Maitland's-Vertebral Manipulation - 7th edition

296 MAITLAND'S VERTEBRAL MANIPULATION Figu..,10.Bl Inl(Mncb'al joints. !o) and Ibl Uppe'ecNlcal/t'ans\"CfSC thrust opening the'ighlll~-) Method Thl'physiolh\"rapisl hugsthl'palient'shl'ad to hold it firmly, and by pressure directed lhrough the crown of hish\",'dwithherthrustingl1.andshetakesuptheslackof longiludinal movement in his nL'Ck. The manipulaliw lhruSI is one of \"<'ry small amplitude performed at maximum speed and wilholltforce Figu.., 10.82 Ocripito-atlanlaljoint.longitudinalmo~(m(nl Atlanto-a)(ialjoinl(rotationlvC~ (....... <PJ) Stortingposirion dl.'SCribedforlh<'POSlero-ant\"riorthrust.Thethrusting Thl'll'chniquewillbedL'SCribedforrolationtothelefl. hand make-.; contact wilh the ocdput immedialely The patient lies supine with his head wl'll dear of adjacenttotherightocripito-atlantaljoinl.andlhe physiolherapist adjusls her righl fo\",arm 10 lhrusl the end uf the couch. The physiotherapisl holds his through the crown of the head. The neutral extension chin and head in her left arm and rotates his head and lateral ne~ion positions are adopk'<l in the So1ml' through 40\". Wilh this d<'gl'<'<! of rotalion there has manner as dL'SCribt.-d abo\"e(figore 10.82) beL'Tl no mo'·emenl of the second cervkal vertebra.SIle palp.>les for the tip of the spinous process ofC2 with her index fingl'r. and lhLon slides her index fing.... beyond the spinous process keeping firm contad between the spinous process and the index finger·slat- eral surfan·, This firm contact must be maintained with the skin and the spinous p\"-'Ce5SthroughoulSO that the tissue can be held tightly. This sliding mow- mL'Tllisconlinued,herarmatrighlangleslotheskinol hisneck,unlil the spinOllS process ofC2 is cradled in the first intl.'TOSSl'Ous span',She is then ina position to hold C2 firmly cradled bet\"\"\",,n the melaca'J'Opha· langeal joinl of her index finger behind the left articular pillarofC2and her thumb. which holds thl'transverse

Cmicalspine 297 FigUl1'10.83 Atlanto-axialjoint.Rot.tion FigUl1'1O.84 InteM\"tt .. ljoinls.C2~1(1v\",1 PI'OC'-'SsofC2On the right-hand side almost from in movem<!flloftherighthandcoru;;stsofa unilateral p<J5-\" front. Her forearm is by this tIme well underneath the tero-anterior thrust on the left side of 0, while the patienl, with thl'elbow pointing towards the floor. physiOlherapist's woole contact with that ,-ertL-bra with This hand position i.vital if the tl'ChniGue istobea her righthilnd effL'Ctsa rotary movement of C2. succl'SS.Thephysiotherapisl'sit.,ndremainsalrighl anglcstotheskinthroughoulthetechnique,andlhe lntervertebraljointsC2-7 (rotation Iv.\":J) fingers of her right hand pass the back of the left hand duringlhemarupulahon_Thephy.iotherapistneedsto Stortingposition ~tand behind the patient's head to be in the mostefli· cienl position (Figure 10.83). The IL'Chnique is dL'SCrilx'<1 for rotation left of the C3/~ joint. Method TI-.epati\"ntliessupin\"withhisheadbeyondtheend !lefore carrying out the rnmtipulalion, the position is of the cooeh. The physiotherapi5t 5tands by the right che<.:ked by two moveml!l1l1;. First,thephysiottKorapist sid\"ofhi5head,supportinghishcad in the crook of her mtates the palil!l1t\"s head back and forth through a left arm and holding his chin in herhHnd. She flexes hi5 small amplitude to ensure that all slack ha. been takl'Il necktoplacelhea/~jointmidwaybelweenflexion up between the two hands. 1bis is dOlle by rotating the Hnd extensio\". With the lip ofher right index fingt:r, the patienl'5headwiththeleftarmtoseeiftherighthandis ph~iolhcrapislfindsthea/4in.k'lSpinousspaceand forced to follow, 1bis is followed immediately by a then mo\\'es her hand late.ally to bring the anteroL1terai deroL11ion mo\"emenlwith her right haoo to \"\",if the surface of the proximal phalanx of the index fingt'r 1eft hand is forced to retum to il1; original position, behind the 0/4 apophyseal joint. She places her fin- becau.-ein fact the head is being turned back by the ger50n the back of his neck and hcad to provide sup- right kand's contact against C2, Thesecondexploratory port, and her thumb lightly on his ~,w. While holding mon''IIll'f1t is a oounter-clockwise movement with both lhisproximal phalanx5talionaryagainst th\"articular hands. These movements are done as small ~lbbing pillarofC3/4\"he06dllatesthehl!adinarotarymo,\",-~ rnO\\'ements with both arms, and a..... the forerunners of ment, starting from the straight head position and grad· the manipulalivethrusl. ~exploratorymoveml'Ilts uallytumingthehcadfurtheruntilrotalionisfdtbythe will give a good guide to thest\",ngth of the movement phalanx at th\"C3/4 joint. She then tightens her right- ~uired to manipulate the joint. The manipulation con· hand gripwiththefinge\"'Hnd thumb SO thHt if the head sistsofa tiny mtarymO\"cment with the left hand and a istumedfurth\"randth\"righthandfoUowsthetum,C3 ml.iIll-amplitudesharpthrustwiththerighthand,TI-.e also follow. the tum. This unifying of the spinc abo\"\" C3withtheheadisvital(Figun'IO,84)

298 MAITLAND'S VERTEBRAL MANIPULATION Mtfhod The nwupulaliorl cons>5IS of ~ snall....mplitude wrp rotation ot the unit, hNd to 0, with ~ thrust being oened behind the artlcubr plll••r of 0. lnttMrtt:br\"a1 joints 0-7 (laWai flt)lion IV..c\") Starting position The patK\"nt liessuptIll' WIth hIS head beyond the end of theooU/;h and thephysiotht-rapist. standing at the head of the rouch, grasps the paliCTIt's chin in her left hand while her left forearm lJ~'S against the left side of the patiCTII'S head. With the palm of the right hilfld at right angles 10 the neck, and the nngers supporting under the hea.d and neck. the patient's head is latently flexed to the nght through a lYw degrees while the ph)'slO- theraptSllJlO\\'e5 her body and feel until. is standing by the patient's nght shoulder f.King his hNd. To localize the Je\"e1 of the ll'\\ilrupulalion, thrph~ lheu.ptSl uses the Iipoflhe right index fingertopilpate forthedesll't'dintl'rSplnOUS~.\\\"''henthPJe\"e1ha.s beenascertained,the~terol.Jteralsurfaet>althPt>.st: Inttl\"VCrtdlr~1 joints 0-7 (tr.IIlSWl'W thrust Iv of the proxtmal phalanx of the nght index finger i5 opening - ) pbc.1'd lIgau>5t the arlKUlar piUaron the right \"I that leo.'e1. The ph)\"Siothl.'np1S1 ~ cornbmes \" pu.>h Starting position lIgl1inst the articular pillar WIth the righl hand (thus nus techniq~ will be de!icribcd 10 open the joints on displ;>CU\\g the neck to the left). WIth\" lateral flexion of til<! patimt's hea.d to the right by th<> left hand and fore- lhe left-hand side. arm. In this way a poe;ilJQrI can be reached whe~ the IIlter'l'l'l1l'bral joint opposite the base of the physIother- The patient lies supIne with hIS head e:!dended apist's right index finger can be felt 10 be folly oc'}'ond the head of the couch and his right should.... stretc!K-d. To complete Ihe tension 011 this joint, the head near the right-hand ~odgeof the couch. The physiothl..- must be passively rot>ted to the left by the physiother· apist supports his head in her left arm, holding his apist's left hand until the sln.'1ch can also be felt under (hin wilh her hand, and ~tands by the right side of his this finger. \"The right wri~1 IS held flexed 10 til<! mid· head. With her r.ght index finger, she nnds lhe int~..· po&ItIOrl to keq> the heel of the hand away from the palJent's ngt>t ear, thereby ke'1\"ng the mllI'l\" latl'nll spinous space bel\\H>en the IWO \"ertebrae lhal she ~ofthepn:oonWphabrulklbmragamstthc~­ plans to manipulale. She then places the anterolaleral 1.ar pil1ar AI the Qme tUlle the physiotheraptSl dlle=b border of her thrusting proximal index finger phalanx her n-orm in hne WIth the plane of the ..poph)'5e\"1 against the Mhcular pillar OIl that 101.\"\\\"(\"\\ on the righl- joint under thet>.st:oftheindex finser. Toperionnttus hand side. She then roUtes his head to the left lila mMUpuLtIion ....>tth nurumum effort. the ph)\")oiother- ~ of small-amphlUde oscillations, I~K ~ ..pI>ot should croudt O'\\'er the patM.nI'S head to hug It and ran~ until the mo)\\'emenl Gln be fell to tat..e place al ho«I both arms finnly lIgamsl her sides (riprr 10.85) tlw joint to be mMUpulated. ThIS rotation ....-iIl ury between ;IS and 55 • depending on the ~'e1 bemg Mtthod mampulak.'d; the hig.t.e.- the Ie'\\-el the smaller the roG- lion. \"The right palm is alall times lep! at righl angle lolheskin surt~,The physiotherap.st, with nrm c0n- tact held agamsl lhe articular pIllar, tHts Ihe paliCTIt'! When the physiotht'rapisl is sure thai she has the joinl head back towards his nghl shouldl\"f WIth her left fully st\",tched she gin'S a suddlon thrust Ihrough the arm. This movement is a combination of slight eXlen· base of the right index nnger along the line of the ril;ht sion with lateral nexion. The mO\\'l'TIlent is continued forearm, at the same lime applying an equal counter- until the joint can be fell to be tight under the phys'o- pressure with her left arm at the head and neck. \"The therapist's right l\",nd. Al the same hme thai she tilts aim i!lto produce a sudden \"In.>tch OIl !he apophyseal back the patient's head and neck, lhe rhYSlOtll<!rapi~t joInl opposite tlw fulcrum. This stretch may result in a displaces the mid-een'i(al area away from her toward!; crack-like sound his left should.\". (f',gurr 10.86).

Cervical spine 299 F\"+g~~ 10.86 InleMrtebral joints. 0-1 (tran5_ent Ih'~~ll_ Whiplash injury typically oocurs when the mJUft'd per5Ol\"l's car is luI directly from behind, especially if --(l~nin9) the injured. per5Ol\"l is Iook.ing straight ahead and is lotally unaware of the impending blow It is encourag- Intervertebral joints C2-7 (trans'«I\"SC thrust ing to ~ that fIex>on and lak'f\"al fIexJon lKn'leration dosing the right side Iv ---) injuries do <:.m5e Ies5 dama~ (Jdf~, 1991) At the \"\"\",,\",\",I of impact, the lnO\\'ement 01 ttw head As .....,th the transH'fSt thrust fOf the uppn cer\\,uI and neck is a totally unguarded mon\"menL Such jolnts, the t«hruquc can bo.- adapted 10 either opI.\"l'l unguarded D\">O'\\'emmtsan oocur In a myriad oIdiffer- fwider) or da5t the jomts. The descriphon of the IKh- enl ways, but they AUoocur in a IT\\MIflel\" that fiicb ruquehere IS the samc as that ~ribed on pa~296 the \\·et1ebral system into and beyond a normal range ..·lthF'j{Il\" 10.81 of acti'\"ee...tens>onal a speed and suddmness that pn'- ,mls the prot«tmg muscles from Y'ingtlvstruc- Mtthod tures from injury ThespeedoithtrolUding<:armaybe as low as 4 kmh, and the goop bctwC'l'fl the patient's Small or;ollatOl)' thrustinj; mon.·..'I('flt5 an\" emplo)'ed head and the headl'l'St ~ only bo.- approKimately by the phn,odlel\"o>p1Sl through her right hand 10 lOon to cause a dama~ing &<n'~ation injury. m5Un\" that the oghl degmeof slack has bem talen up Ob\\'iousJ~, faster ~peed5 and the lack of an effertl\"e ~ small-ampliludl.· thrusting lnO\\eml'TIt5 an\" hcadfl'Stleads to grNt~r damag(', COUI1tened boo\" l!n~ l!pping ftlO\\eml'TIts of the pahtTlt's head, ..-hlCh IS held In her left arm. A small... mphtude When a moderate mjur), occurs tlltn: is damage 10 marnpulall\\l\" thrust with thebody transmith.d through anlerior and posl..nor struclun.'S; posterior damage the nw>1 hand directed to.....ards the left and caudad occurs in bor1y and ligaml.'ntous tissues as well as in l\"fft'Chthewchnique 'rim Il'Sions of the int~r\\'ertebral diSC and zygapophy- !<'ai jQint' (Taylo. and Twomey. 1993). Anterior dam· &ttnsion-Occtltratlon injuries ageoccurs in two phases, the first bemg when the head i. hurled backwards and the second soon afterwards lncontras! to the vigorous techniques descrilx'd, mobil. whoett tilt anterior f1e~or mU!lcles try to stop the head ization must at times Ix' el(\\remf.>ly gentle lO be effl'C' going backwards and thrn cnd{'3\\,our to pull tht head ti,'e. Ono:- such example is nlensiof1-ilcceleration (' ..... hiplash·) injuril'S in the minOf category. To learn and neck forwards. mol\\', t'!;pt.'CioIlly In the area of injurics. Jeffreys (1991. Treatment will not be dJ5C'USM.'d other than 10 statl\" pp.26-29)gl\\csexcellentdctail IWOprincipl.cs: 1. A soft sooIhmg roIlar (not one aimed to Pft\"\\'ent'\" mcr.emcnt) should be USl'd \",hom the patH'rlt feels that tlus gi\"CS!lQml\" relief {day Of rughl). 2. Acti'e mcr.·1\"lTIm1 !Ihould be tnCOUraged.. bul should be under the instruellOfl and gwcbnce 01 a ph)-siotheraptSl. The ,n,t>al mm-eTlen1 .should be a rotMy-I)'J'l\" mm'emcnt while supported on a down-filled pillow, and with the 10ft roIlar on if tlus provides greater comIon. The mm\"t\"lTll'nt is of nurumal range. and $hould caUSol' NO discomfort whatsoe\\·..,. The wordJ 'rotary-Iypr' movement' are used Iltr\\\" to diffe\"-T1tiate the mcr.ement from a 'chicken on a sp,t' rotalion, whkh ,s to be avoided. 'The rotary-type mo....~ment is a rolling of the head in rotation with a functional i~ilaterallateralflex- ion. The range may. in the beginning.. need to be only 2-3° each side, Also, it is often more comfort- ably and successfully performed with thl.' patient's head and neck fully suppo.ted in nl.'utral on a soft pillow while the therapist's hands, ~\"dml\"\"th the pilluw, assist and guid~ the rolling motion of the hcadand neck

Chapter 11 Thoracic spine CHAPTER CONTENTS Thoratit\"lattralflUlOn 310 Whtnapplicablet~ts Jl0 • Introduction 301 Compres.sion~ntt~311 • SubjcctiYcUlimination 302 Tilptcst 312 'Kind'ofdisordc1' 302 Slumptest 311 AMotiattd symptoms 302 8duviour of symptoms 304 Pillpation 312 Sptaal questions 305 PaS5iveaettSSOryintetYert~llTlOYements HI51aty 305 IP~1313 • Physicaleumination 306 Diffe~nli.ltiontestbypoilpation 313 ObstrvaliOtl JOG Pa~ range ofptlysiologic<ll m~menl$ Prestntpain 306 of single ~rtcllral joints (PPlVMs) 313 Functional dtmonstration (and differentiation • Examination and trCJtmcnt techniques 318 whereappropriatc) 306 Bridappraisal 308 Mobililation 318 Tlloracicrotation J08 Thoracictraction 326 Thoracic:fltxion,ulcnsion 308 GradcVmanipulalion 329 • Caschistory 333 INTRODUCTION fQr the- manipulao>c ph\\-~iother~pistthere olre Sf'\\enol fasci.... tmg folCb \",&\"rding Itw Ihoracic spUlll' The rim Ftion:tI'''9factsillbouttMthonc!C~: is~llhl'palpationfindifl&!l'ol~easyto>dcnltl)olnd .ThtpotUltial~longinofsymptomsinand interpret.. H\"\",-\",-n,ltwpat.enllSoftensurpnsed to find lNot hIS thoracic: splf>t'is .1iOA\";md 'Inldn· on pal- a.ovncl\"\",~lopl~ patJOO..HCis\"'~lTlOll',;urpri9!dtofindthatItwSOU-Ke of hIS IKhing5houlder and ann. forexampl.., may w..11 • The eMUI joifIts ~ a loO'.Irtt of ~ath\",g-~lat~ SfI'Iptoms behisthoracicspinc1ll<'!it'rondisth<ttitisanolrNoi tnc spinctNol produres symptoms that can m,mic many • TIM' influence on the t~orKic SlIme of dyn~mic ofth\"\"painsofvi,;ceraldi;;ord~r'!I.l'~uentlytheend~'ilv­ postll,,1 stlibilizat;O!1 ~roond tllcs/lO\\llder girdle our lO prtlv\" that a patienl'sabdominal pain isorisnot v~rlcbral in origin is c~tremcly challenging. I'''ti\"nc.. • The potential for mcc~anicallrrll~hon ofthc symp~lhctk ch~ins to p'oduce symptom~ and care wIth asst'SSm\"nl is of the utmost importance, parhcularly when the symptoms Nove bolh \\·crtebral • Thc cffcctsof open-hc~rt~nd tho'acic surgcry 0!1 and >·iseeral components. It is important to take gn'~t thc IIC\\lromusculoslldctal nruc:III,n

302 MAITLAND'S VERTEBRAL MANIPULATION ca~ in determirnng the ar9 of the patient's symptoms lnspiralion frequently cause pain,\"piral1on does 50 and theu'behavlour, partKularly In telabon to theeffoo far less commonly, I.nd if • patient am;..·('B lhitt of l1$t on the ~ A pahf'l'lt with \"iscrral pain .... N'ly breathtnglS unaffected twshould~;lsledto t.lk.l' in;l Sftksl}ingdownasa~tiootoadopttogainrclicf deep breath, gradu.lly W'liffmg lI'IOn! and more mto r.lbentswhoNtn·LI1termmentdifficultywithbreath- the lungs to PI'O\\\"l.·the point. This 15 becaw;e, Ii Ius mg are be mon:' I.tkely to /\\a\"r an inle!\"\"CQStal.. COli- symp!orn§ a~ mild or inlenruttent.. his normal c<pan- tmerteb....1 or intervertebral problem than a pleu....1 .siond0e5notn'adtther~oflTlO\\·f'I'IlC'I'\\tthatpro­ dl5Of'der, ,·oLespain. There.re many manipulators of the \\ertebr.l coI- When listenmg to the palJenl's story of his pam umn who confi<kntly behC'o'e th.:!t the spine can be the problem, one must bear in mind tlv cost/Xhondr.ol origINI source of visceral di5ortl('fS. HowC'o'er, although articulations and the \"\"apulolhol'acic mO\\<l'fl1rnt as thecer\\'ic.llspinecancauseshoulderjointPAIN,ithi'ls wcll as the obviouscosto\\'erlebral and inlervl'rtool'al yet to bc proven that the thoracic spinc can causc vis- joints. ceral ['AIN. Nevl'rthek>sS, the shoulder, when dis- ordered.cancausecervkal pain, thus forming a double _ CQmpon<-'Ilt to the shoulder symptoms. VlS«'ral dis- 'KIND' OF DIS;.;O.R.~O';.;R orders acrompanied by pain ean dothe same thtng.. ..nd thef'd)y produce a situahoo whcn'!here is a mixture of vertebral and ,·iscer.l components, which adds to the Moreoftrn man not the p;lbmtdDo:s not~tc ~ diffICUlty of assessing the dlffermtiaJ lliagnos15 and SV\"'lltCllllSwmtMtll!lrxle~~~thllughthey thus prognosis. E....'Il so, the cen'ica,1 spW Cln Cllllie maywrll~gtt'ICI'Jlcdfrornttml>P\"'.1ll~ shouldcrpambutl'llltpathologJcald'\\angl',anditwouki S«'m reiOSOfl,ible toll5oSUme!hat the s;omeapplie. 10 \\'_.1 pathology - that is. it cannot a~ from Uw thorOlCicspl11l' \"ThrN furthrr factor.. to note about the thoraoc Often it is not so ob\\\"10US that the thorOlCic <pHleis innll\"ed £rum the patient's initial rompLunts. The Il'\\il\\I\\ spi~areth.:!t: 1. The upperlmld-tllora.cic spine. the ribs and their problem m.y be 'pll5Sure' headaches, or achmg at thr altachmentscaninfluencethe~apulothor;>(k,lod hack of the shoulder Of' O\\'er the pclvis. He.\"II1oCSS;md shoulder regions This can be by directly rdernng tirronessofthearmsorlcgsmayweUbcthconlyclue symptoms or by influencing the dynamic postural Under,;t<lndablythcpMlcntdocsnotassocialcthelhor- stabilizalion and reJatil'crnobilityofthcshollldcr ade spine with symptoms in these seemingly unl'l'- and shoulder girdll'. The lower thoracic spine and latro areas, unlcss then' has bcl:!n an ob,'ious lrauma 10 thetransiliorulthoracollUTlbarrq;Jon may influenct' the thoracic spine ol'a prroisposin&acti\\ily such as dison:lersofthclumlJo.pel\"\"'rt'gion in a similar way. heavyorunusual work which has strained the thoracic 2. The sympathet>o:: chams 4IT' in close proXImity to structures. Consequently, if. patient complains of neck pain or thcct~to\\\"l~rtebnljOlnl5. E'-Ml!i (l997)hassuggesk-d that arthnticCO'-lO\\-f'l\"IebR.l jointsGn cause m«tr.an- shoulder pain or law backache in the.1It-nno of 1TlO\\~ ac:aJimtationofrhesrmJ»theticchalns. Subtle ment restriction in the .-:k or 10...- back, II tS ..·orth autCJl'lODticlo}mptoms. t5p«ially in the limbs. may ex.:aminingthcthoracicsrioe. ExaminaI10n of the thoncic.spine may also be CI'UC>oII ~toe.~ofsuchmechanic:a1irn\\ilhorL inthedi~ldiagnol<olsofthepabent'schlst.~ 3. \\.lobilizationormanipul.1ltionofthelhon.cicspllll' inal or IUdney palm;, or 'indigesbon' m cues whmo and ribs may be necessilry after thor.oc or open mediCi\" imestJgatlOl'l/\\as pnn-ro unn>marbble he.rtsurgery.[nfact,.traumaIOlhl'ribca~during 8urgerymay well n.'Sult in postoperal1\\'emuscu- loskeletalp.ain.nd$tlffncss. ASSOCIATED SYMPTOMS SUBJECTIVE EXAMINATION DisordmofthethoraciC$pinearcoftenaccom~med t>y'Y\"'ptomso.iginatjngfromthe.~tonDmic Table 11.1 outlines thesubjl.\"Clivl'exammation for the tooracic spine. One Item thai IS peculiar 10 this area is nervous system the cffOO of bn'athing on the patienl's symptoms.

