Maitland's-Vertebral Manipulation - 7th edition

34B MAITLAND'S VERTEBRAL MANIPULATION Ill] IIII figu.. 12.!'> lumbar.Mvclrmiorll... F......\"\"\"- ~j dow~'OQrds..ftll Ffom bdow Ul\"Q'lIs /\\ if it .......Figu.. 12.1Lu ipInr~h..\" . . . . . . .~ ~ l O n O'OUtiontot~Itft.I F1Ol'l\"\"\"-dow~ward5.ltllFfombeloM Figu,. 12.6 lumba' ~I'\" la\\rf~1 ~••lOfIlrfl. (01 ~mm abovr downward.. lbI ~,om brl..w upwards, Ioitch,ng I.ft Io,p./d D,opp!\"9 tIIr righlhip

lumbar lpin~ 349 rot.ltion from below upwards 10 Ihe righl \"'produc~ comp.1Tison wilh a pain-fr<-'t' arching backwards of his so;,vere rishl calf pain and Illlmbness of the righl big Irunk.This response is accrntualed ifspinal exlensiol1 is toe, but rot<1tion from below upwards to the left only Ihen added to lhe pelvkextension. When arching rock- reproduces b<1ckac~,rotalion of the pelvis 10lhe LEFT ,,-ards, lhe movenwmt starts from thl.\" top and gradually would be Ihe diK'Ction of firsl choicI>. This would be Ihl.\" low.., joints take part in t:h<' movemenl, and il is more likely to influence the intervertebral discs with- possible thai Ihe low lumbar area is SO protected b} OUI provoking the nervl.\"-rool symptoms muscle spasm that the mOVell1e'Tli is pain m't'. If the extension movl.\"Tl'1Cflt is done in reverse by moving tho> LUMBAR EXTENSION pt'lvis, the il1te,,·erld'ral movemml starts from Ihe low- l'Sl moving joinl and t:h<'n il eXlends upw<1nb. If pt'lvic A patient wilh low lumbar pain may appear to have movement reproduceslhe patient's b<>ck pai\", thccause a full painl<-'Ss range of exlension in standing. If it is will almost certainly lie in Ihe lumbosacral joint. thought Ihat Ihe p\"in may be comil1g from the lum- bosacral le'·el, it is advisabte 10 include the following When, un examination. a patienl appears to have a tesl: the .Ianding patienl .hould bc askt.'d 10 fll'X his painless full range of exlension, or when he is aware of pelvis (i.e. luck his l'lil belWL'<-on his legs as a cat or minimal lumbar discomfort, the t<-'Chniqu\" for applying dog can) and then exlend his pelvis. This movemenl, Ihe over-pressure ne<Xls 10 bc performed in a specific particularly exlension, m\"y reproduce back pain in manner if importanl informalion is nOllO bc misSL-d. The same tl.'Chnique can be used 10 differentiale bctw,-'CTl whether a stiff-looking se<;lion of Ihe spine is Fig\",\", 12.8 ~l'ing lumbar ul~nsion by ov~l-prtSS\"r~. (0) Pr~p\",atory positioning. till ~r-pres\"r~ appli~d

350 MAITLANO'S VERTEBRAL MANIPULATION painfulone~tensionorwhetheritil;;theint\"r\\'erteb,al LATERAL SHIFT 1C\"e1lmmec:hatelyabo...\"orbO'lo.. thl-stiffsection.Tl'Il' dlffen.\"fIlialion ill made by changing !hl.\" pos,tion ofthi' TestlJlg laleral dlSp1aa.\"fl1ent of the thorax on the pelvIS pi'OIln8 ,001'1( finger and thumb (Fi1(l/rr 11.800). ~ is a HTy importantlesl lTlO\\en>ent, esp<'cially for the a\", two stagt'S. The physiotherapillt enc:ourage$ lho> lower lumbar sptne, McKenzK\" (l961) described the patll'flt 10 arch further by intemuttently Ioudung hIs technique \\-ny clei1rlv and Its aPrlicabon ,en full. shoulder$and chest WIth her Iclt arm. lluSlSdoneol5 hght ~ combUll'd w,th a 'erNl romm.tnd, COtt- Hill Iext is \"\"t..,.,.ooy \\'illuable and pro\"idesa tot.alh Mant ron\\.i>Ct with her hand and ann must be .,oi<kd. original roncept... hich must be lnov>·n.md under· stood by l'\\'ery mampulau.e ph\\~aplSt. In the At thesa.me time she ~ her right indl'I< flnse'\"and ron\\el<tofttustext\"t,,'ouldbelm~toCO\\'erhtl. thumb in ~§ame manner. It lSestil'fInal for the phj!>l'O- fieldadequately;hoY.\"l\"\\·l'\\\",'tneNSlDbeunderstoodm therapl!itthalthepallentmalIltau'l!iMOll'II\"\"''''''', the depth that Mct..enzK\"'s bonk p\"\" ides-A method of nee\"but she Can pl'Onde the patJent with il dl'gl't'eofsecu,- testing later.l shift w,lh the palient in the.st.u>dinl lty by allowtOg Ius hair to touc:h her and left posibonisdecribedll\\\"l(w, suprucapul.u area Wlthoul ho!r laking the \"\"Clght of n,.,ph)'SiottM'rapl.\"\" ..tandsonthepatient'sleft.s.df, Ius he~ and neck (Figurr nSlrl. When she knows he 15 and p~ her right hanJ around his right laterill iliilc at the hm,t of his rangeoft\"Xtension,she then applies crest. She then pla<.:.... \"\".... left hand on top of his left the on.,·pressu\", by carrying his thoru bac:k..,uds shoulder in such a manner thai ,hccan stabilizt\"his left with her left arm, pi\\'oting the further edl\"flsion 0'1\" upper thoracic a....a betw('l'n he, thorax posteriorly th\"postero-anterior pressure of her right index finge, and her left arm \"ntcriorl)', and asks the patient 10 and thumb, with her nlock increaslng!hl.\" support ofhjs relaxandallowhishl~andshoulderstoslide\"SI1l! hl-ad and necl\" appliesanequillandoppositl'pn.\"SSuT'l' withl'adl hand making SUT'l' that, as th\" movement of the patient's LATERAL FLEXION (IN STANDING) lumoor spine tales plac<:, the lower lumbar spiroe mows hori1.Ontalty l\"t\"rally and does not go intol right lat\"ral n\"xion mo,·t'ment, 11\\1' rhythm and riln!;i' ~~ilmll'lahon of lumbar late,al ne:<jon is most valuable of the lateral m()\\'t'ment, together with any pain wht.\"fI companng !hl.\" quality and range of mon'l'Ol\"flt re;ponse,isOQted\"ToteslthemO\\l'rTIl\"ntinthe~ fromone5idetoanother\"Tl'Il'rangeoflaleralflcxioni~ best measured to terms of the cun'e of ~ment\"l itedirl'Ction \"\"hileshll standing on the patient's left mobility, Q\\l\"r-pres.sure GUl be lidded by st.1ndlOg behind the patilmt and pbcing both hand~ O'\"er the side, she changes her h.lnd positions. She now plaol!l r\",pecth'esupraspirooussup~.-iculara\"'asofeach her left hand O\"er his right ,houlder and M ngllt hand cupped around hIS left lateral iliac crest .....il. Thlo lateral shift lTlO\\'ement from th~ position lTlO\\'es the shoulder, and fono..·ing the ;an: of Iall'nll flexion !horaxlateraUylotheleftO\"erluspel\"is(FlgIlrrll.9\" beyondtheactin\"~Q\\'er-p~l'\\'anbeilpplied TOilpplystrongO\\er-pfe>oureto,sa\\',ilshifttothe I1'\\On! locally by the therapts\\ 5taOOIOS at the nght$tde righi, she Mands b\\' his left SMH-, rlaong hIs left l\"1booo ofthep;lbenl(for~le}andplaring'-leftthumb bet...emher uppersmnum-<b.'icu1ar-shoulderarea. n.agaillsl the right so&. 01 ead> lumba, spll\"tOW; proces6 and clasps heT hands around Ius nghl iliac <:\"'5t. in tum. 5tW' ~<b O'er~re by holding the O\"er--pressure is pnxlU('('d b) a honzontal push 10 the pahmt\"1 left shouJderwith her right hand and re.t\"'K patient's 10...... ribs 10 hIS nghl ... hile finnJ}' appl)\"'\", her nghl.~.n. on lop of his right shoulder She then an equal horiwntal pull WIth ' - hands on his il.iac bends her k.nees to take the lateral ~ be)\"ood the actl\\'e ,ang\"\" and her left thumb IocaIiZl's the on~r' O\\5Iw..ardshlslefl(FT.l:llrrll.'~). pl\\'!5Ure\" Altomlati\\-ely. if there is height inrompatibll- il\\\"betwemthetheraprstandpatienl,thcthcrapistcan WHEN APPLICABLE TESTS gra'lproundlhepatient'strunlwithherrighta,m Assessingthl'quahty.ran~ ..ndpalI\\responsc.par!K'U' l\"rly as they n:late to rombll1ations of flexjon and ROTATION rotation mthelowlumbilrspine.pro\\idl'SpowetfuJ information on which to b.~st' the selection or treat· Lumoor rotalionC,1nlJ(,cxaminedeither in ,tanding or ment techniques. and {or assessment purposes, To sitting\" t-lo...ever. lumbar rotation as an aclil'l'mo\\'..... \",,,da texllhatdescribcsallofthedetailsn:.-gardmgthl' n\\CflIISO{lenmOrelaluablewhl-nperfo,medincom- tlochniqul'S ...ouldbt't~'dioustosaytheleasI.T~ binedmo\\\"ements,asdescribt.\"(\\lJ(,low. ro~. the drawings with mmim,,1 te~t (and \"\"lngthe

wmbOl'SfI'IIIt 351 abb...,-iatiOffi F for forward fle>~,on, E for exlension, 1.1ll'Tally n~\"'estothe left and thephysi()!hcrapist pulls <D ®I.F for lat~ral ne~ion to the> kfl, LF for lall'ral Wil~;~~~~'7~' 1~~dF':a[ribo~'C;,!:~~~ physiother. nexiontolheright,l<ot©andl<ot®forwtalionto al\"~t us/.s the whole of her left arm and hand to twi'St the Iclt and rtght nspectin'ly)Ciln speak for thcmSolln'S. Anal)'5i5 of the functional de~traOOn or in,unng w thoracic and JumoorspmeinlowTOtaled posItion. mon'm\"nt i'S (lfl(on the m<lI51 uluabk> way of working out which M'q....-na' of combined lI\\O'l'emenlS .. ill An'rystmnggraspofthep;llJmt' pri'lliisneedC'd;<n \"\"I'rodUCE'thep.ltimt'ssrrnptoms. &let she pullsstrongl' t-:.........t ..·ith ..... right hand Combu'I(d moytmtn~ in f1txion around the antmol' ~perior i1iK $f'U\"'I'. ~ pushes forward stmngly ..·,th her right antenor superior ll~ Flgurr12.10tl-FTht-patK'I'lt'sp<'lv,sis5eCUrC'lystabil. sp\"\"'~tnSthisntid·lo-laterallcltbuttock. ized bC'tw\"'_'I\\lh~physiothC'rapist'slC'ftinsuinal fOl:iS<1 with h..r right hand gripping around his iliacc...'.Sl to Figun\"l.IOd-F + LF4)+ [email protected]· thcanteriorsuperiorili\",spinl' apist uses thC' full lenglh of her left fore\"rm lofinS\\'1'!I Fig\"'\" 11./0IJ - F + LF CO WhIle> maintaining the to produce the thoracic rotation to the righl. SIlc also Ileeds 10 work hard wilh her left arm to avoid losing ~positionandwSl.ab,hledp<'I,-is,thep;ltil,>nt the laterill flexion component. HopciuHy. il is 00' iOl.., from the> text of tlllsbook that the rTlO\\'<'mef1lsof lateral fbion and rotation Ciln be performed in a diff~1

MAITLAND'S VERTEBRAL MANIPULATION lllI Ilil _.-~ ., t,. ~,) Fig\"\"\" 12.9 lronrd) lei Lat...1'iIlifr ofth~ Ifun' I~fr. (d1lat~ral ,nilt fight of tn~ Ill'lvis I~fr with over-p,~suf~ S<'qucnccnndlhatlhclC5tcnnnl!)Obepcrform~'<ilothe for control. Then, and onJy then, should she apply Olhl.'rside. through her hands SClme pressure to the exl~-nsion while ensuring that her nean;ide shoulder is near hi!; Combined movements in extension oc<:ipul 10 take Ihe weight of his head if required. By Fig\"\"\" 12.ll-E.Thecareandsequenceofndopting lhe using her hands on hisshouldl.'n;, she Ihl'll guides hi!; extm,ionposition is described on page 349. trunkinlolhecomerbylaternllyfl\"xingnndrotnling his lrunkaway from hcr. Movemcnt iscontinuoo until FigurrJ2.J2-E + Rot Q) The physiolherapisl pulls the limil Oflhl.' rangl.' is rl.'achcd {Figure J2.1J). with her left fingl.'rs, and pUShC5 wilh her Iclt uppcr [email protected] arm/axillaryhold.Countcr-prcssure~JlI.'\\.'<ioothrough patienl'S left shoulder forwards with her shoulder area,and his righl shouldcr backwnrds with her left hl.'1\" right thumb. Iflall.'1\"al flexion tothe Iclt is added lo hand. In this diTL\"Ction il is her right index fing~'l' that thispositionthcpaticnlislheninlhc'quadrant'lC5t posilion. Whcnusingthcquadrantlcstforlhclumbarspine, s\\lpplieslhl.'countl.'r-pressure Ihephysiotherapistshouldstandbehindlt'll.'palienton Combined movements in lateral flexion leh thc ~idc away from which shc inlL.\"ds turning the palienl. She encourages him to extend to the limil of Figure 12, 15 ~ LF ©. Thc localizing (nr cmph1lSizing) his range and thcn plnces her hnnds OVl.'r his shoulders ofth<\"int<\"rvcrtebralll.'\\'l.'lisachil.'vedbylhl.'lherapisl's

Lumb<lrspine 353 thumb ant~riorly and th~ wl-b of h~r hand belwt.-en Figure 12.16-LFlO+ E. By careful posilion ofl\\('r thelhumbandindexfingcrlateratty,andherindl'xfin- grasp around hisupperthora\",thal is by using hl'T geriSrt:'infom.>dbyhl'rmiddlefingcrpostcriorly.She cla~icular-a\"illary-ann and hand grasp, the physio- therapist can keep the pillient's thorax in the coronal uSC5lwrleftaxitla,hl'rup~rlhoraxandherleflup~r plane during the extension mOllemCf1t Also,slwcan ann to keep oontrol of llw Slabilily and apply theo~('I\"­ emphasize the intervertebral tellel of extCf1sion with pressure.

MAITLAND'S VERTEBRAL MANIPULATION Figu,. 12.11 Combin.d m<M:m.nts '\" .xl.n,i\"\". [a1 P••partion I\"\"it,an. (b! OIi.,-pr=u .. counter-pressures between her left elbow and her right Combintdmovtmtntsin rotation Itft fingers Figure 12.20-Rotq) After taking the patient into the fully rotated position (Fi.~urr 12.20a) the therapist ©Figure 12.17 - LF + F. The thorax must still be changcs her grasp so that she can hold th.. full rangeol rotation with her left axilla and hand,thusleavinghef maintain<--d in the coronal plane, The flexion can be righthandf\"-.... emphasi7.ed to ~arious intervertebral levels by al'pro- p.iate pres,Ul'-'S with the physiotherapist's ldt elbow Figure12,2J-RotQ)+E.Theintervertebrallcvello and righl thumb in conjunction withoounter-pressurc bet('St,-odwiththisextL-rnionhasitslevelemphasized by the physiotherapist's thoracicgra,,1' and her lelt from hcr aU-surrounding grasp of his upp<!r thorax upper arm/fo...,arm/elbow countl'ring th\" postero- Fi\",,\" 12.18 - LF ([) + Rot 1) For this technique. antcriorpressurecxcrted at theappropriateintcrverte- brallcvd with hcr right indcx fingcrand thumb tm,physiolherapist'sg.aspofthepati\"nt'suppt!r Figllre 11.21-Rot([)+ F. While adding the flexion thorax. making maximum use of her left axilla and left to the rotation, the tension of the rotation needstobll hand,is imp<!rali\"e if the rotation is to be totally in her inc,\"\"ased;withoutitsbt>ingincreased,theflexionhasa loose feel about it and thus becomes \"alud<'SS asa control. combined·mol'ementtest Figure 12.J9 - LF © + Rot ®. As with Rot Q). the physioth\"'rapist has to hav'\" a firm grasp of the patient\"supp<!rthoraxtomaintainth..,conlrolneces- sary to produce rotation toth.. right of the pati,--nfs thorax and thus his lumbar spine

lumbar ,pine 355 Figu'e 12.12 (ombiredmovcm\"\"tio\".te\",i\"\" figure12.1] Qu.d\"mtt..lfoflumM\"pinr Fig'u'f' 11.23- Rot©+ LFI1) Thephysiotherapist's Fig\"rell,25-Rolq)+ F+ U@Obviously,th<'reare right thumb localizes or emphasizes the intervertcl:>ral manycombinalionsthatcanbeused.butthisisjustone 1e--e1 desiR'd. while the patient is guided intothelat- combination that uses movement in the thR'\" pl,ml.\"S. 1.'1\".11 n\"xinn mO\\'ement towards his left shoulder. This lateralflexiOllmO\"eml.>11tcanhavl'addl.-dloit· PALPATION I Aleft-sidl.x1comp~ioncomponentbythe Phillips and Twomey (1993) have prOOuced the physiotherapist applying a prl'S»ureon the best evidence yet that manual diagnosis, including patient's left shoulder with her axilla p.~Ip.1tionexaminationandpas.si\"einlervertcbralmOVl.~ 2. A di~placement component towards the patient's rightbydi~t;ngherleftaxil1ary.p...\"Ssoreonthe menl tCStillg,Call bea reliable means of identifying patient's left shoolder towards his right hip symptomatic lumbar segmental levels. This is the case when manual diagnosis is compared with the most Fig,u'f'11,14- Rotq)+ [email protected] reliable diagnostic method avaHable, namely scgmen- eral nexioncomponent is towards his right shoulder. t.~l spinalanaeslhelic block procedures. and during this mO\\'ement she needs 10 lift her body upwards to keep the same grasp of his lcft shoulder As has been slated earlier, the first steps in Ihis afl'a with her ldt axilla palpation examination are to dl'termine sweating and kmperature.

