtienfs head straight, il is lhe C2-3 joinl lhal is being euminf'd. or mobiliU'd when pilin is a dominant feature. If, hoo-·l\"\\·er. the pilllent's

278 MAITLANO'S VERTEBRAL MANIPULATION Mn/lod The movement is produced by a trunk and arm action transmitted to the thumbs. which act as springs. Although the mobiliZoltion is created by a postero- anteriorpressureagainstQ,itisin fact increasmg the rotatioobetweenClandC2. u\", This technique is of\\'alue for suboccipit.1l symptoms or headaches arising from theCI-2joinl. It is usually perform~odonthesideofthepainorrestriction fig\"\"'10.65 T..ting for .b\"\"fmaliti.. ofCl~2 rotal;on on Bilat~ralpostero.anINiorvertebralpressuren th~leflSid~(rC2,·ndrC2in30·RolnCD) Startingpasition hcadistum~od3O\"tothelcftand thcpostero--anter'or unilateral \"ertcbralpressureisapplied to the lefl side The patient lies prone with his fOl\"<'head in his p~lrns. nlCphysiuth.,rapistw..,ps\"\"rhands,andinparticular of a, it is 0-2 rotation that is being examinc(\\ or IIl'r thumbs, index fmgers and the wro bet...\",'..n them, comfortably around the pabent's neck. The grasp must mobilized. This is because when the prone patient be comfortable, with the p.lds of the thumbs readting turns his head to the left Ct is rotat~od to the left on C2, and postero--anterior pressure on the Icft articular pil- thearticul~rpillaraodthepadsolthefing.,rsreachingas larofC2 further increas.,s this rotation. faranlL'rior1yasthctransver:;cp~(FjgllrelO.66) When the range 01 CI-2 is beingexami\"'-od by this Method proccdure, the patient fully rotat<-'Shishead totheside, thusputtingCI-20n maximum rolarystretch Further The oscillatory movtoment is produced through the stretch isther> added by applying postt'ro--anterior physiotherapist's anns and body. while her hands are pl'l.'SSureunilaterallyonthearticularpillilrofC20nthe keptstablewithanevenlydistributcdpressurearound same side as thilt to which the head is tum~od (Figu~ the patient's \",->(k.ll is important that the neck and 10.42) in <1!rvical palpation examination. handsmm'e asa single unit. stortingposition The technique can be made to be of large amplitude by lifting the p\"tienl's n('<:k with the pads 01 the The patient lies prone with his head tum~od approxi- fingers. It is a particularly comfortable and comfort- m~tely 30\" toth.,ldt and places his foreht\"ad in his ing technique, and is ~'Spt.,.,ially useful when more palms. The physiotherapist stands at his head and direct cuntact with the bQny parts is very painful. placcs th\" tips of both thumb pads, their nails back to yet movement of large amplitude is desired forth<' back,againstthearticularpillarofC20n thelefl. The treatment articular pillar is fouod in relatioo to the spinous process of C2. which will be unchanged from the pos- AntNoposterior unilateral vert~bral pressur~ '\"l itionit hcld when the head was straight, and the left l~teralmassofC1.Herfingersarespreadtoeachside Starting position to stabilize the hands. She holds her thumbs inoppos- ilion and din>(ts the long axis of each thumb in il The patient lies supine. A pillow is not used unless the postero-anterior dircction and inclin<->d slightly towards patient has a 'poking-ehin' postu,al abnormality. The the head (Figllrr 10.65). physiotherapist stands by his head aod makes a broad oontaclmedialtothetrans\"erseprocessofthevertebra to be mobilizlod with both thumbs. The thumb$ should be used with care, as direct bone-to-bone contact can be uncomfortable. She spreads her fingers around theadjaceotneckarea for stability while positioning her shoulders above the joiot being treated {F(gurr lO.67Q),

CeNic~1 spine 279 Figu'.10.66 (a)Bil.t.rJlpost.ro-.nt.ri\",,,\",n.bulpfCSS<l'. In)_lll)li'ndsposition.(dli'ndsPOSitionrM:~d Mrthod l.aken to see that the thumbs are positioned medial to the transve~ pnxess. 11tis means that at some level~ 1lll' 05Cillatory anteroposterior prt'Ssurl'S aT\\' per- the muscle belly needs to be moved to one side. formed very gently, and the movement must be pro- duced by the physiotherapist's arms and trunk. Any Loca/variations effort to produC(\" the movement with intrinsic thenar This tt:'Chnique can be perform~-d either unilaterally or muscle action will produce discomfort immediately. bilaterally, as is shown in th.. diagrams (Figurl' 1O.67~ and 1O.67b). The interverlebral level to which one Can This technique is not a comfortable one to use unl\"\"\" gRlatcaRlistaken.Also,themuscll'Slyingoverth<>are, make diTl'Ct contact rather difficult, and caRl should be

K'Kh 'anesenonnousll from pallt'T1t to patlCflt.ln the.- the $ides 01 tilt' I'Ol'Ck 10 hook the palmar ~ur(.xe of stocky,hea,'lIybudtpat,entwithashort,thlCkr'K'l:k,. thepadsofho... finb~medialtothetfilns\\'erw P),tt'T1dingdOVl'nintothethQracicaK'aisalmOSlimpos- p~area.ltiscasytolocali;rethe;Ointtobr sible Conversely, in the long'r'K'l:ked, slim penlOl1 mobilized by the accurate pla<ement of Ihe fingen t'lloughspace is allowed lorcach down to approxi- (FigurrlO,67d). malely T3 {Figu'f 1O,67r). With all patients, thett'l:h- Prrroutions niquer\",,~used8shigh8sCl The only precaution n«essary is to 8\\'Old d,o<omfort AnteroposleriormO\"I'm\"ntcanbeproourodwilh fmmunduepn.'SSure. tht-pat,enllyingplUl'll'. The patient ll.'Sts his fotehead in hi5 palms, and the physiotherapISt grasps around

Cervical spine 281 Figu'etQ.6B Trans...,~crirothyroldp~u,etotherigM figu\",tO.69 Transve~vertebralp~sure(........) Uses Transvcrscvcrtcbralprcssurc ........ Application of this technique is reserved for patient:<; Starting position whose symptoms. felt ant\"rolaterally, can be repro- duced by anteroposterior pressure on the side of the The palient lies face downwards with his forehead pain. Pain referred 10 the ear or Ihroal can often be resting on the backs of his fingers or palms, wilh a reproduced by this technique. Anterior shoulder pain, moderate deg~ of 'chin-in' position to lessen the cer- scapula pain (Cloward, 1959) and headache <lssoci<lted vical lordosis slightly. with irritation of Ihestellaleganglia of Ihesympalhetic chain may be reproduced by this techruque also. Under The physiotherapist Slands at the palienl'S right all these circumstances, the described lechnique could side with her hands placed over the patient's nl\"Ck, so be Ihe treatment of choice. that the distat part of the pad of the left thumb is against Ihe righl side of Ihe spinous process. with the Cricothyroid righl thumb giving a reinforcing pressure againsl lhe It>ft thumbnail, The fingers of each hand are sp\",ad QuI Palpation techniques for these non-syno\\-ial joints is Over the adjacent bony surfaces to provide stability for included here because patients can have throat symp- the Ihumbs. The part of the thumb in contact with the toms that may have a musculoskeletal component lateral surface of the spinous process should consist either from the vertebral column (particularly C3) or of as much of Ihe pad of lhe Ihumb near its tip as it is from the cricothyroid articulation possiblto to use; using the hard tip of the thumb causes too much discomfort to the patienl and should be Starting position avoided_It is CSSCfltiallhat the phySiotherapist's wrists be in a position to allow for a hori7-Ontally directed The palient lies supine with his head resting in the flat pressu,\"\" 10 be imparted to the spinous process through position, without a pillow. on the couch. The physio- thethumbs(Figun<IO.69). Iherapisl places her thumb pad at the junction of the cricoid and thyroid cartilages (Fig\"'\" 10.68) Mrthod Method Only \"cry gentle pressure should be used. here, lx\"Cause movemenl is produced very easily. For the Silme Moveml'nt can be produced in any direction, bUI in the reason, Ihe amplitud~ofIhe oscillations should al\"\"be figure a lransverse oscillatory mOl'ement towards the \"cry small.lt is necessary, the\",fore. to judge Ihe direc- right is produced Ihrough Ihe pad of Ih\" Ihumb near lion and prt.'Ssure finely if a feeling of movement is to ilstip. be gained