Tabltll.1 ~spinc.SubJtetivtcumj~tion \"Ki...rofcl'-*r uublishwlty\"'l..nl .... IIt'rn~h>rDr'iOU9h!lrt'allll<'nt I,) Pa,n.S!,ffnes.wcakness\"nSlab,loty.(\\C. Iii) Arul(on~! liiitPost-l<I'9,,:al.trauma.MlJA,l<Ippon,lraetjon.CIC HistOfy ~nlancl~~\"\"\"tor(~) ....Sfquenttofquoe~\"'JaIlouth<SlDrYcanw-...l. bl!ltolisllnk1_ofpalll,SlJ\"\"\"\"~_atMss.do:..? llmln:Ionl!lt'llodydl¥!' l.\"'eiIi1ndokpthgfsympl\\llftS'nd,\"t\".gmainilrt'J1ianclSl.iIt,ngtypeofsymptll<l>S. 2Pa~ttltm.ndal\\Jettltm. 3. Cheek f..... :i'/mpt<>mlill \\lIM. I~lodltecl areas, i.e.; (i} otJ,('~rtroral ..(as: (ii)join\",~anclbtlowtl\\(d,sonM.': li;i)otlltf'elevilnljoinu. ........~ofS'fmll_ 1. WIwn¥t thtypmt\"'lorwhtndothtyflunlDlrlrol....,{z;soa.alr/~\"''''lI!ldJo(s_brS.brcllpoII,o.w..nu-t_l ' l [ f f f t t d l e l o n l ! l t l o a l a n c l ~ ~ l a s s o o i t d d _. .tl h . . , . . a n . . . u a . b t d / p o - . o i l r / o I n t r n l , ~ 1 [Com\"\"\"symplOlMon\"'\"\"'JI ..lthrl'l'OOfn\"'9 ....theonclof~ 3. Pa<nanclst,ffnnsonRso\"'lcdurahonof, _ [fffl:tofJ<:1,v't,rs.(Brginnin90fd-Vc:om\",rt'tlw,thendofdav.) Partlr1Jlar 1 WhatproYO!<nsymptoms-whatrel>evnI.evr\"ty-,,.,.tat.ht\"/)? 2. Arr'flUSUlMllposltioMpnMII;rsymptOll\"s~ J. Nrqud-...t1'l!;pa\",lrssJ I ~;';painfrltonful;MP\"·\"\"\"'6p'raliolf>.cough\"'9or~~ ~qut50borlS 1,0000l!lt,,\"lornl~bIlatr~t,..,... .... t/lrfrrt.orJl'td~oIga,t[cordli9'lSl. 1Grnrralhrallh'nd~wc'fhtIDst.IMrdirllh~J 1.~rt'«f't)(-~bttnUlb:n1 _~tl.ilblrl!;.trbt,ngl.il~rllfo<thlslnclot/lr'condltlO/lSlostroporosisfromrXI(rlSlvrstrroidthrrapyl? ~istol)' 1. OfthiutUtt 2 Ofptrvi\"\"Saltld$,orofa..oriltrllsymptoms. JNrthr'v~worsrn''''IorimproW\\lJJ _ f'roo<tJn·...r~tancl 'tsdfrn.. ~~orhostorya.applicatIIl: IIOttlJGHlMAlHANDtNGSWlTH~ Disord\"rs of the thoracic spm\" arC' oft\"n IIcrompanied symp.~tllCtk chains m the thor..dc spin\". A I'\\'levant by a-.e;ated symptoJt15 other than those !;encr..l1y qU\"lltion to ask at this stage may be, 'If the pain accepted as bcinll of neuromWlCUloskelctal origin. bctween your shoulder blades dl$olppc.:arec!, would you be cured?'. Further spont.l.neous Informalion about TherC'l.'iQlIforlltism.aylieinthep~olo_·t\"Tlap- awxiak'dsymplom5maythenben\"\\·ealed.s,\"Dlptoms pin!; _iso:eral dIsease or mecka.nical irritation of the

304 MAITLAND'S VERTEBRAL MANIPULATION commonly associiIlt-'d WIth thor.xic di!;on:len; include ( p~~type hNda.ches, Iightheade<irles5, n':lUsea, tiredness, 'heavy' anns and legs, swelling of the eJ<\\remilies,excessive~wealing,lcmpcraturechanges oftheext~mities,dl.'f'ressionandanxiety. s.,,;,ause oftheautonomic nervous system supply to the limbs, trunk and head, toora.cic spinedi5Ol'derscan manifest asSFnptomsanyw~inthebody.llIen!fon>, whenpatM'nlsrompbmofgener<llized.~tal, .-ague h\"...-iness or paraesthesoa in the limbs. trunk or head, the thoracic spine should ~ consid~ as an areaworthyoffurthermveshgatlon.ltis'\"CT)'import· ant therefore to defonc theaft.'a of pain. Suggestions as to the di§tributiolls were made on page 1I5,but there are two other importanl matter.;.. The fj~t is that the thor'adc 5pin<o quik> fJ\"'tuently causes symptoms and SIp of irntatKKl and conduction filultt of the poe;tenor pnmary ramus. threE' po§terior prim;o.ry ram.i in the th.oracic spine of interest 10 the m;l.nipula· Ii'e physl<lttleraplSl are n,17 and TIl. \"I'heic rami are long loops, and lhereforesupply areas well away from th..irorism.Figurel'.Ta§how§lhearea§§uppliedby thescramLSecondly,lherea\",farfewerotturrencesof nerve-root compression. Nl\"verlheless, a§SCSSll1oml for sensory changes must boo kq>t in mmd, p.1mcularly jf thepahent'§p.1inisdlStribult-'dlniinarealhatincline. parallel 10 the anatomicill po!>Ition oflhe ribs Also, the first nb can ~ §mgJ«l out for lbo typical pattem of PresefltallQn whom.stJ.ff or liOr\"<'(F~utrn,lll). BEHAVIOUR OF SYMPTOMS Figure tt.ta J'osterio,p,imilryram,ofT2,T7i1ndT12i1ndtllc a~ilSlneyS\\lpply Due to the ,.~ of soov ~rmptornsoriginal1ng in the\\hor;ri( spme (e.g.limbhea''iJws/;/t'l't'dness). the patient oftm has difficultyestotblishing I pauemof oldeo\"'.Such.~tedS)'Tnptomsilrepartolana«qlt­ behanour of ~ symptoms. 1lleft' may boo 'agoe abJell\">-elofild'oe5andpaLl'dlOthepahmt,ratherthan relationshIps 10 poI',tion, poe;tureor activity, but these p.1rt of the widcrspectrum of his dison!cr. are often ,n<:OI1~.. trnt and do not nece5§Jrily occur 011 Likewise, the palient will recognize hi§ limitaliOl'll a daily basis, For v:ample, the palient may I'('poTt that inretrospccl.l-lemayadmil,~nkingaboutit,J'vr 'Sometill\\l..., my arms become 'ery HEAVY and tire noticed lhatwhom I play golf my swing ha§gradually N1>ily whom. I am working \"\"th them above my head. deterioraledoc\"CausemyupperOOckisgettingsl,ffer'. But SQfI\\eIirnes they (an start aching when I'm SIttIng Detailed questioning about the beh.n'iour 01 the down' In such Q5ol.'S there is little 'aloe in pwsulflg the s)'mptlVTlS in the thoracic spine may be a mNJ\\S 01 symptorns behaviour to the nth dt>gree.as the patienl lwlpinglod;f~ti.il~thr5OUrreofthes)mptoms.For ju§t does not know whal consISlently aggril\\'ates and exampIP. iI pabent may complain About expenenorc l\"aseshJ5symptoms.M~vaJucmaybe8\"inedbynot­ pam in the scapula wlulst l'e\\ersing his car and twistIrf ing,indetail,lhebehaviourQflcs.sobviousbulconsist· his head and bodylOdO!iO.1hispainmaybecer\\,i(;lIi'I l\"nt 'comparable' §Igns and §ymploms l\"manaling from origin (Cloward, 1959), and Sf\"\"dlk quc§tiorung an thethoraCicspine.Thebeha\"iouTof'stiffness' between help to de~nninethis. Ask whether the patienllcels the theshoulderbladesmaybea rnoreoonsiSlerll means of scapula pain when tul'TliJ\\g his body or his neck it.sell, ('>'aluahng IINtment l\"I1ects. The patient may admit, Clt'n-an iK1h\"ly that rqmxlueesthes)mptoms hMbmI 'Ah yes. my uppol\"l\"baickal,,-a)\"S fftk stiff in the morn- estabtished,thepotenbl15OW't:t'oflheowsYlnplollll ing. but I thought lhat Ihis \"';0\" beca~ I'm getting (anbecLuified,,'ith.spec1fical1ydeta1ledqUl!5bOllf,.

., Figu\"11.1b Dist,ibutionpatttrnsof symplomsoffi\"tnbsyndromc SPECIAL QUESTIONS sroliosis,jul\"enile discasc such as Schcuermann·s dis- ease and innammalory arthritis such as ankylosing S~cialqu~tionsn ••dtobl'~r<'dtho,ou9hly; spondylitis. The manipulative physiotherapist must pot.nlialvj=ral.respir.llO'Yandcardiacdi~ase look mOre deeply at the problem when thegi'\"en d,ag- should b<: considcred,and spinal tumou\" Otturmor. nosis is 'growing pains' in adolescence. Communication ,.adilyin the thoracic s.\"nc. Fu,thcrmo,., is especially important with children and adolCSCi'nts. d~lopm'Malabnormalitit:sandjUY.njlcdiseasc The manipulatil'ephysiotherapist must gain the lrust should not bl' OVI:r\\ooked when ctlild,cn and of thechild,thus giving lhemtheoonfidence loexpress ad(ll~n1Sp,=ntwllhlho,acicpain lhemselves.Thechild or adolescent often instinctiveJy 'knows· what the problem is,and therapists n,->ed to be skilled at gaining the appropriate information (5« ChapterJ,p.28j In lhe presence of Ihoracic symploms. the manipula- HISTORY liveph~jother\"pi5tshouldalwaysbeawaTcofnon­ Involvement of the thoradc spine and ribcage maybe cstablishedifthereisadearincident,traumaorpre- neuromusculoskeldal sources. Medkal history and disposing activity. Examples of lhis mode of onset relevant mcdical symptoms should be detailed. In lhis indudea direct blow to the ribcage or thoracic spine way. the manipulative physiotherapist is constantly during a fall,rib fractures, a 'whiplash'injury,or fol- lowing th\"racic surgery. qUe5tioningand slretching Ihc boundaries of her own diagnosticabilitiL'S. Potential visceral,respiratoryor InsidiousO!lSet of symptoms may be related toa cardiacinvolvcmL'lltshouldalwaysbeconsidered,as changeofjob,ortounusualorhe.wywork.Forexample, should the pmp\"nsity for spinal turnoursand meta- stai\\<$tooccurin the thoracic spine. The thoracic spine may be a site for developmental abnormalities such as

306 MAITLAND'S VERTEBRAL MANIPULATION th.. pati..nt m~y My 'I'q,'startl'd \"\"orking more on my FUNCTIONAL DEMONSTRATION (AND compull'T recently',or 'I'\\'c started aerobics ~nd I find DIFFERENTIATION WHERE APPROPRIA~ some of tho! c\"l'1'Ciscs d,fficult bc<::ausc I am not mobil.. \"l\\OUgh', Although thep<itimt may not be ablc to perform .. spe- cific functional demonstr..llon reproducmg his symp- Dimrdttsw,ththorac:i<:S\\l'~t'Omponrntsoftfndo toms, there may be a few caSo'S when .. functioonll nol,~,ltthfratfth'twouldbff\"IXd<:d.ln demonstration or an 'injuring movement' ....i11 be use- sudleaws,itisl;kdythnm'<nUlnfdsympathwe ful to the marupulali\"\"physJothcr.. pist. OneeJ(;lmple is the patll\"flt ....ho is ablc to l't--prodln ourtlowisinflumt'ngthf\",b,l'ty'ndprog~of his chest pain by taking a da1' bf'toath as menhoncd thfdisonkr earlier. In otherca!il'5 it may be posslbl;> IOdifferl!'nllilte the,·er1ror-a1 .....-elresponsibll'forthepillient'ssymp- toms using thl' functional dl'lnOr1Stratl()r\\. Fo.-e....un- pie, when a pallent h.:tssymptOfr\" III the urper thorn In some ~ thoracic: symptoms lNy vary from diI}' area posteriorly, il is often dIfficult 10 determllle to day, suggcstmg an clemenl 01 dISOrder ,ftSubWty. whether the sympton>!; are ..rising from the cen-ico- Exp«tedn\"C'O\\ft')'m.aynotoccur'ttheflllll'il~. thoracic: jWlC'bon (01' ....·en O/f, 01' Cf,/7) Of the upper Tbe poohenl thinks IUs symplom5 '\"' .-:>I,-ins. but thoracic inten-ertebral joints. Tbe rroct>dure to dilkr- thm thl'y come b;td. lIS strong as~...,. for no apparent n-ason.ln o;uch cases a strong llwolvemertt of theaut~ entiall'bet\",eentkemifpainis..\"rodLOCedb)-rotiItion isasfoUow$: nomIC nernlUS systl\"lTl 15 ....·Klmt. 'Desenslhza\\ion' 1. \\\\~th the palil'nl5l'ated and facing str.t1ghl ahNd towardsthephysiottwr;apist.hl'isas.ki>d whettlfr of ~I\\'\" Symp'thetlC outflow by mobl1wng the he !\\as any symptoms or no! (F'g..rr\" II.I((A)) thor.JcicspiN\", ribs and related I'IeUnl tiSiS\\H:\" isaften roquircdbeforethcdisordl:'l'sub,hzesandthel1Jl(.'l}\\·- ery~(\\'nghl,I995) 2. As5uming that his spnptoms can only be prtl\\~ ..t theend oi therangeol rotiIbon,.hl'1S ask>d 10 tum hisneadfullytotherightwithlUslnlnkShllf~ PHYSICAL EXAMINATION straightahe.;td.lfnefeelsrKlcha~lf1s)\"nptolm. theph)-s>otherapistapplieO\\'er'pn'5Mlrelothe~ TQNe 11.1 lisb tho! elYmination te<-ts that are U5ed, ,ical rotiIhoro by pl't'SIimg hi>r nghl f(Jl'(>;lrm behind his right shoulder and hi>r nght hand beIund tIw although not e-ery listed mo'\"lT1erIt d roq111red for ......erypahent. backolhisneadontherightsi<k-,whilealso~ her left hand agaUlSt his left zygomalJe arch. In this positionshe is able lOapplyO....'1'\"pTCSl;uretothemr· OBSERVATION viGIl area withoulll1O\\'ement 01 IUs shoulders. This ll'stisnottestingcen·ic..1rotation tothee\"c1usoonof Ob!iervation of the thoradcspme isalten unremark- anythor<lCierotaOOn.astheupperlhor..ac~ able. POSlU.flII;tdaptaIlOn5 such 35 rounded shouldl'rS. does also rotate somewhat. f\\....·erthe~, ,tlS;a II5l!'\" rscudowingLnK of the scapulilot', poling chin, flat tho- fulattemptatdil'ferentiatulg(figu\",'l_k(B)). ralC, kyphosis and sroliOlsis of the tho,acic spi..... may 3. One.. the pain response with oH'r-pressure to ctT- bel'\\'ldmt.llowe.cr,thcsc~r\"ationsneedtobe \"kal rotation isasscsscd. thepiltient is ilSkt.'<1 to rclatcdtothepahmt'sslgrusandsymptomstobeof rotatehisthoralCtotheright ....'thoulth.;:rebems sIgnificance. any rolation of the head to the right The ph)'~ thcrilpist applies o'·cr·pressurt' 10 the thor;odc PRESENT PAIN rotation by applying furth.::r rotary p\"\"\",ure throughhisshoulders(FigrmTlI£1C). Bcfore starling c\"amination of active functional move- 4 With the pain l't-'5POnsc nok'd when o\"er-p~ure mcnts of the thoracic spine the patient should always is applied to the thoracic rotation, the patienti! be asked whether he has any symptoms at pl't-'5l....t. thcnaskl'd to turn his head (ully toth.:: rightar>ll and if so what and where they are. It is important that an}'furtherchang.. insymptomsisnoll>d,1fthel'l'\" ti\\{> assessment of Ihe pain {symptoms} l't->sponsi\\'e to a change of symptoms when the cervical spine is mov..menlst\"rtshl'll.' roIated to Ihe right, then mo\\'cment o(the Cl',vkil

ThorlCicspi...., 301 Tablcll.2 TlIcn6c:5f)I~~JCQmll\\OItion .,.,.,.- I'oslU\"'.WJ1I~1O-' 8totfapprai$JI M_nl> M'_\",~ntslopoi\"Ot_IO'i\"\"1 f,f;lfltl.nd(!llnflndE.Rot\"l1)lndl!llnF.ndE.pain.nd~hl\"iou,.rl•.nr9nunwln9 Il\"ouoct,,,,,\"'fo.mity, l«ali\"ng. _r-prtul,u·t.inle<Wl'ttbQllI'I(IVfcmtnt{ftpt.ttd\"\"\"\",mtntlndi\"\"ftl\\.tdspttd) When lIlIlli<:able.l.illing Pkd<_nllo should be ttslH fofuppt. lhofa<x pain. Cenic;al \",laban mayneH to be \"'pmmpooN lIf'tQ Il\\OrXo(\"roaOOfl fof~l\"'Ig\"ppnl/lofKic;o.n~ Susta'-'E.lftoorardl,*\",Ilol\"~Pil,nlwl>(n-=-yUI~\"\"\"~pain~ Tapll5t!whttlf.E.lf ...... llot\"lttl9lft...,.1R'd. ~anoldliWKt>on(whttlf.E.lf&lIot\"&tI9aft\"\"9\"lNl:~ Coonbtf...:l_tteb. Act~ptnpl>ttaijotfltttsts.. fintfib. InttmlStlo~(05t_l'ttblaL Pl'MtlT.-T\"F.E.lf.FIot\" CanlllslumpsittinglltllS. Sop•...., hssMntttf; ...nge.pa;n!badc.nd]Of.ek.ftdl. SU(I~SjlOfIl!yl;tJsj, Fotstnb. Ntu~ ....m'''ban~~ ................. pmpIItr3l,....tltm. ....\"\"\"\"\",CrT.f.F.lf.Aot'.T••T,,Rol\" 'Palpation' ~ \",intandrobs). Ttmptf)tuft.nclIWtl\"\"9 Soft-tiswc palpatl4ln (musclt Et inlt'fSPonOllI space). PooitiQnofvtl't!'bt'lt.nd.ibstspft'i.ltyhl.ib. rPaSsivl'KttSlOf'ilnttMfltbnlmovcmtnt.COItOvt,ttbral.nclinltf«lSI.lmOYtmtnt(!-··- Comb;M<jr~ttlotS.... tllpt.ysiologi<:II_!fttnlposltlons. ISOMttricltl'\"fOl\"'~ Mtpain. ..... \"'\"E.uooIi.._ofotha rtlNaont factors OItd _ _ts·\",,~of~ttsUDt-..,s..1aIood1tslSl llIGHUGHTIWOfltAHlRNOI'lGSWIDl.\\STEl\\ISll;5.. INST1WCT1OHSTOPAnEHT ~l W.mingofposl4blttumtliitoon. lui llc<jl>tSltoftportclcla;'s. (IU) In\"nKtion.;n'bad;tart·ifft<l\"\".d