356 MAITLAND'S VERTEBRAL MANIPULATION Fi9U~12.14 £+ROl@ Figure12.15 Combin.,jm\"\"\"\"\",ntinlauralflexionlrlt.lf<D ~- midline is the line of the spinous processes (Figurl' 6.31). There are limes whl.'1'\\ a patient will mention that This is not an uncommon finding at an inilial ('<m\"ult· ation, and it is also a phffiomeoon that canoccuraSa his back feeb hot, and onexaminalion thisstalement \",suit of mobiJi7jng an inter\\'ertebral area lhat is thernuseofpain.ltssignificancetothemanipulati\\'e wHlbeconfirmed. physiotherapist is little mOre lhan indicating th\" Th\"re isa \\'ery definite qU3Jity to the warmth; il intervertebralle\\'e1alfaultand,asisquileoften important, proof thnt something abnormal must be fccls as though il is coming from wilhinand working prcscnt; th31 is, it is not pos\"ible to bring about swcat- ingby mobilizing a normal spine. its way out lothesurfaCl:'. When lhis is prcscnt mw Temperature palientswhoaresele<:ti\\'elyreferredformanipulati\\-e In the lumbar spine there isafusiform area, whkhis physiotherapy, it is not likely to be inflammatory due ncarly always warmer than surrounding areas. II has toa disease process but ralher from a mechanicaldi;>- itshori7.0ntal central level at the iliac crests, and its Of<kor, When lhe lempcraturechangcis\\'crydefirule, treatment strength and progre>sion should be gentler and slower, butlhespeed with which the increaSoed temperature disappears is quite a>tounding. On exam' inatiuothelCmpcralureshouldbeassess<-'<lusingthe back of the hand and th\" palm, wilh sWt.-'<..ping large

lumb<lrspin~ 357 'ogu,.12.16 If©+E Figu,\",12.17 lfeD+ f mo\\\"ernentsat first, gradually reducing the SiiC of the there are some aSpl-\"Cts that are spl-\"Cial to the thoracic sweep to localiu..:1 are-as when indicated. It is often and lumbar spines. u>efultoassesslemperalureaftertreatment.espeocially when it is lhoughl possible that a disorder may have All lumbar intt'rspinous span'5 should b<;,palpated becndisturbcdunfavourablybytreatment d\".~plywithdiscemment,a5shouldthelateralsurfact' Softtissur,bonvtissur and position of the spinous processes. Thickening can occur on one Alilumb3rint~~inousspacl5shouldbl:'palpat~d or both sidt'5 of the proa.'55or in the space, evt'll 10 the extent whcrc the interspinous space on one (or ooth) d~pIy, 3sshould th~ lat~fal surfattSofth~spinous side(s) can b<;, completely obliterated by thickt'ned pr0tt5S<\"s hard tissue. Figure 12.26 shows how lhiscan b<;, per- formt-d without thc examincrhaving 10 move herpos- Thisaspeoct has been covered in depth in Chaptl.'T'S6 ition.She Slandsalongside the patient facing his f{'('t, (!i«pp.149-165)and 10 (st'l' pp. 190-192). However, and usesht'r middlefing.·rtip to prob<;, into the righl space and hcr index finger todig medially inlo the left space. She can change rapidly from sidl.'to sidt',and equally rapidly from One le\\\"cl to Ihe nexl,upwardsor downwards.

358 MAITLANO'SVERTEBRAL MANIPULATION •I • '. 'I,,~I ,I (1 l Figure12.19 If®+Rat@ , D \"D Jtisalsone<:(\"i... r}'touS('thl·inde~andmiddlefin­ lheinterlaminararcabutshouldbccxtcndl'dtolhfo gersto palpale into the interspinous space. When adjacent upper and lower borders of lhe lamina and doingso,thefing<'rsarcheldlightlytogctherand over lhe lamina itself oscillated back-and forth sideways in an attempt to sinkdeeplyintothesp.lce_Thiscanbcachievedinnor_ PASSIVE ACCESSORY INTERVERTEBRAL malsbut not in abnormals (Fig..\", J2.27) MOVEMENTS (PAIVMs) Figll\"'U.18-D<:>cpcrpalp<>tioos of the inlerspinous These arc fully described in this chapter under lhfo a\",a.Byusingthelipofthethumbagreaterdeplh, eH'll as dl't'p as the lamina, Can bc reached,An asse5S- heading(}f·t,'Chni'lu~'.but~latelothosele<:hniquE'!; mentoflhisdepthshould bccarri<,doulifthemo~ superficial .. reaisnormal. lhal in\"ol\"edirectconlacl un superficial pariS of the \"erlebra, Asdl'SCribt.>d in Chapter 6, it iSlle<:essaryto Figllre Jl.19-ralpation of th<' para\\'erll>bral soft- \"af)' the point of contact through which the mo\\'em<:nl tissuestructun'S. Both thumb tipsare utilized. and the isprCKluced,and to \\'ary th\" inclination of the manipu- probingdffp palpation should bccarril'doutin many lativ\"physioth\"rapisl\"sarmandthcrebylhedirection differentdirections-medially,laleral,caudallyand of the movement cephalad,Also. the palpation should not bc limited to

tumm.r,pin~ JS9 Figur~ 12.20 rombin~d mov.m.nh in rotation Idt. (0) Initial adopting position.lbl End-position ~fo... adding otll~r mov.m.n\" Thelt-ehniques used lo~ss<-'SsthequaJityandrange above the diseased se.:tion lx\"Cause it has had to ofmO\\·emenl:sa .... d~ribedindetaiJonpages368-372 lakem·ermobililyfunctioru;fmmthesliffa....abelow. (F(gllrt-s12.37-12.41) for example, while carrying out poslero-anlerior pressures, the patient ~hould be asked two particular Painresponsc questions: Hadngcome loa decision as to where there is any 1 'Does the pain feclsuperlicial ordeep?'Superfio.al hypomobility, hyperrnobility Or prot~'Clive muscle pain felt directly under the physiotherapisfs hand spasm, the movement produced by palpation is or thumb may be unassociated with th\"disorder, ~sed for pain fi'Sponsc with Ih\" movement. As a ormaybea ....ferred tenderness and the....forean taint may be hYp\"rmobiJe yet painless or hypomobile abnormal response. A deep pain is always an yetpainlt'Ss,theTClationshipbetw~oenpainandmov.,.. abnormaln'5ponse mentcan()nlybeid\"ntifi~>dbythepatient.Animport­ 2. 'lslhepainfeltundermyhandONLY.ordoc'Sil spfi'ad at all?· Any spread of pain is classed as ant example of this istheexaminationofa patient who abnormal. h<ls an inactive Scheuermann's disease in the upper n\"\"lumbar spine. His pain may be arising from the stiff Duri>lg fxaminaliml for /Oll! lumbar p/lll1 th\" \"1'1\"\" diseased joints or, more commonly, from the joint /\"\",bar Qn'I1 must\"\" '''bjeaM, if\"«~ry, loflr\

,"360 MAITlAND'S VERTEBRAL MANIPULATION S..,.,..\"\"\"Clt'IT-pr$IIn\"\" tNpaslrrD-<l7lltTd'lI,rrctioll PASSIVE RANGE OF PHYSIOLOGICAL MOVEMENTS OF SINGLE INTERVERTEBRAL mvl<W' tlr151rori 'l\"'trftrqunrtly \"\"\"\"'~ lilt low JOINTS (PPIVMs) lu ...NrJlfllIl lhc!icpas.o;i\"etest rn()\\'err>('n!S a ... described indetitil ThereUoonep.tlpaDontechnique~ll5perfOl'Tl'lOO be\\o.... It must be A'ITM'fl\\ben-d that the exammmg mo,'ements .. re usuall)' performed at a slower speed for'lSpamrespon5\"l'3lherlhanloenabletheil!iSe!i/;- than when they all' oS(>(! as t.....lment Ie.:;hnKjI)('5. menl of ll1(rIemenl, and is of particular '-lIlue in the Also, the examinallOl'l mO\\'ement should be taken 10 e~ammatlon of spondylolisthetic-type pain_ The tech- Ihl'endofthca\\·ail..blerangeandtta\"flm-er-pressure ruque ~ ant\"ropo;;terior pressUlt' on the body of the IIpphedsollstollsso:.-ssth.. end·ft'l'lofthemo'em......1. \\·ffil'braWhenperfonningtheproct.'dureltshouldbe done ~Iowly, g.raduaUy sinking through the abdomen Tll-Sl(latC'ralflcxion) to reach the promonlory of the S<lCTllm. The rontact Starting position position can Ihl'n bemo\"ed 10 wh\"re,'\"r it is needed to make Ih\" c~arnination mrnpleh,'. Abdommal discom- The patient lies on his right side with his hips and ktl(.'l$f1e\",ed to allow his lomb.uspin.. to lie rela~ed fori is les>ened by using all Ihe fingers of both hands (f'gu\", /2,30). TlUs t<'Chnique isof \"alue for the lower lombar\"ertroral bodie5only, thusa\"oidingromprom- iseufthedesc..ndingaorta_

.•.~ . Lumbar spine 361 '.t...\",\"\"',' ¥\" ~,'Y • Ngu,e 12.23 Rot(1)+Lf(D~l .fl Figu\"'12.24 Rot(1)+lF@ midway t:K,t>\\'e<:>n flo;,xion and i:'xtension. Jf the patio;,nt side,sho;, laterally flexes hio> lumbar spine from t:K,low has unusually largi:' hip6(omp.1rW with the size of the upwards by rocking his pelvis. She lips his pelvis thorax, a pillow should be plaero under the lumb<1T (ephalad on tho;, left by pulling with her right forcarm, spine to prevent it sagging into lati:',al flexion. The physiothcrapist, standing in fnmtoflhcpalientand fa- and rcturns it by pushing against hio> thigh with m., cinghisfeet.rca(hesamJSShisleftsidewhilerestinghcr lower ribs against hissidewith her left fOR'ann pointing righl side. An 05dJlatory movement produced in this \",udad along his spine and her righl forc.~nn grasping way rocks thcpt'lvis,with theundersido;, hip and femur around Ius peh'is under the ischial tuberosity. She acting as the pivot. Th\" movement is easy to produc:e pla«-s the pad ofhcr left rniddlc finger fadng upwards afldeasytopalpal\"(l-\"igure12.J2}. in tt\\{> undcrsidc of the interspinous sp.1C<' to feel tho;, bony margin of the adjac:ent ,oertebrae (Figu\"'ll.Jl) To test lateralflo;,xion totho;,oppositesideth\"pati\"nt shouldbt-askedtoturnover. Method Tll-Sl(rotation) \\\\'ith the physiotherapist grasping the patienl\"spelvis and upp\"r thigh with her right fon-arm and hl'l\" right Starting position This starting position is similar to that dl'SCribed for lateral flexion, but it is neo;essary IOl'nsurc that lh\" patient's top knl\"C will slide fn\"Cly forwards o\\,o;,r the

MAITLANO'S VERTEBRAL MANIPULATION undffnealh knec-_lhe,*,~'pi5llNns~tJy spinou!; p~ in relatIOn to tJy prmimal 0Ill', 5M' pat>ent. pbocing her left ~arm along his back to pal- pat\" tJy in\\Jt'n.pinOuS spact' from Wldemcath. ... hilst .,.{fectsthe~mmm..........,tolthcpel,·is\",,'iththchftl t»'isnng her tnmk sbghdy to face hrs hips. She holds m-er Ius left hlp ..ith her right hlInd, her fmg,,\" of her right hand ,00 her right fon>arm. spreadmRoutbetundhistrochanterand thc heel 01 her Rotationintheopf'Ol§l~dil't'ctloncanbele5ted ..·,th- hand antenOr to the trochanter. Her nght foreann hokba....ghis left femur (figuR\"ll.JJ) out dwmging the palJo!nt 10 the other side Ho,..I'\\·~ uniformity of 'feel' is best achic\\ed by \"-'P\"'aling the Mtfhod techniqueontheolherside Wh,l\" the phys,otherapist slab,hrei the patil\",rs thora~ with her l<'ft arm and side, she rotat<'5 his pehis Ttl-51 (f1uion/tKttnsio,,'J _ towards he!\" by pulling with her right hand. As his top Storfing position m-e slidl'S forwards o\"er his right knL\"', the pelvis TIle p.:ihent 11<$ on his right side with hips and m\"e§ and lumbM spine rota!\" forwards on the left side Ensuring that her p.~lpating finger h\",ps p;lce with this n\"\"ed. The physiotherapist, standing in front of the mO\"l'fIlcnt, she will feel the dISplacement 01 the distal patient. reaches behind and under the patlenrs fle\",d km\"l'S tu grasp anteriorly around the right knL.... SM then lifts his kn~'5 and rests th\" low\"r legs against !leT own upper thighs, placing the knt't'S just beyond her

lumbil.spinc J6J left thigh. With...,. left ann stretched 0\\..... the patient's 1oY>.t'f\" SGlpu1lr area 10 prevt\"l1t any backwiln:I rotation 01 the thorax.. the phys>othenplSt places the lip ollhe pad ollheindeo:or..uddJe finger in lhe tntersptnOUS spKl\"lobe tested. whrre It an fed lheildpcent margins ol \"\"0 spinous ~ To IYIp ~palf' l1\"Illft'deep!yw,lhout Iostngsensibility,ttusfingeran be...mrom.d\"'\"ftthen.lilbythemiddJef~ (Fip\"I2..J4). Pas&'''' lIlOVftnmt oilhi' spine IS pn;:duced by rocking thepatienl's knee back and forth towan:lslu.5chest throughanarcofJO\".o.er-r u~~houldbelpplied at the linut ofeo:tension lO_any backwan:l sliding of a 'ertebra, which nu) indicate instability The test mO\\'t'mefll is produced by a side-Io-sid\" movemO'fll of

MAITlAND'S VERTEBRAL MANIPULATION Rgun.12..29 PaipabMIoftho~t'lIQllOh-~ fi9un.12.JO M:fflllIOSI:mor~ Wl,.et~on thPph~'SOOlher.Jpbt·5pe\"is.c;orrying the pahenrsIcgs along the duenion of lhe femoralshaftso~10 push. Io...·er \\\"t'nebra backwards beneath the neishOOunll& m.with The p.1-lpating h.Jnd CIfl, help 10 ~ the n·rtcbraaboo.·eit.WhenlllStabIUtyex15ts,theexces6ll,~ lIlten'C'ftC'bral nn~ by pres.sing agamst the $pu.... when the p.1-t.......t·s \\eg!; ~ \",leased from the... f1e,ed lnO\\\"l'mCflt backwards of the lo....er spuwnn beaJlPft'\" position All, ope.ung and closing of the intt.\"rSJIlllOUs dated by m p.1-lpatlllg flllgff SImilarly. dunng thr ~p nn be fdt w,th the rockmg of the pat'lI\"r'It's pel ...is a5S<'SSIJ>ffit of flex>on the ~mpuLati\"e pb)'l'iotlwr- apist\"bypullingin line with the !ihaftofthe femu', wiU .nd Jes.' The arc of 30\" will be with the lllls in rela- produce e'CCSSIl,'e interspinous movement if instabil- ity in flCJ<ion is present. ti,ely Ies6 flexion when palpalLng mOl,'ement III the upper lumbar spine. and \",labvely more flexlOll when T11-S1 (fltxian/txttnsion)-singlt-ltg ttchniqut palp.HIllS for moH,mL'nt in the lo....e. lumbar sp,ne. As SQme physiotherapists find the technique using Instability both of the patient's leg5 to produce the movement awkward, a single-leo lL'Chnique isd~ribed. How\",'er, [',ulieula.ly i., thl'lower lumbar spilX', ..~Ct.'SSi\\'e mobil- accurate poliitioning of the underneath leg be<:omeI ity or instability in the sagittal plane can be a~5l'SSCd by import.Int. \\\"aryingtheaboveIL>chniqueslightly. During the tCSllllg ofexlens.ion, the manipulalive physiotherapist pu\"hcs

Lumbar ~pin~ 365 TF1ig1u-S••~ ll.Jl fIln.~\"i<..,..\".)..rtrPoo.<a.lifti\\o\"nlOoVfem.nt. Iialtral palpalOng fing.r fo. lumbar SIlin. Figu\"'l1.32 (oland(!lllnl.......rtro.al mov.m.ntT11-S1(lat.\",lfI.xion)