282 MAITLANO'S VERTEBRAL MANIPULATION Loco/variations 'Nh~T1 applying prc5sure in Ihis position there is a Fig~~ 10.70 Atte,n~tive tronsverseve,tebral pft'Ssure moderate degree of natural tenderness, which must be (C1-6--1 considered. This makcs it neccssary to usc as much of the thumb pad as possible 10 produce Ihe movcment withouljeopardizing the ability to localize t:he Pr<'s- sure to the one spinous process The SC'Cond and the s,-'\\'enth cervical vertebrae ar<'the most easily palpated. However, although the lateral,urfaceoftheseventhcervkalspinousproccss is superficial, to r<'ach the lateral surface of the Sffondcervkal spinousproccss it is sometimcs tle<:es- saryloget underthepara\\'ertcbral muscles. The spin- ousproccsk'Soflhe third to the sixth cervical vertebrae are much smaller, but can be reachcd by r e d u c i n g t h e c. .rvicallordosiswitha>lightlyincrea~ chin-in position of the patienl's head. It is sometimes necessary to use each Ihumbagainst the sam\" sid\" of ~l:~~~~f.inOl}S processes to gain sufficient feeling of Uses As with the postero-anterior central vl'ltcbral pJl.'Sliure, zygapophYSl'al joint while the pad of the right transveTSe\\'ertebralp ....'Ssureisofmostvalueinc3S<-'S thumb r<'infol'U'S the left Ih.,mbnail. The fingers of where the ccrvical >pine shnws marked degenerative each hand spread out Over th\" left side of the p.~tienl'S radiological changes. liS greatest application is with ni'Ck on to the head and thorax re5pe<:I;vely (fjgul'l' unilateral symptoms of cervical origin, This is particu- 10.70) larlysoifthl!symptomsdonolexlcnd very far from the vertebrae or are ill-defincd in thcirarcaofdistribution Method when no neurological changcs are evidenl. Whcnlhis technique is used for trcatingpain that is \\Vithlhisl~'Chnique,thesupportingfingersaI'{'U~lo felt unilalerally, it is more likelytoproduceanimpmve- appiy a lateral flexion mO\\'emlTlt oflhe neck around mcntifthcdirectiOfloftheprelSureisperfonned from the fulcrum uf the thumbs thenon·painful side towards the painful side. The oscillating movemenl is produc~'<l through the thumbs,with the fingecs cither acting as stabilizcl'li or Variations supplying a counler·pressureby laterally flexing the nC'Ck, lllis irount~'f-pf('SSure sproduccd by adduction There are Iwo variations of'lransveTSe vertebral pres- of both glenohumeral joints and ulnar flexion of both sure'thatcatlbeu~effecti\\'Cly.Bothinvolvepr<'s­ wrists. It is poor tl'Chnique to atl~'TJlpt to produce this sureatthemostlaleralaspectoflheverlebrae.Thefirst counter-pressure by finger flexion. Also, the thumb d~riplionisforthemethodapp1iedtothesccondto n...xorsmustnotbeu~asprimemo\\\"ecs. thl'sixth c.-'rvical verlcbrae, and these<:ond is for the fin;tcervicalvertebra Loea/variotions Alternative tran~ver!iC vertebral pre~~ure C2-6 Thistechniquecanonlybeu~fromtheSC'Condtothc Srorringposirion sixth cervical vertebrae, and any st.>nse of movement that can be felt is moregen...ral Ihan that felt wilhthe With the patient lying prone and his forehead resting former method. On the backs of his fingers or palms,thephysiothera· pist stands 10 the patient's right and plac~'S the pad Uses of the left thumb agairu;1 the lateral bordcr of the These are the same as for the former method

Lcrvi(.ISflinc they are distributoo evenly to both sides or unilater- ally. If the symptoms are unilateral, the te<:hnique should,as the fjrstchoice, be carried out on the non- painful side. This avoids tendem!'SS from the Ie<:h- nique,whichcanronfusetheassessmentofitseffect.lf th... symptoms are bilatl'TaI, the mobilization should be performoo on both sides. Rotation:J Starting position The position described is fora 'rotation' to the ldt This particlliar starting position is chosen because it is the most suitable position for l...aming f(.>Cl, and be<:auseit IS thestartmg position forthemanipulativc le<:hniqued('SCribed later t'« pp. 2%-297). The patient lies on his back sothat his t>...ad and neck exlend beyond the end ofth.e couch. 'The physiothera- pist stands at Ihe head of the couch lind place:st>...rright hand llnder the piltieflt's head and upperlll'Ck.with Figu~10.71 Tronsvmc •• rt.bralp='illro(Cl-----) the finger~ ~prcad out o,·.,r the left sid... of the occiput and adjacent neck. 'The thumb extends along the righl Transverse vertebral pressureCl----- side of the neck, with the thenar eminence over the right side nft .... occipul. She grasps the chin with the srartingpasitian finge~ofherl\"fthand,whilethcp<>lmofthehandand the forearm licalnng the lefl side of the patient's face Thepaticnthespronewithhisheadtuml.'dromfortably and head just anterior to the ear. The patient's head Iotheldt.n..,physiotherapistsl.andsfacingthepali~'J\\t's stiould be held comfortably yet fjrmlybetween lheleft oc\"dandplacesthctipolherldtthllmbovcrtht>tipof forearm and the heel of the right hand, and also lhe left transverse process oflhe first cervical vertebra betw<,,-'Tl her left hand and the front ofher left shoulder, Thetipofthetransverwprocessisfollndsitllateddeq->ly Wh,-'Tl oscillatory movcmenl5 are being performed between the angle of the mandible and the mastoid near the beginning of the rotation range, the physio- pro<:essjust distal and anterior to the masloid proccs.s. therapist standsh...ad-.on to the patient lind the occiput The righl thumb points towMds ttie crown of the head, is centred in lhe palm of her right hand. Wh<.'11 the andisplac<JdtiptolipwHhtheleftthumboverCt.'The movements are performoo at the limit of the range,she fingers of each hand are spread oul over the ad~lC'l.'nt moves her body to the right until S\"\", is facingacrtJ6S surface of thc crown of lhe head and back of the neck to the p<ltient. and moves her hand fllrther around the stabiliz..-theaclionofthethumbs(Fi!(ul'flO.71) occiput toward~the ear. The t>...ad should at all times be Method romfortablysllpportoofrom llnderneath.Th... physio- therapist ShOllld crooch m',,, the patient SO lhat she As with the previous mobilizations, the pressure must hugs the patient's head. The position of the palient's be transmitted tl1rough the body and anns to the head and I\\CCk may be raised or lowered to position thllmbsandnotbytllumbmovem<'Tltonly. th... jointbeing tteat<.xI approximately midway belween its nexion and ...xtension limits. A position of nexion is The bony prominence;s sometimes '\"Cry difficult to showninth... diagrams find and it IS normally a particularly sensitive a...a, 'Theslartingposition finally adoplooshnuldbe lh... which sometimes prevents any d\",-\"p p\"-'$Su.... The on... whe.... th grasp with either ann should be able sense of mo\"...m...nt with mobilization in this aR'a is to perform th mOVCJl\\('I\\1 On its own (Figu,,,, 10.72 'erysmall,and fTCqUl'ntly it is impossible to feel any andlO.7J) mo\\'ement at all because of stiff1\\(.oss in the joint It is used for symptoms about the head or upper neck Method thM ariS(' from this level of thecen'ical spine,whcther The position is laken up by turning the head to the left wilh a synchronous action of both hands. It;s must