308 MAITLANO'SVERTE8RAl MANIPULATION 10 be involved more. detaIled cum\"\",tion of this al'l'il can corrunerore. n.c «'I'\"I'ic:al sp,ne should also be ...-_ - . _'~--\"H1'-, tested quickly so lhat itcanbee~ducledOr cleared of ;n,·ol'-ement. --~--\"H1'-, HlldUnldYrb'\" THORACIC ROTATION .....\"\"'* ...... Thoracic rotation can be a5IiII'S5ONI Ul DWW'difirren! positions. but the first pc5ltion choN.n shOOkt boo tNl mdicak'db)'lhepatM:'nIUl~tothe'luetilJn.'l th.en! any turning or twlSbng mo....~ment which)'ON find plU\\'okeiyoursymp«xnsr, It m.l)' be lhathe\",,;ptt>ds with demonstrating IUs golf <wing as the exampko. Under~~itisnecellS.Jrytodelenmneilt whatpo;ntinlheffiCf\\'ftlll'ntlhepainisplU\\\"Oked.sothat thepassi\"elllO\\'mll'T'Itcanboo~rr>or1'spectfic;oUy, RotationCanalsobeas&eSSo.'dinlhestandingpo6ibon, with or without the hdp of outslretched arms or folded ....~--..H1.-, ThtnrrtU1eclIO'9It arms. Such rotation IS mono likely 10 detect mO,'emL'Tlt \\IIilt1read!ut;h.ITlId of the lower thoracicspint With the patIent in thcsithng posilion and with his armsfolded,askhim to'hug'himself;rot\"tioncanbe leste<! in t!>e erect orextendl'Cl position of the thoracir spllU',and thiscanbeoompared with the same rotation but performed in the nexed posilion. Over·pressuno 10 Ih.. movement can be performed by continuing the rotiltionviapressunoagilinstlhe!iCilpulaandpectonl areas(figwlY'l,z\"j Upper thoracic rotation can be performed in the§ll· ling posihon, with the p;otlent c1aspmg his hands f\"\"\"'1l.1c lAJl'IlJctu.;tting,ww ..... ~.181·(E} bel-lind his oroput and the phys>otheraptst ~tabihzin& 'h,oousrotalJOrlpololtJom his )o....er thoracic atN. In this po5JOon, if the pabenl lu..... tusheMiandshoolderstotheleft.I... lthhishNd sp.nemUSlbein~·oI,·l\"dinlhepalient·ssympt0m5 keptinastilticposihoninrelabontohis~the (Fig>IrtJI.Jc(OI)· main JTlO1,'ement will OCCUr in the upper and midd~ thoracic spine. 5, \\\\'hiwintheJlOSltionde5cribedabo\\'e.thephysio- thenplSt cl\\angl5 Mapplicittion of O\\-'er-p_l'l' _ fromtheupperthoracicMl'ato~icalrotationto THORACIC FLEXION, EXTENS.';O;,;;N the nght whaleat the same llmeallowing the pabl'nt totdea5\"lhe upper thoracic rotation slightly, and Upper thoracic fMoxion and extension ill'l'included in thechangeinsympto~isasse55l'd.With this \"'\" _~bOn of neck Illl)\\·emenb. and \\cn...er thor- dwnge of O\\-'i\"r-Pl'l'SSUl'l'. the l\"Il1phaslSof the rota- acicf\\eJcionandextcnll,on.a~includedinthee>WlUtl­ hon 1~\",1Nsed from the upper tho';IoCic:al'l'il and ation of lumbar spine lTIO\\\"roloI\"Tlts. Midthoraci<: f\\e:rion incK'a5ol'd at thecen-;cal area (snFigwlY 11.JqEjj andextmsion ilreexamined by asking the patio.'nl 10 ciasp his hands behind hlSheild whilst in thesittmg BRIEF AP;,;PR;;;A;,;;ISA;,;;l,-_ _ position. and point his elbows forwards 50 that they Come together. When the functional demonstration provides valuable Flexion tnfurmlllion aboutlhe~u~oflhe pati..\"'t'~ ~ymplo\"'S, themmupulativephysiotherapistshouldbricnyappraise Having adopted the above position, the patiet1t is Iheninstrucledtocuflhisclbowsintuhisgrointopro- thl'areasinvolvt'Clrogivecluestofurtht'rI'Kamination. duce thoracic flexion. Tlletrn:,rapist nolcsthcrangeoi from tho.' e~ampl\" abol'e, if the thoracic spine appeal'll

Tho.:tciespine J09 bttnsion m(n'ernmt, symptom re5poMt' and quality of man... meotlfnecessary,o\"er\"-ph!§Sure-canbl>addoov,alhe ~ same starting position as for flexion is ..dopted. suprada\"icularand5uprascapularareu.~u.e,.apist with one el«X'phon: ~ patll'nt places one or both feet stand~ In fror1t of the pallent and p1.>celi her hands O'o'er on a chair in order 10 flex the lumbar spme. The patient the top of his shoo.,lders wHh her fingers JlOStl'riorly is instructed to direct hiS elbows upwards. Thether- and her thumbs anteriorly. (h'er-pre5Sure is applil-d in apist notes the range, symptom n.'Sponse and quality the din.'CIion of die continuing arc of flexion. Ovl'T- ofmm·emenl.lffl<'Ce$Solry,over-pn.'$Sureeanbcadded prt.\"SSuredirectcdcranially.t>oril.Ontallyorcaudally by the therapist, who stands by thesidl' of the patient canputemphllsisontheupper,middleandlowerp.1rts \"nd places an arm under both his \"\",iliac and acl'OSl> of Ihethor-.lClc spine respectively (figurt Jl.Zb) h\"sternum_Shoe plares the other hand on histhorack

310 MAITlANO'S VERTEBRAL MANIPULATION spm..to localize thi:'O\\\"cr-pl\"i:'5Sure. at the same time sid~~fJexing her tn,mk in the direction of the thoracic extension (I'igure 1l.2c) THORACIC LATERAL FLEXION Lan,ral fJexionoflhcuppcrand lower thor<lck spine is incudedintheexaminalionofth.. ~rvicalandlumbar spines rcspectivt\"ly. To locali7-\" lateral flexion to the mid-thoracic spine in sittinl; the patient is asked to place his hands behind his head and diK'Ct his t\"lbows away from his body. Hi:' is thi:'n instrucled to curl his elbows inlohissid\",l'},., range, symptom response and quality of movement is nOled. Ch'\"r-pressurecan be appiied locally at l.\"ilCh intl!rv\"rtror<ll I\"\"'d by the \"\"'nipu- lativephysioth\"rapistslandingbytherightsideofthe patienl. Taking right laleral flexion as an cxample, she pbces her righl axilla On his right shoulder and holds undl.\"r his lefl axilla with her right hand, Her ldl thumb is then placed against the sidi:' of l.\"ach spinous process of the Ihorack spine in turn. and she bends hl.\"r \\meestoirocreaSi:'thethoraciclaleralflcxion(fig\"\",ll.14j. WHEN APPLICABLE TESTS Figur~ 11.4 Adding lat~\",1 fi •• ion to tn~ Idt to tn~ IOUltfO/l toth.l.ft Combined movemenl tests 3. The physiotherapist then laterally flexes his trunk If,at thisstageofi:'xamination. the palknl's symptoms totheright.againusinghi:'rrightaxillatostabili1:e have notoc,,-'ll n:produced or comparable signs have andcontmlthelat\"ralnexion.whilenotingchanges notlx>enfound,whenapplkabl.. testssuchasC{)mbin~-d in symptoms. Once more, it is necessary 10 rctain movements can be used. The sequ\"nce of combined movemenlS should reflect Ihe patient's funclional limitations The following example is bul onl' of many sequences of combined movements that can be used inlheexam- ination of the thoracic spine. In theexampl\".thoracic rotation to the left is the starting position, to which is added in Ium lateral flexion 10 the lefl. laleral flexion 10 the right, exlL-nsion and flexion 1. With the patienl sitling he is asked to tum fuHylo thclefl,and whe<1lhephysiolherapisthasadded over·presliUrt' to Ihis mOVi:'m~onl his symptoms arc as..es..ed(Fig\"'·l'lJ.3). 2. Whileovi:'r-pr.-ureismainlainedforrotalionto Ihe left, the ph}'siotherapist lalerally flex~'S the patient's trunk to thi:' lefl while at the same time assessing changes in symptoms. It is important, du,ingthemo\\'ementoflatcral fJuion to the left. that the same strength ofpressurt' to the mtation is mainlain~-d. This is not as easy as il may SLocm; with her right axilla stabilizing his right sholiider she must follow his lateral flexion (Figurl' 11.4)

Thoracic sp;n~ 311 the same strength to the rotary ov\"\"\"pressure (Figu .... n.S) 4. To the sustainro over-pressure of the thor.lcic rota- tiontotheleft,thephysioth<;>rapistthcnaddsflexing at the appropriate level of the thoradc sp;ne and as.~thechangt':Sinsrmptoms(Fig.u... T1.6) 5. Tothesuslailledover-preso;uretolhcthoracicrota- tiOfltotheldt,thephysiothcraplStthenaddsthoracic extension at the appropnate level while notmS change!iinsymptoms.Toproducetheextension,thc phy,ioth..rapist uses her right forearm aSa fukrum whilcusinghcrtwohandstoextendthepaticnt\"s thoracic spine (Figurl\" 11.7) COMPRESSION MOVEMENT TESTS All of the physi<llogical movements can be perfonned Figu\", 11.1 Addjnge.t~nsion tOl~rot.tiontothel.ft Ix>th with and with<lut oompr.,,;sion. The patient sits with his arms f<llded. and the physiotherapist stands while the compression is maintained. II is uncommon br-hind him and stabiHzes his thorax with her body, in the lhQradcspine that the addilion of compression makes any difference lo the p.1in l'<'Sponse found whlm applying tm, compression by pUlling her forearms the same movement <lr mm\"em\"nls were perfonned around in front of his should,,1\"S and grasping <l\\'cr his without compression suprMpinou5fossaareawithherhands.Shetht'fluses ht'T hands in conjunction with her upper stemum (at approximatt'lyhisTIlevel)toincreaseherbodyweight gradually, thus pushing through his thoracic spin.. l<lwards the floor. Localized oscillatory mon~menls<lfflexion,exlen· sion, lateral flexion and rotation can thl.'nbcpt'rformed

312 MAITLANO'S VERTEBRAL MANIPULATION TAP TEST The presence of any localized a\",as of sweating is determined first. Tcmpemture chang\"\" are assessed by Ifacti\\'e movements are fuH and symptom free, Ihe wiping th\"baclcsof thi.'fingersorhandsover the thor- patient sits on th<! plinth with th<!spine fJ.,x<!d and each,pinousprocessofthe thoracic spin<!and th\" rib aciearea,particularlyintheareabetwL~ntheangIL'5(}f angl\" are tapp<->d with a \",flex hammer. One spinous process or rib angle may e.xhibite.xquisite tend\"mess thc ribs or the Idt and right sides, It is not uncommcm ov<!rand above any of theoth<!rs. In some cases. this to find 9cm areassituat<!d centrally which do TIOt indi- resonanceeffect may be a way of d<!l<'d:ing boned<!min· cat\" inflammation of eilher mechanical or pathological eralization, stress fractu\", or bone tumour, disorders. SLUMP TEST Soh-tissue changes This test should form part of th\" L'Xamination of the ThickeningoflheinterspinoustissueandthctiS1iuesin thoracic spine. However, it i,essential to remember the intcrlaminar trough arca isextrcmelyinformative, that this test causes pain at approximately theTS/T9 The thickening can be totally lateral, and can be areil inat I<!ast 90 percent of all subjccts. If the patient eXf\"'CtL'<l to be found on the Silme side and althe does experience pain at T8 or T9and it is for this pain appropriateintcn·ertebraIIL-velasunilateralpain.T1Je thiltheset'kst\",atment,and if the pain is increased thickening can extend ovcr morc than one le\\'el on dUring the slump tt.,;t,th\"n th\"onlyway in which a thi.'same sidc, or it can bc on the Idt sid<!of,say,TS/6 decision implicating th<! canal structures as a rompon- and the right sideofT4/Sand T6/7.1he texture of the entofthecauscofhisdisordercanbemadeistobalanre thickenings can clearly sort th\"m into new and old it against the physioth\"rapist'sknowl<!dg\"and expcri- ch':lrIges. Thil sorting is far more difficult in the low enceof what is within theronsidered normsforthis test. lumbara....a. The longsittingslumpcan be used asan adaptation Quite often thoracic physiological. combined of the slump test to emphasize the testing of the mobil- mO\"l'ments and mov<:mcnts under compression are ity of the canal struclur<'S of th\" thoracic spine. In this pain free. However, palpation anomalies can always position and with the addition of trunk side flexion to brfound the left, for example, the ribs can beexamin<!d and treat<!dontheright.Thisisameansofinfluencingthe Ata firstconsultation,ifapalient has upper abdomirul sympathetic chains via the slump position and move· pain of skeletal origin itisrommon for all physio- ment of the costovertebral joints logical mOVCmLTlts to be pain free even when combined movements and movements und\"r romp,,-'SSion are Other neurodynamic tesl~ such as the upper limb tested. How\"vcr, palpation anomalies can always be neural tests (ULl\\'Ts), the straight 1,,& raise (SLR), found.providL'd theexaminiltion ispem:ptively pel'\" prone knee bend (PKB) and passive neck llexioll(I'NF) form<!d and \",Iated to the history of progression of the may also be ronsidered as part of thc thoracic spine disorder.ThisreliabilitymakL.,;palpationaskillt1lat examination. should bc learned by all general surgL'Ons. PALPATION Bony changes and position tests The pali\"nt liC5 prone with his arms by his side or over The two most common findings when examining the the<!dgeof the rouch to widen th\"interscapularspace position of the spinous processe5 in relation to each other in the thoracic spine a.... Areas of sweating and temperature changes 1. AspinousprocC5sthatfcelstobemorcdceplyset It is not uncommon to find areas of increased than its abnormally prominent adjacent spinous tempi'ratur~ s<tuated centrally in the thoracicspinc Pl\"CJCeSS above. This is the most informati\"e Thoc areas do not indicate information of either finding. indicating either that il is thesoun:eofa mKhanical Of pathological origin patienfssymptomsorthat itisa disadvantaged intervcrtebralarca which has thc potential to cause symptoms if pla«.>d under \"xc~'SSivc stress 2. Onespinousprocessdisplacedtoonesidein rclalion to the spinous pTOC\\.':SS above and below.

Tho.acicspine 313 This only indicates rotation of the wrteb.a when it is direclion, and nor should provoking the pain be the confirmed by being able to lell that one transverse aim, as will now be explained process is more postcriorly posilioned inromparison 1lleusefulncsl;ofa'D-plus-I'responsewasdesoibed withthevertebra'stra\"\"ve~p~ontheopposite in Chapter 6, and use of it should be made in chronic side. That is to say. if the spinous process ofT6 is dis+ disorders when other test movements are uninforma- placoxl to the right, this displacement only indicates tive. Therefore, when a patient with a chronic skeletaJ rnlation of the vertebra if the tranS\\'erse process of T6 disorder causing unilateral referred pain is eKamined on the left is more prominent (or posteriorly pos. althefirstronsultation,partofthepalpationexamin- itionoxl) than the transverse process of T6 on thc right ation lhat should beemphasil:ed is the use of transverse This is rarely thccase, and it ill sorprising to find how pressure from the side of the referred pain against the often a patient's symptoms, when .elated to this spinous process of three or four adjacent v\"rtebraeat malalignment, are found to be on th., same side as that the appropriate lev,,!. The aim ill to endeavour 10 pro- to which the spinous process is deviated vokethcreferT'-od pain.lfthisillnota<;hiev~>d at the first When one spinous process is deeply set and the consultation, its repetition may sensitize the joint at .djacent spinous process above is prominent, pfC55ure fault and thus make the same transve:rsc pTC$ure pro- o\"erthe prominent spinous process usually provokes vokethe referred pain at the s«ond consultalion-Le. • superficial sharp pain while pressore over thesorc on 'D-plus+I'{D+ I). deeply-setspinouspro<:ess,iffirmandsustained,pro- doC'CSa \"cry dreply felt pain. Tht'St\" findings indicate - - - - - -DIFFERENTIATION TEST BY PALPATION that thejointbetv.''''-'Tl them is abnomml and is thepos- sible site of origin of symptoms When trans\"erse pre5surcon.\"\"y, T7 to the right pru- vokes the patienfspain, it maybe necessary todete.- PASSIVE ACCESSORY INTERVERTEBRAL min.. whether the symptoms are arising from the 17/8 MOVEMENTS (PAIVMs) intervertebral joint Or the 17/6 intern-rtebral joint. The techniqoe fordoing this hasbecn dC'SCribcd fully on pagel62. The two main mO'il:'ments to bl:' t~ted in the thoracic PASSIVE RANGE OF PHYSIOLOGICAL ~inca.~crnt.al postc'Q.-ante.iorand transver!.C MOVEMENTS OF SINGLE VERTEBRAL JOINTS (PPIVMs) v~rtebral pr~ssu.~ Tl\\c two main movcments to be teslLod in the thoracic Ashasl>c<-'Tlstatedbcfore,theoscillatoryteslingmove- spincarcpostero-anteriorcentralvertebralpTC5surcand ment is performed mo.eslowly(asagene.al.ule) than transvel'5Cverlebralpressure,andlhesearedescribed it is when uscdasa treatmenl lechnique. This is only onpages31D-311 and 320,Ashasbecn stalL-d befon', so h<-'Caosc sometimes the through-range quality of these movements can be va.ied both in the point of movement is less easily appreciated with quicker contact that produces them and in the indination of movements. The end-Qf-range feel can sometimes be mm·emenl. The other movement that is impo.tant for determined by applying an o\"e\"'pressure romponent examination porposesby palpation ispostero-anterio. to IheteslingQI;Ciliatorymm·emenl. unilateral vertebral presSUJl', which is described on pages 321-323, It is also essenlial that costovertebral The movements aJl' described below for the and intercostal mO\\'emcntsbeassesscd for their range sel~'Cted intcrvertebrallevds. and pain TC5ponse. Theseanl describcd respcctivelyon pages 323 and 32J-324. C7-T4(fle)(ion) In earlier editions of this book. in the chapter regard· Stortingposition ing selection of techniques, the suggestion was made that thcdirection of transversepressuTC'i should be With the palient sitting, the physiotherapist stands in pe.fo.med initially towards the side of pain. This fn:.mt of him and slightly to the patient's right. She rests statement is based 00 the f.1Ct that the technique opens her left hand over his right shoulder with the middle theintervertebralspaceonthesideofpain.thusavoid- finger positioned betwccn two spinous processes, ing provoking pain, This is not to say that the tech- while the index finger palpatcs the upper margin of nique should never be performoxl in the opposite the spinous process of the upper vertebra and the ring finger palpates the lowe. margin of the 10werspinoU5