366 MAITLAND'S VERTEBRAL MANIPULATION F;gur~ 12.33 (0] and (b] Int~N~rt~bral m~m~nll11-51 (retation] Fi9U'~ 12.34 Inl~\"\"\"t~br.1 m\",,~m~\"l Ill-51 (fl~xio\"'txt~nSlon]

lllmbars.pint 367 ,-...'ogu\",12..35 Ifltnvmrtnl~t. T11-5'llIwonJut~~Si\"Sl~1fg Starting posItIOn The -Iolump ~, ',() called beocause of its agn.oernent with tho- term • ~ by engineers and ardul«t!l. is The patll'f1t lies on his right SIde and the ph~,,\". ~bed fully ....ilh dldgrams on pilge; 144-149. The apast stands In front of his upper chest facIng towilrds description of thi.\\o test w.as J>la<-I in Ow.pter 6 his hIps, She pbce he!\" left fuftoam> along his back to b«au itlSall'5tthatshouldbeUSotdrorce\"\\'icaland pillpatebet\\<,een~tspll'lOU5pl'OCl'56l'5from tlv:lr.x~o&S~aslumbudisordtn.,*\"\"l/'\\-'er, ~th Wllh her nuddJe finger \",'1U1e stabilizing Its moe;! U5l'ful apphcahons lI~ in the lumbar spme histhorubet\\<,'eenherleftarmllndlef1side Wilhher andserondl}'inthece\"\\'lClIl~\",I', righthandshegrll5psluslef1uppertib~frominfront A$ WI'U asperfonrunt; thetest in the sagittal plane, 'I (flgurrI2.35) Car'l lIlso be performed byapplyingO\\·......pres6ur('tolat· Mrthod eraJOexiooorrotationinsilting.befureincorporatmg lhe irutial slumping of Ihc thoraric and lumbar spines. The physiOlherapist produces nexion and extcnsion of The information being !iOught is a relahO!l5hlp the plltienl's lumbllrspinc by Ot'xinlland releasing the betwecn the range of movcmcnt and reproduction of nt'xion of his left hip whilesh\" assists extension by the pat;ent'ssrmptoms. Added 10 lhis is the change o( pre5l>urewiththchcclofhcrlclthandagairu;ttheh.m· rangc/painrespom;elhatcanoccurwl>cnoneaspeoct bar spine. ofthetensionedseo::ttoo\\Srcl~,Forcxarnple.f':llk'fld­ Dtst..rbrIlIlCt5O{spi1lllImol\"\"\"'\"h,T'hesoecanbe ......alu· ing the left kneoc may be hm,tro by 30\" compaM:! wilh ated more clearly by study of the physiolog.ical and e:<h.onding the right knee, and it may ~UCt'buttoek pilthologKalchangeslhatoccurmthediscandapophy· pain.Onrcleasingnedfleuon,.thebultockpam may ~l joInlS (Ha....... and \\Iacnab, 1954). SimiLuly, it is dlS;lp~ and the piltJenl may be abW to \"\"tend his impona.nl to be flImilwr \"'Ith the raddogical appeaor' anct'ol the normal spuv; forft.llrnpk>, therontourand ..,.......kneell further 15c , ~ 15 the most cornn-.Iund of po5ltJ()f'lol\\~,the!>l~lInd appeao'anct'01 dlK ~lI\",many\"·I}'5\",whichthe_CMlbecar· ~ and the intel'\\\"l'rtebral forllnunal', This knoI'o'. ned out to fI'\\'elIl abnonnlIlttiel: in the lnO\\-ernent of the IfttgehelplOlIltheronelalJOnofrongerutalandd..\"\",. p.lm~h\\·e structure ,n the spinal and ,'ertebral opmmtal abnormalities wllh ph}\"SKal findings. canalsandaloog,,*,·lntperipheraITll'f\\·~.Thettung th.1t is important 15 thaI, when signs all' presml, the Slumptl.'5t treatmenl should initially beaimed al impl\"O'l'ing ,nlcr· \\cnebrallTl()\\'ement while watch'ng to sec if there are Testing for movement of p,lln-senslti\\\"c StructUfC5 in parallcl chanses in canal mO\\'t'Tllt\"nl.lftht-,mprove- thevertl-bral canal,asdishnct from movemcnls of the mcntsare not parallel,ll1cn the canal movcmcnttl1111 lumb;lrinte\"'l'rtooraljoinlS,isthcmostimporlantll'St reproduces the lumbar symptoms should be substi. that ~hou\\d be included in the examination of all tUled or added astreatmenl. patirnts 50 lhat it can be dl'lCTTl1lncd whclherthcre is ~a\"\"\" the dura mater is strncturally d,ffenmt normal ffi()\\'t'Tllent Or noI. frum ligamentous-Iype tissue, ,t can acrepI n'ry strong

368 MAITLAND'S VERTEBRAL MANIPULATION mobilization. Its \"'1m rL'SPOnse. when produced by processofthel'l\"rtd.ra to be mobilized. For this bone strong mobilization, isusuallygreaterthanthat which to be the major point of contact while the physiothera- is prroictabll.' when mobilizing ligaments, and the pist'sshouldl.'rs are positioned dif'(.'Ctly ab()IIl.' the \\'l\"r- pain tah-s 10nSer to scttle than do<>s ligamentous pain. tebra, it isnl'ClOSS<1ry to extend the left wrist fulJyand hold thcforearm midwayhetween full supination and The slump test can be adapted to investigate all full pronalion. If complete wrist extension is not main- parts of the lumbar and lumbl'O$<lcral plexuses. For tained the whole 01 the ulnar border of the hand will insl;lnce, if a patient has back pain and anterior thigh bl'Come theconl<lct area and accuratelocali7.ation will pain, the extent to which the C<lnal structure and the be lost. This left hand is then reinforced by the right by fl.'moral nervl.' arc contributing may nl-ed to be tested. fitling the carpus of the right hand, cupped by the The patient can be 'slumped' in side lying. TI>eadd- approximation of the thenar and hypothenar <'mi- nences,O\\'er the radial aspect of thc left carpus at Won of knec n..xion and hipexteru;ion may n.\"roduce the b.,,;(' of the Idt index finger (Figur/' 12.36). Then. byalJowingtherightmiddle,ringandlilllefingersto his anterior thigh pain. Further addition of cervical lie betw('('n the ll.'ft indl.'xfingl.'rand thumb,andb}' flexion may increasc the thigh pain and tighten the leg allowing the right index finger and thumb tolieo\\\"er so that less hip extension or knec flexion is possible. the back of the left hand,stability is gained by grasp- Such a response would strongly implicate thl.' neural ing the palm of the ldt hand between the thenar em;· structures as part of the mcchanism of symptom pnr nenee and the middll.'. ring and little fingers of the duction(Butler.I99I) right hand EXAMINATlON AND TREATMENT To hold this right-hand position with the physio- TECHNIQUES therapist's body weight oVl.'rthe hands, the right wrist mustbeextendlod. Ashasbecnstatlod~all'<lly,then:isnolimittothe Tbl\"physiotherapis!'ssholl1dersarebitlancedo\\\"l'r treatmellttechniques that can be used. nw.... are\"a.ueh the top of the p.ltient, and the elbows are allowed to flex slightly (Figure 12.J7) Iili\"gsu.·MJlitla\"dll'd,,,ique$·.However,aba.isnl'<'<l. to be formulated toco\\'er thc·teachingsituation·, but Method it must be rcmemberro that all ~ to be tailorl..-:l to thepatient'ssymptoms,signsandpathology.Thet<.'Ch- ThepositionistakenupbygraduaJlymovingtheth~ niquesdescribedinthefoUowingpagesformthatb.1,is. apis!'s body weight forwards more di«\"Ctly over the MOBILIZATION patient\"s \\'ertcbral column, and the osdlJaling mo\\'e- ment of the \"t.'Tlt-bra is obtained by a rocking mOve- Postero-anteriorcentralvertebralpressure(!} ment of the upper trunk up and down in her vertkal axis. The pressure is transmitted through the arms and Starting position shoulders. which aet as strong springs Thl.' patient h-s face downwards with his armS by his Loco/variations side or hanging over the sides of the couch and his head ruml..-:l comfortably to onc side. There is no natural lelldeme'SS to be felt when mobiljz· ing the lumbar spine. Mo\\'ement can be felt readily. When extremely gentle mobilizing is being p<'r- but isnolicl.'ably less at the le\\·eJ of the fifth lumbl'r formed thc,tarting position and method isid,,\"tical ,·ertcbrathanitisabo\\'ethisJcveJ. with th,'t describl..-:l for postenranlerior centr\"l vertt.L bralpressure lor the middle and lower thoracic area When a patient has an excessive lordosis, a sl1l<\\l1 ($I't\"p.318). However, as the need for stronger prcssure finn pillow plaet.'<l under the abdomen may be neces- arist-s the thumbs an: inadcquate, bccausc the lloch- sary for joint po,;itioning. Whether a pillow is u>ed or nique becomes uncomfortable for the patient and the not, the physiotherapist often needs to alter the direc- physiotherapist loses thedl'gn..... of fed thatsheshould h,l\\\"e.ltisbettertochangl.'tousingthehandsasthe tionofherarmstoenablethepu,;htobeatr;ght~ngles mean.~fortransmillingthcpn.'$/;ure to the surface of the body. The physiothl'l\"apisl stands at the left sidl.' of the Uses patient and pJaees her Icft hand (this one is ehoscn for convl\"nience) on thepatlent'sbaek so that that part of I'ostero-anteriorcentral \\'ertebralpres,;ureisbe51 the ulnarborderofth.ohand between the pisiform and used in oonditions of the lumbar Spinl.'lhat cause a the hook of the hamate is in contact with the spinous

lumbar'Pin~ 369 pain which is e\"enly distributed to both sidl'S of Postero-anterior central vertebral pressure as th\"body. combined movement. in lateral flexion right (inlF@dotJ Ali in the cervical spine, this technique is of value in p.1tients whose symptoms ari5<' from an area of the Starting position lumbar spine that has marked bony changes, whether these changes arise from degener,'tion Or an old injury, The patient lies prone and the manipulative physic-. Or a\"\",, struetural changes a>socialL-d with fuulty posture therapist positions his lumbar spine in lateral flexion to the right. She does this by moving his trunk Ilearer This technique is indicated when pain or protecli,'e to her. IUs pelvis away from her and his legs towards muscle spasm is felt with movement in this direction, rn,r.ln fact his right hip should be abducted alld his left but under these circumstances it is perfonned in such hip adducted so that they stabilize his pelvis ill the a way that the pain or spasm is not provoh-d. position, which laterally flexes his lumbar spine to the right. Examples of treatment include chronic lumbar ner\"e root ache. pages 414-415; low back pain. page Once the patient has beell positiolled correctly. the 430; buttock pain, page 432; spondylitic spine with therapist places her hands on the le,\"e[ to be mobilized localized lesion, page 433; coccygodynia, page 434; and then ensures that her shoulders are vertically juvl-niledisc lesion. page 436; and abdominal pain and aoo\\'e her hands (F(~ljre 12.38). vague pains, page 443.

370 MAITLANO'S VERTEBRAL MANIPULATION Fi9u~ 12.38 Imlcro-anurior ((nl\",1 ~.rt.bral pr..su~ as a Uses irombin.d m\"\".m.nl, in lat.ral fluion right lin LF ®dO I This technique Can be used for any low lumbar dis- order, but has a special value for those patientsexperi- Method endng pain from a spondylolisthesis or intradiscal n.., t<'Chnique is the same as that described above disorder. without the lateral flexion positioning Postero-anterior unilateral vertebra! This te<:hnique is used as a grade IV (nudging at th.. pressureCr) start of pain). or asa gradelV+ if stiffness is thc main component Startingpositian Anteroposterior central vertebral pressure 0) Thepalient lies pronewilh his arms by hisside,and Starting position his head can be tumed to the side. Iflhetl\"Chniqueisto be performed on the left 5ide of the 5pine, thephy.io- The patient lies supine with his hips and knces flexed therapistsland.bythepatient'sleftsideandptaces and his feet resting on the couch. He relaxes his hcrthumb5onhisback,pointingtowardseachother, abdominal wall as the thcrapist vcry gradually Sinks immediatelyadjacenltothespinous pnxesson the her fIngers into his abdomen until she reachl'S th.. sacral prominence. lefl.hiswi~nottorcinfon:;eonethumbwiththeother, The manipulative physiother,lpist owrlaps the as this destroys the feel that can be obtained throughthl' middle three fingc.... ofea<:h hand and places as much pad of the thumb. n.., finger.; a\"'.p\",ad around the of thl'ir pads as possible On th<-pati\"\",rs abdomt'n cen- thumbs to provide slability. The baSt' of the thumb is trally and midway between his umbilicus and sym- brought a. near dircctly above the tip of thc thumb as physis pubis. She slowly and carefully. so as to a\\'oid possible. This position is governed by the ability to abdominal discomfort as far as possible, sinks her fin- hypcrext'-\"'d the thumbs {Fig\"rt 12.40) gers to rcach the sacral prominence (Figurc 12.39) BecauSl'themusclebulkinthisan'ais large,itisdif- ficulttof'-....lthetranS\\·erscprOC'-'SSdearly.However,if the points of the pads of the thumbs are used and the pressure is applied slowly, th.. majority of the mu~ bulk can be penetrated to reach a firm bony b.lst' Method Method In producing the anleroposterior movement, thether· rhephysiotherapist positions her shoulders above her apist \",,-ws to allow the distal interphalangeal joints to hands,andtransmitsthepressureofherlrunkthrough hyperextend fully so that the broadest contact possible her arms to her thumbs. The thumbs act as springs iii of the pads of her fIngers is made On the sacrum the P\"-'Ssu\", is appli,-'<I,and in no way do tht'thumb During the oscillatory pres5ure, all of the nexors of f1t'xors act as prime movers her fingers and wrists must work <'Cccntrically. not concentrically. n1l'ha\"dscanbeusedtoperformthistechniq~, and when using this method the position of the hands

lllmbilr ~pine 371 right thumb is used as rcinforrement by placing the I\"'doflheright thumb O\\'eI'\" the Mil of the left thumb ItisnecessarylohYI'f'l'l\"Ktendtheinterphalanv-aljoint of the thumb and hold the meliIcarpophalangeal joint in a position of slight f1exion 1lle1eft thumhi§ then \"'edgedinlopositionbythepallNlrsurf\",-\",ofthebast\" of the mdex finger 10 pn'\\eIlt the thumb sliding up;and O\\'erthe~sproce&1llefingersofbothhand5UlC' then sprNd out O\\'er the pabenl'S Nck 10 hclp stabi- lia the position of the thumbs. and presUA' '\" ~pplied to the thumbs through the forearms held nnr the hot- izonulplane(Figurrll.41.). is tnesame as th~td<'SCribed forpostero-anterior(en- M~fhod tral\\'crtl.obr;llpl\\'SSure(5ft'p.369).However.thedisad- vantage of using the hands is that the prL'S§ure cannot When applying body prnsu~ through the thumbs belocalia'(l aswell,norc~nthercbeasmuchfcclfor agamst the one SPUlOU~ pfUO\"\".'l, a certain amount of the very locaJizoo abnormalitics 01 movement that can c..reis~rytodjflenmti\"tebetwcenlheintervCf­ bepillpatoowithlhclhumbs tdlral joint movement and the rolhng mO\\'elTl<'flt of the JXltient's trunk, The plftSure is apphl-d and relaxed repeatlodly to produre an OSCillating typc of move- menl, small movement be.ng produced by small pres--- sUN$and larger movement by stronger PrL'!iSures. Loco/variations Localvoriations In the upJX'1'aoo mJddle lumbararcas it is easy to pal- MOl ement is much 8'\"\"alCf at LI than it is al U, and in pate the lateral margin 01 the transl'erse processes.;as fact is felt read.ily al Ll. Thespmous process is far more they are qu.te long. In the lower lumbar splllt', heM'- C\\....,., the technique must be performed near ltw spin- ~ibleatLlandL2thanJtJ5~tthelowCfIl\"l'els. ouspr0ce55andhmemustbetakenO\\eJpenol'1Tatmg thrmus<:lebulklorcachthebcJrwbase When stronger pI\"l'SSlln' IS reqUIted, 11 lNIy be easoer 10 remforce the left thumbw.th the ulnar border of the right hand in the UlC'a of the pisiform.oo hook of hamate as described on pag 320-32\\ (thoracic spine trans\\'er!il' \\'ertebral P'\"e5SUA') nus technique is \\!>.tmndy \\'a1~ w!'len m\\I5C1e Ust:s ~olthedcepJntr~ ... lmus<:lcsca.nbefell \"This technique i§ ofgreatt'$t \"a!ue when used WIth \"The techruque IScamOO gut on theSKie of the m\\I5C1e symptoms that n.a\\·e a unib.teral dlstnbubon- Undct\" spasm or the pam. aoo JIs angle can be laried il5iooi· ~nn:umstancl5it IS more hkely 10 prodlX'l'il/\\ CIted by the ~ 10 the tKluuque. impn;l'I'ement in the p;onent'ssymptQmS ..nd signs if it IS done from the p;oinles5 side. pustllng the sp,nous TrilTl~rscYCrtdlrllpressurel-) process towards thepainn..l side. In !his way the joint of the painful side is opened. StartingposiflOfl When me<! in the lower Iuml:>arspule thIS mobiliza- The patIent lies prone w.th his arms by his sldc or tion is 1l'SS valuable than .-jtm rotation or po5tero- hanging o,-er the s.d\"S of the couch and his head com- anteliol\"ccntral \\'\\~·rtcbralpTl.'S5ure,lt isllSl'ful,however, fortably tumlod to the side when used for conditions of the uppt'r lumbar spine. and the higher the lumbar level causing the symptoms TIle physiotherapist stands by the p.1tient's right the more Jikely this te<:hnique is to succo-od. side and pluC1!S her hands on the patient's bitck SO lhat the thumbto arengainsllhe right side of the spinous IfastrongtechniqueisrequirL'<l forthepurp<:>5Cof processo(thevertcbralobcmobilized.Asmuehas stretch,ng the joint, which is not pamfuL the following possible of the pad of the left thumb is placed agilinst lechniquemaybcadoptcd. the nghl lateral surfare of the spinous pr~. The