284 MAITLAND'S VERTEBRAL MANIPULATION Fig~,. 10.12 (1I) and (lI! Retation Gradoll ~nd II important that the fingers of the ,ight hand should Pr~routions pflXlureasmuch movement of the occiput as the left hand pflXluces with the chin. This turning movement Ifa palient feels neck discomfort On the sid ... of the of the patient\"s head can b<! likened totl>emovement neck to wh.ich the head istumed during or following ofa barbecue chicken as it .....volve'Son a spil. Inmost this t~'Chnique, it will readily disappear in a few min· other techniqu~'S the oscillatory movement is pro- utes with active neck mOVl.'Tl1ffit5 duced by body mO\\'ement, but with rotation the physiotherapist's trunk remains steady and the rota· Although it mayS<.\",m reasonable at times (when the tion is pflXluU'd purely by the physiotherapist's arm technique is ,\"ery gentle and symptoms are localized 10 movement. The movement of the left arm is gleno- the neck) to do rol....tion towards Ihe side of pain, it humeral adduction with the elbow passing in front of should rarely be done in this di,,-'Ction asa strong the trunk manipulation when pain is referred from the neck Particular caren~x-ds to be exercised. to be Sure that Rotation should never be used in treatment if it pro- a nonnal rotation is being produced and nota rotation ducesanysignofdizziness,and to this end it is wise to distorted by deformity or muscle spasm. The ,ange at do an exploratory rotation beforc carrying out rotary treatment ~~~;~~~i~;:~~~~;;t:~~:~~be kept at the limit Uses Lorolvariations Rotation is one of the most valuable mobi1izing pro- The upper cervical ,·ertebrae are more readily mobil- cedures for thect.'Tvical spine. ltis frequently the first ized with the head and neck in the same plane as tffhniquechosen when treating symptoms of cervical the body. To mobilize the 10W[>1\" ~rvical v[>1\"lebrae. the origin, and is ofgrealesl value in any unilat...ral distri- nL'Ckneeds to be held in a degree of nl!Ck flexion. The bution of pain ofcer\\'icalorigin. In such cascs, the pro- lowerthecervicalle\\'elbeing mobiHzed,thegreat...r cedUTe is carried out with the patient\"s face being tht'angle of neck flexion ,,-oquired forsucc<.\"SSful move· tumed away from the painful side. ment of that vertebral joint. The level being mobilized can be isolated soml'whatby using th., index finger of Exampll.\"> of treatment include pain simulating car· the occipital hand to hold around the vertebra above diac discase, pages 421-422; pain simulating supra- the joint. spinatus tendonitis, pages 422-423; pain simulating migraine, pages 424; scapul\" pain. pages 426-427; acute torticollis, page 427; and shooting occipital pain, page 429

C~rvkal ~pinc 285 Fig\"'.10.72 (ronI'd) lei Rotation G,ad.III.(<l).ldand (~ROlation Grad. IV Latcralflcxio,, _ adopted for I'Qtation. This position should then be altered so that her left forearm lies behind the 5rortingposition patienl\"s left ear almost under the occiput, and the The posilion describoed is lora 'lMeral fk-xion'mobiJ- right hand is brought forwards so that the palm IZalion to the righl. This tl'Chnique is One of the most COvers the whole of the ear. Slight left rotation of the difficulltodowell,and the starling position isbe!lt patient'sheadwillbalanceil mostoomfortably until reachLodinthR\",\",stag<-,,\" the \"\"\"t stage is adopted. Without permitting any lateral flexinnof thepatient's head or allowing any 1. The patient liesonhisback,withhishead and neck mo,\"ement of the heel of the right hand away from beyond the end of the couch thepatienfsear. thephysiotherapistmoVl'$TOund alongside thepalient's right shoulder to facediag- 2, Initially the physioth<.'Tapist should stand M the onally across his head. If the right hand is felt in head l....d and take up the head and armposilion

figu~ 10.73 Llltralnt,ion,(o)Slartingposition(b)gradtlli (c)g'3dtllllV position, the physiotherapist's right arm will lie the action of the left hand and arm and the right ao::!'OI>S the fmnl of the palienfsright shoulder and hand. [I is imperative that the palmar surface of !he her right elbow will be almost in her right ilia~ fossa. right hand remains in contact with the p.11ient if !he l€<:hniqueis to becomfortable.lf the physiotherapist 3. The final stage invol\\·cs crouching to hug the is properly crouched o'·er lh(' pati('nt, her right fore- patit'I\"lt's head while adopting the ~uired degree of arm will be fIXed bem·ern her side and the front of lalcral flexion by displacing his neck to the left with the palicnt's shouldcr (FiguO'lO.7J) theright hand and laterally flexing thehead wilh the left hand and arm. The movement can be localizt-d M~thod to a particular intcrverwbrallevel by the prcssu~ of the palmar surface of lhe index finger, just dislalto The oscillatory movemenl is produced entirely by the metao::arpophalang..al jomt, on the \",levanllevel body mO\\'ement, which is a combination of mo'·e- of tht· articular pillar. Head rolation is pr<'vented by menls in two directions. The physiothl'rapi,t rocks her