314 MAITLAND'S VERTEBRAL MANIPULATION away from and Iowal'dsearn otht-rdunng thebacl< and forth mo\\'l'!I'II'fltsofthO' head and neck. C7-T4 -(tluionltx\",'\",\"=';='\":!.-) ---:c--...,.- An aI\\Jemat\" e method for testing fIcloon. ... lUch is more CO'W('Oll'fIt if rotiJtion.u>d labi\"ral f\\e).100 are also tobet6ted,ispe'l'fol'lTtt'd .....ththepatll'ntlVU1g00 his side. Sfortingpos;tion The patient lies comfortably on his right sidc......ar the forward edge of the couch, with his head rl~tlngon pillows. The physiotherapist stands in frollt of the patief1l,cradling h,s head io ht-.lefl arm with he-rfin· gerscm·c.ing thc l'ffl'terlOrsurfaceofhis1ll...:k,lwrht. llefinger~\"\"hif1gdowntothevertdl.alle\\el being examined SOl-' ~tabihzes his head bet\\.'C\\.'O he. \\efI fumormand lhtfm1toiher leftshoulder I\\e>.tshe INns acTllS6thepatlel1tpJaanght-rright foreann along his b;ock to stablJue his thor;uc, and palpates the u~ §urf~oithetntersp..--.sspacew,ththep.doiher indt''\\ or middle fmger facing up....ards (.;gUIf 1'.!J) pnx'l\"'i6_ To produce a finn )·et comfortable grasp with M(!thod thelefthand,thO'~oflhcthumbisplacedintht\" supraclavicular f056a. The right hand and forearm are Withherleftarm.thephysiotherap'~tfle><esand(';\\.1erld:I placedo\\'erthetopofthepatlent'sheadsothatthO'ylie thepatjcnt·slo....erl1o.'Ckasmuchas~ible.Thespllle in the sagittal pia...... Thc fingeNand thumbgra!lp the above C6 and the head a~ not fle-xed or extendt'd. occiput .....arthenuchal Iincs.and the wrist is newd to becao~ mOI'emCllt in this a~a makt:s n,o\\'cn,ent in the permit firm pressurcon the front ofth<-helld by the test area lesscontrolle<l and less isolakd.The p<llient's (o«!arm (Figul'l' Tl.8). head and n,~k arc \",o\\'cd only until the particolar joif1ttL>stLodhllsoometothehrrutofltsrange Ml!thod C7-T4 (lateral tluion) MO\\'ement of the patuml's head is controlled by the physKJtherapist's right hand and forearm. All scalp IocJ!!eness mu~t be takm up by the gr;osp between the The starting POSItIOn is i<Mlli.cal ....,th that describtd fingen and fon'arm to pemut complete control oithe forflel<>on/r<tmsIoo. ThepurposeoithtsmethOO islD p;>tieot's head ...d male h,m feel that suppon oi his achie',e lalffal fIaioo at the partICUlar jamt bemg hNdcanbrleftlotheph~apist te>ted, and then-.fore the head does not l.aterallll\\e. As the amount oi mo\\\"I'ITlI'I\\t that can be felt at thIS butl7ltherisd~upwnds.u.k'.r.lRexionis~ le\\-el b much Ie56tlwnelse»'here io the \\·ertebral roI- duced by the ph)\"$OOlher.oJ'iSt lifbng the patient's hNd UDUl, twocomp\\emeolaryactionsare\"\"-\"C\\'SSolT)toptO- w,th a huggtng Slip oi his head, the ma,onty oi the bft duel' the maximum intenertebral mO'cement, First, bcingachie-·edbytheuln.arborderofherlefthand theOKillatioo of the kcad and oeck needstobe through against the underside of his cenicothorxM: juncbon a ranseat least of 30\" performed near the lim't of for· (Figul'l' 11.10). To tl'St Lateral n(\"J(ion in the opposite ward nexion. Secondly. bt,>(au~ the le\"er producing dirc\"'ion, the patlCllt must lie on hi~otht'l' SIde. The mo\\'ementislong,pl\"<'5Surebytheth~palpatingfin­ palpating fingcr (..-..els for movement betw\"....n the two gerso\"crthespi..... willhclptolocalizemovementlls adjacentspif1ousprocl'SSCS. Thl'lIpperprtKl'SSmoves the head is movcd back through a range of 30\"'. first, and when the lower procL'SS starts to mO\\'ethi5 Thc inte'....ertebral ffiO\\L'llU'nt is felt by the ring, will signal thec~tcnt oftne lateral nt-xion at this par- middleandindexfmgersasthl'spinous~mo\\'e ba.llarinl\"'.... t'rtl-b.alk'\\el

..Thor\"cicspinc 315 Figurcll.9 Int<r.e'teb'almcrvcmenl O-T4(f1e>;io../extcn.ion) Figu,cll.lO Inter.ertcb,,,ltnll,,,,mc\"l C7-T4(1atc,,,lfte>;ion) C7-T4(rotation) which is faring upwards against the und,;,rsid,;,of the Method inlt!rspinouS5pace. With tne patienl\"S head cradled between thl.'physio- The starting position is again the same as for fl,;,xionl ..~tl'OSion. Toproduce thc rotation properly, it is n(.'CC';o therapist's left forearm and shouldcr, and his lower saTy to ooncentrate on moving the joint being exam- nt-ek firmly gripped in thc ulnar border of her hand inctlwithoutcausinganylillingorflexingofthehead b,;,tw~,,-... tlu! little fingcr and the hypothenar eminence. and n~'Ck. Movement of the upper spinous process in she rotat~'S his lower cervical spine towards her. This i, relation to its distal neighbour is palpatl'C! throogh the achieved by elevating her5Capula to its highest point pad of the physiotherapist's ind,;,x or middle finger, whi],;, maintaining a stable thorax (FiguI\"<'lI.lI). As thl' mov,;,ment is difficult to achic,\"e accurately. more

316 MAITLANO'S VERTEBRAL MANIPULATION Figu,\", 11.11 Inl(Mrttbr~llII(lY(m(llt C7-T4lrotillonl careisneed«llh.anwitht.... othcrrTlO\\·emmlstestro tIMo trunJ..rxlenstoo w,th the hlloe:I and uln.ar border of in!hisare.J,. \"-right hand. In dou1g ltusshe mU5t beC3R'fu1 kt kftpthepad ofhernuddloe fins\"lnaconstantpo6lbOn T4-11 (flexion/extension) betv>·ftn ~~tspmouspl'llaS5eS. MO\"emmiof the patient's trunk is from the neutral po6lbon into Stortlng posmon extension.lIisimportanttori\"l'tlenlberthat,t;';mo\"(- Tlw pabent SIts with his ....nds clasped bmind his nec:k ment at only 0l'Il' jolI\\t that IS bems eQnuned,. and whi~ ~ physKltkerapt5t, ~nd;ng by h\", left ~, pbre<; her left arm und...,. his left u~ arm.md g.rasp5 theref~largetrunkrTlO\\emml§a\"'nollWCf\"5Silry;iIl his right upper arm In her supinaled hand. She pllKe her right hand Krass hi« SPll~ just below the le....-I fact they detract from W6ilJ1\\lr\\;l1l0r\\. being tcstro,and the pad of !he bpoftlMo middlcfinger int}..,farsideofthe;ntersplnOU~5f'iKE'l.O.f.,I.odjacnll T4-11 (lateral flexion) spU1OWiprocCSiS<\"!S. Srorringposition MNhod TlwpatiefltsilSandholdshis~ndsbelund hIS neck or While lhe patu.'fll \",la~es to allow his lhorax to b.. CIU56CS his armsocl'055 hi5chesl whilc the physiothen- flexed and extended. tho> physiotkerapist take!i the pis! stands sidMln behind his right side reoctllng WIth weight of his upper lrunk on her lefl arm. her right arm to hold high around and behind his Idt shoulder. She grips his trunl< firmlybetwt.'Cn her right Toll\"itflexion,shelowershistrunklTomlheneulral arm and her righl side in her lefl axilla. ThIS high grasp positioountilmQ\\·cm..'fllcanbcfdlloMvelakenplaCO' with the right hand is ~CSl>ary for e'lilmlnatlon of the alherr;ghlmiddlefinger;lhepalicntislhenretul'nl'<l higher le\\'c!s;as thcexam;natiorlextCl'ldsbelow1'8,so 10 the neutral position by lifting under his arms. Tlw lhegrasp needs 1o be taken down 10 the lower scapul.lr oscillalorymovem\"'Tlllhmughanarcofapproximalely \"rea. She places Ihc hccl of her left ll.and on lherighl 2O\"oflrunkmovemenlisfllcililal..>diflllepalienlislleld 5ideofh;soockaltheleVl'lbcingexamined,sprt\"olds firmly and i( Ille physiolhcrapisllalcrally fln'-'\" her hcr fingers for stability,and places the tip of the pad of lrunklothelcflasshelowcTSlhelTunkinloflexion.This her flexed middlefinger;n lhe far side of !he Inler- makeslheretummovemcnloncoflalcrallyflcxingher s p i n o u s s p a c c o f l h e j o i n l l o b c t , - ' S t e d {f is u r r l ' . 1 2 ) . lrunk to tile righl Talherlhanliflingwithherlcflarm. Mrthod Theexlension part o(lhc IcSI is carried out in much thes.amcway,e~replthill thcphySiOlhcrapistassisls T1>cphysiolherapisllalerallyfiexeslhcp.llienl'strunl: lowards herby displacing his lrunk away from 11ft

Th,nonpine 317 F''9U~ 11.12 InttMr1WnlI_~t. 14-11 (I~tt\",l«tensjonl physiotherapist, standing in fronl of lhepatient, leans O\\·erh'strunklocr.ldlehispelvisbet....t>enherleftside With the heel of her left hand and her COf;IaI margm. ~nd her left upper arm. 1lUs po6Jtion stabi1u.e5 the andlatl'TaUy6e>anglUsuppertrunkby~herright patient's pelVIS. The physiothel\"apl5t's forearm 15 then ~rm.oo PI'e:!l6ll\\S oo..-nwanis w,th heT right ~ulLa. She palpates for the mtefSpinOUS rTOO\\'emmt through the inl~W1ththepaberlt'Sspu,.,.andherh.andlNd'aes lh!-k-I\"e1wherelTlO\\~tislobeeomined_Shtthen ~ofherrruddlefinger,ensuringthatduringthelat­ place;. her left hand on hisspUle with the pad of her rralfleltionherfingerl1\\O\\·e!lWlththespine.malntam- middle finger f;loCing upwards apUlst the under-sur- mg t!\\en OOTllaet against the spinous pl'OCe!lSl\"5. Ttoe palpating finger fwlslhe spaC(' bclweerllhe spinous faa'oftheinlerspUlOllssp.oa'lof~'ellhebonymargins pl'l)Ce5Se5open and d06C as the pJHcnt'slrunk is laler- aUynexed and relumcd to thc neutral position. of the ad;acent spinous processes, With her right hand, she grasps as far mlodidlly as possible over the Laler,1I neltion in the opposite direction can be pal- p;ttient's suprascapular area and places her forearm pak'd without a change of posillOn simply by lalerally over his stemum or grasps the pat......tselbowo.erhts sternum (Figurt Il.lJ). ne..,ngthep.atiml·.trunktheotherway.Hm<.~er,ilis M~lhod _ .-ccurall' tochange sKIes ~nd reprodlK't' the tech- niquI!' on the 0f\"P0S,!@§ide. The patient's trunk IS rt\"J\"\"ak'dly rotak'd back and forlh by the physiotherapist's right forearm and hand T4-11 (rotation) through an arc of approximately 25\". Care must be takentoensu~thatlhemovementdoesnot include Stortingposition scapulothoracic movement. To examIne mon'ment in the upper thoradc Ultt\",yertebral joints. the an: of Allhoughrolationcan~I~'Strointhesi\\lingJXl'>ition. mo·..ernenl should be pMormed just: behind the frontal plarw,Aslmo'ermlervertebt31joints aree:anuned.the il is more easily and more successfully tested when the U'C of rotation used 10 _lTlO\\ement lTlO\\·es back- patient is lying down. The patient lies on his left side wards until an U'C of rotation bet'\\<o·em40and fl:rfrom w,th his hip$and kneesoomfortably flexed while the lhe frontal plane is used to ~m.tne the lTlO\\·ement bet....l!t\"TlTIOandTII.Thepalpatmgfmgermuslfollow lhe palient's lrunk mm'emenl, and when m\"\"emenl occurllat the joint beingexamincd,theupperspinOllS pruces,wHlbe fclt to press into lhepad of the middle finger, which is f;loCing upwards. When thc lower spm- ous processstartll 101llO\\-e, this is the\"\"tentofrotilhon at the Uller.ertebral Je,,·el.

MAITLAND'S VERTEBRAL MANIPULATIDN EXAMINATION AND TREATMENT abov\", may be u...od, but the essential factor is that the TECHNIQUES direction of thc Pl\\.'SS\"'\" musl be at right angles to the body surf~ at the Je\\'el This 1JleJIn5 that the shoul- MOBILIZATION ders m.ly need 10 be anywhere bct>'I'een \\'ertic.lUy abO\\·cthelo-.-l\"l\"thoracicspinrilnd\\l'rtiI:aUyabO'ethP Postero-anterior central vertebral pressure (tl sacrum (Frgu\" 1J./4). If the patient has difflCUl~ lyi\"l! Starting position prune beoluse extl'llsion IS pamful. a small pillow u~der the chest WIll ilSSisl. ~ physiotherapist's pos- The ~lIent Iie!i prone,ll'\\thft WIth his forchcad restmg iliOn must also allow pressure to be applied 10 the spin- 00 the IYcboi. Ius !\\andsor,.,ith Ius head mmfortabl) rurned 10 one 5ldc' and tus ;nms lying by h~ ~e 00 0U5 pl'OCe5lS using the anteromed.ial lISped of the fiftb the oouch. TIle position dl-pends on the amount 01. chest ll'lotUGiIrpal,simil.1r to tNt desaibl'd on pages J7G-371 tightnes. creatoo by the 'arms up' position, which is for the lumbar spllle Howl.\"\\\"('r. It rn.:Iy be essen~1 to avoid dIrect oontact bctwt'm the pisiform and the usu;llly reservoo for uppcr thoracic mobiJi£atioo. spinous process for the sake of comf\"rt (Figll\" 11.14) If the ~tient is on a low CQUCh. the phy5lOther- apisl'SposilionforlnObi1WngtheupperthoraOc5ptnC M~thod (appruwnarely n-5) needs 10 be at the ~ad of the ~hent WIth hershoulder.l O\\'er thearea 10 be mobililed n.... mobIlIZing 15 carried out by an OlCillating pressUI'l' to enable th.. direction of the pn.'SSure to be at right angl.,.lo thesurfoceof the body. The padsofthe thumbs on the spinous pcoc~, produced by thl' body and tran<milll'd through thearrns to the thumbs. It Is impor- are pJaad 00 the 5pinous pr'O«'SS, pointing trall$- \\~)' across the n\".tebral roIumn. and the fmgl'f'J of tant that this pressure is applied by the body wc;ght -n!\\and are 5pfNd out O\\er the posterior chest ...aJI O\\'CTlhehandsand notbya squee~ingactionwith the IogiH·stabilitylothethumbs.Asthe5pinous~ thumbs themSl'h·t'5. lbe fingers, which ~ ipread oo.rt are large, the thumbs may be positIOned lip to hp Or O\\'er the patient's b«k.- should not l.\"XC'I'I an)\" pre;!!iUI'l' with the lips side by side in COIllact with the upper and bu.t acI only as stab,llz..rs for the thumbs. It is easy to dlSS.patc thl' pressure and lose th\", l'lfl'Cth'clll\"'ll of the 10000·ermarginsofthl>samespinousproces... Togain the thumbs by faulty use of the fingers. ~t rontm! and feel of IT\"I(I>'emef1t with the least d.... romfort 10 the pahent, the pressure should be trans- If the physiotherapiM's e1bo... lire kept slightly mItted through the thumbs!lO lNt the interph.1lang....1 IIo.ed and the thumbs mIllntalnl'd U\\ the potition 01 h}'Jl<'r1!\"1ln>ion ofinl<!rplw.l.1ngeal)OU\"llSilnd slight f1n- jolnts art' hypcre'<tended This enablt\"'i the softf.\"St pari ion of n>ctacarpophalangeal jolnts, the pres.suR'can be of the pad to be nat O\\'er the spinous pCOCl'S5<-'S, with a transmitled to the pads of the thumbs through thIS slight degret\" of flexion in the ml>tac.ttpophalangl'al S('ril'S of stron~ spnngs. This springing action at the joints. Notonly ~ thIs _comfortable for the patlml, \"'lnls can readIly besem as the body .....ight is appliN but It hIDders the ph)\"loiottwrapl,n intrinSK muscles during ..... mobilizing. from producing the p~.... To mob,lize the mid-thoracic 5pllle (15-9), the ph)'Slo- Locolvoriotions ther\"pist should stand at thc pat,ent's side witl, her The dt-grt'e of pressure required in the upper thoracic spine to produce mO\\'ement ;s far grt'al(>r than tNt thumbs placed longitudinally along the \\'l.\"Tll.'bral 001- l\"«Juired in the cen·ica.! sptlY, and slightl~' slroogt'r umn so that they POint to..'ards e;ach other lbe fingers than that\"\"\"uiredforlhl\"rt'lJ'WJ\\deroilhethon6l: c~then\"i'readoutO\\'erthepooster>or~I,,·.lJ,1o each ~de~ the \\\"l.\"rtdwal roIumn abO'-e and ~ the ~\"-It may be mort' oomfortable (and this is far ea~ier to \"'~. TIled~,&reeofmovement JlO5!iible in the middle,nd do if the patient is lying on a low couch) lor thephysio- luwer thoracic spmeis cCII\\sidl'rable, and it ishereth.Jt theraPISt to stand to one side of the patient. appruxi- il tScas;csl to learn a feeling of mol·('mf!nt. 1'hl'degrt'l' matftyllt waist Ie\\\"cland f;ocinghlS~,ilnd place the plIds ofthi' thumbs on the spU'lOU5 ~ pOinting of lnO\\'ement possible in the upper thoraoc 5pme is Kros.5 the ,·ertcbral roIumn. ~ fingers of each h.1nd COl\\SIderilbt) limilN. and th~ is p.trbCularly 10 betweenn andT2. Can then spread over opposite sid~ of the posterior Ches~W~;::~\"f'IJll'(Tl()-12),\"\"'physiother_ U~ IIpist's po5ltiondcpendsupon thesIYpeofthepatient's r~leriorcmtral \\'l.\"r'tt:'braJ pressUft\" 15 as useful ~. Either of the l.1lter two plllioilions described for thl\"thoracicspmeas rotal>on IS for thecenial

Thoracic spine 319 Fi<)ur.ll.t.lol.(bjandjclThoracicregion.l'o5t.ro-ant.fior «\"t,al~rtw<al ~f<'SSllrcltl spine. In all symptoms arising from the thoracic \\'erte- Rotary postC'ro-antC'rior intC'r\"o'C'rtC'bral pressures bl'i\\{', it is worth trying this procedure firsl. Storting position ·Central p~ure' is more lil<elytobesu<:ceiliful with 11le patient lies prone with his arms by his side while symptoms that are situated in the midlineorevenJy dis- the manipulative physiotherapist stands alongside the patient (in this case by his right side). She places her tributed to each side of the bOOy, but it should also be right hand between the spine and his right scapula,and tried for unilateral symptoms, partirnJarly if they are ill- her left hand between the spine and his left scapula, defined or widespread in their distribution. and transmits pressure through the lateral surface of the hyp<)thenar eminence ncar the pisiform bone Examples of treatm<'Ilt indude: glove distribution symptoms, page 4.35; thoracic bad<ache, page 440; and traumatic girdle pain. pages 441-443

320 MAITLANO'S VERTEBRAL MANIPULATION To reach the final position, the first step is to place the ulnar border of each hand in a line across the patient's back in parallel lincs, the right hand beingslightlycau- dad to the joint to be mobi1i7.ed and the left hand slightly distal to the joint to be mobi1i7.ed. At this pr<.o,. liminary stage the physiotherapist's forearms are also direct('C! across the patient's back at right angle:; to the vertchral column, and her pisiform bone is tucked into the space between th... para\" ...rtcbral musd('S and the spinous proce;S('S. The next step entails taking up the slack in the soft tissues. This is achieved by applying both post\"l\"(WInterior and rotary pressures; the rotary pressure is achieved by changing the direction of the forearms, in a swinging or twisting fashion, from aCross the body to somewhat caudad (the right arm) and cephalad (the left ann) as wen as laterally. The final stage is that of being certain that all of the slack has been taken up and that the pisiform bone:; are now opposite each other at the same int...rvertebral l...vel (T6/7; Figurr 1I.15.l). Method Fi9urtl1.15 (o)lntt\"'t~bralm~\"'.nt.rotarypo'ltro­ >nl..ior mo,emenl mid lhor\",i~dockwi~. (b! M~ments When ru;('C! as a mobilization, the technique consists of shownona,kelelonmidtnoracic-antidodw'.e an oscillatory movement with three dift'Ctions; postero- anterior, cephalad and caudad, and latl'Tal. It can be Transverse vertebral pressure (._) performed as a very localized movement by rn;ing the pisiform as the main rontact point through which the St(lrtingp(l5iti(ln pressure is transmilled, Or it Can be perform('C! much more comfortably ov\"r a wider arna by utilizing the When the middle and lower thoracic vertebrae are to base of the palm of the hand together with the thenar be mobilized with transverse pre5liures, the patient lies andhyp<.>thenar~inences prone with his arms hanging o\\\"er the sides of the couch or by his sid... to aid relaxation of the vertebral The technique Can be performed rhythmically with column. The h...ad should be aHowed to rest comfort- increasing and dccreiL'iing po:;r;tcro-anterior Pre5liUI'(' in ably by being \\luned to one ,ide, preferably towards time with the patient's breathing rhythm the side where the ph}'siotherapi.t stands. Howewr, as this head position tends tv produce SOme d\"gn.\"l' of II can a1.so be used ,t> a manipulative thrust, usually rotation in the upper thoracic \"ertebrae, it i5 bell\", for the patient to adopt the 'forehead rest' position atth... end of the patient's ...xpiration. There are times when these v...rtchrae are to be mobilized in order to when the technique c.n be u~ully employed in the eliminate any rotation. Alternatively, some couches lumbarspi\"\" The technique can be selected when mov...ment is desin.'C! in a po:;r;tero-anterior din.'Ction but the spinous procCSl\"oCS are too tend ...r for direct contact. The ranges of movem('I\"lt of single costovertebral, costotransverse and intervertebral joints are quite small, and yet if this techniqu... is perfonn~'C! through the palm of the hand as d('SCribt.-d above, quite consid- erable movement between three or four contiguous levels Can be achie\"e<!, This can produce im\",(~ diate comfort and improvement in movement (FigurelJ.15b)