312 MAITLAND'S VERTEBRAL MANIPULATION spinous process. the lefl arm abducts the patient's right leg until movement is felt to take place at the ver· tebra under the right thumb. The oscillating mo\\'l.'· ment is then produced by a combined action 01 !hi' right thumb against the spinous process and the left arm acting on the patient's leg. The range through which the femur is mov<'d to assist with mobiliZing after the slack has been taken up is quite small. Examples of treatment include spondylitis and I spondylitic spine with a localized lesion, pagel433-4J.l, ROTATIO_N _ Figu\", 12.41 laITrans~ef'5e~rtebr.lpressu\"'I_),starting Rotation, as a tcc:hnique, is almOSlthe most important position. (b] Tranwo:rS< ~rtebral pressorei-L <tmng ttthnique tcc:hnique. The manipulative physiotherapist net-ods l<l; Starting position Master the rotary movement. Know when. the centre of the axis of the A position similar 10 the abcwe isadoplcd, but wilh the movement is right thumb pad placed against th.. spinous process of 3. Know how to vary thc technique to alter the the vertebra being mobili~ed. The patient's right knC(', central axis of the movement 4. Know how to combine the technique with n..\"ed to a right angl<-. is then cradl\"d in th\" physio- different stMting positions for the lumb\", spine. 5. Know how to perform the rotation from the therapiSt'S left hand 50 that the grasp is around the bottom upwards and th.. top downwards. medialasped of the kn~~ (Figure 12.4/b). If th~ concepts have not been consciously c0n- Mf:thod sidered, moot people would think that whm performing the rotation movement as described on pages 374, 375 Whcn the leg is used as a levcr, care is needed in taking (Figurl' 12.44), the centre of the rotation would be up thc slack because of thc movcment that takes 5Omewhe,... in the middle of the vertebra. This would place at the hip joint. VI/ith the right thumb against the be quite wrong, the centre is 50mewhere belween the under-surface of the treatment couch and the noor. Imagine the rotation gradc III (figurt' 12.44) being per_ formed - as the patlenfs left iliac crest is rollt'd for- wards. the right iliac c«-'St's contact with the couch ~ at first, the lateral or post..roJateral margin. and at the end of th\" movement the contact point has m\"\"ed IO\"\"ard towards the anterior superior iliac SpiOO1 Therefore, tf>e cent,... of the arc of the arcle described by the left iliac eft'S! must be below the top of the treat· mentcouch. It may be mort' easily understood if an analogy with theold-stylcwagoo whffl is used (figuTl' /2.42). Imagine that the rim of the whC'C1 represents the crest of the ilia (plus the 5aCnlrn and alxlomill.ll wall). Although the lombar vertd>rae arc nca«-'l\" to the back than theabdom- inal wall. the analogy is just as perlinent if thchubo;>f thc wh(ocl reprL'St-'flts the vertebra. We tend to imaglnt that when we perform the simplest of lumbar rotatim techniqUe5,the centn. of the movement is the axle 01 thc wagon wh~~1. However, if the pelvis at its highesl superior Sllrface is pllshed forward, as occurs in p;'l\"\" forming lumbar rolation, it is the same as pushIng the

Lumbj, spine J7J ,, f\"'!JIl\"'12.43 O\\a~poloItIOI\\SofPOO\"lSAlndBc\"m\"'i rotation 2. Wh..t effuct do I thmk l.am h;wmg on ;ony pilthologic.1ld.i50rder? V.......tion§ of lumoor rotation tl.'ChnlqlJe!l a\", 1100\" d<><rib<d Rotation (C.l Stortingposition F;gurt12.0 A,qggonwllttl_ .... analDg'fro. ...... routoo For !hi_ mob.w...tion. thE.- p;lbenl should be lpng on top of thE.- wagon ..·hecl forwards. 51multanoousl,-, the his right side ..,th pilk...'s supporhng hl5 hc<1d, While lo...esl poinl of the wagon w~l mo'elo fOf\"'ards, thE.-pabent ........ins rebxed, lhe ph~·siolherar'~1nO\\~ aJbeItafarshorterdlsbflC\\\",ilndthE.-nklnO\\o\"!>for- the patient around to adopt the pOIS.hon requlTl:ld. lbt w..rdstn .. hncp;lrallcl tolhc$UrfolUa!ons\"'tueh It IS pa~r~ lefI arm is adjusted so thai h.... hand lets on being\"\"\"ed{Flglltr 12-43) lheleflsideofthe..bdomen ..\"\\thlheshouk\\l\"l\"extendtd ..nd the ....bow flexed. When the S\"\"tlest rotalKJn is If ...c .. ;onl to ..pplf mllUmum rotabon.ll t.:>r5ton to bring used, the patient's thora~ '\" kept in the sKk- thcinter.~IJOffiL..·ewoulo.tN>'-elopuJlpoinIBon lying position while both hips and knceo;aIY fIe~cd, lhe gon ...heelbod:.wardsuf..r.;md ..llhcwrnctirnt', the top one slightly more than the right The ph)'!>IO' ;t;; clnO\\cpointAfon<·..rds.lf,,'edothi$,llIII'adeof thel\"apistlhensLmdsbetund the pat>enl and,w,th her lhewh!-\"l'll'm'lo1IJlSatOl1l'poInt ..ndlhll'nmofthE.-whccl spinsaroundthts ..>.Ie ItlSqu,lepossibietodothls, ..nd hands,gr.tspsthE.-pallcnrspelns. POSItlornng of the IOlen·ertl'braljoinl being tre..lcd SO thai il IS mKl ..-ay lhelt'dlniquellishownanddt~onp;lgc37landin bet\\<ocm flexion ..nd l'.xlcrlSion is \",hlC\\·cd by the dcgree of hip fJcJ<ion and the lhet\"3p.srs grasp of the Figwrr 12.50. And tim. 15 not l.lking into <>«ounl lhe pel'i$. Thi$ grasp erwbles the physiotherapist 10 lilt 'inst.mtancousC(Ylln'ofalOillrotallOll'(F..rfan,l973), thcpeh·islOwardsfJc...ionorcxtcnsi~thepel\\'iS( ..r- wtudl III a separ\"!f.'COl'\"I§ideriition altogt'ther. rics the lumb;u spi..... with il Wh~n Uunlung of JX'rfonnmg the rob\"on m differ- If the rotillion i$ to be performed furthcr inlo lhc enloorQfUll axes, as would bc the casc when JX'rform· range, tllll' ph)'~iotherapist rotates lhepal~nl'5thora... mg thl' rotation with the patl~nt's lumbar spml' in to the left by liftmg the pallenrs right arm towMds the flex;on orexlension;or in diffl'n'nt sagillal axes, as in cei\\lng so that thechcsl faces upwards. This range of rotalion isgo\\'C~mcd by the fle\"ibility of the patienl lal~talflexionldlorright,lhcrcarccndlcssthingson HlSundcrneathlcg(rightlcg)isslightlyflexcdinrcla· lion 10 his trunk. Ho...C\"cr, Ihislcgca.n bc~xlcndcd which to ponder. The aSfX'Ct~ tl'at are primary in the slighllr or nl!xed morc d~prnding upon whl'lher the clinical applicdlion of the rotation Il\"Chniqueare: rol;\"\\tionistobeappliedwithlhelumbarsplfl~lowards 1. Amlp\"rformingtheNllJliontupro\\\"okeorease the symptoms cxtl!nsion Or flexion, The left leg is positionC'd so that a)Whenp\"rformingil;or the hip and 1m\"\" arc nex~-d with tile \"'l-dial tibial b)Afl~Tha\"mgJX'rformt'<lit? cOI,dyl\" resting just beyond the l-dge uf tile ct)u~h. IVhl-nadditional prcssur(' iSI\\.'quir«! during mobi- IL....~tion, this top leg Can han!\\ 0'1\" lhe sid.. of II\\(' couch

314 MAITLAND'S VERTEBRAL MANIPULATION Figu'e12.44 Rotati{lf1.loIG'adesland II. Ibl and l<i Grade III

lumb;l, spj~~ 375 Fiyuro12.U (conld)(d)G,ad_lV,w,th n_\"ral_mph..\"s l1>ephy5iotherapistthenSlandsbehindthep.1tient M~thod and places the palms of her hands over the patient'~ pelvis and left shoulder with the fingers pointing for· Ilecause the lcvcragc is long, thephysiother~pistmust w~rds, Th.. hand on the shoulder is cupped o,'er th... at all times be in a position tos.-'e thepatienfsback to head of the hum..rus, with the fingers spreading for- watch the mo,\"ement taking place ward ovt-r Iheptocloral muscles. In S()mecases where lhe ,1I0ulder itsdfis painful it is nec..ssary for the With the gentle techniques the small oscillatory patient\"sshoulder to be in a l,..,;serd..grt.... ofexlt'flsion movements are produced through Ihe physiothera- and for the phy5iotherapist\"shand tobemovtod fur- pist\"slcftha\"d,which has a double function. First, by itsgraspofth\"p\"lvistheinter\\\"Crlebraliointis~ ther towards the p<.>o:toral area 10 apply th\"prt'SSUl\". itioned midway betwt...n flexion and extension. Th.. h.md over the pelvis is placed nearthecn.'St ifth.. Serondly, while thcpelvis is held in thisposition,the rotation is to be carried out with the lumbar spine lcfthand imP.1rts thc rotary movement to the pelvis. towarrlsextension. or Over the greater trochanter if the Norounter-pressureto pre'·entthoracicmovemt'fltis rotationistobccarrit>doutloward~fkxion. rt><juirtod,but greatcarc i, necessary to be Sure that the mov..mcntlspurelyrntary. When thetechniqueisbeingcarrit'd outasagencral rotation wilh the p.:Iticnt\"s lumbar spin.. midway Even with the change of start,ng position required bdwt'Cf1 flexion and eXlcnsion, the physiotherapist's forstrongertt>o:hniqut'S,therotarymovementisstilia shoulders arc placed over the palient\"sbody midway mo'·ementoftht'pelvis(nott\"\"thorax)aboulacentral bt'tw...en the hand positions.ll>e elbows should be axis. There is a nt>ed for the Ihorax to be stabj],~,ed by minimally f1ext'd.lftherotation is 10 be performed the hand on the shouldcr, but thiscounter·pressure is with the lumbar spine tending towards extension, the not one Ihat pushes the should...r and thorax back. physiotherapist should mo,·c slightly towards the wards; it is ralhcra holding action, which allows the patient's shoulder to,..\"able the line of the left arm thorax to foiJow Ihe direction of the pelvicmovemenl but only toa iimited degree oper\"lingonthepatient'spelvistoencourageexlen· sion by its altered position. Similarly, if the rotation is DuringtheoscilJation it is often desirable from time to be done in S()me degree of flexion, iI is nen'SSary for to time to roll the p.llient's trunk back and forth. with- the physiotherapist to move towards the patient's out altcmptingany increase in !he amounl of rotation, pelvis to enable the left arm operating on the pelvis to to be sure that maximum relaxation is being obtaincd encourage flexion with therolation and that all slack hasstiJi becn taken up When a stronger mobilization is required, the With thes<>tcehniques the axis of the rotation is patient's posilion rcmains unchanged but thephysio- beneaththesurfareofthecouch,asexplainedonpag.. therapist lowels On the couch behind the patient. The 3n (Figure 12.43). The same comment applies to the physiotherapist can then carry her weight directly descriptions of the local variations. which follow However, if they are compared wilh the lumbar rota- overthepalientanduS<.\"herl<.nt~underthepatient's tion lcehniquedescribed on page 378 it will be see\" bultock to assist the rotation (Figu,.. 12.44)

376 MAITLAND'S VERTEBRAL MANIPULATION th.at the centre of the rotation ismU(h nearer thewrt('- technique. In ttus \"\",nt tilt' ca~ of t\"\" pam is bemg bra than the hub of the wagoro wtwel, \"roled and nothing is b<omg done lOall.-\". thepathol- \"Sr. Un.der t~ cirrornstances the same tlrlmi.q~ Locolvoriotions performed at thc iImu of the\"'illLWIe ranS\", in \\.ery snwll amplitudes. ..·iIl often eff«1 unpron'D'll'n1. For The sen5e of ll1O\\-ement than can bl' obtililWd here IS \"\"\"mple. if lumbar rotatlOn used as grade I does not quite IN-rked, and a noticeable degree of (wI can be prod.- p.m )..-1 CoIuse5 an eK.Kf'fbabOl\\. the $il1lW Kquued d~,k' tht' fact that the Ie\\'erage is 50 grNl. rotation performed ti ill Vt'f}' genUe and '\"I\"f)'....wI ThI5 is aided by ..'atching the patienl'~ lumbar..,... of iID'IpiItude grad<' IV may well fttect unPTO\\·ement. ll1O\\·t\"nlII'f\"It througt-J.t the procedure Alternilti~ method of rotation (.») W...... theph)\"Siotherapislh.u<Jifficult:yinobtaUUlllli Rotation w,th thor lumbar spmt\" towards extensIOn sufflCil.'r'llpahentrelv;atlorolOprodlK'l'goodll1O\\-e\" is bl'tter used wt.en mobilizing the middle or upper mmt,. the following altemau,·\" medlOd may gi\\e the lumbalr spul\". and rotation m..·uds f\\e).IOO is best patient more feeling of ..xU\"t\\', thus ft\\I1bling him to ~-edforthelo\"l'Stjomts. Il\"laxbetter. ~utions Stortingposltion The palient lIes on hiS left Side, well forward, on the Occa~ion;llly a pall('nt will dC\"eLop ce..... kal discomfort couch, with his undern\"alh hip and knee fle),ed fol1owmg treatment by lumbar rotation.ll is preferable, ~lighllyandcomfortably.lle rt'Sts his right upper arm therefore, not to alter the head position from that on his side and plact'Sboth forearms, p«ral1<'lloeach which he feels is comfortable unless this is nect\"\",SMy to oth\"r, in front of his abdomt'1l, with hislclt furt'ann improve the starling positiOrl. This cervical irritation nearer his chin. The physiotherapist leans 3CrQ5Ij 1m usually St'ltles without any dIfficulty, but it i~ better trunk. facing his pelVIS, to piaa' her right forearm avoidedifpt)S5ibl\". 1Ilong his back. stM. then holdsbl'hind hJs right femur distallytograsphisinnt>rlno.'t'wllhhcrlcfthand.She The pos~ibility of irritating the lower thoracic SplllC supports his nght leg In appro'ornately 90\" knee and orofcreatmgathoracicronditlOncanbt'COmeavery hipflexion{frgurrIH5) rcal problem with strong mobilization, an.d reqUires watching. Particular care is requin.'d wi!h thaiepatients Method With her trunk and nghlarm. the ph~ap;\"tsU­ I\"\"\"\"\"00 have (or h.a\\·e hadllower thoracic symptoms all bilizesthcpal1enl'SlrunkwhllerotoltinghJspeh'isfor- \"'-ards on the nght 5ldl- through t~ medium of his weU as lumbar CQndillon for whIch till')' are betng treated Figur.12.45 AIt.rnali.. rotauon\"\"\"tllod(';', If thc rotatton IS done lOCI vigorotl!ily whil\" rotating the pehis towards the pamful ~'de, ~)'mptorns of rekned pam can bl' prodUttd in the p.m-f\"'\" leg. \"'\"RotatIOn 15 one of the most Ulieful procedures in treat- ms p.unful rond,hons anstllg from the lumbar spine It 15 most ,-..Iu.abW- ..'...... used for symptoms thai .. re unilateral in ttw1r distribution, whether they are re:l'erredtotheJegorlocalizedlOthclumbalr .. realn eumpae. where the symptomsarecentr;ol but theSlgr<S aR'wulat\\'filLthe;eSlgnscanbl'taken as thcgulde to the painful <Ide. In suehcase§ thc technique is more hkelytosuro.'t.'din relie·\";ngthepatient'ssymptomsand ~IJln~if,t is done \"\"Ith tht\"pahent lying on !hep.unless ioi<Je;that is,wilh the painful side uppcrmOSISQ thai Ihe fl'!'l\"iscan be rotatt'd away from the painful side. Oncfurthcraspec1n.-gardingthcapplicatiOrlofmobi- Hz.~tion t~'Chniqucs for distally ref('l\"rro p.lin rt'quirt'S t'll1phasizing.l'rcquentlyatechniqueperlorm~xlcarly in the ran\",~ resllll$ in an exacerbation, even wilen symptomsarenotcrcatedduringthcperformall~ofa