C~rvical 'fIinc 287 hipsg('nllyfromsidelosideloflexhisn~'CklaterajJy, Example:; of lreatment indude acule torticollis. and al the same lime employs a forward movemenl 01 page 427. her right pelvis to displace his ncck away from hcr, Th~'Se movements are transmilled to the pati('nl's head C~rvical f1~:tion (F) by a VLOf}' localized p,,-'SSure again~1 the arlicular pillar Startingpo5ition whilc his head is firmly hugged It is veryea~y logi'\"e an unmlanced pull 00 the The patient li<-s supine with his head near the end of patient's chin, which will resu1\\ in thepati('nt's face the couch. The physiotherapist, standing by his lefl being pulled out of its coronal plane. Care muSI be shoulder,placl\"Sherlefthand over his slemum and her taken 10 control this wilh the hl'l'lofth('righthand,If righlhand under the oe<:ipilalarea. She then gently the posHion of the lateral flexion io the range is cor- f1l'X~'5 his chin towards his chest and directs her right rectlymainlained,lheh('adwillnotbe,mynea\"-,,the hand su thai the rn,.,l of her hand is under his occipul shoulder at the end of the procedure Ihan il is at the and thc fingers al't'spread forwards over lheoccipital beginning The position of the right hand depends upon the Localvoriotion5 level of the cervical spine being lreated. The lower the levl'l beinglreated. the more the heel of her right hand Varialions in theposilion of the patient's head in rela- iseXlendoo down his neck (Figurt 10.7411). lion 10 the right shoulder are necessary whcn localiz- ](thehigh cervical are\"isbeingtreated,thephysio- ing the mo\\'ement at Ihe differenl vertebral levels thl>rapistplaeestheocciputinthepalmofherrighthand When carrying out lateral f1exioo at C5 Or C6,the nL'Ck and her left hand is placed over his chin (Fig'''\"' 1O.74~) is takcn further into laleral f1cxion. ltmaybenecess.ary 10 depress the patiL-nt'sshoulder to obtain sufficicnl M~thod space in which to work, When localizing the muvement to the first cervical \\'ertrora, the mo,\"\"ment becomes a The right hand is used to flex Ihe head and neck in lateralflexionoftheheadwithoutanymark~'<l(urving asmall-amp~tudeosciUatoryfashionwhilelhephysio­ of the oeek iOlo lateral f1exioo. therapist directs her forearm in whatever direction lflateralflt'xion islx-inglocalizoo to any of the lower is \"->(juiff'd to emphasize the flexion at particular lewis, the oeek should be flex~od, and for the upper intervertd>ral levels. For example, if the middlecer- cervical levels the neck ~hould be nearer Ihe neutral vicalareaisbeingtreatedherforearmisdirectedapprox_ or straight position. imatdy horizontally, whereas if the lower ~rvicallevel The feeling of movement is greater in thl' mideervi_ is being treated her elbow points slightly towards the cal spine than it is in l·ithl'r thl· upper Or lower cervical floor. Whcnthe upper cervical area isbeingmobHued spine, although ina\\1 positions the fL'Clingol local sheplares her left hand On the patienl'schin and raises movemcntispossible. her righl forearm SO thai her dbow points slightly Ca\",must be laken to slabilize the localizing index lowards the ceiling. Under these circumstances she finger adequately. This is necessary because sliding on works both lmnds in an equal and opposite direction 10 thearticularpillareallSL'Sdiscomfort.lk<;auseofnat- emphasize the stretch in the upper cervical area ural tenderness, pn!SSure must be moderate and the pal- mar surface of th.. index finger must be u>oed Preroution5 US~5 This technique is not one:'ielected early in treatment. particularly in the presence of disc pathology,neilher Lateral flexion is used in patien\\:> whose symptoms of is it a techniqu.. that should be used \"ery ~trongly for eerviealoriginareunilaterallydistributed,e,thercra- unstable discogenic disorders. niallyorintheneck,scapulaorarm.lnsuchcases,when thismobili7..ation isbcingused for the first time itis U5e; done with the patient's head laterally flexed away from the painful side It can be used towardsthepaioful side, The main indication for this technique is stiffness in butlhL~isusuanYOlllyofvaluewhentheassociatedstiff forward flexion in the absence of pain or when pain is painful laleral flexion is towards the painful side. only minimal. It Can also be used as a technique when this movemenl \"--produces Ihe patient'5 pain in any Mobi1i>;inginlalet\"al flexion is oflen of value in area aSSOciMLod with the vertLobral column. This means improving a limitation of the patient's aetiv(' range of Ihal if left buttock pain is n'produced by neck flexiOll rotation.

MAITLANO'SVEATEBRAL MANIPULATION Figu•• l0.H C.rvkJlll...ion.(a)lowcrlbjUppo, In the supine poliitiOfl, then it can be us..>d tomobllilc The\", a\", many typ<!S ofccn'ical t.action hailer in USI! lho.'f~uhystru(luresinlhelumbarverh.'bTalcil\"\"l. tod~y, butlh05e th..1 support under t\"'-' patient's chin ..00 occipul musl be ..djuslabk in Iwo of their n'lah\"\"\" ~n~ra/ romm~nt ships. Wheo .. pplied 10 t~ pat,ent It must be poss>bIr to \"ller the height of the occiplbl band m \",lalJon to TcehnlqllC'5C<1n beperlol'n'led io general or H\"ry spe- the band thai wpporu the dun. II must also be pm- ciroc ...·a)'$. For example, if cer\"il:al rot;ll!OIl is bemg sible 10 adjust lhestrapat IhesldeoflhepatJent'she;ad USE'd 10 treat C.f/S, the physiotherapI,;t'~'head' hand IOrontroi the dIStance hoet\\.een the chin band ..nd the c\"o be lnO\\'ed dawTl from the OCCIpUI50. 10 grasp Col SuruJarly.,(we ..g;lintaleC4'5asthele...ri,butt..... t- occipital band. Once the adlustmcnbo are made ttwr ment IS by pIl5kr'o-an1t'rior unib\"\"..,] n~rtrlori>l prer Ml\",on thl-lritskie.theleChniquem.1ybe used mustnotbe ..bletos!ip,Anyhaltl\"l'USol'd ford1ffurmt gf'r'ler.llllyb) employmg lheb!duuque from CJ IOC6or pahenll;lhal is not adjlbtablcmthese twodirecbon!; it \"\"\")' be used only on CI orCS, or oro the \"poph\\\"l;Cal joIol h~ betweenC4/5, Also, 1heC4 etc. ;articubr pil· mustU'le\\'itablyresultm!lCln1epitlt'l'llSbeinggi''ftl LUQnbetwW monehand ..nd theCS\"rticu!.rpilbr traction with too much f'Ie>1On or \"\"tension oftt.. m lhe OJ'p\"\"',le hand. While C5 is mo\\'ed pIl5tl''l'oanle- norly. C\" can be t'lther mo\"ed in the opposIte direcl101l hNd. ~ haltl\"l'S han\" the50e two Mlrustmmts. .II1d toC5orju!>I tabilized. \\'Ihen tr\"Il5\"erse pressures arc some that do ..re ,Ndequatl\" btxallSt' tht-). '\"\"' not b(>ing u....>d, simil..r olCCUT3C)' 10 00l' k-.cl c..o be st.1bIewhen theadjustnll'nll; ...... made. Foreump&e.cnr ao:<hil\"\\1'd by pushmg adjacent spmous pfOCt'SSCS '\" , ..riet}' has the occipItal ~tr..p ;md chin strap em. opp......it.. dir«tions. structedoutofonepit..... ofmall\"l'ial IuchISCOrltm... CERVICAL TRACTION ous through .. metal ring from hJch the halter is Although cervical traction mn be administe,,-'<l by suspended. \"Though 1\"'-' p;!t1COrS posll!on may be hand il is mOTCcfficientiflhisisdoncbym,,;n,~of;, adjusted with lush<'ad m thc frontal plane. lhepor halter. Ihus enabhog longerpcriodsoftraclion tube ition may be losl during lTCalmentbeeauset\"'-'haTnl\"!il mamlaim'CIwllhlcsl;effort. material is ..ble to slide through th.. nn~;s Th.. two adjustm..nts that mu~t b.> possible art:' first, lhe\"erticallengthoftheoccipitalandchmstraps;and \"<-'Ctmdly, the hOfizolll~1 disl\"nc.. betw ....n them. It is n,-'Cl!SSilry to b.> abl.. to fit thepatl..nt ...·ho has a long or shortj,aw ..s ....ell asthl'p.>Iit.'llt ....hohas .. smallor