Thoricicspinc 321 have a hole 10 allow Ihe head to remain ~ntrally T1 being almOl>t immovable. l1te lower thorade Vl'l\"Ie- placed_ lnsomeeasesil maybeusefultorotateordero- brae (1\"8/9--12) are more easily moved and do not tale the spine using Ihe head position to produce the require great pressure. Local ll'1ldemess in lhese two movem\"\"t. If the mobi1i7.alion te<:hnique needs to be areaS is compmatively negligible. Mobilization of the performed strongly as a Grade IV+, it may help to mid·thoracic spine is mad.. difficult by the relative a,k the patient 10 face lowards lhe manipulative inaccessibility of the spinous processes and natural phy$iotherapist tendemtsS. and when a painful condition is superim- posed on this natural tenderness, adequale mobiliza- The physiotherapist stands al the palient's right tion may be \"ery difficult. Wh\",re stronger !l'Chniqlll_'S side al the level of the verlebrae to be mobilized, and are N'quired 10 be performed for longer periods, better places her hands on the pati\"\"t'$ back so that the pads effL'Ct may be gain,->d by reinforcing th.. contact thumb of the thumbs are adj.:lc\"\"tto the right side of the spin- with the pisiform of the opposite hand rathl'l\" than ous processes while lhe fingers a... spread over the with the opposite thumb pad. In this way, the flng,-TS palient's lefl ribs. The left thumb acts as the point of can be spread Over the ch,-'St wall and th.. movement conlact and is fitled down into Ihe groove between the can be producm through the thumb and hand via the spinous poxess and the paravertebral musc1<.'S, so that therapist'strun\\: part of the pad of the Ihumb is pr<.'Sscd against the lat- eral aspecl of the spinous process on its right-hand Us~s side. It is essential 10 have as much of Ih\", pad in con- tact wilh the spinous process as is possible. To pn.'vent This lechniqu(> is particularly useful for pain of unilat- the Ihumb sliding off the spinou$ process, the palmar eral distribution in the thoracic area. In such cases the surface of Ihe mdararpophalangeal joint of the index pressure is best applied against the side of the spinous finger must be firmly broughl down on lOp of the process that is away from the pain, applying Ihe pn.'S- inl\"'rphalangeal joinl of the thumb. This is a valuable sure towards the patient's painful side. When using position 10 learn to adopl, as its stabilily is of value in this !l'Chnique il is fn.'quently necessary to mobilize the other h_'Chniques. The righlthumb, acting as reinforce-- ribcage by a postern-anterior pressure directed through \"\"\",t, is placed so thai its pad lies ol'er the nail of the Ihe angle of the rib. If progression is needed. the lefl thumb_ This thumb relationship is chosen because \",anipulahV(' physiotherapist may need 10 c1(>ar the considerable effort is N'quired to Iu.\"'p a single thumb roint signs by using pressure on Ihe spinous pror,-'SSon comfortably againsl the spinous poxes.'> the painful side and towards the pain-free sid.. The fingers of both h':lIlds should be well spread out Examples of In'almcnt include pain simulating Car- over the chest wall to slabilize lhe thumbs, and the diac disease, page 421; scapula pain, page 426; thoracic wrists need to be slightly extended to permit the pr<.'S- backarhe, page 440; traumatic girdle pain, pages 441-442; sure to be transmitted Ihrough the thumbs in the hon- and abdominal P.lin and. vague p.lins, page443 ronlal plane. &'Cause of the slightly different functions re<juired of the left and righl thumbs, the left forearm Postero-anterior unilateral vertebral is not as horizontal as the right forearm (Figure 11.16) prcssurc(rJ Method Starting position The pressure is applied to the spinous process through The patient lies prone with his head tumt'd 10 the lefl the thumbs by the mOl'ement of the trunk; allemate and his arms hanging loosely over the sides of the pn'Ssure and relaxation is repeated continuously to couch Or by his side. produce an oscillating Iype of mo'\"ement of the inter- vertebral joint. For the gentler grades of mobilizing. To mobilize the left side of Ihe middle or lower thor- very littl\", pressUIl' is needed. When stronger mobiliz- adc spine (approximately T~12). the physiotherapist ingisust...:I.,muvemL'fltofthepatient'stnmkisinvolved stands On the lefl side of the patient and places her and timing of pr<.'SSUr<.'S should coincide either with [mnds on th.. patienl's back SO Ihat the pads of the the patient's rolling or, in ordl'r to make the technique thumbs, pointing towards each other, lie over the trans- stronger. to go against the rolling. verse processes. l1te fingers of the left hand spread over lhechcsl wall pointing towards Ihe p.lti,-'l1!'s head, Loco/variations while the fing,-'I'S of the righl hand point towards his kd and lhe thumbs are held in opposition. Byapply- The upper thoradc spinous processes (Tl-3/4) are T\\-'ad- ing a lillie pressure through the pads of the Ihumbs, ily accessible but have a limited amounl of movement, they will sink ;nto the muscle tissue ad;ae\"\"'t to the

322 MAITLAND'S VERTEBRAL MANIPULATION ~~ 11.16 llll.tbl.[et .... [d11l1cncicrqion.T~vtmbnll'f1\"W\"'l-) 'P'flOllS~unblthelnnS\\'erwp~isnsJChcd ph)'SOotheraplSl's5houIdersand a~, with slightly 1l'M' metaarpophalangeal ,om! of the thumb needs to ne-l.e1bows,5houJdbeinthedU\\Xt1mettuough be ~hghlly f1exed and the inl<i'TpNlangeal join! must be which the pressure is to be applied, and this is al right hyperextended to Cf\\,1ble the pad of the thumb to angles to the plane of the body surf3a'. transmit the pJCS6ure comfortably. When a much finer Bec3U5l'ofthecun'eofthethoracicspine,itisl\"Ol'Cel\" deg,,-'t: of localization of the pressure is requi,,-od, the sary when mobilizing the upper levels (1'1-4) 10 thumbnails should be brought together so that the stand ei!her at the patient's head or towards theshoul- tips of the thumbs make a very small butromfortable der of the side being mobilized to accommodate the POint of contact. In this position, the metaCiul'0pha- necessilrilyalleredangleofthephysiotherapist'sarms. langeal joints of the thumbs a~ brought much d<l!iOer llisadvisabletou~thelargestamountofthepadol together to lie di\"-'Clly above the thumb tips. The the thumb that can be brought inlorontacl wllhthe

Thoracic:spiM 323 f~ofcons>deo\"ablcun~Whmthehand:l&n' ~,thetechrUqueisfn,quenllymore vigorous than is required. u'\" Poslero-anterior unilaleral vertebral pressure is used, alm05tenlirely, for unilateral dlStributerl pain an-\"';'ng from the thoracic spine, and the technique is done on thepamfulside.Unle9sthepabent'tpainis5e\\~ltis ieslIlikeIytoprod~ab\\vurablechmwemthe~t's sognsand symp&0rr6 if it isdoneonthestdeawayfrorn thep.1in.\\Vl-o>lhistechNquelSusedmtheprelt'llCeof ~ the pressure must be studily applied and not hum«l.inordertoallowtimeforthe~lorelaJ(. Postero-anterior unilateral costovertebral press~lre(~) StortingpositlOfl The p\"timt bes prone withhisarms byhlssideor hotong- mgO\\..,..thesidsollho>rouch.and theph)'5iOlhrfapl§t trans\\\"eBIl'pl'OC'e5,loeNblethepresosuretobe.drnin- stands ..t the $Ide 01 the pao..m where the mobWz.abon I$Ierfd uromfortably u possible (F'gIlrr 11.17). isllO~effe:ted.Theph)'5iOlhrfaptst'sthulnb5~pl;o<:N ..long the lmeoftheribat itsang\\e!lO dlat themallamum Mrthod arN of rontitct can be made between the thumb$ ;ond the rib (Figurr 11.1811), Alternatively. the whole ulnar Averysteadyapplkalionofpn.'SSureisnen.,;s.'rylobe border of lhe hand and litlle finger may bc used to pro- able to move ~me uf the muscle belly out of the way d~themovement{Figurr1/.18b). \"'ndmakebone-lo>bonecontitct,Asthispl'OC«lurecan be quite unromfortable for the ~Dent,. can mu\"t be gi\\'enlothe~bonofthearrnsandhand:lto_blea Mtthod ~-IiI.eKt1onIot>kep~altheelbow3...ndthe AnOlSClllatoryll'lO\\~tistransnultedlotheribby thumbs. Th~-'lX'ethefHhngofhotordne5sand5Oft'­ the thumbs or hand$, and the range 01 movement P\"O' . - betw...... the p/'l~\"'PlSt's thumb$ and the doced atone rib angk! iscompan!d with thai prodoced P'l'tient'slrans\\·_p~lhallSp...sentifthepres­ aline rib anglell aoo.'e and below, The pam produced lure 15 applied by inlrinsic muscle itdion by the mc....ement of the faulty rib is also romP'l'rW Once the n.oquirW depth has been INChed. the with thcp\"in (if any) produced altheribabovelll\\d osollahngmo\\'emenlat the inler\\'ertebraljoint is pro- lhll rib bclow. Similarly, both the range of the move- dulX'dbyiflCre,lingandt~ndecreasingthepressure mentand the pilin shouJd aJsol>eoompared with the produced by trunk mo\\'ement. rib$ on the opposite side of the body. l.oCfJ/YOriations loc:olllOriatiom Ileca~ofthesuuctureandattadunenlsoftheribcage, Fint rib. ExaminatJon of the first rib is ~hat dil- 11 if not possible 10 product' \\l'f)' much ll'lO\\'ement ferentfromthatoftheotherribsasthe!t'duuquecan With thrs mob.liution. beappliedinthreewa)'Sduetoagreaterareaoftherib oc'lngp\"lpable: Some people may find it easiCl'\" 10 carry 01.11 the mobllizahon using lhe hands (as described for the 1. The pressuillcan be applied against the rib poster- lumbarspinc)insll'adofthelhumbs,bullhilshould Iorlythroughlhetrapeziusmu5Cle,andthedirec· bediscourilged asthc thumbs hal'e a greatcr degree of hon of the pressure is I\\Ot only poslero-anh.-'riorly 'fl'eI'andcanlocali«themobi1i1.ationmo... a<:(urately. bUI isa!so inc:lined towards the feet (Figul'l' Jl,l!1) TheyalsoaUlll'muchlessd~fortlothe~tient-a

~-=3=-\",--,==..:..::====== _ Figu,~ 11.18 101 Post~ro-int~'io. unilit~'il COSlov~rt~bril p~lur~ u~ng thumb. [bl PosWO-inte,io, unilateral <:<lSt~\"eb\",1 prmu~\"!inghinds(~l Figurel1.19 ~su,eapplied39iin!tthefif'Stribposteriorty standing at the patient's shoulder level ofthl.'side thrQugh the lriPCliu\\ tobctreak-d,oppliesthep,,-'Ssuretoproducetllo.> osciJlatoryantcropostcriorandcaudadmo\\'ernent 2. Alternatively, the physiotherapist can place her on all partsoflhe firsl rib thai are palpable (F(g\"\" thumbsundemeath (anterior to) the muscle belly of the tr<lJX'l.ius and th.. diTl>clion of th.. pressure 11.11). The symbol for IhislL\"Chnique is.J RI can be inclined a liltl.. mOre towards the f~t as \",en asbeingpo>tero-anteriorlydirected(FigurrjJ.10) Otllfrribs.Alloftheribscanbee~amined throughout their entire length by thumb palpation, including the 3. For this n..\"t technique that mobilizes the first Tib. coslochondraljunctionsandthejunctionwithth<'ster· the patient li..s supine while the physiotherapist. num. The freedom of movem\",,1 !J\"lw\"\"\" adjacent ril>5 can alsobc lesled,bul os Ihese are nOI pari of the \"l'f tcbrolrolumntheyarenoldl'SCTibedinthisbook.11ley

...ThoraClcspine 325 FI9U~ 11.21 (oJ.(!IIand(dPrtsWrt~pplitdlothefirstnb ant~riortv a~, howc\"er, descrioc-d In Prri,>Irmll M.lnipulallOII ,rog=toint. This mmbiru:alion may haSle\" the fatl' of (M~III~nd,197Oa) Ifpamisinan.>fern-dareaoflneriocilge.thesymp- toms may be ilriWlg fT'(lO'l some abnontwlily bmo.\"\"\"\" A Il\"Cho\"tue ~rlonned wllh lhe pallen' supine is adJK'l'f'1 ribs. Palpatlon will ~'eal abnorm.1lihe5of de.lCT1bedbelow. poioIhon and of tnO\\'emml bro.-\"\"\"\" ad).>renl ribs. This iSpl'CI of lreatmg costal paUl IS de5cnbed in Pmpllmd \\\\~('f '\"\",Imenl ... appht-d 10 lhe thoracic inler- M<r\",,,w..I,,,,, (MaitWld, 1'1i'tY). \"('f!d>ral pots, the inclusion of mobLlizal>m of the Thoracicspinc:rotiitionto~right(T2-12) rib:s!iihouk!be~fl)C\"lwofNli(JnS; Srorrmgposition 1.ltifrequentlvdifficultto_whctherapatienl'. pam anses from the mll'T\\\"<'f1<'bral jomt. theCOll- \"Thepatil.'nl lies supine wilh his al'T1'lll folded iICI'O!llI his to\\:enebral joint or ~ CQSlotr;lffi\\'er5<! JOUlI. chest, resting his hands on the opposite should.:.n Thefl.'fOf\\\", if mobilizatlon of the thor3dc Inll'T\\·CftC. (rigu\"JI.22). Thl.'physiOlhcr~piststandsonlher;ghl- br~l toml is not producing adequale improvcmenl handsidl'ofthl'p.>ticnl,till;ngholdoflheleftst.ouldcr whcn use<! onapall.:.nl,mobHiMl;onofthcribat wilhlhclefthandandthclefliliaccreslwilhlhcrighl il~ ,.ngl\" should ~ add~-d 10 lhe Inl\",ycrtcbral hand (F(glln!ll.2J). Th\"lrunkisthcn rolled towards mobili~\",1\\ion. lht'lht'rapist so thaI lhc Idt shoulder rom\"\" off lht' rouch,exposing the thoradcsp;ne,\"The righl hand is 2. If lht' rib is moved aSa lreatment lechniqul.',il must also creal\" some mm'cmenl at the Inler.,.erld>ral

326 MAITLANO'S VERTEBRAL MANIPULATION lhen placed so lhal lhe f1ex~..::I interphalangeal joinl of (Figure 11.24). The p.1tienl·s trunk is then rolled back- lhethumb is placed oVeTlhetr,Insverseprocessoflhe wards over the right hand,and the lherapist leans over lhoradc vertebrae to be rotated. allowing lhe fingers to the patienl so thai the palient's flexed forearms are tucked into the physiotherapisl'schest (Figure Tl.25). lie across the thoradc spinous process. Theronlact hand isposition~>d in such a way as to Mf:thod alJow the thumb to be nexed al lheinterphalangealjoinl The mobili7.ation is lhencarried oul by the physiolher· apislroHinglhepati..nt'strunkovertherighlhand. and adducted and slightly opposed. at the metacarpo- This is done in an oscillating manner interphal.angeal joint SO that it lies in contact with the Mobilization ofth~ ribs (R2-12) patm of the hand. lhe proximal phalanx being in line Wilh the index finger. Thesame position is adopted as above, with the excep- tion that the righl hand is placed SO lhat therighl The index finser of the right hand is placed owr flexed thumb is over the angle of the rib. allowing lhe lhespinous process of the vertebrae being rotated fingers 10 be directed lowards the lhoracic spinous pl'OCCSS<-'S,Thi! index fingl'T is in conlaCI wilh the spin- ous process of Ihe verlebrae. 10 whose lransverse processtheribisallached(Figurel1.26) Figure tt.22 Thoracic rolation - patit~t~pi~t THORACIC TRACTION An example of \"\"\"troent is thoracic backache, page440. Traction can be administerftl to the thoracic spine just as readily as it can to the cervical and lumbar areas, and lheguiding principles are exactly the same. However, it is truc to say that it is lcss frequenlly suc- cessful than H is in either of thcother two areas, and Fig\"~ II.Z3 ThOricicllllation- r.acningaclllo;s!onoldthtpalitnt

Thora<:ics.piM 327 Figu,\", 11.24 Tho'~cic rotation. {oj Hand position. (b] Hand position on s.pin~ Figu,\", 11.25 r\"\"racic rot~tion. Finill starting position this may be due, at least in part, 10 the presence of the Upper thoracic spine (iT 1') thnrackcage Starting position The principle is to position the verlebral column so The patient lies on his b<lck wilh 01'll' or two pillows thaI lhl/' particular joint to be lreat<-\"li is in a relaxed under his head 10 flex the neck until the intervertebral position midway between all ranges. The amounl of level 10 the trealed is positioned midway between flex- p~ure 10 be u.>ed is guidoo first by movemt'I\"lt of the ion and extension. A cervical halter is then applit\"li joint, with further changes in tension made in l't'Sponse in lhe same way as has been dt'SCritx>d for cervical to changes in lhe palient's symptoms as outlint\"li for traclion in flexion. If a lower level is to be treated cervical traction. Furtht-r treatmt'I\"lts al'<' guided by and if the strength of the lraction needs to be very changes in symptoms and signs, as all'<'ady discussed firm, it may become nec.\",sary 10 apply some form of with cervical traction (sec p. 288).