Lumba. $pin~ 377 right leg. It is important that the t,-'Chnique does not 3 The first three of these four techniques have the invoh'c any abduction o' adduction of the patiml's axis 0/ the rotation below the surface of the couch, hip; the leg is uS'-'d merely as a lever to produce the the first two with the axis below the patient's right pelvic, and therefore lumbar, rotation ilium and the third with the axis below the left ilium. In thc fourth t,-'Chnique, the axis is in or ncar Toassist the movement, the physiotherapist Can use the'·ertebra. her right hand on his back Rotation in extension from abo~ downwards 1 To feel the rotation between adjacent spinous (in E do Th .:n p~ Starting position 2. To encourage Ihe rotation at a p\"rticular level by lifting the lower spinous proress in rhythm with The patient lies on his right side with his left hand therolation. !\"C'>ling on his abdomen at th,-' level of the upper ver- teb.a of the jQillt to be mobilized. TIle mallipulative 3 To hold back agaill5t the spinous process of the physiotherapist sits behind the patient, facing his upper ve.tC'bra, SO localizing thcmovem'-'TIt mOre head. alld uses her left pelvis to stabilize his pelvis in a to the single appropriate toint. positioll that encourag<-s a lumbar extension position (FIgure /2.46). ROTATION WITH COMBINED MOVEMENT POSITIONS Method Thcre are many ways in which the same di~ion of a With her nght hand holding his elbow and hcr left lumbar rotation can be performed, and obviously the hand pushing his left hand inlo his upper abdominal combined po5itions can also be varied both in combin· quadrant, th<> therapist oscillates th<> rotation through ation and sequcn«'S, her Iwo anns. Her stabilization of his pelvis is not one that is <'qual and opposile to the diR'CI;on of mO\"e- 1. The first tffhnique described demonstrates that ment being produced by her arms but is rath<'r a hold- th\" rotary movement Can be performed from thc ing, which prevents his pelvis rolling backwards as far top downwards (Ihat is. the rotary movement is as his lower thorax perform,-'d by rotating the thorax backwards) (figure 12.46) U~s 2. The next four tffhniques are examples of exactly All lumbar rotation combined movement!l are per- the same din.'dion of intcrl,,,.tebr~l rotation (that fonned in a manner, determined from Iheexamination is, rotation of L5 clockwise (viewed from on lop in combined movem\"nt tests, aimed at repr<XIuctng or the standing po5ition) under U, or rotation of U avoiding reproduction of thc paticnt's symptoms. anticlockwise on L5}, and in the same combined movement position figure t 2.46 ROlation in ••ton$'on from abovo downward<; (in Figuro 12.41 Rotation in fin.,n and latoral finion loft f,om EI!olx:J) ~lowupward'(i\"F+lFCD,dotL<C.1

J18 MAITLAND'S VERT£BRAl MANIPULATION Rotation in flexion and lateral f1uion Methoo I~ft from Ixlow upwards (lie on The rotary mo\\\"l~ment is produced through the ther..· ® in F + IF_<D, do Lx Co) pist'5 al'Tl1S 50 ~ to r(Illtlw pat\",,\"t's mo.-ax backwards 5tortingposition (i.e. l() the left) while ..,.intaining the flexion and the With the hNd end of the couch raised, the p.1t.ent ;, Lateral flexion Idt l() lus lumoor spIne. po6ltlOl'la1 in Lateral flexion and f1v.ioo for the lumbar spme The manlpuLathe physiother..plSt finnly gasps Rotation in fluion, and lateral flexion left, from hrsleftpd'i:swiththe~ofherrishthitndaround the anterior 5Upenor ili.:o<: spine and her left Iw\\d below upwards (lie on (0 in F + If <D, do Lx Co) graSf\"ng around 1m left buttock. Her grasp should ~ wch tNt the pabent'5 1eft pel..,s and M two arrn5 Stort;ngpositicm Momeasmgle urnt and will mo'I'\\'.loSOIV1' {Figurt 12.47). Thi5 lime the p;lt>entloes on M Jeft M<k with the much Method aldled upwards al hl5 .... ist \"\"g~(pillow5orblankeb rolled up on a flat couch can prodlK't' the SlIme po!!- \\\"',lh her gra5p of h'5 pelvIS. the therap'5t directs her ltJon)l() produce the l.. ter..l ne...ion Idt in tlwlumb.lr rotary pl'e$u\"\" towards his arms. No rounte\"'pll'S!>ure SPll'll\". Ill' is al50 p(l!uho\",-d in lumbar flexion. 1be i5 roqUll'ed for the patient\"5 thor\".... Thedir«\\lonof her manipulative physiotherapist kneels on the couch JUSt rotary movement mllSt encourage or maintain the distal to hi5 buttocks and grasps around his ili..c crest lumbar fJ.'xion and the lateral flexion left in such a way thal5~can makea 5table5ingle unit of his right ilium and her two hands (Figurt 12.49). Rotation in f1uion, and lateral flexion left. Method from above downwards (lie on ® in F + IF@ do Th oJ) c c - - - - The lhcrapist produces the I'l)tation by using her body weight through her armS, No counter-resista~ ;s Stortmg position \"'oeded during the t~hni(lue, but she should watch the pati'-'rJt'\" lumoor spllle tOSl.-e that she is producmg The patiO'llt's starting position is the s.:IffiC :15 tholt therotarylnO\\·..m.... tandlsnotl06ingthepo!iitionmg described for the technique abl\"'e I-l()\\\\'~'er, tIu5 nme of lumbar flexion and lateral flexion left. the manipulah\\e physiotherapISt sbbilizt5 his pel-'is wilh her p\"'lvlS l() pl't'\\'ent It from roIlu'S backwards Rotation in flexion. and lateral f16ion I~ft, from dunng the techmque. She holds tus left elbow with M nght hoInd, and makes a solid unit of hi5lower thorax below upwards with a vcrteb,\"\"\",'u\",;,,-, _ by PftSSing agitinst hr.1eft hoInd \"\"m her left !\\and (Fiprt 12.48). \\\\'ilh thi5 tec:hnique, the aun is to r;use the axis of the ~vic/lumbar l'OIallon from brIow the MUfota' of thr couch l()the,·efWb,....themsel\\es. Figure12.48 ROlOltoninflexionandIOl.flIlfte.i<lf1ldtlrom Figure 12.49 Rotationi\"fI~.io\"andlawaifl~.iGl'l,and aoo.. downwards(i\" F + Lf<Ddo Th oJl lat.'al ft~.i<lf1I~ft, from bdo.. uI'wards(in F + If@dooJ)

Stortmgposlflon Stortingposition The patN'l\"lt hes on h,s ngllt side, positioned in lumbar The pallent lies on his nght side ..nd the physiother- f\\exionandlateral{ko,,;ion.11't.i!it:imethemanipulaIlH· apISt positionl; him for lumbar rotatlOf'l ali' decribed ph)\"siotherapist gnsps his left iliac aest With hn\" left Pft'·iously.Sheallowshisqloha.ngO\\l\"rtl>e51dE'of hmd 50 that slwan push It forv.·ards, while at the same iiint' grupmg undeo\" IUs IefI ilia<; crest. reKhlng therouchwithhis~~ngbl\"yondll$edge. 115farantniorlyashlSanlerioriliacspU1e.'lOtNtft an pull his nght ilium ~kwards(FiSUrr 12.50). She sbnds in front of the pallent and place; her M~fhod nghtao...·eflegbetundhisalfandherleft~infront ofhlSleft~.Shr1oNnso'il~,.thepiltN'l\"lttop~her The rotaI')· IN)\\emer>t is produced by a synchronous Irithand<.\"UppedO'o·.... thefrontofhisleft~ldlerand IT>O\\-m>eflt of the therapist's IefI and right hands III oppositE' dil\"t'Ctions. Hl\"r rigllt hand undef- his pel'·is her right hmd <.\"Upped 0'0.\"\" his Icft lup. ~ IeiIns far IlIl'O'ds 10 slide backwards and f\"\"\"\"ards on the couch mough across to be able to dll'l'Ct hn\" ng.ht fonoarm §Q lhallxMh of her hands JnQ\\.E' equal distance, thus t-':kto..·ards herself(Figllrr 12.51). centring the roIation near the '·l.'l\"Il'brae. Rotation with straight leg raising (..i) lumb.u rotation and straight leg raising have bttn described as sepi1ratc techniques. Howe·..er, it is some- timl'5uscfultoallowthepatient'slegtohango\"erth,~ side of the rouch during a lumbar rotalion tL'Chniqul;'. One advanbge of this is that the weight of the leg assists thcrolati()flbclrlgperfnrm~bythephysiotht'rapist Howe-.·l'f, another Important use is th.aI.'lOmctiml':'l the efft'Ct 01 the leg hangmgover thesideactsalmost Iikt'a straight leg ralSmg to'Chni<jue. Under <;in,:umstar\\(t.'S whena finn straight leg raising techrtiqoeisdesm.'Cl, the lumbarrotillJOrlllll'O'dslO~donesJjghtlydifkrmtlyso f''9Un: 12.50 RotallOn,nllo>on,lndlatmlflwonlrft,frurn that the ph)\"siother.IplSt can stand in front and U!!Ol' Iwr bflowupwards\";Ill.m.tnllUllSiin f + [email protected] Jess 10 strmgthen the5tr.ligllt leg raising strm:h. figoI\", 12.51 llotabOnwllllstra.,11q ~1.)1

380 MAITLANO'S VERTE8RAl MANIPULATION M~thod The physl()l:ho\"raplSt pr<nidesa hoIdmg a<:tlOfl with her left I\\;>nd againsl ..... patient'5 $hould.... and ~ the rotatlOfl \"',th her nght hand \"&'l'Mt hill f..'I11ur. At the same tune as she applie rolatiQn to his lumbar spuw,she abo irlcrN5e> ..... tension ltI ..... straighlll'g raISIng by plH'tlng on her k'l't 10 boI.h mamtaln knee e>.tensionand~theangleoilupflexJon.. Pr«ourions nus lechruque should not be used until other tait- niqucsha\\e bt.-en lried and II i§ known thai S1raighlll'g raisingl5a Ill'Ct'S5'llry part of trl'atml'lli. It should not bedOlW''''hcn radicularl\"'ini$n>produ«'d in the lower leg. unless the I\"'in is long§landing and IIw di§Orcler $table, Ex.1mplesoitrealmenlinclude:se\\'en'lumbarnel\"\\'e root pain, page 414; chronic lumbar neI\"\\'e root pain, page 418; il\\$idiou;; onset ofl<:-g I\"'in, page 419; low backpain,page430;3('\\llebackpain.page4JI; sponuylilicspinewith locali7.ed lesion,page43J;co<:- cygodynia, page 434; juvenile diJlc k.\"ion, p<lge 436; and bilateral Icgpain,page4J7 LONGITUDINAL MOVEMENT ( ...... ) Figu~12.!>2 101 and (II) l.onglhllhnal tnOYl'nKnt Th.:re an' two mettl(xl$ for producing thi<; 1T>O\\emet\\1. palient'sankles. Longitudinal mOl'emenl is Ihen pro- The operator ll\\3Y use either one or boI.h of the ducedbythephysiothcrapislflexinghere1bowsalld pali...,t'sko&s- extending hl'! shoulders while in the crouched po5' ition .......\"Llh gentle mobili~ing lhere is no movement Using tVtoItgs( ...... 2) ofthepatientaIQngthecouch,butwithst~ Storrmgposltion ThefYt>entlw!s on hi§b3d:on a Iowrouch WIth pil- 1ow5p~ under Ius head, while the physiother.;lpist sUndsal the foot~ of the oouch fa.cmg the pabenl and gl7lSp5lhe patient's heelsand ankles from theout- §>de. ~ palient's Icp a..., bfled, while maml.;llmmg some 1T0IctI0n, 10 a height th.iIt will .;Illow lhe lumbar spine 10 n'U\" in I. posillon ntidway between flexion and l'lilm~oon To do this, the kp need 10 be r..ised appn;u\"m.;llely 25~ from the honzonlal pl.;lne. It isad\\-isabk: (or the phpiiotlwr.. pisl 10 stand with oocfootinfrontoflhcOlherandcmuchrorwan::lso\\'er the patIent's feet. The physiotherapist's body and arms are Ih..'fl in thi: position where maximum pull can be giVl'fl with minirnum effort (Figurl' 12.52) M~tl1od All loosenl.'5S of contact between the pat;\"'flt and tlw oouch is loth'fl up by gently pulling on the

Lumbar spin~ grad<'S only thrt-e to si~ tugs can be transmitk'd pn'SSurelothepatient'sanklesoastocoolinuctheelnng- I>t-\"Cause the pahent slides a little along the couch. Th\" ating acti{)fl <lfthe leg. The line traversed by thepatienfs patient should not make any elfortto pre\"ent this h('('1 must bea straight line from the starting posilion mo,·ement. to the point where thetraclion isappJied,and the line is the lX'Sition of the straight legchoscn at the outset Using one leg (.--(b:i) to place the interverlcbraljoint being mobilized in its mid-position. 1\"/u, timillsufthephysiotherop;,t\"s Qctitm 10 Sto'tingposition coillcidewi/11 thrfitlllidropplllguflllepali<'IIt\"s klUrill/O exlerrsion is vi/ol. The physiotherapist's arm.~ and lhe T1lepatient li~\",on hisbackona low couch with pil- patient's loot must at all times be held cJOSI' to th\" lows under his head. To mobilize. using the patienl\"s thorax Icft leg, the physiotherapist slands by the Icfl side of the couch towards the foot end If the patient is unable to allow his knee to drop lreo:lyintoextension,thisaclion Can be assisted by ask- The important part of the technique is executed ing him to kick gently through hishcel. Dorsiflexion of when thepatient\"s Icg is straighl. II is better, therefore, the ankle may assist further to take up lhis position first, so thai thephysiother- apistcanstandcomfortablyinancfficientposilion.n.e Once the physiotherapist's action isoomplcted,the physiotherapist grasps the patient's left ankle so thM patient's leg is returned to the flexed hip and knee position ready for th., n.,xt mo\\emenl.Aseriesofthrec th{'lefthandisplacedundcrtheh~l,graspingitfrom tosixmovemcntssOould be do!\\e before reassessing pmgI'L'SS. The patient must not hold on to the sides theoutsideintheareaoftheAchillestendon,whilethe of the couch to prevent sliding, as this may hinder right hand is placed in front of theanlde with the adequate relaxation. As the p.1til'llt slides along the thumblyingovertheouteraspectolthefoot in front of couch,thephysiothcrapistmU5tmo\\'eh.crtl.'ettoremain the lateral malk'Oluswith the fingcrs sp\",ading Over in control of the proccdure. the inncraspcct of the foot and the medial maJicolus This should give a comfortable l.'flcircling grasp of the Prrroutions ankle. Theph}'5iothcrapist placeshcrf~tina 'walk- st,mding' posHion opposite the patient's lower leg, When using the single-leg procedure, lh\" state of the with the fLoet pointing towards the loot end of the patient's hip and knee must be checked before and couch, and crouches forwards over the patient's left during trealment to avoid injury. 11 back pain or foot.Theangleatwhichthepali~'Ill\"sll'gisheldshould muscle spasm is produced when the double-leg proce- allow the lower lumbar spine to lie comfortlbly in a dure is being used. th\"techniqueshould be done gen- neutral position midway between extension and flex- tly and changes accurately assessed afterwards. ion whiJetraction is maintained on the leg, and the kn('('shouldberelaxedinexlension. Usrs To mo'-e from the position dcscri'wd to the true Thedouble-Iegm.,thod is used for evenly distributed starling position, the physiolherapist flexes the patienl\"s painful conditions, and thesingJ.,-leg method (using hip and kneewithnut mo,-ing her own I.,.,t. Theamount the painful leg) for,ymptoms that are unilateral when of hip and knee flexion employed isgovemed by the thcse symptoms h.1,'e a lumbar origin below the fourth gentlen<'5§<lfthemobilizaliondesired.lfthetechnique lumbarvertcbra istobedoncstrongly,aratherfullhipandknceflexion fK>Silion is adopted. If the mobilizalion starts Irom a Thisisa very useful technique, particularly when lower posilion of hip and kn.,., flexion. it becomes cor- appli~>d as a gentle double-leg procedure for acute rt'Spondingly more gentle. As it is necessary for the pain that is localized to th., lumbar spine pati~'Ilt's ll.\"g 10 be relaxed, it may be nec~'Ssary 10 pre- vent any abduction <If the hip by supporting the lateral Examples of treatment include: acute back pain, aspect of the lowl'Tleg with the physiotherapist's right page 431; abdominal pains and vagu., pains, page 443 lorearmjFigurl'12.52j Mrthod FLEXION (F) Fromthcflexcdposilionthephy,iolherapistguidesthe Flexion is often considered a movemcnt to bea\"oidl-d, leg and allows it to drop_ but should be sufficienlly but the'\" are times when it is a necessary part oft\",at- ah....dolthemovementtobeinrontrolofthelegpos- m.,nt, both with the \"erygentleand the stronger tech- ition. A, the kneedrups into the relaxed,fuHyext<md,'d niques. Four techniques showing varying strengths fK>Sition, the physiotherapist applies a gentle. sharp ared{\";Crilx;odbc!nw.