Cervical spine 289 .1Chieved by vertical adjustment of lheoccipilal strap in relalion to thc chin strap Aswive1hookinthl'spn:aderbar.asshowninFiglm' 1O.75,isnotanesso.-ntialrequin:lJI\"nlbulilmaM\",for oonvenience.ThetrilClionisappliOO hest through double pulley blocks and a rope,Wilh a mechanical advantal;(' of four. small adjustmenls are possible with- oUllosinganyfedofthctrilCtivepressure. Treatment Trmtment may be administered in thn.'t' ways: 1. Conslanttractionrequirescontinuousbedrestror the patient, with lhelractionapplit'd 24houl'$01 the day or 1Il cydC50f I hour of traclion followcd byahalf-hourrestrepeatedthroughouttheday. This type of traction;\" maiJlly used for patil'1\\ls withS<','e\",nery~~roolpain. 2. The second method is intermittent tr\"c(ion. admi\"· istert'donceortwiceaday for short periods. Th;s is the mo\", common variety used in physiotherapy. and;sUS<.'ClforpatienlSwithll\",sscveren....veroot andothcrintervertcbraljointdisordel'$ 3. Thirdly there i5 the method, alsoadministen'<l only onceortwi(eaday,thalcompri~agradualappli­ Figu~ 10.75 Cervical traction hailer calion of traction 10 a certain weight, which is held momentarily and then gradually released; this;s follo\"'<.-dby momentary rC5t before reapplication large hcad. If the head is small it will be n~'l:l'Ssary to or the traction. Thiscyde is n'P\"aled for varying bring th.. chin strap closer to the occipital str~p in ils periods, and the limes for the 'hold' and 'rest' horiwntal di!\\.'l:tion. and if the chi\" i:;,mall it will bc I\"'riods, as well ast\",alment timcs, can be varied This 'intermittenl variable traction' has a wide n<.'l:<.'SSiIry to bring thl\"chin strap c\\OSl\"r 10 the occipital applicalion among palients whoscjoinl condition Slrapinilsvemcaldireclion.Fis\"\",1O.75showsthe requires movement, and is bc5t performed with an occipital strap and chin strap. each wilh its own pairof intermittent traction machine. Many brands are buckles for adjuslmcnl in lhc\"erticaldinx:lion. llis a\\'ailable,bullheesscn(ialqualitiesitmusthave more cOIlvenienl 10 ha\\'e both seclions adjustable. altho\\lghtheoccipitalstrapcanbeoffi~edlenglhwilh are that a more widely \"ar;ab1e length 01 chin strap. or .~ce a) The movement of applying and releasing the vt1Sll. Thl\" other adjustment is made by the pair of hor- izonlallydiIt'Cl~'<lstrapsfromlheoccipitalstrapIOlhe traction mUSI be extremely smooth. bl Controls mu\"t be available to vary the treat- ment time; the time on 'hold';thc time on 'rest'; chin strap. They fNIss on each side of the palicnl'sjaw theslrength when on 'hold'; and thest\",ngth and buckle under tbe chin 10 a\\'oid the palicnl\"s hair when on 'rest' bt'romingenlangled during adjustmenl 4. Thespccdofthetake-upandlhespccdofreleaslng Discussion surrounding the advisability of giving thc tractive force should be variable. lrilCtionin flexion or in a neutral position Is common. However, the amount of f1e~ion or extension of the A gradual stepping up to (and releasing from) the head on the upper cervical spine during traction lreal- sclectedtractiveforcecanalsobeofvalue m('f\\t should al;;.o be consideR.'d. Thisconsideralionis A patient with severe nerve-rootpain,ifheistobe partkularly relevanl when tbe upper cervical spine is treated conscrvatJVely, requires cervical traclion. A treated. It must the!\\.>fo\",bepossibletoadjusllhchal~ choice needs to be made between cervical traction l\"r, not only lofil th\" various shapes of h\"ad and jaw administl\"redinahospitaloralhoml\"onlhconehand. bul al;;.o for diffcn'nt 'head-n,\"'k' \",lalionships, This is and in physiolherapy rooms alone or in conjunction

290 MAITLANO'SVERTEBRAl MANIPULATION witllilelf-adminiShm.-d traetion at Ilomeon tile other '.,i., -::-.';~I.., The forrm.. method seriously restnds tile p.:!ticnl's daily mO~enll.'nts, and this must be borne in mmd. bul lhl.'se\"entyo(lhl.'p.lm may demand it as the treat- mcntofchoi«:. l(trac:tion is to be giH:n in hoospi\"'l.the mcthodisasfollow Hospital trKtion Figu\",10.76 li...,.oftom.lajT,a<'llOllinfle.;onlllloltlJng UIlTt;>Ct;oninf\\Wotlinlylng The patl......t ;s romforlably $Uppom>d by pillows in a ......·er cen·ica.l intenertebral joint and toward5 the half-lying position. w,th a pillow $Upportmg the head neutral poo.,tion for an uJ'PC'TCl\"\\'\\'ical/OUlt and neck UIlhl.'rorredposltlon.If the tracbOnisbl'mg Whcthe.. apalientis~h.'dSltl1ngorlyrngisgO\\­ adllUl\\1Sten'd fora Iowe.ottr\\\"lcal ner\"e-root pam. the erned by factors related 10 COlIlfort ..nd ~ of oJdmi..... istcnng the tracbon. and not by wlletht'r the f!t,.:l'd or neckl5~shghtJyonthetnmkandtheheadissup­ neutralpo6itionis~\"\"\"'Forex.amplt-', hentraetioa ~beingapplied inthe ........ tral po6ItIon t patlt'fll15 pom>d in a neutral poslllon on t..... uppe' neck.. If trae- usuaJly~comf~lntheSltllngposlho\".lIthe tionisbeinggi~'mforahlgheer'\\icalner\\e-rootpa1Jl, tradlonlSappliedmthesupineposllion.thethoncic the neck is supported in • neutral poslbOn of romfort spme ~ monI! e>:t....ded .and Can bi!come uncomfortable for the patH!nt and his head is supported in. position durin~ tn>atmenl Howl\"ler, ..'hen !he$Uplnepo5lllon midway bd....em fMoxion and eXlension, of the upper is used for troOdion in f\\erion t..... thora6c: spine is not extended. so it thenb«'omes the poslbon olchotn- cenicillspmeT1lehah.... l5thll\"nadjUSlt'donw poalient's head 50thal wd'!osen POSItion will be maIn- AllOOughthesittingpositioncanbeusedfortr~ taIned when the Iracbve force is applied. Thedlnrtion tion in flel<ion, it ' - the d'M<hantage that the tnmL ofthepulie)' rope should bern Ii..... wilh the Iongitu- may be less stab\\co than when suplne• .and II g\"'(5 dif- ferent counler-nsstance to stRlllK\"f tr.acti\\-e fotc1o.J. diNlaX15olthejointtobl'tw.atedForthepatient\"\"th Nl\"\\-ertheIes6, with the pahmt SIlting m a s1um~ ......·.... cen\"al ner\\'e-fOOl paLn,the rope will fonn an ang~ 01 some Jtr with hb tnrnk; for high cenical po6ition(suppor1edbyalumbarpillowlf~') ner\\e-rootpoa\"'.t..... .ang\\colSmuch~I ......·.... lrnllal Wt\"lghts.-d.aft' law,arPl'OXlmatel) 2-Jkg; ~can the 'traction-inflerion' position can be ad\\lc~·ed. and be incrrasoed by 05-1 kg per day up to a maximum of its \"roe of puU IS more dU'l'C'l (no anteropos!erior g.n- 5kg.llwpoatMmt'sbuild.and gener.... joint mobility on Ityrompav:nt) than In the lyIng po5ItN)tl (f.gllrt 10.76). the one hand .and the Soe...~nty olthe poain on the other lhe following text describes tr\"\"ion in neutral for lhe ~·emthe\"\"l.'IghlPalienttoler;mn'totheapparalus upper cervical spine performed in sitting and tr.arnon gO\\-ems the penods spent on Irktio:ln. but I hour on in fio:JOOn for the ........... cen-icill spine pt..-formed IJ1 trachon follow~ by hall ilIn hour \\ I'l.'!it repeated throughout the ...ak.ong j>(\"l'1Ods IS usually all that IS lying (f'8\"rr 10.77). \"\"luirro in the most _en.- nen~~root poain if It is gOtng to respond to this l) pe ofma.....g(-'lnl.'nt_Ten days Traction in n~utfal (CT f) is usually suffiamt tIme 10If the tramon to be mam- t.1iJ>l;'d, but if then: is no Impl\"O\\ett\\CT'lt O\\'er the first Stortingposition fe..• days ,t l5unh\"\"ly lhal the patlt'flt will be helped lhe patient sits in a romfortabl~ eha,. With adequate bywC()lIStant trac:hon, Tr.achon at home may be used support forh;s back and. if possible. for hIS arms, to enrourag~ complete n'laxatlOn. This is an Important Intermittently foUowing the hospital traction. consideration. For Ihis n'ason,;t isad\\·isabl~tOlsk thf pati\"\"t toslideh~butlockss1ightlyfo.r....ardsonthe ll1crean.· many J1'O!>ihonsdl'!iCTibt'd in the lileralul'\\' ileattoproduceslightslumpmgandthereforebelter for applying Iraction to the cenical spine, \\'arying n'la><ation. from full fle.:ion to full C>.tcn~ion. Basicall)', the pos- iti<mchoscnshouldbo:!ooethatpositionsthejoinlbl'ing The head haIler is applied ,1nd lhe nl'a\"sary treated appro':lmately midway bl.-'lwl~'n the limits of adjustments are made so thaI wh~n thl! traction is flexion and ~,.tel1Sion for that joint. This position may applit.>d the h~ad, in l'\\'lation 10 tile n~'Ck, wtll be lifted vary from paticnt to palicnt becilUse ofstroelural joint in the <leulral position, The occipital strap musl lifl chang~'S due 10 diseaile, congemtal anomalies or undef the occiput and mu,t not indudesubocciplw trauma. It may alsovolry in theSolme patient as treat- structures. mc\"teffectsimpro~ement(lfilpainful .......trict;on(for example, extension). As discUSSl.-d earlier (!i<'l' p 172-173). the neck should beposit;oned in flc,.;on fora