328 MAITLAND'S VERTEBRAL MANIPULATION oounter-tr~elion.Abclt islilloo 3round the pt.\"lvis and the weight of thcp.:!tient'stooraxor pt.\"lvisofftheoouch isallaehoo to the foot cnd of theeoueh to stabilize the andallowingittorelaxbackint03newposition.Friction dist~1 end of the vertebr~1 column. The halter is then is almost completely eliminated bya oouch wh05\"SUT- attached to its fixed point s.o that the angle of the pull faceisint>\\'oha)\"esthatarefreetorolllongitudinaUy on the neck willbeappl'{lxim~tdr4S0tothchorizon­ (secpp.)89-394). Releasing thc traetion does not pl'elt'l1t taL The actual angle used varies with the amount of any problem, but it is advisable to release slowly. kyphosispreM\"nt in the uppt.\"r thoracie spine, and it should bc an angle that wHl allow the thoracie inter- Lowcrthoracicspine(TT 1') vertebral joint to bc movcd longitudinally while ina Starting position position midway between its limits of flexion and extension. To tl'lieve strain on the patienl's 10werbaek Forthelowerthoradcspine,athoraciebdtsimilarl(> during the period when the traction is bcingapplied. that used for lumbar traction is used in placeofthecer his hips and knees may be flexed (FIgure 11.27). vkal halter. Traction is usoally more effective if it is carri~>doutwilh the patient supine, but itean be done Method with him prone. The thorade belt is applied to hold thedlt.'St ab<w. l1lc trilCtion can be adjusted from citherend or from the level of th,> spine to be tn'atoo. and it;s thl.'ll bothend.s,but which\",..,. method is uscd,care must be attached to its fixed point. Aft\"'rthis the pch\"ic Jxolt is takentoensurethatfrictionbetwecnthcp.:!ti~'fll'strunk applied andall'aehed to its fixed poinl. The dift-'clionof and the couch is reduced to a minimum. This can be the pull is th~'I'llongitudinal in the line of the p.alient'~ doncwhile thctraction isbcingapplicd by gently lifting trunk, but pillows may be n,'eded to adjust thl'

..Thofa<:icspiM 329 position of the spine so thilt the joint being movLod pah(>nts ....hose thoracic symptoms do not appear to bc i5 relaxLod midway between nelfion and edension aggravated byactivc mOVemL'Tlts of thc spine or when (F(~1I11' 11.28), nl'\\Irologicalchangt.\"Sareprest'nt.Similarly,itisth(> Mrlhod In:atm(>ntofchoia!forpatlcnl~withse\"\"renervl\"\"root Traction is applicd from either end 01' from both ends, palO. When,,'\"er mobili,-in~ IL,<:htIiques have been used but agam C3re is requIted to reduce friction 10 a min- intrcatmenlwi!houtachie\\inglhedesiredresult.trac· omUIn both at thorilcicand al pelvic le\\'e!s.As m<!I'I- lion.shouldbetried. boned pre-.'>OOSIy, a roU-lop couch tliminale!< friction. ASlmplr. cheap and I'Jitremely dfecth'e roll-top couch Somctllnesa pallent iHblr loguide the therapist itS isdcscribed briow(5«p. 391). to what to do because hIS body tells him what ,t W;1111s (and what ,t doesn\" ...ant). Figlltr tl.29 is. perfect RritUU>8 the lraction shoukI be done !>l\"~ily, and thepahenliihoukin!Slforashorttirne\"\"'\"-standing l\"UJ1lr~of5U<haca5('.~potienl'sdisorderhad Inll.'nmtlent \"anable lTadJon can ..Iso be used in been V'l'f)'d,fficult Iohrlp in that progress gamed ala ttus ..fNolthesp.........nd thedetllilsoltimesror're5\" treatment !il'SSion WitS not !eUlned \"'ell mough. ~ and 'hold' penods are the same ilS hne been discussed for the cerl'ical sp....... dlSOl'der\"a'iatthele\\'e1oiT6J7,andhadbeo\\~­ ingto~tremelygentletraroon.Qnoodaythepot~t Loco/variations ...,dthil'heneededthet~buthea.lsoneededto NWt' the ,·ertebra pushed Wckwan.b and towards the Thethoracickyphosisvariesconsidcr;lbly from persoll IriI ...hileha'·ingtheIL\"'clsaoo..·ctwistedtolht'right to pcl'>lOn. and the positioning of tile patient i5 con- trollLodby thiscur....e. Throre'icillly, the dirl;'(:tion ofth(> riK\"rt 11.29 shows how the position wasobtained while pull may be thought of as being al ngh' angles to the the mobilizing was produced through the paticnt's upper and lower surfaces of the mll.'l\":ertebral discal sto:rnum, I'll' claimed that he was 60 per cent beller the len-lth.1t 15 being mO':ed. 'Jllto kyphosis usually af~rthefjrstofthesctre.. tments,and80perct'ntbell\"r mfluenct'S the pc6l00n fOl' uppw thoracic lrarbOn morethanrorthelo........ lhQracic5p~ \"ftl'rthesecond.Athissug.gestlon,treatmentwasd~ fucoutioM continued, and on \",,'\\(>w 12 months later he shawi'd no Signs of nxurrencc. A~.. mustbekpt<ll\\thepattentlon>SUrethilt the GRADE V MANIPULATION ~doesnotcall5l'anylow-backpain. As in other areas of the spme, the mobilization redl- As ..~th the reoiall tnlction m flexion. it is possibte btheheadhallerinupperthoracictraetlonlocaUS<! ruqll('5describedcanbeperionneda'i\"~rapKl omp'lal headache,but this can be climmated by the smaJl....mplitudl' thrusts. ~ may be genenl in d~ rnNnsalrt'ildydescribed(.-p.290), tribution. CO\"ering mon': tlwl one intrn'mmral Jeo.e1 u,,, (asm rotary PAs described on p.319),or~canbe performed In a much more Joc..lized manner so thai Traction is of greatest value in patients who have the emphasis of the lnO\\'emenl IS focusoed, as much as wldt'lydlslributedareasofthoracicpilin.p.1rlicularly lSpossible,onasingleintcrvertebralle\\·el.lhesemorc if they are associated with radIological degenerative localized manipulative tL'Chniques are oow described change51fl the thoracic spine. It is also of \"alue for for the thoracic spine. Intt'~rtt'braljointsC7-T3(latt'ralflt'xjon(r\"') 51artingposirion The patient sits w,,11 Wck on a medium-height rouch while the phys>otheraplSt stands belund. To pnwide

330 MAITLANO'S VERTEBRAL MANIPULATION Fig~rtll.29 '..a,Oftofl~ mid-tl\\otxi<:$plntromblntdwllh localiztd'6/7mobilizal'OftYlat~ --=-------' thr p.ibmt WIth comfomIble support. the ph~\"Siother­ Intervertror.Jljoints 13-10 (PAs;) aptStpian'sherki1footonlhtrouch\"\"\"tlolht~tienl'5 left buttlxk. rests the p.illCflt'S left ann O'\\'er her left Stortingposition thigh,andasksthepatlmtlord.a\"b;a(kag;ainstt-. lhepat>enlliessupirw>\"'ithoula p,llowand hnksha$ LocalWrbOfl 01 the mampulatiofl il.ilCroe..-ed by finnly hands beIund IwI neck while the ph)'SlOlheraptSl standsbyhisright!lide. By grasping the patltf>I's left Pl.lcins the bp 01 the righlthumb a~nst the right SIde shoulder in her righl hand and both elbOl.:s In her left 01 the spmous process 01 the lower vertebra of IN- mteo·er1ebnljoinl.rres\"u~isapplll'dh0ri2:ontallyin hand. the physiotheraplS! holds the p.ltient in this the frontal plane by dus lhWl1b, whIle the fingeB position; she release her hold on the shoulder and sp~ad forward o\"er the paho,>nt's right cla\"iNlar area. lcaru;;O\\'er the pallcnt 10 palpate for thespmolls These fingers aoo siabillze the vertebra. lhe nexl step pr0ces6 01 the lower ,·ertebf\"a form,ng the inlen'~ is to flex lalt'l'\"ally the patient's he<>d 10 the righl until braijotntbelngmampulated.Stillholdi\"8thepat~1 lhelensioncanbofellalthelhumb Wh,!ema,nlain;ng irlthispo5JOOn..thephysiotherap,stmakellaf~tw,t IhelaleraJfle\"iool_ion,them,ddle~IIonbt-tween the righl hand by flexmg the middle, nng and Imle fin. flexion iIJld extension i5 found by rockinglhene<:k gers into the palm bUI Iea\\'ing the thumb and index back and forth on the trunk. Afler dcterm,nmg this fmgerextended. Asmall pad of m~lerial gras.pt.'<! in tht poIiilion, rotation (fltCl' upwards) is added in small fingers will gJ\\'eaddro support. This fist lSlhenapphcd OIilCilJatory movl.'m<.'Ttts until the lillUt of lhe rotary range lolhe palienl'sspinc (the Ihumb points Il)'n'ards thl' is found. The therapisl then posltionsbolh forcamtS to head) SO that the lower SpinOUS process is graspN work opposite each utht-'I\"(Flgurr 11.3C) between the terminal phalanxofthemiddlefingerand the palmar surfJccof thchcado(theopposcd firsl Method metaearpal. The patient is then lowel\\.'<! bacluntil tht physiotherapisl'S right hand is wl-dgl-d bctwl't.'\" the The manipulation consisls of a sudden short-range palilTll and Ihe couch. The welghl of Ihe patient's Ihrusithroughiherighithumbtr\"ns'·\"n.elyaerossthe trnnk is taken on Ihe nat of the dorsum of the hand body. while a rounter-lhrust isgi\\'en bylheoperator's (notontheknuekJcs),andthefo~armshouldprojecl ldthandagainsllheldlsideofthepalienl'shead lalerally to avoid inrerferenre with mo\\'ement of t!le

Thoracic ,pin~ 331 Figur.ll.30 lo)annlbllnl.\"....trbraljointsO-TJ patient's trunk. lfthe surface of the couch is too hard. manipulation is then carried out by a downward it will bc difficult for the physiotherapist to maintain Ihrusl Ihrough his elbows in thedir«lion of his upper bcrgrip on the spinollS proct.'SS.To achieve firm coo- arms. This thrust is transmitted 10 the palieol's trunk lrol of the patient's trunk,his elbowsshol1ld beheld above the underneath hand. The thrust may be given firmlyaodp~againslthephysiotherapist',ster­ as Ihe palient fully exhales. num. Howe\"er. when a patIent has exe.;,ssi\\'dy mobile joinls it may be ne<essary for him to grasp hisshoul- Int~rv~rt~bral joints TJ-10 (longitudinal der5 wilh opposile hands while kecping the elbows in drn;eappositionratherlhandaspingthehandsbehiod movem~nt_.) the nl\"'k. The patient's upper Imnk is then gently Stortingposirion moved back and forlh from nexion 10 extension in decreasing ranges unlil the stage is reached where the 'The patient sits well back on the couch and grasps his only movement laking place is felt by the undemeath haods behind his neck, allowing his elbows to drop hand to be at Ihe intervertebral joint to be manipulaled forwards. The physiotherapist stands behind the (Figure Jl.31). patienland thrcads her arms in fronl of his axillae 10 grasp over the dOr5l1m of his wrists. When grasping Method his wrists, she ,,\"courages his elbows to drop forwards while at the same time holding his rib!; firmly from PrL'SSU~ is increast.'<llhrough Ihe patient's elbows, each side with her forearms. She lhen tums her trunk causing stretch at the intervertebral joint, and Ihe slighlly 10 one side to place her \\ower ribs againsl his

332 MAITlANO'S VERTEBRAL MANIPULATION Figur~11.31 lal.nd(bllnmvm.braljOint.T:l-lO(PAs!1 small movement with the therapisl's ribsagainsl the patient'sspine, performed atthesametimeastheliftis spineallhel<'vclr«juiringmanipulalion,Whilef<\"Cling cXL'CulL'd through the arms. for movement with her ri!xage, she flexes and exl=ds his lhoracic spine above the level to be manipulaled Interverttbral joints TJ-l0 (rotation:;) unlilthencutral p<:>5ilionbetw('(!n fl<'xionand <'xtcn- sion is found forlhejoinl lO be lreated (Figure 11.J2) Starting position Method If rotation to the left isto bcpcrformed,thepatientsits on lhe edge of the couch rlearthe right-hand end while The physiotherapiSl [ifll;; the p\"lient\"s lrunk in the lhc physiotherapist stands behind his right side. The direcliun of the long axis of the joint being treated. and patienl hugs his chesl with his arms and turn1' his makes a final adjustment of the flexion/extem;ion po:si- trunk to the left. For the mid-thoracic area. the phY1'io- lion to ensure that the mid-p<:>5ilion has been retained. lherapist reaches with her left arm around his armS to The manipulation thenCOf\\5ists of a short·amplitude grasp his righl should<,rwhile placing the heel of her sharplifl righthandalongthelineoflherighlribabovethejoinl lobemanipulated,Shecradleshisleftshouldcrinher Some d<,g\"-'t' ofext=sion may b<'added into this left axilla (Figure 11,3Ja). Forthelowerthoraciclel'els, technique. This exlra mo\\\"<,menlisachievedbyavery sh<,graSp5aroundhischCSlundcrhisarmstorcachhis scapula. This time she places the ulnar border of her right hand along the line altho:' ribs (Figure ll.J3b) Wilh both techniques she then takes the movcmcntlo the limit of the range, laking upall slack. Method The manipulation cOllsists of a 1'Yllchronous move- menlofthephysiothNapist'strunkandanextrap\",\", surc through h<'r right hand. Withhertrunkshccarries

Tho,acic,pine 333 FigufOn.33 InteMrtebraljoinll..TJ-l0Irotation).la)M,d-tllOr.!CIcarea.llIllowe,thoradca~a out an oscilJatory rotalion back and forth at the limit M\" R of the rot.ny range. At the same lime she maintains A S1Jmmary of the report from the physician and constantprcssurcwilh,·ithertheh.'Cl of her right hand gastrocnterologistfollows or its ulnar border l'\\erting an extra rotary push at the limil of the rotation. The manipulation consists of an Social o\\\"cr-pressureatthe limit of the rangc, bcing donc ina This40-ycar-oldpatientwa'Sttn4wecksago,She;s \"ery small amplitude and very sharply_ ma\"'ed with one daughter. She isa htl\\lsew,fe and her husband runs a motoring school,which has been poor!y CASE HISTORY altcndcd,causingmajorfinancialproblcms. Theexampleoftreatf'l>entgiven~lowisindudedatthe Past history end of this cr>apte, for a verysprofie purposc. It is well Her pMt history revealed asthma, and she wilsdiagnoscd mown among manipulators lboth lay and medicall that by her local medical officer 7 ycars ago as having acute many patients have undergoneabdom,nal surgery for chol«ystitis.Shedidnotha\"\"ag.llbI~(finVl5tig.ation: symptoms thought to have COf'l>e from S1Jeh structures as nor has she had one since that time. She has had an the gall bladder. the appendil(. ovaries, etc. When the appendectomyandhystertctomyandtuballig.tion patienthasnot~cnrclievedofthesymptomsbythe S!1chasal50bccndiagnoscdashaving a hiatusherni., S1Jrgeon.thepati(nlsoflcnfindthei,waytothc which was confirmed bybilrium mcalin 1978 when slie manipulators who, under the: appropriate cirC'llmstan~s presented with ch~51 pains. Three years.go ~he was ofcourse,have~enabletotrcattheapp,opfiatelcvelof seen by a c.rdiol09istfor iIfull Cilrdiac.ssessment thcvcrtcbral rolumn and relieve the patient of his becauseofth~scchcst~ins.Finally,shehadhad. symptoms. Surgeons who are aW3te of this possibility are transient fight hemiplcgia 4yca ... ago. the c.use of con~rnedth.ttheex.min.tionofsuch.~tientshould which was not known, despite it ocrurfing in i1young indudeamusculoskeletalexaminationtodcterminethc woman.Shehad,however,becnontherontrac~ptiv<: possibility, when there is doubt with a p\"tien~s pill fur lOme considerable time. There was lOme symptoms, that the symptoms may, in fact. arise pos.siblesul/9cstionth.tthesymptomswere from the vertebral rolumn functional

MAITLAND'S VERTEBRAL MANIPULATION Right up!M'r quadrant pain Neuromuseulosk<:l<:lil uamination and The patient wa~ noted to ha\"\" had backache 14 years treatment ago and igain more 'ecently. e~p<:<:iallyo.e, the past The patient's symptoms wele as shown in Figurc l1.34 5 years. She had wffe'ed a con,tint burning pain inthe The examination findings wCre as follows. right upper thorax neneath the ,ight seapula, and she noticedthatshed~lop<:dpainintherightupp<:' Fluion quad,aM at the same time. The i>3tient he,selfnot<:d that Th<:patientwa~onlyabletOleacl15cmll<:lowher kn<:cs, and this prol'Oked lowllick pain. Recovery from the pain in the right uppe' quadrant of he, abdomen and that flexed po'lition was difficult and provoked more back her Ilicl<ache tended to Ottur togethe, consi~tently.The pain. After completing the te~t movement. she d....eloped i>3inwa~worsewhencoughinganddeepbreathing.and pain in her right abdomen. ittendcd to ll<: worse with walking. She hid undergMe Doth an ultrasound of the gall bladder and an o,al In the flexed po'lition. rotatron of the thorax to the rightprovokcd right leg pain chol<:cystogram. both of which we,e normal. ,ais.ing the mong~ugg<:5tionthatshep'obiblyn<:verdidhaveacute Exten~ion chol<:<yltitis 7 years ago and that thisdiagn05is was There was no low lumllir movement at ill, but the ~mill amount of low thoracic exten~ion that she could perform p'obiblyincorr<:<.:t.Thepatientdese,ill<:depisodcsof provokcd Whit ,he dcsc,ill<:d as 'shocking pain' in the Sl'\"\",eg'ipping pain. whichwassos<:ve'ethatshewa~ ,ight butlockind abdomen. unable to walk.ThcSl' pains tended to ll<: worse in ll<:d 0' urly in the morning when she had been lying in ned Lat<:ral fluion right overnight. She was unable to ~Ieep on he' right_hand ,ide Thismovcment pro.oked hel low back pain. ll<:cauSl' of the discomfort, but had some relief when ,oiling onto her back or he,ldt-hand side Rotation left ThiS movcment was ,estricted to 50 !M'rcent of her CIOSl'que~tioning fC\"\"aled some abno,mality of her rotation to the right, and it provokcd low thoracic pain bowel habit with small soft stools. and she often notcd that extended into the abdomen and also includ<:d the herself to ll<: bloat<:d with abdominal distension. as wholc of her ,ight 1<:9. if she were p'<:9nant. and she notedthat~hehad ,elief of many Gfth<:s<: symptoms following defccation. If she Slump Knee extension was limitcd,reploducing her leg and b<:came a lillie constipated. shc d....elop<:d i>3in in the abdominalpain:then:wa~alm05t no range of 'ightlowe'quad'ant.pa~ingintotheleg,andshenoted dorsiflexionoftheankleb<:cauSl'ofmarkedlyincrea~ that this pain tendcd to ll<: worse if her bowel o'bladder abdominal pain we'efull Right hip The patient also had fat intolerance in that ~he The movement of flexion adduction was limit<:d by i>3in. This pain began first in the right buttock. then it ~pread des.crib<:d abdominal diseomfort after euing an to the abdomen. excessi\"\"ly fatty meal. wmination Gfthe paticnt Palpation '.....ealed her to ha.e a blood preswre of 140!190. and Thele wa~ marked thidening in the inters\"inous spaces eJ<ilminition by the naked r;yer<:vcalcd he, to have quite on the right side. i>3rticularlvatthe level~ll<:tween the an abnormal po'llUre with a ronside'abl<:dropped right ,pinous proc<:sSl'Sof l2-4. This wa~greatest at the lllJ ~pace. which wa~ completely obliterat<:d with both old shoulde,; One could quite simply reproduce much of heI and new thicken<:d tissue. pain and ~ymptoms by examination of the spine with fore<:drotationtolhe,ighl T~atm~nt By the s<:venth treatment. which includ<:d verygentl<: Sigmoidoscopy was normal. as was full blood scrffn. lumba, traction, t,ansverse pressure~ towards the right ESRand haemoglobin and WBC. With an MBA-20.and when I first saw the patienl,1 thought sh<: had roIonic symptom~thatthedi\"9no:;to;madeSl>me7y<:arspr<:vioosly ofcholaystitiswas probably incorm:talldthat her i>3inin the right upp<:rquadrant was almost entirely musculoskeletal inorigin.lcons.ider<:<! the'e wa~no <:vide~ofbiliarydiSl'aSl'orany~pticdiSl'aSl'. that 5I1e did not rn:cd endoscopy. and I thought that she <JIould have a birium enema alld some treatment for colonicsymptomsandll<:r<:ferr<:dfo,ass<:ssmenttoa manipulative ph';Siotheripi~t to:;<:<: if she igrecdthat the i>3tient's pain was musculoskeletal in origin.