382 MAITlAND'S VERTEBRAL MANIPULATION First starting position Figu'~12.S-4 Flnion:=oodstartingposition(F) The patient lies pronE\" arms by his side and with his thc flexion action on the lumbar spine by raising the head tumedcomfortably to one side. Thephysiother- pel'-is. The oscillatory flexion action Can be perfonned apiststands to rus left side at the 11\"'1'1 ofhis thigh,fac- inanypartoftheflexionr,mge. ing his pelvis. She leans across the patient to grasp his right antl'TOSuperior iliac spinl' in her right hand while Third starting position holding the left anterosuperior iliac spine in her left hand. She places her right forearm against his lower The patient silS with his legsextendro in front of him right buttock (Figurt 12.53). and his hands on his shins. Thephysiotherapislstand~ d05c1y by his left side, with her left hand o'<erhis Method knl't.'S and her right hand posihonoo approxillliltely over his thoracolumbar spine. Her legs are positioned Using a very gentl,;, pulling action with her hands, the in walk-standing. She crouches forward towards his physiothcrapist raises and lowers th,;, patienl's upper fcet(figun'12.55) pelvis slightly. Thl' ffiOl'em,;,nt is facilitated by pivoting her right forearm againsl his bUllock. M~thod Second starting IJfJsition Thetechniqueha~fourphases,thefirsttwoofwhKh Thepatientlicssupinewithhishipsandknccsflexcd are identical. For the first phase, the patient takes his and his feet resting on tile table. The physiotherapist hands off his knees and gently stretches his hands stands alongside his trunk,facing across his body, and towards or beyond his toes and th~\"Il returns to the passe5 her right arm behind his knees. She reaches hands on kn\"l'S f'O\"ition. The second phaseinvol'1':I across with her left arm in front of his thighs to link hl'r repeating this gentle stretch and return. During both hands together on the outside of the farthest knee. By these movemcnts the physiotherapist follows his two lifting and pulling with her arms, she flexes his kn~,,-'S gentle stretches, maintaining light pressure with hef towards his chest (Fig\"\" 12,$4). right hand against his thoracolumbar spine while fol· lowing his trunk movement with her trunk flexion. Method The third phase is the actual mobiliz.1tion, which is an exaggeration of the first two phases. tn this third phase The physiotherapist uses both arms to flex and return the p<ltient stretches as far beyond his feet as he can thepatienl's I,;,gs; this gently flexes his lumbar spine while the physiotherapist, holding his knees down. andthenallowsittounroll,Mostoftheactioniscar- pushes against the thoracolumbar spine with her ricd out by her right am1, but her left arm assists the hand,using her body weigl\\t 10 produce an effident flexing action, By virtue of the position nf her right stretch. The fourth pM,.., involves returning to the am1 behind his knees, she is able to exert a certain originat starting position where the patient's hands amountoftractionalongthl'lin,;,ofhisfemur,assisting ll.'St On his kn~...'S.

tumtmSfliM 383 f\"'!J'l\"'12.SS fIu>on:thinl,tartinoJ pos<llonlF! Fourth starting position The patit-'nt stands with his feet lOem (4in) apart. The physiotherapist. standing behind the patient, placl$ her right f\"ot bctwt't'n hi5 feet She places her right f\"\",arm 'ICWS5 his middle or lower abdomen and gra~ps her hands firmly together in the region ofh,s l l . ' f t l l i K c T t . \" S t T h c p a t i c n t U . e n f l e x e s f o .....· a r d . a n d l h c physiotherapislrontrolst1lt.'rangelowhichsheallow him to fle\" by the posibOnofher righl f\"\",ann through ..-hKh she exem pressure (Fig',\" 12.56) Mrthod The pahent Tt.'P\"atcdl)· but genll~ bounres<k>wn ...10 AexiQn. The ph) IOtheraptst at\"\"\"·s him to go as far as sN-{~.ttwmA't\\Jms;hun_hortdisbnceby pulling ..·,th her forearm. \\-I,hUe pulling ..·tth her fore.- ann sN- INns Nclward5. \\t>\\enng her nght pdns agairn.thisWCTUm Prttauf;Ot1S Thclastlvo-OlN'thodsllrE'notusedinthepl'CSmC('ofa hcrniahngdlX. Fkuon is not a tedtniquetou§cunlil others IhiIt ef'kct rl\\O\\'cmcntal theinler..-crtcbral/Oinl ha,'e been Ined WIthout Sll~ When It IS first used It should be performed gently soth.al ,ts df<lC1 can beassessecl before progressing to stTOl'lgert<lChniqllCS. Usrs F;gu,~ t 2.56 FI~\"ion: fourth '!-lining po5I!>on IF) The very gl'ntle t~,<:hnique.described first. ise~t\",mely \\'aluablewhcnlhcpahl'1lt,onforwardfle~ion.exhibits cons'derable lordotic mU!ICle spasm. The two Slronger

384 MAITLAND'S VERTEBRAL MANIPULATION Figu,e12.58 Rotati()/\\ techniques cannot be used underthesecircumstanccs, The first tl'ChniqUl' that may be considered is bilateral but are valuabll! WhLTI fl ...xion is limited bysliffness longitudinal movement (scc Figurr J2.52)caudadas~ and is not hindered by muscle spasm or pain gradelmoverJlCnt Accessory movement in flexion (e.g. IN Lx FF 20' The following techniques can be performed in ~ do~L41 very localized and smooth manner. Starting position Rotation The patient rL'Stson the LTld of the plinth with the end stortingposition just proximal to his anterior superior iliac spinl!, and lies down Over the plinth. He then bends his knees n.epatient lies supine with his hips and 1meesromiort- unrler the plinth to allow thl' lumb<!r spine 10 flex via ably fleXl-d. The manipulative physiotherapist stabili7.1'S the pelvis. The physiotherapist stands by the right side his kn<'<$ with her axilla, and places her hands com- o{the p\"tient and pl<>ees her thumbs on hisbacl<, fortably on his lateral mac crests. for rotation of the pointing towards each other and imml'diately adjacent pelvis to the right she placL'S her left Ihumb in fronto/ to the spinous process on the right as described On hisant(>rior-superior iliac spine (Figure 12.58) p\"gL>s370-371 Method Themelhod is identical to thatdL'SCribL'd on pages 370-371 for thepostero-anterior unilateral vertebra Bothofthetherapist'~handsworl<simllltanl'OUsly,thl' pres:sure(l'igurrJ1.57) right hand lifting and rolHng its crest anteriorly and to the right while the left hand encourag~>sa backwanh and rotary mO\"ement of his right ilium. The te<:hniqUl' must bcsmooth and slow, and must avoidpro,'oking painandsp\"sm Uses Extension \"This1L'Chnique may be usdul as an end-.of-range mobil- Starting position iz.;ltion if flexion is stiff. On theotherhand,itmaybe Again,thepatientissupi~with his hips and Imee valuable to use as a pain-relieving technique if the comfortably flexed whil\"bcingSlIpportl-d by the ther.t- fMtient is most comfortable in this position. pist'srightaxilla.Sheplacesthefullp.llmarsurfaceofall finl;erson thc posto:rior lateral iliac CfCSt:s (Figurt' J2.59). DEBIliTATING lOW BACK PAIN CONFINING PATIENT TO BED Method There are many ways in which extremely gentle mobil- A '-cry gentle_ smooth and slow 05dllatory movl'lTlelll is izingtffhnique:scanbeadministl.'TCdadvantagrously. tmnsmitted through her hands to his iliac crests, lifting

Lumba.spinf 385 FigUf.12.59 Figu\"'12.60 Flexion Figu\"'12.61 mo.ement

386 MAITLAND'S VERTEBRAL MANIPULATION thetn towards the ceiling and lhus producing an exten- sion of thc low lumbar spine. Flexion The same starting position is used, but the manipula- ti,'e physiolherapist's hands are placed near the grcater tl\"QChanter of the femur. Tl>e oscillatory flexion oflhe pelvis, through her arms, produces a flexion of the lumbar spine. Again. the tcchnique must not cause pain or provoke spasm (F;gurr12.60). POSTERO~ANTERIOR MOVEMENT Stortingposition This is the same as for the pn.'Q-ding tL'ChniqUes, except that this time the manipulat;\\\"(· physiotherapist places the palmar surfaces of her fingers as cJose to the \\'ertebralcolumnasshecancomfortablyreach(Figure 12,61) Method Figur.12.62 (a). Ibl Staning l'O'ition for fkxlon, \",,,nsio\", l~t.r~1 ~ ••ian, rotabon from b<low upwards.nd 'coupl.d' bot It n.'quires great care to apply thc lifting movemmt in the loin arca without producing a poking k\"Cling with u,ingth.f.murandpl:lvis the fingertips. However, a very satisfactory move- menl. 51owly, gently and smoothly, can bcproduccd The I\"vel at which the movement Is empha5lzed can aI5(lbevaricd,ltiswls-elnthestagcsofseverepainto avoid direct contact with the spinous pl1lCCS6e5,but as movement improves 5(lme of the pressure can be transmittcdtotheareaofthetranS'·\"r>eproces..o;es FLEXION, EXTENSION, LATERAL FLEXION, age. For flexion, the therapist lifts her heel in order to lift ROTATION FROM BELOW UPWARDS AND his femur and pelds, thus producing lumbar flexion. 'COUPLED' BY USING THE FEMUR AND PELVIS Loweringofh;,;h;psandlm~'eS\",iJlproduc\"exlens;OIl Stortingposition Lateral flexion is produced by swinging his feethori- Thepatientliessupinewith his hips and kneesf]exed 7.onlally in an arc from Icft to right or via l.YT'5II. Rotatioo to 90\". The manipulati\\-ephysiotherapist stands by the o(the lumbar spine is produced by moving his knees left side of the phnth. forl'xample. facingacruss the and feetina parallel arc from leh to right and Viceomd. patient, 5he then plares her right foot on the plinth so that her thigh is placcd under the palient's \\mees and \"'/hen gL'1ltle mobilization of the lumbar spine is cahe•. Her right hand holds his Imees togelher from n.'<juircd and dircct cont.lct with the vertebrae is not abov.., and her left hand holds under both hishet'ls possible due to tenderness and sensiti\\'ity, this ted1- (Figure 12,62) nique may be of\"alue (Figure J2.62) Method STRAIGHT LEG RAISING [SLR, (Ill Flexion,exl<--ru;ion, lateral flexion and mtation arc pro- This Is not a tKhnique to mobIlize an intl'rvertebral ducedusingthelegsandpelvisofth\"patJentaslever- joinl,butHlsamobilizlngprocedurefrequentlyessen- tialinthetrrotmentoflowl'rlumbarronditions

Lumbar ,pi... movements, by th.. physiolherapisl raising and lower- ingh~'Ttrunkfromlhe5<luaUingposition AsrensionisappJjed,thepati~'Jltmayliflhispclvis on th.. painful side. If this dot.'S OCcur it can be pre- venlL'<l by thumb pres.sure in the iliac fossa. Similarly, he may abduct and laterally rolat.. his left It-g. Thi:> action can be prevcnl~'<l by the physiotherapist's Iefl hand holding the patienl's leg medially rotat<'d. and by directing her stretch into flexion and slight adduc- lion of the hip. Precautions When lower leg pain is scv..re or paraesthesias are present, this 1~'Chnique should not be used or should be used extremely gently with careful assessment. Care musl also be l'x..msed when n<.ouwlogical changes arc pn.'St'nt. However, such changes a\", nol necessarily contraindications Starting position Uses The patient lies supine and rests his left leg on the Straight leg raising can be used when the symptoms or physiotherapist's left shoulder, which is kepi as low as signs indicate pain is arising from the nerw root or its is ''t'<juired by lhe limited range of the patient's associated investments, wh('\\her lhis is due loncrve- .Iraight leg rai.ing. While lh.. physiotherapistkn~'Cls root compr~'SSioo or olhe.....'ise. The mosl common alongside thepatient,sheendeav-ours to kecp the indicalionisunilaterallimitationolstraightlegraising paticnt'srightknL'Cextendedb}'ll!slingherleflknee with minimal pain, and when OVl'f-pn'SSure produC't.'S lighllyjust above thep.ltient's knee. The patient's left a pelvic lifting. This sign may be present when lhe knee must be kepi extended and slightly medially patienl has back pain or limb pain. Under sorne cir- rolat~>d by Ihe physiolherapist's lefl hand (figur<' cumstances th.. rang.. of straight I\"g raising may be 12.6Jl· To this position. inversion and eversion in dor- full; Ihe lechnique then merely mobilizes and tensions siflex.ion and plantarflexion Can be added. then..r\"\" Method 11 is not the method of choice when the limitation is muscular. and it Is not a technique lhat should Tension Is applied. usually as a single fairly rapid be used uolil other tL'Chniqu~'Sthal donol mm'e the st....lchingmovemenlorasaseri~'SofsmaIJO!iCillalory oerve rool so much have been found ineflective.sLR is also a valuable melhod of improving n~\"Uro­ dynamic mobility following lower limb peripheral ner\\'eenlrapment SLUMP Any of the posilions of the slump test (see pp. 144-149) canb<'used asa t....alm..nt mobilizing technique. The circumslanceswhen it would mQ!;tbe used are' 1. Whenthekneeextensionislimiledand reproduces the patient's pain 2. When Ihedorsiflexion of th(' ankle reproduc~'S his pain. The One qualificalion is lhal mobilizing for the inter- \"ertebraljointsallheappropriarelevelhasnotproduCt'd

388 MAITLAND'S VERTEBRAL MANIPULATION any improvement, or enough improvement, in lhe harnesS. Some wrilers have described it with the canal signs patit'nt standing (Lehmann and Brunner, 1958) while othersh;wl!lhl'patientlying;someusea lhoracicbelt PrrCQutions as the means of fixing the upper end of lhespine, while others use padded pillar> again,t the axillae (Crisp, These are the same as those referred to in relation 10 1960j; some have described it with the patient in thc straight lcg raising straightpo>ition,whileothersinsistonlumbarflexioo (Mennen, 19(0); some give traction on cam·as-top couches (Scott, 1955) while others use rolieNop LUMBAR TRACTION rouches ([udo\\'ich and Nobel. 1957);.>omeadmini,ter it as constanl traction (Cyriax, 1975) and others as Examplesoftrealmentindude:severelumbarnerve- inlermillenltraction([udovichandNobcJ.1957).Evert root pain,page416;chronic lumbar nerve root pain, lhe application of manual lumbar traction has bt>en page 418; insidiolls onset legpain,pagl!419; low back dl'SCribt'CI (Crisp, 1960). A useful summary of th~ pain, page 430; spondylihc spine wilh localized lesion, and other authors in relation to all forms of traction is page 433: and jUl't'niledisc lesion, page 436. given by Licht (1960). There exisls quite commonly a false impression of A patient wilhseverenerve-rootpain,ilhe i, to be traction. One fal,.. impres/;ion is that traction is differ- treated conservatively. should be treated with lumbar ent tomobili.tation. This is quite wrong and it is unfur- lraction. However, a choice n\"'-ods to be made between tunate-parhcularly when a patient does notimpro\"e constant Iractionadministered ona 24-hour basis in becausegentlemovemt'nlinthisdirection(thetraction hospital and traction administered in physiotherapy direction; long-axis extension; longillldinal movement rooms on a 3O-minute pcr day ba,is. Provided lraction caudadjhasnotbf'{,nlltilized.joinlSha,·etlwcapacity in rooms stands a reasonable chance of success it is the toflex,extend,rotate, laterally flex a\"d to b,>/>I;Jt!,dis- treatment of Choice, as it lea\\'es the patlent freer than Iraclrd and compresst'd as well as bcing moved inacces- does traction in hospital. \\'Ihrn pain is severe il is no! .>ory mo,'emcnt directions. When a manipulative easy to make the COTR\"Cldl\"Cision from lheoutset.1I physiother\"pist does this, it is seen lh\"tsheismobiliz\" constant traction in hospital is to be uscd,themelhod ing. However, when she is seen to use a longitudinal is as follows direction {by means of harness and a machine of SOme kind),it is St-'en lobetractionand not mobi1i7..ation.The second false impression related to traction is thai il is Hospital traction thoughlby many that the slrength of the pull must be greatenoughtodistractthevertebraebyameaSlIrable The patient lies supine cither on a horizontal bed or amollnt. Many surveys have bf'{,n caTTled 0111 to prove wilh the foot of the bed raised25cm (lOin).Acomforl- thai a force of 136kg(JOOlbj isr\"\"luirect to separate the ablesofl pel\\'te belt is placed on the patient, to which vertebrae. Otht'r writers goas far as 10 say lhateven ropcs arc attached and fiuedtoasprcader. Fromlhe with that force thl!reis noseparalion. 1'heseattitudes spreader a single rope passcs m'er a pulley at thc foot are indeed unfortunate. £.ulier in this book. the text of the bed to Ihe weights allacht'CI at its end (rigurt refl't'Kod to grade I muvements. Also, reference has 11.64). It iswiSt'St for lhepalient to remain supine Bt all bcen made to the rhythms of mobilizing tcchniques- times, but a change of po>ition may sometimes be these references relate (jrst to extremely gentle It''Ch- permitted. The patient should be al1ow(od commode niques,and<.cc<Jndlyloasustainedpressure,thelaller faciliti~,astheuseofabedpanistootraumatictothe beinguscd,forexample. in overcoming muscle spasm back ofa palient with severe pain. Fowler's position Traction IS just anolher diR\"Ction of movemenl, and (Figurt 11.64) is only rcquirt'CI if lh(>palienl h.>sa lhe very important intersegmental intervertebral marked lumbar kyphosis that isnotlargelyreducrd musclesarempableofprotectingthisdirt.\"Ctionofmov<-~ whl'llrt'Cumbenl.lfFowler'spusitionisrt\"luired.as mcntinjust thcsmne way as tht'Ycan for any other SOOn as the kyphosis improves lhc normal tractioo direction 01 movemenl. Tractionisa mobilization in po>itiondescribed (jrst should beadopled. Initially the lhesensclhatlhatwordisustodinthisbook.Therefore tractive force Should be approximately 5 kg. This lh~re is noelinica; reason why a '·ery gentle grade I weight can be increascd on a basis of approximately traction (3-4kg) cannot be ust'Ci aseffectivl'ly as 1kgperdayuptoamaximumof9-11kg.Tenday<;is mobilizations. usually long enough for the lraction to be mainlained, Tractionforth~lumbar,pinehasbeendescribedin after which the patient should become fully ambulant a variety of ways and using many different typt.\"S of over the next 3 days. Iflherc is no impro\"ementafter