C~fVlullpln~ 291 Mtthod =:\"\"\"\"presureshouldbe5115ta'nedf~IO Before applying ..n) lr;ochon. the phY!iiolhel\".. ~ shook! know. ~al'9 ..nd §OI\"\\'entyofthe~tienl'!i 4. Symptoms mack' \"'OfSI\" by this genlle IrKtKln shouldbo!giwnhaJfthepl'\\'S6Ureandre~ If symptoms ..t that rnorrot'fll. The physiotheJ.pISI pI.a.ces the symptoms are shU wor.;,t, changt'!i of pallhon tht hpofherindcx~nuddle fingeragalllst theSldeof of the head-neck rela.honstup by ahl'rauon ofttll' thtin~'nous~pa.ct'oflhe;o.nllOb(olf1'd«'d_~ harness or 5,lbng po5'llon should bo! carried out traction is lhoon\"pplil'd and A'l..xed in an O!lCillarory and the gentler traction I'\\'applied Iflhe symptoms 1J\"I(I\\emer>1. \"ery gently at firsl but gro>c:h.wllv iTlCft'MUlg until mO\\l'mml can be felt bo.' the fin!{l'1' ~ the mter· areshlJ wor.;,t, then one of two CQUJ'!i('5 rerrtil,lt5 spmousspaa, ThI505C1llatory lracbonshould ronlLnu~ open; if the aggravation. is not 100 great. the gml· until the right ~ure is founoJ. which is minimum Ie5Ilract>on Can bc maintained for 5 m'nute or a.mountrequin'dlopnxluctmO\\'etr\\t.'T1t ..llheml\\.'T\\I'r_ less; if the aggrn'ali.,., is more than mmmlaJ, tDC- tebralle\\t1bcingllt'ato.'d.Whmthasprt55urehasbeen lion should be dlSC011hnued. On re-assessmg the sustamOO for ..pproximak'Jy 10~, the palient's nextday.onIyifthen.~tothegcntlepn'SSUrc symptoms are re~. TIle following chitngcs in shows impro\\'emcntC<1ntr<1ctlonberontmuro. symptoms w1l1 indicale h.::Iw lhe pn.ossure should be For the initiill treatment, orM' point muSI be cmpha· furtheralleredandhowlongilsoouldbeSU$tilllled siz~. The angle Or d'r«lion of the pull is not altl'red I. Whl.... )C\\'cresymploms ilrecomplNcly relieved by dunng tn>almcnt; It is the5trength and durat,on lhitt is thlsgtmlJe pressure,lhcprt'!i5ul'\\' must be redured modified by changes in the symptoms, The angll' of byhalfandthetractionllmckl>ptwlthin5minu«'S bec:al!So' the patient is li~Jy to hav\" a severe the pull musl bl' as near 10 lhCT\\('UlraJ position {mId· cxilccrbationlaterunlcsslhisl'('ductlonismade, waybelw~lheintl'r-\\'ertcbr<1Jjoint'5rang{'!jofn('J(­ 2. IfsymplomSha\\'\"lx'\\.'rtp.~rtJyrdieved,thetraction ion,extens,on,latcraln~ionandrotat;on) as possible shouJdbe~ptatthislevcJandsustallledfor5 so as to achieve the max,mum longitudinal movement for that joint with the minimum Mrength of lmcllon. minull'!iiflhepillllWasscvercbcforolraction,and for 10 mInutes ifilwas moderatc Method of progression 3. lfthc symptoms havc not .. Iten.od, the traction The importance of continually aSSl'SSing synlptOIl15 can bcincrcased a littlcand a furthcrilSSl'!i!>mlOJlt and signs for changes resuJtingfrom treatml'nt WaS