ThofacicSjlinc 335 .,gu.t 11.34 Patienl'.dimibuli<>nofsymplOm. Continuingthistfeatmcntandaddinginac~ssory movcment5 10 hc, right hip (theacccssory movemcntS from Ll-5 as grade II movements, and small-amplitude Wefc longiludinal caudad while she lay on her left side Smoothgradcllrotarymovementsofthehipwithilina and had pillowsbttwecn her Icgs to make thc hip neutfalposition,it~cameobviousthatshehadtwo position more neut,al)impfoved herfu'the,. separale problcms, cach of which aggravated theothcr when~infYI.Shehadadcfjnitchipdisordcranda ThCSC:lreatmenlswcreC1lntinued~raninte\",alof definite spinal disorder. 6 weeks on an altcrnate day ba,is. Asshc impro_c-d. the ThencxtfOYftreatmentsconsistcdofe.t,cmely gcntlclymbart,act,on.Top\"'rformthis,nothoracicof techniqucscould~progrcsscdbymakingthemiargerin P<'i_icharneSCIwa.u~d;thetwomovablcpartsofthe amplitudeandbybcingpre~redtotakethcltchniqucs lumbar traction couch werc scpafatC{j andblochd in the separatcd position, and the paticnt was instructed lhat into a small degrcc ofreproducc-d pain. At thc end of the the only two things.hc could do whilc shc was on this 6 weeks her mo'itment, wcre almost normal, and shc traetion WCfC to b.eathe and to blinlThc traction was considcrcd she was not hav,ng any real problcm. only admmistcrtl! for 12 minuleS. She fclt that il eased her back symptoms as wtll as hc' abdominal symptoms An interval of 3 wccks was leh bctween her last At the nul lreatment session trcatmcnt fOf hcr hip, t'eatment and the timc when she was reviewcd by the e.tremely gentlc slow and smoothlyc.tcuted g,ade II docto'. This wasd<>nc dtlibc'alely so as tobc able to asscSCIlhclong-te,meffcctsofthct,eatmentmorc fOtationswercu~d,andthisrclie'V'l:dhe'bultoc~pain. dcarly, $hc wa.again reviewed in t2 months. and shc considc'edherselftobc'cu,ed:

Chapter 12 Lumbar spine CHAPTER CONTENTS PassNcaCttSSOryintc~rtcbr;ll_mcnt5 • Introduction JJl (PAlVMsJ JS8 f'assiYc range of physiologiaJ IIlOYefTlCnlSof • (Kneral JJ8 slI'lglC,tltcrvcrtebnljoints{PPlVMsJ 360 Firsl:group 338 S«ondgroup 3J8 • wm\"ution and treatment lectlniqucs 368 • Mobilization 368 • SYb.ttttMuaminatiOn 338 'Kind'ofdoordtf 338 RoaMn 312 311 Art, of symptoms 340 RotatJOll with combined movement ~tions ~haviourofsymptoms 341 longlludinalm~mcntl-) 380 Ac,ltionlF) 381 Spetialquestiol'lS 341 Oebilitating low back pain confining patient History 341 lobed 384 • Physicalcxamination 342 Postcro-,ntcriormovcmcnt 386 ObstT'l,lion 344 Flcxion,cxunsion, lateral flcl(ion,fotation from Functionaldcmonstr3lion/injuring below upwards and 'couplcd'Dyusing the femur m~mcnl 344 Lumb<lrflcxion 344 andpetvis 386 LumbartxttMioo 349 Straiglltltg raising ISlR.COI 387 Slump 388 LatcralfluionOnstiinding) 350 Rotation JSO lumbartraetion 388 G~ V manipulation 394 l §tCfillshiftJSO • Cast historio 397 When applicabk tesn 350 PilpOllJon 355 --------------- INTRODUCTION (1997) suggests that, through clinical trials and w,th Symptoms ~rising from disoroL'B of the lumb~r present knowledge, m., most important sources of low spinearemored;fficultandcomplicatcdtodiagnosc specif1callythanat~lmostanyotherspinalle,'elT.he ba<:kpaina~theinter\"\"rtdmlld;sc(40percentl.the p.lUemsofprt.~ntahonoflo\",b;u:kp~inandaS5QCi­ ~yg~pophrsical joint,; (15 per cent) ~nd the iioiIcroiliac .tro~ymptomsg\"ethemarupulJtl\\'ephYSlOtherapi5t joint (15 percent). There;s httleevidcnce<1vailableas ~t1le clue as to their prlrise source. Ilowl'\\l'f. Bogduk to how disorders of tht-\"e structUre5 C<lll be idenlifiL-d from prt.'<lictabledinical pn.'St'1ltations. The lumbar spine is also the5l'Ction of the spine.' that recel\"'5 the most atl<'nllon from mampul<1ti,,~

338 MAITLANO'S VERTE8RAL MANIPULATION physiotherapists a\"d orthopaedic ~urgeQns, and it is Th\"re is now strong evidenc\" that th\" lumbar intL'C· the a~a of the spi\"e that cau~ the g~atest loss of vertebral discs arc supplied by dL-n5C and microscopic work time, 1\\ demands the~fore that we should be nerVe plexuses originating from the sympathetic trunk prepall.'d to put our energies into determining the and the grey rami communicant~(Green ..1 al., 1990) most successful forms of treatment and also into The~ a~ strong indications that Ihese nerves have a allempting to u\"del\"!itand mo~ clearly the anatomy, sensory role. Therefore, the generally acccplL'<l sensory physiology, biomechanics and pathologies so Ihat both supply to the disc, thai is, thesinuvertebral nerves,are diagnosis and progn06is can become more accurate only a part of the annular innervation GENERAL Nakamura eI al. (1996) haw hypothesized that the lower interverlebral discs have sensory pathways \\'ia For the sake of convenience alone, the manipulative the sympathetic chain. This may explain why patients therapist can think of the lumbar spine in two b.1sic with discog\"nie low back pain have ',·isceral' type groups symptoms amongst Iheir somatic scnsory pains. The pati\"\"! often dL'SCribes his discog,>nic pain as 'sickly' FIRST GROUP or 'nauseous' Th~ l4/S and lSl'Sl int~rvm~bral di= al1': fl1':Qu~ntly There is now ,Irong \"vidence from MRI studies that a ~u= of ~ymptom~ in paticnt~ rderl1':d to the inte!\"1lertebral disc Can be damaged internally manipulati~phvsiothcrapywithlowbackpain without causing pain, and only whL'll th,' damage affe<:ts the outer part of the annulus is somatic pain This group consists of patients whose symptoms arise mo~ likely. This corresponds 10 the density of the disc from the lower two intervertebrallevds, with the main innervation by the sinuvertebral nerve (Bogduk, emphasis being placed on the intervertebral disc a\"d 1994b). However, patients often complain of e~peri· the stTUclUres iI can affe<:t when it isat fault. This is not encing periods of 'stiffness' in the low back prior to an to say that the interverllobral discs at other levels 1le\\'l.'1\" overt disc; disorder, and this may well be the warning degenerate, cau$C symptoms or prolap$C. Hem'ever, it sign Ihat internal disc damage has already occurred is meanl to point 10 the frequency wHh which the discs atth\" lA/5 and L5/S1Ieve1s CauS(' symptoms and are SECOND GROUP ~ferred to manipulative phy,iotherapists. It is also necessary to stale that these two discs aloneare not the Puswrt, musclt balance. muscle weakno::;~. WOndylitk greatest causc of low back pam. N\"\"L'Cthdess, there andarthrit;c('hangeS,mtchani('almO\\'cm~nt has seemingly been an increase in the number of low d;~rd~fS,~tC.canallbta$Ouretorcau~of lumbar disorders occurring in modern Westem society ~ymptoms in patients wilh low back pain over the last 20 yeal\"!i. This increase may have been brought about by the length of time modem man Within this group can be included patients having spends sithng. particularly in the motor \"ehicles of symptoms from other kinds of disorders such as those all kinds, and even more particularly when this caosed by posture, muscle imbalance, muscle ....\"ak· position i, in,ulted by the addition of vibration ness, spondylitic and arthritic changes, me<:hanical (Troup, 1978) disorders etc. Most of the disorders ronsidered in this 5<-><:tion have oo,n dealt with in Chapter 8. As well as h.wing hydrodynamic and biomcchankal propertiL'5, the intervertebral disc may have a proprio- SUBJECTIVE EXAMIN:;;A\"'T1;::,:ON'- _ ceptive role. Note Ihat patients wilh discogenic prob· lems often lose their position sense and e~hibit poor Table 12.1 sets outlhe examination pattern, but certain quality and control of movement; proprioceptive dys· points require e~pan5ion. function as w..11 as pain inhibition may contribut.. to this. The patient may say. 'I feel as though my back is 'KIND' OF oIS\"O.;.RO,,'.;.R _ like glass, it just docsn'l support me'. Pas,i\"e mobil· ization may also influen,e th\" recovery of propriocep· In the majority of cases the patient's main complaint is ti\"e functioning of the disc (Zusman, 1985) /mill, either in the back, buttocks. lower abdomen, gmill Or legs. Any functional limitation will give clues

u.mbirspin~ JJ9 Table 12.1 lllmbarspine. Sllbjecti~e examination 'Kind'ofdisor(/.,. ESlablis/l\",hylhepatienlhastl(enrefemfororSOllgMlrealm(nt, j;) ~in,sliffness.\",~aln('iS,instabHity,.tc (ii)Al:uleOf\\S(t liii) I'ost-surgical,lf1uma, MUA,support, traction, (tc. Hi,tory R«<ntandp~ouslste'History'brlow). ....~uenttof~u~t;oningabouthi'toryr.nbr •• ried Is the diso,u\",. OM of pain, 'tiffn~ rffIj\".n~. w.akness, etc? Rtt<>rd on the 'body chart', I. Area and depth of symptoms indicating main .,ea, .nd 'tating types of ,~mptom .. 2. ParR'ilh..i.and.na..th..... J.O,,:dfo.symptoms.Uothefassoci.tedareas.i.e.: til othef~rtrllfalaf.as; (ii) joint,.boveandtl(lowthedisof'def: {iii! other <l'levantjoints. B.\".vlou.of Iymploms (kne,..1 1. Wh~naretheyp .... ntorwh.ndolheyfluC1u.t•• ndwhy(lo<:..la\"dreIClredl 2. Effect 01 rest on th. \"\",al ..nd referred SymptOml (..sso<:iate/disso<:iat. with day'S aetiviti~. tl(d, inflamm.tion). IComllllre s~mptoms On ,ising in th~ morning \",ith end 01 day.) J.Painand,tiffn.,;son.ising;du...tionof. 4. Effectof.C1i\"ili.... (~inningofd..ycompa,.d\"'ithendofd..~.) Particula. 1. Wn..t p<o>'I>I<~ symptom, _ \",h\"l .ell~s (~rity. irfltability!? 2. What fsth. pain likewilh ..cli.iti.,th'l invol •• the 1o\",•• back (particula,\",lloion)? 3. Wh..teffectdoes\"\"lngh.~onthebl.kllllinandthelegpainlo.oth.rSUstainedpos.itionsl? 4. AnydifflCUlty.isingf.omsil1ingorfi\"tf~\"',t.psl 5. What.fftttd\"\"coughingo,,,,..,ingh.,,,,onlh.,ymptoms(badind/o.legpain!? Sp«i.. iqU'CSlions 1. [)xsthepati.nth..~.nybl.ddClre\\(nlion.or.n ...thtsi.inthisare..! (ClIud...quin.. compre\"ion) (initial fr(ljuency may indicate cauda equina irritation] 2,Gene\"'lhealthandf.~nt\",.ightloss. (Medic.1lhhtor1-! 3. Ha•• f'CentXo\"'YSOl:en taken? 4. Wh..ttablelS ..n:bl:ingtakenlorthisandoth.fCOnditionsl\",t.oporo,isfrom.xlensivcm,oidth.\",pyl? History l,Ofthis\"ltack 2. Ofprevious ..ttacb,ofof ..sso<:i.. tedsymptoms. 3. Af. the symptomsworstning Of improving? 4. Priortreatm.nt.ndits.ff.ct. S. 'iodo·tt<>nomkhistoryll5.ppiic.ble

340 MAITLANO'S VERTEBRAL MANIPULATION to the likely findings on phySkal examination - for manipulation for low back pain was reviewed, and the example, 'I cannot put my socks on in the morning'; advisory groupconclude<:l that '\\'Vhen I lie ,m my front or arch my back a pain shoots downmyk'g'. Witl\"\" tlU\"firsl 6 Inns \"!<>nS€1 lJ!acul,' low bark pain, m\"\"ipulalionprm.,idcs bellrrshori-Ierrr, Lowcrlimb:;poftinginjuricssuchilshilmwingtcars, im,JrlWl'mc\"lilll'aiIIUlulartit>ilyll'l....lsmldl'igl1rr m~dialligam~nt sprains of Ih~ kn~. achill~s palienlsatis!acli\"nlllm,tlwlre\"lme\"tslowl,icll,1 j(ndonitis,ankICSJlrains.ctc. maywcll ha\"C a spinal !lasbcrncompared. contribuling faC1or. The hislory (onsct,pr09rcssion) is vitally important Most ,~sca,dl pfOgrnmm~ on low !>ack pain f.ilto tilkeinloacrountthewidevaridyofciiniCillproolems The manipulative physiotherapist should payalten· th~ pati~nts present wilh. Grouping of p.ti~nls n~eds tion to patients refern.'C! with lower limb 'joint' prob- to~ mo\"'~ficifthcdfi:ctorman;flUlativc Icms or lower limb sporlmg injuries, Topickupona i>hvsioth~raP'fis 10 t>l' d~I~rmin~d uscfully spinal rontribuling factor insllch cases can bc \"<'ry rewarding. Yct with aU tile programmes Ihat have bet'n published \\andth\"reo1remany),non\"oftheauthors~mtoreal· For example. a patient referred with a chronic i~~ thai ~ patient who fet\"ls pain as a very localilecl sprained anklcre\\\"ealed: 'I fell and twist('d myankl(' spot, for example betw<\",n th\" spinous processes of U lOmonthsago,but the pain on Ihe olliside of my ankle and LS,doesnol h'l\"e the same problem as the p.lhent is still making me limp even though the swelling and whoha~painspreadingina line across his back at ll>i' bruising has gone. I rubcreilm on itbut it doesn't make U/5inl<-rspinousspacc.Nordotheysccmtorcalize any differeflcc. The doctore\\\"{'n gave mea rortiSOfl(' that a patient who has a band of pain across his bad, injection and it's still thesame.l\\·egotnoconfid<'TlCe whkh may extend superiorly to L30r L4 and inferiurly in it'. Qn furtherquC:itioning the patient said thalh<: to 51, is different again, as is the pahent who has a had an ongoing back problem, which he had lcarnt'd bandofpainsp...,adingacrosshisb.ackalthemiddleor to lil'e with. Ill.\" did remember twisting his back when 10wersacr~J leveL These areas of pain that hav'ebt'en h('fdl,resultinginstiffnessforafcwdays. mcntion<'<! do not take into account the differences thai exist if thepatienl has pain thai spreads across his Physical examination reve,lled tendernl'SSowrlhe back but isgrcateron One sid,· than On the other, orif lateral ligament of th(' ankle, but no increase in the his pain is only felt ollone.ideofhis back. Similarly, painwithmo\\'cment.SLRwasshghtlyreslriCled,and thescarealldiffercnt from the pati<'Tlt who fee1shis his lumbar quadrant rc\\\"{'aled local back pain and stiff- pain in the area of the sacroiliac joifll or in his gluteal nessonthesideofth('anklepain,Aunilateralposlero- area,yet thesc arc still frcquentlyclassed in the b.ack anterior p,,-'SSure On l50n lho! same side as his ankle pain grouping for survey purJXl!'t'S. 1t is Ihe author·s pain waSl'ery 'tender'and stiff, and also madchis belicfthalforanypro;ecllodelcnnineuscfullythccffM ankle ache more. Two treatments later, by mobilizing of manipulative treatm<'Tlt, the grouping:; of patients his lumbar spine, his ankle pain had gone must be made rnuch morespt-'Cific. And this is rclating the problems to·site-of-pain' only. The behaviour of the AREA OF SYMPTOMS pains then n-.:ls to be classified into separate groups. Research Sile Many attempts have OC'CTl made to carry out rescarch The sile of the palient\"s pain is as imporlant 10 deter· progra\",meslodelcrminelho!efficacyofspecificlreat· mine specifically a. has wn described for the hi&!, ments (commonly manipulative treatment) for low cervical a...,a (\"\"\"p. 231). This is particularly SO when a back pain pati<-'Tlt has pain in the region of the iliac cm,t. It is CS5ential 10 determine whelher the patienl's pain is in Asyet,th\"re is no 'gold standard' I'L'Searchon the faci imm<'diately above thll crest, On the crest, C1I dficacy of specific treatment. for low back pain. How- immt'diately below the lip of thecrc51. Similarly, when ever, in the Unitt'd Kingdom, encouragement has a palienl has gluteal area pain it is neressary lodetcr, been given to manipulative physiotherapists by a mine whether this pain is felt medially, centrally,Of National Clinical Stando1rds Advisory Group documc.'t more laterally; it is also essential to determine whethef (CSAG.l996).Ailavailablef'<\"Seilrchon trn,cfficacyof

lumbarspint 341 lhe pal'.....1isable to dIg a finS\"\" mto theglulNI are., to lhe phys>cal eum\"'Olhon she may nt.\"fd to look for tesl mo'ements that pro....d .. dJff..rent parts of lhe symp- deftne lIl.:! spot of p.ain or \\<ohcther he is unab'\" to do IOITI$. if there is any hkelihood lhal lhey may b. com- this and can only dl.'saibe the pain ..\" being >agudy :~~~;\"~lstn>cturesordLffer\\.\"'I..spectsofthe ~aledinthebuttock.. Pam fell OIl rnughing, 5I'lt\"ezmg or slr..lIUrlg can When a p.allent ha!i sym~oms that radiate mto the proo.\"ide useful mfonnabon. For eamp...... patWnl legitise5lSO'Tlh\",ltodffi'nmnetheSlteanddepthdthe ,,\"1>0 has back pain that ra.hates into ~ leg mar. on §}\"mptoms. ... hile al the same time diffenonlialmg roughing, pr'O\"'okeback pilJn.IIO'We\\~, It maybe that belween the kmds d §pn~oms that a p.1henl <:an fl.'l.\"l it i~theJegpam thai ~ \"l'rod~bythecoughJng.in For elWllple. the symptoms may be !hose of a da-p \",hich case his s)\"mptoms willllE' mud\\ ll'lOn' dtfficult .:tv,'\" ~rp f'o\"n.'\" burning feeling. a he\",,\"} ft-\"\"iIlg.'\" 10 rd....·e than ....oukl have been the c~ if the cough- fet'ting of nU11'1bnes6 thaI is in factn<JI In aetLlilI d,m,n- \"'g had pf'O\\.ok,j p.111\\ 11\\ hIS back onl} utioo of _hon. or'\" feeling of tingling or ·pins.and l'Il'l'dles', The p.ahenl may \"'00 rommenl \",bout cramp Again. '\" patJenl \\<0 ,m pil11\\ r..d,..llng mto Ius Itg.. (.and II islhen necess.ary for US to dcteI\"Tni...... lwther .. hoon gethngoul of a chaIr .. ftt-r prolonf;«l SIlting or gelling oul of bed fi\"'l thiOJl: in the morning has diffi- he is '\" persor> who frequently\"\"\" cramp or not), a culty in Straighlenin~ mlO the normal e,,'CI pa5,llOn becauiit' of back pain. h.l~ quIt.... different problem to \"''''nn fa-ling or '\" coldness. II is aoo neress.ary 10 lhe pattent who l1> Olb1e 10 hland Imm...halely but has ddemllllt' whetht... pa'ns in different \"'reas increase dlfficultv wilh hill first kw Sleps becauiit' of se,ere ll'g and d<'Creaiit' \",t the same lunes as each other .md for pain. The lall\"r patient luis a disorder tluil is far more difficult to help th.,.. lh.. fOnTll'r. Other aspects of the thesamerea.soons,orwhethcrtheybeha,·e~rall'ly, behaviour of th.. p;,lienl's symptoms are hStl'Cl in Ilw 'General' and .Particular' sections of Tnbl. 12.1. \"'00 whetm... one \",re.. of the ,ymptoms is greall'r than lII'lOIhl....,lnf3CI,'lisabsolutelyessenti<llthallhem.111lpU· lall ..e physlolhoo;,rapi!il silouid be abl\" to 'liw' aSp'-ocific p..tient's symploms in her Own mind Three Ihmgs in particular should be rcm\"mberl'Cl when con,idrring arca of ,ymptoms' I. A palil.,,1 can feel S}mptoms«\"Tltrally in Ihe lower SPECIAL QUESTIONS. back. yel lhoo;, origm may be in lhe upper lumb.,r. l\"'enlhor.J<:(llumbar,area_ As \\<o'ell as a~king the obvious qll!'5hoM related to gen- 2. A pilhenl can ha, e an iln!a of genera1i~ lower eral fIk-dical condilions. elc,. it is p.artlCUlarly import- abdoITu\",,1 symptoms lhal ..riiit' from .. low lumbar ..nl to determi.... whetht... I i!> anv indicabon of dl5Of'lk>r Ottasionally (bul far 1CS6 ~uently) svm~0!n5 may be fell uniLamally in the Io<- ..r cauda e<juina inml'emenl ( p 18) N..turally. such a p.1tJent ....ouId n<JIbe ..dem.-d for man,puLtti,elre..l- ..bdomm. in the groin, or '\" en in the \"\"\"tlCULar \"''''\" men!. but there is lho! po&:>ibilJly that tho! first signs of from the Io<--t'f\"lumbar di:5on:lt'f\", 1I\\\\'ohement ma\\' n<JI become l'\\'Jodlont unhl ..ker the doctor·s referral and before lho! man,pulah\\e ph,-\".;o. 3. Sonw pabents wllh d ~ in\\ohing the low lher.lpLSl·S fu5t consultation lumber ......... 1' roots ('3n !\\a\\'e §}mpt0r\"n5 thai theY describeoll5bemg·in·theknf.eor·in'lheanUe When ..tternpttnstodiffi.=ntia.lP.... towhctherthe:ieS)·mp- HISTORY tom!i~ammgfrornthebacl<orfromlheloc.Jjoint. thl'JXMIblht\\ oftheu\"betngrelated to an old ITl/Ul')' All other aspects of lhe5Ut,ectr'~l'Xam'\"\"tiontable tothepart..:uLorJOUllmustnotbl-lorgottm. are slraightfo.......rd ~nd obvious. bUI some comments should be made ..boullustory for lumbar dISOrders. BEHAVIOUR OF SYMP~TO;;M;;;S _ An a<XUrale hislory i!; most importanl if the manipu- Lati,y phy,iother\"plSt IS to hiI\\'1l any idlla of When a p.lti',,\"1 ha~ S)'mplOms in his back.. buttoc:k ..nd The 51ruclure or SlruClures Lll\"oI,·oo k-s- thu symptoms may vary ,n inlet\\!iJty at tht same The stale of the struclu~ in\"oln-d time as Nch other. llowe\",~r, it is nol uncommon for The rate of progression of the dIsorder, especially the back or bUllOCk symptoms 10 fluctuate al quite dif- if it is one th.11ll'ndS to haW.1 '''1Iural prog~ion_ fl'o.'l1lliml.'ll and for qUIll' diffe\",nl reasons from Ihose 4 Thedegrreofstability of til.. di\"..-mleral the time inhislcg. of Ihe initial col1Sllllation. lJelermininj; th,' diffeTef11 behaviours helps Ihe 5_ The likelihood of beinK able to help the pati\"nl's mampuL11\"'\" physiotherapist to be aware that during diwrder ....ilhspecifickin.dsoft~'iltffi(\"\"t