lumb.. spinc 389 1 week on constanltr,lction,persistence with thetrac- The traction is then applied from either the head tionwillnotproduceanychange end or the foot end of the apparatus. or from both Fundamentalty, the two essentials for lumbartrac- ends, but care must be taken to diminate friction lion administered in lreatmcnt rooms arc a comforl- between thcpatientand the couch if a roll-top traction able,adjuslable harness for allaching the thorax and CQuch is not being used. The physiotherapist does this pclvistofixe<!points,andaoomfortable~itionfor by raising and lowering the paticnl's thorax and pelvis thepatienl. to assist relaxation. With thcsc two factors alternatcly to cnsure that the stretch is being applil)(! in mind. the following method is gi,-en as a basis for between the belts and that it is not lost in frktion traction therapy. betweenthepaticnl'sbodyandtheoouch Although a friction-frceoouch is not essential,it is Starting position such a tremendous advantage that if it is possible to make up a simple one cheaply thet'ffort is more than A belt is firmly fixe<! around the patient's thorax while rewarded. M05t palient rolHop couches consist ofa he is standing and a sccond belt around the pelvis fixed thoracicscctionand a roHing lumbar section. but while he is lying, making sure lhat no single garment this arrangem~'Jlt has little to recommend il. An effi- is caught undl'l\" both belts. cient friction-f,,-'C couch has both \"'-'Ctionson rollers. The pati\"nl then li~'S face upwards on the lraction llisaISOl!S5<'ntialtobeabletolockthesections oouchrnthesupine~itionitmaybenect'SSaryfor tOb\",ther. not only to malc it stable for the patient to the patienl'ships and kncestobe flexed, The position climb onto but also to make it usable forpurpoe;es of choice is the one lhat places the intervert~-bral joint otherthantraclion. midway between flexion and extension to permit the greaK'Stlonb\";tudinalmovemcnt By means of straps, the thoracic belt is lhcn attachl)(! A friction-frrr lroction couch to some fixe<! point beyond the head of the oouch and the pelvk be1t is attached toa fixed point beyond the A friction-free couch isnot an essential requircment for foot of the couch. Ilefore the patient is ready for the traction thcrapy. but thead\\'antag<-'S to both patient traction to beapplied,thesestraps must be tightened and physiotherapist are considerable. These advan- to remove all l(l()S('nessfrom the harness (Figure 12,65) tagescanonlybeappre<;iatedfullybythecomparathe 1JS('0ftraction with and without the friction-frt-'C top Method The time sawd in eliminating friction when applying lractiononafriction-freecouchisvaluable.butproba- ltisnec~rytoaSse5saccuratelythepatienl\"sarea bly the most important factor is the ea... and accurac)\" and degreeofJ'<'in, while he is lying rt'ady for thetrac- withwhichsmallincreasesanddecreasesinthetractivi' tion to be applied. forcccan bc made, knowing that th,oy arc imml)(!iatcly Figur.12.S4 Tractioninn•• ion IFowl.\"sposition)

MAITLAND'S VERTEBRAL MANIPULATION cffe(tl\\e,n Ilvspu....AnotlwrimpeJrUnl faetor is thai roudo de5cribed,and the modif\",allOnSGln be<ld.1opWd a se.1t' used during traction pro'>ldes. n>Of\\' \\rU(> for anrroudl that hits. wooden lop, or ,,-ODden ed~ measuA' of the Irloct\"·e fom.obet\\o<\"ft'n the thoI\"lICicand 10 ils top. peh-i(bel~ n.e fricti<;>n-frcc top IS formro b) placing two we- \".ny.-..Iiel..... ofpalmtedfrictlOn-freerouchcsare Iioosof l.85cm (lI-in) plywood end 10 end on topoi. a\"a.ilabk!', bul ~t1y they han' a mobilt' lumbar <ec- normal coud>, with do\"elhng toan as rollers betYo·em hon and .. flWd thoracic section. Th,s IS nol sattsfa<'- the plp.·ood and the lop of the couch.. n.e thorae.: lor)' beaUSil' the thorax rTIO\\'es when lraction is applloo, t'\\en lhough the m\",-\"menl may j;(Jffil'11l1leS plywood sectKJn is i6cm ()(lm) long and the lllmbu ]x,'rn\"II.1flhelhor<lCkpartoflhecouchiSflQIf...\"'lo S<'ction l07em (42in) long.':lI'Id theuwodlhseqll.l!ht' mow, lI(Jm<' of thol IrKIi'e forcewil1 beta.,en up by widthofthecouch.lfthollopofthcrouch mca!;1l11\"$ friclion !>elw(X\"fllhepalienl's thorax and lhecouch 1.98 m (6.5 fl) in l~nlllh, and both plywood seclions.rr Therefore, bolh lumbar and thoracic s..·ctions must be placed end 10 end ... ,th the head end of Ih~ thoracic: fll'l'tomo\\'~.llmustalsobeJXl'>Sibl\"'lofixlhefrkti\"\". fN:eroll top in a Slabll' posilion toallmv thepall,,'nt to sectionle\\t'lwilhlhehl'ad~\",doflhecollch,therewiU lll'ton and off the couch,and to enable it tobc u;.o:.od fll. other treatm~lIlS. These requirements ;,re met ill lhe ]x, IScm (bin) of th~ couch uncovered by plywood ]x,yond IhefOOlcndoflhelumb.Hplywoodscction. Four pi<'«.'S of dowelling 1,85em (Y. in) in diam~tcrand equal in k\"'llth to the width of the couch are plaad

lumbirspine 391 ~ lho- couch under lho- plywood. Two do....els ,,1\"0.' ('( uS('d. to support each ply....ood 5ection fig\"~12,66 [aIFloII-loptraclianlablf,IIllEnlarg.m.nlaf tneend To pll\"\\'enl lhe sections of plywood from rolling off Ihl.-headend oflhe C()U(h. a p\"\"'\" of timber is nailed to al the opposile end. This method is pMl.'rable to the end of the couch so NI the top of the timber 15 wheel-operated traction on a scfl.'Wlhreadbecaus.eof Je-.eI ....,th the top of lho- plywood wh.crl. il is in J'OISIhOn ,15 quicker action. Also, lhe rope and pulley syslem oro top 01 the dowels (F1SV\" 12-660>- To Pre'o\"mt the gi\\\"CSlheoperalOl\" some feel of the tracti'e forcedur· plywood from roIhng off the foot end of the couch• .ll ing application. Acrommodanng for lhe stretch of w NmesIS during the first few moments of treatmenl is L-~isrn.wielofilmloanL-sha~tdecutOl.ltof al§O folreasief' WIth thepulll\")' system lhe table lop Immrdia~)\" be\\oIo' the foot end of the If a lube N\\\"ing an inlCTT\\olI diameter of J.17cm lumbar S«tKJn ofpl~,.,\"OOCI(FIS'''\" J2.66b). To lock lhe (l.25in) is fixed under 11 norD\\oIllr'eoltmcnl couch by frictiofl..fr«lopin1l5tolblepositioroaga'nsltheplCCl\"ol mel.al straps al earn end. two lubes hanng 01 slightly limber nailed 10 lhl> hNd of the couch. the U-p~ is Sm<lllerexICTT\\olldiarnl.\"lerthan317cmcansbdeinside wfixed tubcfrom each end Each inner sliding tube 10wL\"Il'<lmlOthe\"'rgeslp.1rtolthecut-oul~ionol st-.lldbehalfwlenglhoftheOl.llftfixt'd tube. Astnlt st-.lld be welded al nghl angks 10 one end of thecouch.puslungforwarostodampO\\'Cf\"t.... lopoi eolCh UU'IO'T tube, and a length oflheend slrul5houk! the plywood and under the top of thecouch. and lho.'l'I bcsuch that whom ilisposinoned \\\"I~rtlcally,withthe pushed SIdeway.. 10 lock the U-piece inlO the smaller innt'T tube w,lttm the fIxed OUlt'l' lube. its lop is appmximillely Ban (Sin)abO\\'e the le\\e1 of the lop of part of the hole, In ltusposihon lheU-plecealsoprY- lhe couch. When the couch IS not being used for lum- n'l'lts the fOOl end of lhe lumbar section of plywood bar traction. theseslidlOg tUM coin be slid 01.11 of the way insid\" the fixed tube.\\'lho.... they an' 10 ust\",they fmm lifhngwht'l'la pali\"ntsits in the middle of lhl' should be extendoo a distance of approximalely 36cm rouch.Thisli(lmgmUSlbcpl'C\"l!Illooifthecouchislo (14in)al tht'head end and81 cm (32in)al the fool end, bcuS<.'<lfortrl'atm('ntsotherthantraction,Whcnthc and arc held with the end strulS uprighl by a pin U-piece is removoo, bolh plywood SL>ctiOns are ff(~ 10 inSt'rledlhmughholesappmpriatelyplacOOlhmugh mil indl'p<:ndenlly towilrds the fool end of lherouch, Iheoukrandinnerlu~aleacht'ndoflhccouch. The lour dowels muSI be carefully posItioned to n-diSlanC\\.'Saliow the ropc:s and pulleys to be fittoo ffiablel'ach ply\"'ood SL'ClionlomUfarcnough for 1O Ihl' fOOl end. and the scaleal lhc head end Iraction In'almcnts, and for the friclion-free top to be made stable enough for ~ ....Jlh other formsol ph)'SlO'- therapy One dowel should be position<->d undet\" rach plywood S«hOf'l 12.7cm (Sin) fmm lhe head ffld. and the other should be k.-.eI with the foot end. Each ply- wood ~1Ofl can tlK'l'I rolI275cm (l2in) before each head..end dowel rt'aches the end of it'> plywood we- lion. The pai-ltlOfl of the oo..e1 under the fO\"1 end of thetOOr<KX:SOOChonoilsoallowsthepabentlOsilmthe mKtdk> of the couch where the Iwo plY\"\"ood S«1>OnS meet, ....'thoul the head end oflhe thor..ocscdlOfl bft- ing. The foot end ofw lumbar section is pn...cnted fromlifling..swouldbtlheca5l'ifwpahents;olon the lumbar S«tim roe,Uff ,I!> head end than the oo..'eI, bythelockmgrif«tofWU-pi«e. The lotal L\"O<SI of m;I!ena1 for coo\\\"erlLng a norm.:ll trealmenlc\"\"\"h,nloasbbk>andeffKioenlfriction-f\"\", couch ~ m \"nid. and thoe labourrosts aO' o;ery smoili. kau. many rhy~iotherapislSare deten'cd from acquinng IrkllOn-f....\", lumbar Iraction eq\",pmenl by h'gh prtCL'S and by equipment which is 100 cumber· some l<:l be used for mutme physiotherapy. a che~p and Simple mlothod for prO\\'iding lhe lwo fix<-'<l points \"'-'<luin.'I! forlraClion on a normal l\",almenl c\\>uch is dcscribcd. The tractl\\\"C force is effected by a system 01 ropesandpulleys.TI\\e~andpulleysarealladled 10 one end, u~ual1y th... foot end, and a !'Cal\" is insertL'<l

While on the sub/'-'Ct of couches, there are many dif- ferentbrandsand Varietil'S of couch available and they a~ all,'x)Xonsi\"e. A good manipulative physiotherapist ,., should be able to improvise using a norm\"l examin,,- o lion couch, without pl1rchasing special ones. Hadng '\" be\"\"Silid this, a special col1ch can enOrmOus advantage o both in conserving stT'-\"ngth and in being able to apply '0' smooth rhythmical movements to heavy p\"tients \",~~~L_J For those patients with low thoracic pain Or lumb.lr ,., pam, when a IMge-.amplitudl· Ihroush·range t('ch- Figure t2.67 Exampll'Sofa moMiling coucil. (01 Floor plan Ib) Rotation. (c! Exten,ion. (d) Lateral fI~xion\"lcl Rotation nique is need,'<l, the a\"is of the mobilizing couch for taken. the patient will almost certainly suffer a lateral flexion and rotation t~hniqul'S must be in the markl'd exacerbation of symptoms. 2 The symptoms may be \",lie'\"OO minimally by 13 kg right place. Akron Therapy Products supplied the of traction. and under these circumstanCl'S the drawings of their couch in Figure 12.67, showing the different axcs. It is the only couch the author knows of at this time that has the COITl'Ct axis for latl'Tal fie\"· ion. The captiun fur each of the drawings should Ix- interpretl'<l as the direction of movement that would take place if the patient were lying supine It should be st\"ted here th\"t the survlj's tt\",t ha\"e \\x>l'n pcrforml'<l to show how small is the interverte- bral mO\"ement produced by firm traction forces show il lack of chnic,,1 appreciation of the relid of a patienl\"s symptoms and imprm'ement of his sigt15 with min- imal weights. Quite frequently. traction produced b} merely w,'<lging the thoracic and lumOOr St'Ctions of the friction-free (Ouch apart is all that is needed Under such circumstallC't'S, tn.c p.llient must nol m,,,,e- other tha\" to breathe and blink his eyes. It is not the intention of traction to pull the \"ertebrae apart and produce negative intradiscal pressure; this is only on,' other direction of mobilizin.l\\ t~h\",que, a, are all thl' others menhoncd in this chapter. When a p.ltient is gi\"en lumhar traction lor the first time, a ,·ery low weight (not great('r than 13kg) should be used and this should be m~intatn,'<lfor a f't'riod not exceeding 10 minUll'S. The patient should not be per· mitted to ha,'e his anos above his head, and if he wants to read while on Iraction this is permissible if, and only if, his elbows are rcst,'<l on the couch. A careful w<llch should be kept for low b.~ck symptoms caused by the traction, even if these are only felt with mo\"eml.\"t of the lumbar spine or coughing. If low back pain is experienced by the patient. the duration and preso;ure of this first treatment should be reduced. If 13 kg can be applied, the p.ltient's symptoms, both local back pain and \",ferre<! limb pain, should be asSl'SSl'<l after a watting period of 10 seconds. One of the following courses of action should Ihen be taken 1 Whl'\" severe symptoms are completely .....lie\"ed (particularly symploms in the leg). the weiSht should be reduced by at least half and the duration should not excM 5 minull'S. If this action is not