292 MAITLANO'S VERTEBRAL MANIPULATION d~ in Chapt......, ..nd ,tIS br these methods t.... t d&omfort or ..ftl'\" effects, Similarly, rrunor dlsromfort tre.. tmerol IS guided_ As w,th techniques of moo.hu- felt with a Iraction fon:emexcessof IOkgnu\\-, under bon. dwlges in tt\"Chniqlll'5\"rl' guided by chKktng thl.' the on:umstances mentioned. be classed ~ nonnal. p<1t>mt's mmemenlS ..f~ tho> usc of .. IKhmque;mel \"These facts should be borne in mind .. hen trealln& ..Iso b) the amounl of chan~ that is retained from one p;>tienlswhoha\\'edi~fortduring traction Ireatmmltothenol\"\\t.Whmthetr.Ktionis~the p<1henl's mon'n>en1S should be re~, but II is tabo important to .._ tIM' symptoms and tIM' igns TrKtion in flexion {CT I on I1M' day following treaunenl. 51ortingposition Follow-up treatment c..n be ronsidered in two Cilt· 5l.''''''''l'gOfies; thosE' pat,enls WIth pam and lho!;ewilh The patient lit'S comfortably on Iu;, back w,th one or mooerale pin. Tre<llment ofa patienl \"'ho has SC\\'l'''' twopillowstos\"pJX-lrlhisfll'(:kinshghtfle~ioninrel.J-. pain should be progressed very slowly, as circum- tion to histnml<,S<l that th,'jointbt'inglre31oo will be stances allow, until the symptoms b«ome mooeral.., midway betwl'.m flexion and eXCension, and 5OaS!Q AI fillit the pmg~ion should be by small incn.'asl.'S support his head n..utrallyon his uppercervkal spine, indoralionofthl'lractionralherlhanStrl'nglh, When If he has at any hm\" had any lowerb.lcl< symptoms, it tllE>rl' is little or 1\\(1 r('.l<:lion from Ire1tment, th.. is advisable 10 have him flex his hips and 101ees!Q SIn.'I'1gth c..n be increased In small sl.1g'3 also. allO'\" the 10w(\"I\" b.ock to 1\\\".51_ The hailer is \"Wh\"d and l'rogression can be by both strength and durahon the occipital strap iii posilloned first. 8l'CiI1JSl> thr when symptoms ..,.. mod......Il.·_ \\\\~th the exceptIon of p<1l1ent resb Ius he<1rl on this strap on the ptllows, ,t tronment for se\\ere ner'<@-root p;>in. the tobl hme wiUrem.unmposJtlonwtuJetheSKIestrapsanddUn reqUIred for lrachon IS not gre<lt.... lhan 15 minut'3 slraPS\"l'l'being<1dltlSted_ToensurethattlM'harTll'!i!iis Kesultsthat~beobUinedwithtr..ctionofthis rorrectIy<1dlusted,theph}~plSlappbes_ dur..hon will not be xhle\\ed .. ,th longer pt'riod., traction \\'Ia the spTNder boIr wh,1e she w<ltches!osee and tr<1Cli\\e forreo; rarely O«'d to be hN\\1' Traclwln, that the head-n«l relationsrupis roeutral <1S .. form of tn'atment. should be dIscarded ..ht!n symptoms ..nd sIgns rem.un unchanged ..ft..... t.. o to Mtthod fOl.lrtreatmenls. KnowingtheareaandlheS<.'\\'erityoflhl'palJenl' pain, No m\"\"tion has bl'(on made \"'S\"rdingsttt'flgth, and the opt..,.ator allt..'fI\\oltdy applIes and relaxes pll:'56UR' II is assumed that the amount of tr<lclion given will be gmemcd by careful assessment of symptoms and through the pulleysyslt'm while walchinlo::lnd plpatmg .igns before, during and following traction, As has formo\\'cmelltatthcintcn'l'rtl'bralle,'elbclOgtre;'t,'<l, bl.'I.'f1lndicatcd, thtoapplication of pressure al first is The pressure is susl.lino.'<l at that amount which ill the go\"emedbymovl'1nentproduccdatthcinlervcrtt'bral smallest f\\.oquin.od to produce mO\\'ement at tIM' joinl len.'1 bl-ing treated, Obviou Iv.\" kg of tr<lChon applied Afterappro>,irnatclyIOseronds,thepatl''nt'ss)\"mptoms loa 1D2-kgpatient will product' 1C55 mm'emenl lhan if are~,Fromthispointonw..rdstheprocedW1'iI .. pphcdto .. U-Iq;p;>t>mt.1l>erefore,although!IC.. I0.\"5 idmtical with that described for trac!lon on neutral. that Indicate strength of traction are necessary in n:oseard\\ pfOll'Cls and In hosp,tal departmenl!l wllE>rl' Precoutions staffcNI\"'8f'SOC'CUr, II ISC'5I5C'nbal to reahzt'lhal tfiICI't'e f~shouldbl-g<l\\ernedbyassessmentandnotb) A fre<Juent problem WIth strong cen-....ltr;tction is dIS' tlM''iCale comfort or palO m the p<1hent's tempol'Olll\"ndibulir 1'hefe ... one illTIl' when knowledS'\" of the weights pnls. \"This pam maybe \",Iie\\'ooby malh-\"ralioonofthe tlYt(an beconsiderl'dI'I(lnI\\;IIforcervi£\"'tracttonis posilion of thrstr.lps, or by pL.cing a p;>d be1...\"\"\", the \\aluable_ I'eople of middle age ha\\'e SOITll' ache5 I.... t p<1tient's mol.us, Ilow\"\"ft, traction of thl~ magrutudt do not \"'orry them and that they daS6 as normal is to be a\\oided unless 3bsolutcly essenllal Examination of their mo\\ements f~uently eJ(hibilS 1t is surprising how often pre-exlStmg.bul potiSil:l1v shght pam at the Iimil of ranl5e. but agam Ihi5 is con- dormant, lhorackor lumbar symptomsarl' irnlilted by sidl'nod normal. Howl'\\,er, if this pain increaSCS,thtose cen.'kal traclion, Traclion in ncutral can irrilaterilher prople seel< trealment, With thl\"\",thoughls in mind,a lhoracicor lumb.u conditions, but Iraclion inflexion p;:,rson's cervical spine, \"\"'I'n with a dcgn.'C01 symp- only irrilak-S the lumbar spine. Th..\",fo\", when Irae- toms and sIgns th.lt mighl beclasSl'd as being within lion isbcing used, Ihc patIent should be qUl'Stioned iIS normal acceptable limits, .'>hould be able to accept to the ..xist..nce of such srmptoms, and c.lrl'shouJd be tr<lClIon of up to appro~mlately IOI<g (22lb) \",thout taken to a\\'oid any aggra,-ation of them.

CUViCllspinc 293 When traction in neutral is given wHhthepatient Of the general manipulations, there are rotalionand sitting..itisaswel1tobeawa~ofthcfactthatapatient the di=t palpation techniques such as postero- cancxperience nausea, but this usually only occurs anteriorccnlral vertebral pressure_ The method is to wilhprolongroor\"\"rystrongtractionorwithexces- take up theslack,ease back fractionillly, and then add sivcly app~het1sive patients. On ~Ieasing traction, a very fast small-rangemoVemt\"l\"l1. patientscanexpcrienceafcclingofgiddinessifthe It is mandatory that all manipulalive (Grade V) tech- traction hasMn Vt,rystrong. niques must be preceded by te5tingfor vertebrobasilar Traction in flexion can cause a buming feeling or insufficiency (as dl!SCribed on pp. 242-249) paininthc\"icinityofthl·firstcervical,·ertcbra.lnsuch High cervical rotation manipulations should not be a case it is advis<~ble to alter the harness 50 that Ihe the first choice if other manipulative techniqut'S that head isexll.\"l1dedmo~ontheuppern<-..:k,whilethe are generally thoughl to be less risky in terms of verte- lower neck is maintained inflexion bral artery damage Ciln be used wilh the same effect. Uses Cervical rotation (.j) A piltient whose neck movements of lateral flexion and The symbol indicak'Sthedirechon of the rotation of rotation towards the painful side are markedly limited the patient's head by arm pain should be trcatro by traction only, and it is traction in flexion that should be USt.\"d. Traction Thismobilizationcanbeconvertrotoamanipula- shOlildalwaysbetht'firstchoicein~atmentwhen tion by applying a sudden movement of tinyampli- =entneurologicalchangesa~prest.\"nt tude'S to the nl'Ck. Manipulation in this instance pn.'Suppos<-'S that treatment has progressed through Traction is of value in almost any distribution of stages from g('ntl(' mobilization to the stage when pain arising from the cervical vertebrae. However, the manipulation has b<-,<:ome nccessary_ rapidity with which complete relief of symptoms and signsisobtainedisusuallyslowl'Tthanwithmobiliza- The posilion used to manipulate is the same as that tion. When intervertd>raljointsarestiff,traction may described lor the mobiliCGation (see pp. 283-284); the beineffecti\\eifnolprecedt'dbymanipulation. head and neck are slowly rotatoo. Over-pl'CS5ure is applictl,and any indications of verlebrobasilar insuffi- Intermittent variable cervical traction (lVen, ciency are sought. The over·pressure is then fraction- referred toon pages 288--289,can be applied in neutral ally~leased,andaquickrotatorymovementthrough orin f1\"xionforth\"samereaSoOflsashavebccngh'en }-4\" is given. This mOl'eml\"nt should never ever be a already. Weight and duration ar\"also !;ovemoo in larg\" movement through a full rangefromthl\"central exactly the Silme manner. The only faclor not al~ady position; to do Ihis is to court disaster. co\\'eredisthemodeofl'5tablishingorprogll.'SSingthe hold and I'l.'St periods. Whcn symptoms arc ~\\'erc the Thespecific techniqut$ for the different levels of the amount of movement should be less, which means cervical spine follow, and examples of treatment that the hold and rest periods should be long. As include acute torticollis,pilge427,and shootingoccip- symptoms b<..><:ome less severe, the rest period can be italpain,page429 made minimal. When symptoms can be clils5t.>d as an ache rather than a pain, the hold period shouldbc Ocripito-atlantaljoint (rotation Iv C. 0/1) approximately 3-5seronds with minimal !'l\"Stperiods Starting position EAampk'S of tcc,ltment include: severe cervical The palient lies supine and the physiotherapist slands nerw~root,pag('5414-415;painsimulalingcardiacdis­ at the head end towacds the patient's left shoulder. By reaching around the right side of the patienl's hl'ad, ease, p\"t;es421--422;painsimulatiJlgmigraiJle,pag~'S the physiotherapist grasps the patient's chin in her 424-425; acute torticollis, pag~'S427-428;and shooting right hand. She then plilces her left hand undl\"r Ihe occipitalp\"in,pagcs429-4JO patienfshead so that her middle finger is against the po5terior margin of the rightan::h of the atlas, with GRADE V MANIPULATION the pad of the lip ofthe finger pressed firmly against the posterior margin of the transversc proccss. A firm grip As has b<..\",n mentionoo earlier, there are two kinds of of this \"erll'bra is then achievoo by hooking the thumb manipulati\\·etcchnique: first,lhosc that are the gen- round the left trans\\·erse process of the atlas to rcach eral tl'Chniqucs;and sccondly, those that emphasize its anterior surface. Rotation of the p.~tient's head to the movement, as much as is possible, to a sp~..:ific therightisthencarrictloutunlilthcoccipitc..atlantal intervertebrall\"\"e!. jointlsfelttobestreteh~>d(approximiltely1000shortof