MAITLAND'S VERTEBRAL MANIPULATION MECHANICAL LIGAMENT ARTloiROTIC ~SClNERVE I 8LOCKI~ SPQNtIVLOTIC ROOT AND ~su.st \"\"'''''(Sprar1,SlI..., <Ml'\\IMI,lltioJseelc,1 6 Thelikly prognosis for the palient's disonkr, and lumbM spine. Coughing and/or sn<''ezing would also the future 'management of the disorder' in tL-nT\\S of probably pro\"oke back pain. 5elfhelpandtheroleofmanipulativephysiotherapy. Asthl'di5cdisorderprogressi,'elydl'terioralL'Sfrom At the beginning of this book it wassugf;L~ted that episod\"toepisod\",itwillfollowoneoftwopaths. patients could be divided into groups (fiS\"1'f' /2.1) first is Ihate<lCh episoderesult,in back pain onl)'-TIw l1lehistory for the group ofpalienb with symptoms 5<.'Cond path is that, with each increasingly progressing arising from sprain, strain, posture, misuse or abuse is episode, the pain sprc<1ds from theb<lck intOlhelimb obvious and easily determined by appropriate logical in,-\"riouslyincrcasil'gdegrcesandmay,inthelaler questioning. with which all readers are familiar stages, includl' neurological chang<.'S lumb.:lr dis<:og~nic disord~f~ follow faiflv common Therc are many variations of nftrred pain and radicu· pallCfnsintcrmsofcpisodicprogrcssionand behavloufofsymptoms larpain,.md It is not the intenlion to discuss these in differential diagn05lic terms, as it is not the aim of this The histories of patil-nts with low lumbar discogenic book Ralher, the information given in this chapter and disorders also follow fairly ,ommon patterns, both in in Chapler8is to give the newcom,,, to the field of theepisodicprogressionofthedisorderandilllht' manipulative physiotherapy an outlin\" of the com· \"\"haviour of the symptoms. There L~ an elemL-nt of thl' monlyseendisorders hi5l0rythat isindicativeofa low lumbardiscogenic disorder,whkh also helps to guide the appJ\"L'Cwtionof Themechanicalblockingorlockingt)'pedisorderh.ls both theS<'\\'erityofthedisordl'rand tru,staS\"0fdl'vel- th<:'suddL-n severc onsct hislory, and totally p\",,'ents the opmt'ntof tht'progressionofthedisorder.Thiselem- patient rctumingto the upright posilion.Thiswasdis- ent is that the patient may be aware, frequently at the cussed earlier (S<'t' p. 232). With \",gard to thl'arthritk endoftru,day,ofaslil;httwingeinhisback,usually spondylotictypcofdisorder,therc is One important as.sociatLod with a trivial lifting or twisting incident. He point to be menlioned. \"The history is the s.1lTK' a!; the is able to continue working. but when either he coots sam\" kind of disorder it prescnt!; when in the limb joints. down later, Or wru,n he tries to get out ofl>t-od the next In lhespine, however, if the onset indicates involvement morning, h\"is,·l''}' much aware that he has a 'bad ofa single intcn'l'Ttcbral level and thisk,'cl is only ooe back',Thedegrreofthepro\\'okingincidl.'lltisthecom- of5('veralll',-c1sshowingthes.lmeradiologicalchangeo;, parison that pro\\'ides the information regarding the it can be clearly 5.1id that it will be \"erydifficultlo state of the disc disorder. relicve the patient of his symptoms, Con,'ersely, if the symptoms a\",diffuse aching arising from S<'veral adja- Symptomatically, thl'pati\"nt having a discogenic cent lc\\'els, thl'chanct:'sofmakinga\\'aluablcreduclion diwrder ,ould expe<:t to have stiffness of his lower in thl' symptoms are prffiictably Vl'ry good back on firsl getting out oflx..J in the morning, whkh would last for betwL'en 10 and 30 minutes. It would Obviously, the foregoing does not provideco\\'erage also be likely that after prolonged silting he would ofthl'historyofall disord\"rs the manipulalive phys;o. han~ difficulty in standing straight on first gelling out therapist may be asked totreal. Howc\\,er, it is hoped ofachair.llewouldprolxlblycommentonhavingdif- that it opens her mind to the kind of questions sht ficulty getting out ofa motnr vehicle, it again o.-ing should ask to elicit the kind of problem thepaumt difficult for him to stand >Iraight. lfhe has difficulty may ha'·e. There all' many reference texts ll'garding getting in and out of the car, it may be thenL'Ck flexion thl' subj<'ct including Praeticlll DrillO/JaMle Mtdlmlt (a neural sign) component of the movement that is lhe (Corrigan \"nd Maill<,nd,t983) problem ratherlhan the straightening process of the PHYSICAL EXAMINATION Table 12.2 summari,.\", the physical e~amination for disorders of the lumb<lr spine

LYmbar~iM 343 Table 12.2 Lumbarspln~PhysicalVlamlnatlon \"\"\"\"',- Gtlli\"!lOlllofthc ......... w __...,...,...to_.~'t.jlO\\l --~usUl'lll,r>g l){/>tfJO<\"ulquodl~ \"*\"\"ro.-._loli\"\"tF.E.Lf.<D_®_AoI\"<Dand®and,ftflftd(:IlI'....... ~...... \"\"\"'ltn\"llI\"lc<1N11:6cfgnnoty, lo<aItz.\",..--~~,;\"WWrtrtlral-....mlrtpralrcl_l.lftc:rnwdoprftland/or for~tu\"\"'JD'ftll;doF.E.Lfalt\",1tanoI .... froool~upwardl,byU!Mlg~_lwtItn~AlYl o:ombiftrcI_l_ utt.... ~sMt. Whmappl~ s..m'I\\rcI(andLf(O ...anlsp;l\"(\"'I'I«tSSal'fIO~prodll«pI,n~ lkIadraftul;fF. E.Lf. ;N;!Rot\"a..., ~uwl Taplntf'ff. E. Lf. Rot\" al'ldOmntgalivt) COI\"'prnsjona\"d Il'stra«ioft [if f. E. Lf. Rot\"and 0 al'ld Tap an: ntgaliw) tffilrolog,caf!calf) .....liwpt\"pIltraljo'ntlnts. CanaltnlslsJumpSlttorlg) Supint l'assi.e ntc~ f: IIngt. pain (b.d Indlor Itg I»,nl (Mav n:qu\"c comb,n,ng with <Jump-sitting & suq ~~St.R[Slrlighlltgrliloi\"g):\"'ngt.pa,ft. (Compa\"\"Sup,ne w,th \".ndil\\9.) SO Nwrologocalua\"'inat;OI\\- ~lrclslalo(lntsfor~l.1rpa'n. (\\'.'ht\"a~abltcompa~fal'ld/otSt.RiftsWIll'''!l'''lnS/,lp'oeJ l'a$o>,<:pr,,~tJO,fttlna. Instabiltyl& -'-tlIUtlOftfrooolbtlcrwu~iIN:I·t'OI.IpIIftg·bvtlSl\"llkn>u'-ptMl. Ultra, tk_ f11IIn bdow upw;l<t2ll>y ....\"9 pt~ huMMllp<or>okl'ftbmdl. NaI~'c.....' _ Ilt5istrcl<Ulo(t15tsfor\"'5CU.¥pain. hiIII''*' Sof!-t_palpa'OIIII'106dt.,nlmflllllMspitt). f'I:K.ol_of>,<:o1~ InttM1ft'bt;I~_ftWlIl Combon«AAM.!I15ts\"lhployl.iologial_ntpoSltoOM. Pas\\kpcf.....ralpftllats. SocW~r>g I'PIIIM F.E.Lf.RoI'aIldF/(inm'b\"tylnts. &;\"\"nll_ of aiM!' r.kYo\"t factOt'i OTH(~nSTS o.('Ck·tastIlO10'S·fo\".portsofr.INantt\"I'(X-~bloodtcSIS)

344 MAITLAND'S VERTEBRAL MANIPULATION OBSERVATION injurLod him. This movement principally in\\'oh-esrou\" lion of the spinl' and hip. By using the lumbar spine! When watching the p.llient's lumbar movements of hipdiff\"rcntiation test describ<..:! on p,lges 162-16J, f]exion,extension,laleral flexion and rolation, notice involvement of the spine rather than Ihe hip maybe shouldinHially~lakenofthegross5pinalrangeand \"l\"\"aled{oroiCt\"f\"'rsa) the pain responsc to the movement. This may wdl ~ Furthcr brief apprai5.;l1 of thf! spme and hip will con\" the first asterisk used for a%e$mcnt purposes_ The firm the need toex.lmine \\he spine or hip in more detail \",-\"'ond aspect isto notc(during the movemenls) the Trt:'atmentshould then reinforce the initial hrpolhl'Sis appearance of local intervertebral mo\\'ement so thai if Further differcntiation of the functional demonstra\" lateral flexion, for example, is limited, the statement tion or injuring mo'\"ement may Ix:: of valu\" wn...'fl may be recordl'd thM Ihc limitation oc<:ul'5 mainly impro\"l'menl has slo.....ed or SlOpped. Afler scveral from L3 downwards. Watching Ihe mO\\-ements from St-'S,ion5 of treatment, the palientmay ha.-elo strctcna these twoaSpeclS (i.e. Ihc gross mowmentsand the lot further into th\" backhand shot 10 reproduce his local movemenls) can be likened to taking a photo- p.1in. Furlherdifferentiiltinn may reveal that lumbar graph with a wide-angle lens for the gross mo\\'emenl, extension and latf!ral flexion to the painful sideaddsto and a sccond movement using a telephoto lens to thl'bullock pain bdngn.'Produredby rotationoflhe highlighttheloca1izedlimiledmo\\·ement. spincduring the backhand shot. Therdore a lumbar Anysignofaprotecti\\'edefonnityinstandingmllst rolation trcatment technique in lumb<!rextension and be noted and correctl'd (cj. laleral shift rorre<:tion, ipsilnteral lateral flexion will bea \\'aluablele<:hnique p. 350),Thepatil'l1IShouldbeaskl'd iflhisisa normal asaprogressionoftrealmcnt. stance for him. Ifit is indeed prolcct:i\"cand only asso- ciall'dwilhepisodesofpain,hcmayslillsay,'Whatdo you mean\" or 'This is usual for mc'. Sometimes when LUMBAR FLEXION il isml'l1tioned to Ihe palient's spouse or partncr,lhey recall having noticed il coming and going wilh thc Examinationoflumbarfl~ioncanincludc' epis.xk'S of p.lin. To make the piclure clear, th\" delonn- itymuslberounlercd.lfbypassive[ycorn'Cling{coun- • Forward flexion (FF} wilh ovcr-p'~ssure and relurn tcring the stance or mo\"emcnt) orovcrcorreding the to tl1~ upright position ddonnity thc patient's symptoms (associated with this episode) are changl'd or reproducM, then the • CI~aring I~SI of lumbar ~xlension fromfull flexion antalgicposture is related to this painfuJ episode. This atspecd may then ser\\'e as another important asterisk to usc duringreaSSl'Ssmenl • CI~aringlestofsuSlaincdovtr-pr=rcinfl~xion, fluionrotationtl1cnrapidlyintofullcxl~nsion • Forwardn~xionwilhtt:rvi\",lfluionaddcd • Forw.rd flc,ion with rot_lion to the I~ft _nd rigl1t FUNCTIONAL DEMONSTRATION/INJURING add~d MOVEMENT • Halfflcxionplusrolalionlcft_ndright • Fluion from b~low upwards The patif!nt will often be able to dl'Tllonstrate a mO\\'l~ • Flcxionwithanyprot~ti\\ICdcfo,mityeountcrro menlor aclivity, involving the lumbar spine, which reproduces hi..'i symptoms. This may be a daily activity that hekno.....s hurts hisback,such as bending for- Forward flexi\"n is a very important mo\"\"ment in ~ wards to tie hi..'i shoelaces. He may also be able to lumbar spine, and shouldb'-'examinl'd in depth and demonstrale the mO\\'f!ment he was doing when his with intimacy. Smooth, even unrolling from above back was injured-for instance, a backh,lnd at tenni..'i downwards occurs during Ihf! normal mO\\'f!ment By asking the patient 10 demonstrate such an aClivity R{'(o'\"eryfrom flexion to the standing position should or injuring movement to Pj,ortothe limit thether- also ~ a smooth mo'\"ement. I !owf!ver, a palicnt may apist can analyse the range of movement, symptom hal'e what appears to!>c a normal mO\\'ementduring response and qualily of mo,'ement. Thus she hilS her flexion but dilficulty in dropping ill10 thc normal lum\" first asterisks for reassessmenl b<lr lordosis whl'l1 rt:'tuming to the upright position. Differentiation at Ihis stage may help to confirm the This is an import,lntabnormality to be noted, and it structures at fault if there is any doubl. Forf!xample, musl beeliminak'd iflreatmcnt is to be successful Ihepatientmay~ablf!IOreproducehisleftbullock Taking the considerations surrounding lumbarfl\",,\" pain bydl'11lonstraling the backhand tennis shot that ion one step further, it may be nccesSJry to pro\\'e tlut

lumb;\"\",i... 345 the pahl\"nI'sdLSOrder has not bemromplclcly I'\\5Olwd While still considenng ~ion. ,md needing to 1he fQllowmSdl'aring t<5t of forward flexion should pro~ethatthedisorderhasnotcompletelyresol,'ed,a be perfOfmcd_ First, the patient ~ asked to exh.'fld further variation should beex.amuw:'d.Su<:htesl$a.'i backwardsasfarashecanandthephyslOlherap.st thIS and the one de5Cribed ..bove should not be per- sust.a,nsh'minthlSposilioonbygi~'inghimgeotlesup­ formed if, on the normal aamin.lltlon of mo...ements porl\"-luIesusta,mnggl'fltleO\"er-Jlft5SW\\'.Beforethe and palpation, it isdr.'1OUlI that lhedisonler hils not pabenl mo>e5 from this po$Ili<n, and \"'hilo,> the pos- been A50h~.n-.. spKial testf should only be used ,tIon IS betng SUStatned, she e:<pla.1f1S 10 tum that when ascJe.ring tesb. To perform thls test the patient IS s1w ....}1l'bend kwwards NOW',he is to bend forwards ~loflexfullyand5U5tilmthepo$lhon(ltmUSlbe from the fuU) e ..;tended posibon 10 the ltmll of tus painles5). o...\".-pres.su... is added 10 the fJa;on and rallb\"eoffor... ardfko:,;ionat~ximumspeed;andthen sustau-l (say fOf ';\"10 seconds). The patienl then nnmedialely and as qurl.Iy as possible CQIl1f' up from tumsltishead.thcM'\"uandlumbar'i',nefuU)klthe the fulh- fIe><cd poslllOf'- to the normal upnght stand- left, and this pos1tion is sustomed .. lib O\"'·er-J>l\"'S6Un'. mg po5lbon. Any dlStuJ'baoce 10 the normal rhylhm of ll>esame proct'du... is perlormed With rolation to the mte.....erteb...l mo>emenl indicates thaI the disorder oppos,te Side, and the palJml then I1'tums to the has not b<'ftl complelely resoh'ed. 1he normal ~p\",e Slraight position. still susblinmsIus fuU Rexion.It~ will roll and unroll ..·ilhout any distortion of the then explauwd to Ium thaI he IS, a~ rapidly as pcw;ible, rhythm of intl'l\"\\crttobral rno'ement toretum to the upright pos'hon and pass beyond that

346 MAITLAND'S VERTEBRAL MANIPULATION to a fully extendL'<l position. The normal spine will then turn his shoulders and trunk to the left, This i~ a show no lendency to a lumbar kyphosis at any stage of cnmbinl>d mO\"ement of flexion and rotation to Ihe left. this l'l.'Cov\"ry (or e~tension) movement, and Ihe move- Over-pressure can be applied to this movement, and ment should be smoothly eU'CutL>d its pain rl'Sp<)nse mUSI be notl:.>d. This i~ different from the dearing test described above, because there is 1\\0 During Ihe normal examinalion of lumbar fl(\"xion, 'sustain' comp<)nent to this tesl movement. To add time can often be S'WL>d and information quickly dis- rotation 10 the left the physiolherapist stands on Ihe covered by adding two tests. The firsl tcst is adding p<1ti\"nt'~ left side to slabilize hi, I\"\"ki, betweom her c(\"rvic\"l flexion once the pain response 10 the normal pelvis and her right hand, which gra<ps Mound the o\"er-pressure (or to 1'1') 10 flexion is known. Any p<1Iient's lefl iliac crL'St, Sh\"thcn \",acM under his ch.1nge in the pain fCSp<)I\\5C (in the lumbar spine, but· thorax to grasp his right shouldl'r posteriorly. tock or leg) once Ihe neck flexion is addL>d Can be attributl:...J to movement of Ihe pain-senSitive Slruc- Over-pressure 10 Ihe rotMion is achien>d by the tu~ in the vertebral canal rather than to any chanb\"e physiotherapist pulling downwards lowards the floor of the moV<'menl of the lumbar intervertebral joints with h,.. ldt hand and a»i,ting the backward. rotation (Figure 12.2) of the paliL'Ot's lefl thorax by the use of her ll'ft arm anterior to his lefl shoulder. The rotation is Ihl'O per- The second addition to the flexion test is 10 ask the forml-d to the right (Figure 12.J) patient to fold his arms, turn his head to the left, and Figure t2.3 lumi)arflexion ove'-pres5Ure ~l!ding rot.tion \",ith over-pressure. [01 Rot.tion left (t>! Roution r;g~t

lumbafspin( 347 If lhere is any sign ofa protectivedefonnity (em,. pelvis may displace backwards on the opposite side nrouslymllt>d'sciaticscoliosis';Maitland,I%I)dur- Nor does heml.'lltion thaI these lists may be p\"-'Sent inganylestmo,\"ernenl,thelestrno,-ernentshouldbe only on extension. In addilion they may be present in repeated with the physiotherapist countering (pre- conjunction with a protective spasm of either the venting th... dcfonnily laking place) the prulL>cti,·... flexor or extensor mu»eles.or the flexor Or exlt-nsor defonnity and assessing the change in pain response spasm can also be present wilhout any list. Wht'n If the pain response inm.-ases dramatically, thedefonn- spasm is present in the extensor muscles. response to ity on movemenl is dinxtly ...,Iated to til<' disorder treatmenl is slow whether this spasm is bilateral. Caus.- causingthep.~tienl'ssymptoms,asdiscus5Cdearlier. ingamarked lordosis localized to two vertebrae. Or ~Se2.e(195S)dt'5CribesandHiustraleslhecom­ unilaleral. moo varieties of protective deformity \"ery dearly He Movement in thelumbarspinein particuLarhasone states that the L5 sciaticas cau5C<! by the U/S disc are fascinating feature: its movements can produce accompanied most commonly by a contralateral list, entirdy different pain responses depending upon while the ipsilateral liSI occurs more frequenlly with whether the movement is perfonned from the lop 51 sciaticascaUS('\\\"I by thelumbo!iacral disc. Lumbar downwards or from the bottom upwards. kyphosis occurs with e<jual fre<juency at the U/S and All of the basic lumbar ph)'5iologiml movements lumbo!iacrallev\",ls. Somelimes the palienl\"s inability tesled in the standing posilion Can be perfonned by toe~tend his lumbar Spinl' or laterally f11'X il towards the patient from abo\"e downwards (whkh is what the painful side is exp\"-'ss•.>d in a ont~leggt'<! stance, most ...xaminers would dO,and becontt-nt with tn., wilh the leg on the painful side resting on the ball of pain response answers obtained) and also from below the fOOl wilh the hip and knet\" slightly flexed llpwards. F'I?\"res 124-127 explain the example,; Allhough~Sezcdiscusscstheallematinglisl,he Rotation from below upwards is of particular \\'alue does not mention the arc of list that can occur during whenlhelowert\\\\'ointerverlebraldiscsare5uSp<\"Cled forward flexion. lllis may be seen aSa deviation of the of being a source of symptoms. It may also be helpful patient'sthora~toonesideduringlhemiddlethirdof in d~'Ciding the direction of rolation as a treatment the flexion movement, orallematively the patient's tt.....hniquelxlS<.>don thedl'5iredefk.....t. Fore\"ample,u Fig~.. 12.4 lumt>afspin. fi.xion. (a) From al:>ove downwards. [bl ffOln below upwards