Lumba'ipIM 393 Sl.......gth mav be incTe-.d 10 \"rPro~lmal\\>ly 20kg If, dunng w firsl In'atmetJt, the s)'mplolnS1 w~ UJd the dur.. tion can be 10 mmutes. HO><o'l\"u\"., if made \"'orwirulially and the \"'elght had 10 be reducro 10kg comPletclll\"t'lie\\es sympkJm'!i (especi.J.lly if considerably, and if the s)'mptoms ~1J\\ U'lCn'.JSo'!d they a.... 5e\\.......), tim sm.ngth should be reduced 10 ..nd thesognsl\\a'·e.llsodeicnor..tcd,trilct>on must be somcttungles6thanl8kg. dISCOntinued. If, h,oo,.'''''n;. the svmpkJm'!i do not renoam J. If 1M sfmplOlTl5 remain uncholnsro, the tracbon wor.;eand thesignsdonotdctcnorall', w traet>on un =~~ iJl,cn,;r;ed 10 10 kg .00 ~\\lSlained for 10 be ~ted. During the seoond trealment, an ment should be made of thr \"eight thatcan be ..ppll('d 4. If 1M symploms a.re w~, the Iraclion should be \"'Ithout increase of S)'mploms, k) be able 10 compare reduced 10 a welghl whe.... the p~lietll is the same Ihiswilhlhep\"\",'ioustrc..tment.lfahighl'r\"·cll;htl5 as before the traction was applied,and thedur- ntion should be n:.'l1uced to5 minules possible, then fa\"ourable progress has hem made. When lhe strenglh on lhe fir.;td..1y was reducccl oc'Causc symploms we~ completely relieved while lhe Whilelhetraclionisbeing ....least.'l1sluwly,lheP<'lienl patient wason lraclion,lheprogn:.'S!;ionisguidl-'das should mme his pelvis genlly by rolling from side 10 much by changes in the o;c'erHy of any temporary sid\" and llllmg it If pain is ('-\"P\"'ril'flCt'd \"'ilh this exacerbation thai foliowN lho- lreatment as by the pel\\'k ll'\\O\\'cment\" the traction should be held al Ihal changcsinsigns.O\\ ..... lheJ\"l'riodofthcfir>tth~or pornt until the pam disappears. When the lraction has four stretches, the lmpnwcment in signs will probably bccnR.'mO\\·ed,thepal;entshouldn51foraf(\"\\O.'mm- be.smaJi. \\\\'hen SIgns Lndl(,)1J!' that traction should em- ulcsbefCJn'5tanding.Thisisnot ..l.. a)-s~·,bul bnue, any lTOl;n'ase m the treatment should be in the st-old be mslSled upon ..I the liM treatment. The patient st-old be warned tNl 'I os normal fix his bade. length Ntlme ..nd not III the weight. When thertis no 10 ~ strange for approxunatcly 2 hours. ~tion folJowing treatmenl or afler the durotbon of 15 minutes,the ....eight can be gradWllly oncrNSoed Lndet arcumstanas other lh.In the Iwo lust dis- ~, weighl and tune ColI' be tncreascd. logether, Method ofprogression Generally, the a\\ .....ge Weight 15 ....ached between JO .. n.J 4.5kg. HO\"'l\"\\'er, OCC;I5lonally \"'hen the rail.' of On the day following the first 'stn'teh', the pallen!'s p<og~~tooslowWlth lowerstrcngtm,stn.'Iches symptoms and SIgns a.... a~ and compared with ofupk)65kgal'l;' ....'CI~rY-DuraI1Ol\"ldO\\\"'SnotnecdlO lhoso.'presenlbefo.... tra.ction.Fromtl1esefaehllispos- UC\\.'t.'d 15minuteo.,a~ 1\"\"lIer P\"'riodsdo nOI produce siblelodelermil1t'whcthertraclionshouldbere,\"'Jled any further prll);n..'!tS eXC1.'P1 when Il'l'ating dIsc palh- andhowit~houldbegr\"du\"led.SigrulC,)nbea~1 ology causing ner,e-rool ~ymptoms in\"\"ediakly following the tracbon, bul fle-\"ion fre- A1thoughstrcnglhsha\\·ebl..~nsuggeslcd.lheSCotle qUtYltly docs nol pro\\'ide any u!>Cful informMion. and should not be the cont\",lllng guid\" during trcatl1l\\.'I1t certainly it is nolthl' m..m crilen\\m on whieh to bas..' In facl it should only be rcfl'T'l'l'd to when trachoo has furthl'rt......lrJ1enl because it is fK'quently more limited OC'\\'l\\ applied to thl' \"\"'el n-quirN by the patll\"lt\"S lIIUnI;-'l;iialely ..ftet'traction.lU-'aSSo....~ lhe;ostenslc signs, symptoms and SIgns. The main \\'alue of a scale rncas- 1e..'ingl'lellionlOthelasl.l(thelnlllalallcmpt~I~.­ urement is for reoonhng puTJlO!i'E'S. \"\"I100 ~ dIfficult, 'stdfisn' ~nd slow, slop the pallent As in other ..tN5 oflhe ,-ertebral column\" mt\"\",,,l- and$ .. ~I.thennpbmllulthl5.ufrequent talt \\, ..riotbIe traction CM\\ be used for the lumbar 5p1Tll.' find'ng follo mg traction bul does not mean thai tra(- Theduration and stmlgtholMKto treoltment falls wtthm tJonLSl\\'lhelpfulThe~lof!.Jtcrall'lellion theQme limitalions~$l'l:out\"'·e.Turung for the and e-:1eMion can P'O\"ide helpful mformabOn. Some- hoIdUJd rest periods\\'anes~dtSCUS5edonpage289 tlrl\\CS !.Jter.! f\\e)OOfl rna) not be pilllnful, \",-en .... ith l,;nfortul\\iltell,therc~~tlJnotlllerm'ltenttraetlOl\\ O\"\"r-pn!lo<>ure,but ....tr..ncurnparingrighlloleflthere m.Khme Ih.ol can ~ \"aned til 11$ speed of pulltng UpOf i5 deflrull' R'!>lricbon orsliffne55. Following traction, k'ihng down.. For the patient ....110 hoIs generalized tho:; d,ff\"'n..'nCe bct....ecn tl\\csides may be lessened. Ina aching til an of thl' sp,ne whc~ marked degcner~- 5imil~r way eXlrnsion may exhibit more ffiO\\l'1lletll, hve change> ~ e\"id(.'I1t on X-rays, ;nlermihenl lrac- albcllsmall. tion with nO rest or hold lime is very useful, It would In th.., ab:;..,nce of uther signs, on.., faclorthal will be beller still if Ihe ~fX't'd 01 pulling up and kiting ~how whelh..,r traction is being succI'Ssful is if it is down could be doubled comp.lrN with Ihal which known th,11 al a «'rlain weight p<,in is produced, and e.iSlsinthebc\"crmachll1l'S,Similar1y,ifp\"inis~·'e... this ....eightcanbeincreasedalasubsl\"quC'Ollrealment }'el;ISI.\"Cmsthejointnl.\"edsmO\\·em(''I1tinthislooi\\itu- without prodUCIng the diliromforl. In this cast', lhl' dmal dircction,il would be nIce ifthesp<.'t'd rould be pallerofscondiliun must bclmpronng. halved

394 MAiTlAND'S VERTEBRAL MANIPULATION Precautions GRADE V MANIPULATION With the exCt'ption of discomlort from the harness Most of the mobiliz.~tions can be performed as manipu- used,there is no natural,;,onmess to be felt with low lations by merdyinereasingthespee<i of the technique weights of lraction. With this in mind, great care at or near the limit of the a\\\"ailable range. Of the h\\'O should bc lake\" when any low back discomfort is fell types of manipulations (gen\"ral or locali7.ed),in the while the traction is bt-inggi\\'en. 1t is advisable, once general grmlp the main one is rotalion. lhe traction hasbeenapplied,loask the patit.'llt to aUempt alternate Ilattening and lordosingof the lum- Lumbar rotation (c,) gcneralisedV bar spine as well as coughing to,;ee if lhis causes any bilckdiscomfort. The symbol indicatl'S lhe dil\"f'dion of the rotation of thepclvis ltiswisetoconsiderlhefin,tSt-'ssionoftractionasa 'dummy run' SO lhat the embarrassing but h.armless Although lhe mobili7~~lion described on pages situationofapatienthavingdifficullygettingontohis 379-300canbecnnvertedtoamanipulationbyasud· feet is avoided. Following carelessly strong traction, den increascof the operator's effort, the st\"'ting po5i· particulariythcfirsl lime, a palient may be unable to tion described bt-Iow is easier to perlorm get to his feet OOcauscofsharppainsin the lower back ThJs is unpredictable, bul can bca\\'oided if care is StDrtingposition exercised wilh every first treatment Uses The patient lies On his back wilh his head supported on a pillow, while the physiotherapist slands by the Tractionhasth~primary uSL'S in the trealmentof right side of the couch fadog the patientaod abduets pain arising from thc lumbar wine thepalicnl's right arm out of the way. The physiothcr- apist cups her left hand over the paticnt's left shnulder, 1. Any symptoms. whelher they are locali7.ed to the graspsbchindthepalieol'slcftkneefromtheoutside lumb.~r area Or referred into the leg, which ha\\'e Wilh her right hand. and fll'~l'S the hip and kn\"\" to~ graduallyappcilred ovcra pcriod of days Or longer, rightangle Then,byadductingthepalient'slefthipto and which have not bct-n P\"-'n\"\"l\"\" by any known pull the knl\"\" across the body and downwards toward5 trauma, may bc trealed successfully by traction the floor, the pel\\\"is will bc rotJIl\"\" to the right. Careful positioning 01 the paticnl al Ihehcginningwill prevent 2. An ache arising from the lumbar spinl' in the squL\"Czing his lelt leg against the l'dgeof the couch prl'senee of marked bonyehanges, whether this (Figu'l'1l.68). has been brought about by exct'SsiVl' degl'nl'ra- tion, old trauma or po5tural deformities, usually Method responds well to gentle traction Or intennittt'llt variable traction. Wh\"nthep05ilionoffullrolationhasbct-nreadted,tt.... physiotherapisl changl'S her righl hand to grasp 3. rainarisingfromthelumbarspineintheabsenCt' lheposterolaleral aspe<:t of the uppcrcalf; the hl'el of of any obvious loss of active range of movement in the hand liesbchind lhe head of the fibula and the fin- the lumbar spine usually l\"C5l'ondsbctter to trac- gersextend down lhecalf. Rotation is stretched further tion lhan to manipulation. by increasing the pressure against the piltient's shouJ- der and leg, then a sudden downward and rotary Traction should always be tried when no further lhrust is applied to the leg and strong count\"r-pressure progress can be obtained by mobiliz.alion. When treat- at the shoulder. The all-important factor is that lilt' ment~primarilyforslilfnC5s,tr,'etioncant>eaddroto dircction of mo\\\"en'ent of the palient's lcft leg must the mobilization, usually aftt'r the efled of mobiliza· producc rotationolthepelvisand not adduction of tile tion has been reassessed. Inlermittenl trilction is com- hip. This rotalion Can be done wilh the lumbar spine in monlychosen for its mobilizing effects. flexion ore~tension by positioning the underneath leg and altering the angle of hip Ilexion used for the leg. It isoftennect'Ssary for traclion tobc preceded by which acts as the leyer. manipulation. particul\",ly when traction is gh'en in thepr~nceofpainlt's5Iimilationofmovementatan n,emorelocaIi7..edmanipulalions,whicha\"\"mt'l\"Cly intervertebral joint. When traction of a particular mobilization lechniquespcrformed al greater spced, patient has reached a stage when it is nol producing aremcntioncdt>elow. any further prog\"-'SS il isad\\\"isable to retum to mobil- i7.ahon,asthis is then often successful whereil h.,d not beenbefo\"\"lraction

lumba' spine Figurc12.SB lumbarrDtation gtneralistdm.nipulation[olBtntknte upwa,d,;(b) bmt krICC to <ide on back;(clbcnt~n«:KrossbodV

396 MAITLAND'S VERTEBRAL MANIPULATION Postero-anteriorcentral vertebral preSSllre, the front of the patient. From this position it isadvis- postero-anteriorllnilateralvertebralpressllre able 10 tell thep,Hient to ll'lax, explaining thai he wiJ] and transver5e vntebral pressure be put into the \"-\"qui,,-od position. The first SK'P is 10 Conversion of these mobilizations to manipulations flex the pilticnt\"s left hip and km·.. until th.. dorsumof rteCCS6itatesa sudden tinyamplitud~ in<;rcil5Cof p\"-'S- the foot can lie behind his right knee, and thC'llthe sure,gi\\'en from the position where thcjoint is stretched straight right leg is put into slight hip fl~\"Xion sufficient to its limit, to producea >lldd~'fl mov~mentof very sm.,ll to place Ihe p;!rtkular inten'ertcbral joint midway range. T1w p,,-'SSure required to produce this small betw~'Cn flexion and extension. The piltient'5lefl arm is movementisconsiderablyg\"-'aterforlhelumb.1rregioo extended at the shoulder and flexed al th~ elbow 10 than for lhe ...mainderof the spine. To incrcasetheeffec- allow th~ forearm to rest on his side. To actucve the ti\\'enes5 of the manipulation in the lumbar spine the pill;\"nt's trunk Or 1~'gS Can be supported in extension, ne>.t stcp, in\"ol\"ing rutation at the intervertebral joint, thereby increasing the lumbar Inrdosis(Fig\"re 11.69). the patient's right arm ispull~>d towards lheceilingto twist histhora>. until his I..ft kn .... lifts from the table. IntervertebraljoinbTlO-Sl (rotation C) localised manipulation Carcmustbe~xcrcisedto\"'-'Cthatthejointisslillinlhe Stortingposition mid·flexio~xtension position. Theann is then allowed The paticnt is asked to lic on his right side while the torclax in an abducted and laterally rutated position physiotherapist stands at the side of the couch facing out of the war. The phyjiolh\"rapi~t I\"ans O\\'\"r lhe patient. threads her left fOll'arm through the triangle made by the patient'~ I..,]t arm and tnmk. and plact.'S her left upper fo...ann against the palienfs lefl shoulder. Atth.. same time. ~he plac,,'i her right upper fnreann Figure12.69 f'l>sr.ro-ant.,i\",,,,,nlral vert.brall'f~SSUr~ Ilumbar) localist<j manil'ulation. (0) Distal ~nd raised lbjProximalend,aist<j

Lumlm~pine 391 behind the patient's left hip. This position lea,'es both laterallwo t~s PSI radiculaf symptam). At no time h.lnds free to add to the rotation at the intervertebral prior 10 18 monthsaga had he eWOr had any back joint. The left thumb presses downwards against the svmplom~. and there was no ~milial eamponenL He had left side of the spinous process of the upfX'r \"L.,-jL'bra, and the right middle finger (usually the strongest) undergonenumerou~fa.msaft.eatmenl(arthado.and pulls upwards against the right side of the spinous unorthodo.10W'r6manths,butwithout~uc<:e~Overa process of the lower vert<.'bra (FiglHY' 12.70) pefiad of time the ~ymptom~ eas.cd, bUI he did nat Method bl:come~ymplamfree. Maximum rotary stretch is applied by rocking the patient back and forth with the forearms, altering the Fallawing a fall 3 weeks ago. whkl1 e..,(erbaled hi~ position of the right forearm On the buttock if the lum- diSQrder, he had a lumbar punetufe (which prO'Vei! bar spine p<J5ition neo;ls to be adjusted. Gradu,llly. as negativeland hospital Iraetion fora week. Fallawing more and more stretch is achieved, the pressure this, hi~lawba(kpain in(fealoed.Wl1en he firsl went against the spinous pl'OCt-'Ss is increast-od until the joint for physiotherapy hi~ ~ymptom~ we~ a~ follow~ is tight. The manipulation then consists of increasing (r'9u~12,71I: the push through both forw.mls and sharply increas- ing the pressureaga;nst the adjacent spinous processes 1. He would waken in the morni\"'1 with back i>\"inand hack ~tiffne~ and the ~tlffn~~ would last for a few CASE HISTORIES hau~(Unusualforanan-inflammalory musculoskeletald,wrder,j E~en though there are case hi~torie~ at the end of the Coughing caused ooth bad pdin and left ealf pain book. it seem~ uloeful to indude he~ an example of how Hewasusingindomelhaein\\lndocid)~uppositories the manipulati~ physiotherapist thin~ h~r way through every night, and he feit that the~e were esloential to a i>\"t,ent'~ d,fficultyand atypical spinal problem. This I~loen Ille level of his pain. {~fl1ap~ tl1i~ mean~ there particular example demon~trate~ how to link the th~ry must llean inflammatory component.] with the dimcal pr=ntation. II al!.O demomtrat(S the differentcomponentsapatient'~problemmay have, and 4. BendingCilus.eilhimloeverebackandlegpain,ooll1of how one com~nenl may improwo and anolher not. Thi~ whicl1 ea~e<l immediately an ~tanding upright. (Thi~ palienn diSQrder demonwates how the Iherapi~1 mUSI latter fact indiCiltt5thata treatmenlle(hniquell1at adaptherlechniquestothen~Cleddndune~ted provoke~ leg pain may n011ll: a cnntraindication 10 chang\",inthesymptomsand~ignl. The example alSQ its Uloe; Ihe teehnique, to Ill: effective, may in fact demonwates how open-minded !.he must be, and how need 10 prClV{lke leg pain.) detailed and inquifing her m,nd mustlle in making asse~smenh of cl1ange~ and interpreting them S. On ~tanding for 1 minute, the pain wauld inc~aloe i~ hi~ bad and would spread down l1i~ leg. (This M.l indicatesthata~ustainedle(hniquemaybe~quircd.) Eighleenmontl1sago,a34-~ar-aldfit,well-builtman 6. The oniyneurologieal changepr~entwa~calf IMrlj with no history of previous back problems wakene<lwitl1~ininl1isleftbuttod:area,Overthe weakne~1. p~vious2dayshehad S\\lfferel!~erybad low lumbar backache,whichl1i\\doclorhaddiagnOloedaslleingvifal The initial physlOlherapytreatment,wh,chhe had Ill:cauloe he alw l1ad g~neralachlng in oll1er parts af hi~ undergone elloewhere, had imprO'o'ed all of hi~ symptoms body. Mrldid say that, althuugh he had 'f1u-likacl1es marginally. The first three oft~elC treatments (ansisted all O'Ver'. his luwerbad was the worst area. He had been of PAs on LS and unilatefal PAs to the left afL4,The On holiday during th~ previaus week and had done alot latter, he sa,d,provoked calf pain in mythm with the of lifting and been wind-\\tlrfing(a new e.pefienox for teehnique.Onthethirdtreatmentinte,mittentlraelion him]. Two days after the onloel of hi~ buttock pdin il hadbl:en introdueed,butthisdid not help him. spread. owornight, down the Idl leg with tingling inlo the bigl~areaofhisleftfO<lI(?L5radieularsymptom) Asloe§Sment Some days later, tile big tue tingling alternated witl1 I saw l1im for Ille firsl time Sda\".. laler. lingling along the latelal oorder of hi~ foot and into Ihe I. Onmore~sitivequestioninglodeterm,nehisarea afpain, il wa~ inte,esting to nate thaI, altl1augh his main lower leg pain was po~terior. he l1ad whal l1e descfibed a~ 'a different pam' in the upper posle.olateralcalf.Theloelwopainswere!.Ometimes preloent althe ~ame lime. but were mOfe frequently felt s<::paratdy, (Thislend~ to indicate Ihat theVmayariloefromtwadifferentsour\",,~­ twol;Omponenh.)