294 MAITLAND'S VERTEBRAL MANIPULATION Figu'etO.78 Oc<:iPilo-atlan13ljointRo13tion(lvCO/il the contact is made too far lalerally, it becomes very painful. The posilion of lhe re;t of the hand is also full rotation). from which position the head is rotated import\"n!. The fingl'fS are comfortably flexl'd at the backappro><imately H)\".lnthisposition, lhegraspof interphalangeal joints while abo supporting the lheatlas is tighlencd (Figure 10,78). patient'shead,and the thumb is brought forwards to hold the occiput more laterally. The wrist is ulnardevi\" Method aled and held in a position midway between flexion and extension, Thisdescriplion of the thrusting hand Sudden rotalion of t~ patient's ~ad to the right position (figurr 10.79) will be referred to when lhrough tlJ-tS°should be effe<;ted by the physiothera- adoptlodinothl\"Ttl'Chniques piSl'S right hand while the left hand auempts to pre- vent any movement of the alias. The~ is no danger l1le patienl'shead is now rotated lothe left through attachLod 10 this procedu\", since, although a maximum approximately 3O\"forcOTlwnicnce, and his head is r,mgeof ocdpito-atlantal movementisachieved.lhe then firmly Slabilized tJ.:,lwccn the physiotherapist's range of head movemenl is still shorl of the palienl's left armand her shoulder. While the physiotherapist fullrangeofacti\"erotation palpates tJ.:,hind the occipilo-allanlal joinl with the proximal phalanx of her index finger. she adjusts the Ocdpito-atlantaljoint position of the occipito-allant,lljoint with her Icfl arm as follows. First.sheadjusts the flexion/extensionposi- (unilateral PA thrust Iv \"l O/t) tionofthepaticnt'sheadonhisuppcrccrl\"icalspi~ untillhe occipilo-atlanlal joint is positioned midway Starting position between these two mOVeml'l1ts. Secondly. she adjuslll the laleral flexion position for the joinl. Thi5 she does The palient lies supine with his head beyond lheend by tipping his head sideways in anoscillalory fashion of the eouch. If the te<;hnique is 10 be performcd on lhe on the uppcr rervical spine. Once this neutral position right side, the physiotherapist stands by the right side hasbet.-nadopted,lheheadshouldbeheldslablyso ofthepatient·shead.Shesupportshischinandhead in that lheposilion is not lo>t (Figurr 10.80) her left arm and holds his righl occipital area in her righl hand,Sheplaresher right hand in such a position Method that the contact point of her right hand is placed behind the right ocdpito-atlantal joint.l1le position The physiotherapist hugs the patient\"s head firmly in she adopts with her right hand is one lhat is us<-'<1 in her left arm and lightens her eontact againsl therighl many t(\"Chniques. The eonLlct poinl is the anlero- occipilo-atlantal joinl. She then din.'Cts her forearm Iateralsurfaceal lhejunctionoflheproximal and middle pointing towards his right eye. Small preparatory thirds of the proximal phalanx of the index fingl'r.If oscillatory movements are produced by pushing

C~rvical 59inC 295 ,., (I.\"\"lFigure 10.80 (a) and (bl Occipito-atla\"taljoinl. Unilateral post.ro-ant.,ior lnrust 0/11 though her right h.. oct. along with very tiny mO\"c- afte, which ~he both extend, and laterally flexes his rnl'nts of his head with her leI! arm. These movements head to Ihe lefllothe limit of their rang~'S (hgurt 10.81). allow the head 10 be lipped by the right-handed push, but dQ not allow il to move far. Method The manipulative thrust ;s then executed with a The technique is the Silm\" as with other thrusting-type short. very fasl thrusting-IyfX' movement throullh her t~'Chniqu~'S, When the position has been accurately right hand and through the right ocripilo--allantal joint adopted, the thrust is transmilled as a fast, small- This thl'U5\\ is countered by a controlling and guiding amplitude t.,;:hnique with the physiolherapist\"s left movemt'lll with her left arm hand while her body and right ann give a s!igllt increase 10 the palient\"s extemion, lateral flexion and Upfler cerviCal joints, occiput to C3 (transverse rotation of hi. head. thrust, Iv - . opening 0/1,1/2 or 2/3) Upper cervical joints, ocdput to C3 (transverse Thist<XhniqucR-'Semblesthetram;versethl'U5ldescribed thrust, closing the right Iv--) on page 298. but a greater raogt' of extensioo of the he.1d on thene<:k is inoorpor~ted n.., technique for dosing the intervertebral joints util- izes the §<1m\" .\"'rting position as that described above Starting position for opening the opposite side. The dlffel\"l'llCe in the technique is that tile thrusting left hand is dill-'Ctcd <;aud· Toopen the joint on the right-hand side, til\" patientlics aUy and medially rather than ceph.llad and medially. supine with his head beyond the md of tile couch and !tis whole body \"\"ar the left side of the couch. The Examplesof treatment includerervkal joint locking.. physiotherapist supports his he~d in her riglll arm, pages 428-429, and pain simulating mIgraine, pages holding his chin in her rigllt hand. She then palp~tes 424-425. with her left index finger to identify tile level she intends to manipulate. The ne.o:t step is to place tile Ocdpito-atlantal joint (longitudinal thrusting hand, particul~rly the proxim~1 phalanx of movement ........ ) her index finger, against lheposlcrolaleral aspect of the joint. The physiotherapist rotates tile patient's head to Starting position the rigllt ,,·itll small oscillatory movement. until she can f~'t'l tIlat the limit of tile r~nge h1l5 been rc~ched. The starting position for this technique IX\"formed on the right side varies in only one aspt.'Ct from that