Maitland's-Vertebral Manipulation - 7th edition

448 MAITlAND'S VERTEBRAL MANIPULATION I\"D- \"A v.p, 'h l'< B Figur~ AlA -Limitofth~ ,\"n9~ Figu,~ AI.3 On\"'lofpain l (A) WHERE I-D· A -l'<P, L'h l'< B Th{' nt'>.1 stt'p is to dt'~rmin\" th{' avaHablt' range of Fi9u,~ AI,S movem{'nt. This is don{' by slowly moving th\" joint Ma>.imum qualit~ or int~n~ry of p;lin b<'yondl'l until tl\\{'limH oflh{' range is reachoo. This poinl is markoo on the baSl'Jine as L (Figure Al.4) Figur~ Al.6 -Yt~nl \",a(1;on of maxImum qualiry or int\"nsiry ofp;l,n L (B) WHAT The next step is lodetermine what component it is thai prewnts or inhibits further movement. As we are only discussing p\"in at this stage, P2istl><-'llmarklod \"erli- c a l 1 y a b o v t ' L a t m a x i m l l m q u a l i t y o r i n t e n s i t y { Fil',tre AI.5].Thl.' intl.'nsity or qllality of pain in any one pos- ilirmisaSS<'SSC<!aslyings<:>mewhereon!hc,·erticaJa>.is of the graph (Le. b<'lween Aand C) between no pain al all (i.e. A)and Ihe limit (i.e. C). It is imporlanl to real· izelhal maximum intensity or qllaJily of p\"in in thl.' diagram ....prt'Se'l1tstht'maximumthephysiotherapisl isprep\"\"-od10 provokl.'. This point is well wilhin.and qllile differenl from, a 1\"\"eJreprescnlinginlolerable pain for the p\"tienL Eslimation of'm\"ximllm' in Ihis way is, of course, enhreJy subjeclive, and varies from p\"'r&Jn to pel1iOn. Though this may seem 10 50me \",,,d- ers a gra\"t' wl.'akl\\t'S> of tl\\{' movement diagram, IT IS IN FACT JTS STRENGTH. When the studt'nt com- paK'ShCl\"'L\" and 'p; with her instructor's, Ihediffer- encl'Sthal mayexisl will teach her thai she has been looheavyhandl'tlortoo'kind·and-g\"ntle'. L (e) QUALIFY inlensilyoflh\"pain lhal is the reaSOn for stopping al L, lhen P2should be qualified lhus: '1'1 (intensilyJ' Ha\\'ingdocidl-dtostopthemo\\'eml'OtatLbe'CauSl'of th\"p\"in's'maximum'qualityorinlensilyandlhe,,-'- If,however,thenamin{'TlJelievl'Sthaltheremaybe fore drawn in pointl'l on the lin\" CO, il be<:oml'S necess.:IlY toqllalify whal 1'2 represents; if it is lhe somebtenlreaclionifsh\"mo\\'l':Slhejoinlfurthereven IhoughlhepainisnOlsc\\'ere,lhenl',shouldbequali- fil'tlthus:'P2 (Jatent)'(F(guo:AJ.6)

Mov~m~nt di~9,~m tllffi'Y ~nd compiling I mov~m~nt diag,~m 449 c P,I~) 0 l-lZJ-\" IfTI-A Y. y, ~. B -Figuf.Al,a 1,~ula,ifIC~aS(ofpainY.P, 'II:v.L8 -Figure A1.7 Pain inc,.~.ing \"\"\"nty with m~m~nt. -_Pain Thl' next step ;s to depict the behaviour of Ihe pain I[]] during the movement betwl-en P, and Pl' If pain \" '1,P, 'n LV. a increases evenly with moveml\"Tl1 into the painful iC-D'Fig\"~ Al,9 Pain ~ac~i\"ga maximum at thrCe-llu3,t•• ,~ng. ra\"ge. Ihe line joining I\" and P, i5 a 51raightline (figu\", f'n y, AI.7). However. pain may nol increa5e evenly in thi5 i '-I \\ljP, V.- P'jq..aiilyj B way; ilS build-up may lx- i\"'--gular. calling for a graph A Pain wi,h no limi,ing im~n\",y thai is curved or angular. Pain may be first fell al about quarter range and may initially change quickly, th\"n Figur. Al.l0 the movement C,ln be taken fu,ther until a limit at three-quarter range i5 reached (F(~ure Al.lI) al,eady dl'SCribcd, and an example of such a graph i5 given in Fig\"reAI.13. Wh'\"Tl Ihe joinl is painful al K'SI. In another \"\",~rnple, pain may be first fdt al quarter Ihe symploms 3l'l' easily c.-x3cerbatl'll by poor hand- range and remain al a low level until 5uddroly il ling. However, if ex\"minalion is carril-d out wilh ca ... changes, rNching PI althree-quarter range (F(~ure A1.9) and skill, no difficully is encounlc.-Kod. Thl'examples giVl\"Tl demonstrate pain th;lt prevenls Again it must be emphasi7.cd thai this evaluation of a full ,ange of rno\"emenl of the joint but Ihere are pain is purely subjective. Neverlheless, il prescnl5 an instances where pain may fieV'\" K'<lcha limiling inten- sity. FigureAl.1Qi5an exampte \"herealmlepain may be felt at half range. but the pain scarcely changes beyond this poinl in the range and lhe l\"Tld of nonnal range may be reached without pro\"oking anything approaching a limit 10 full rang\" of movement. There is thus no point L,and P' (I\" mealls P prime)appearson the vertical line BD to indicale Ihe relah,e significance of the pain at that point (FlgurrAl.1Q). The mathemal- ical u\"'\"' of 'prime' in this conK\",t is that it repK'S<.-nls 'a numerical value whkh has itself and unily as its only factors' (CollciSl' Oxford Dietio\"\"ry) If we now return to an example where the joinl is painful ~I rest, mentioned at Ihe beginning of this appendix, an estimate must be made of Ihe ~mounl or quality of pain prescnt at rest and Ihis appears as P on the v\",lical a~is AC (Figure AU1). Movemenl is then begun slowly and cardully unlil the original level of pain begins!o increase (P, in figun'AJ./2). Thebehav- iour of pain beyond this poinl is plotted in the manne,

450 MAITLANO'S VERTEBRAL MANIPULATION ,... Figu,. A1,I4 il.fc ofp~,n Figu,.Al.l1 P.inat,.lt An are of pain provoked on passive mO\\'ement mighl be depieled as shown in Figure Al.14. RESISTANCE (FREE OF MUSCLE SPASM) ,... These resislanCL'S may be due to adaptive shortening ofmU5<:lesorcapsules,scarrissue,arthriticjoinlchanges Figur.Al.12 L.~lwh.r.p~int..ginSl0inc,.ast and many olher non-muscle spasm situations. 1,rr-1, A no,mal joint, when completely relaxed and moved passively, has the f\",,1 of being wdl oiled and 1~ friction f...,., (M<litland. 1980). It e,1n be likened 10 wei ,...A ..., 'h 'I, B soap sliding on wet glass. II is important for th\" physio- therapist using passive mO\\'ement as a form of Figu\",Al.13 P:ain~u.to\",b-.qu.ntmOV'l'm.nl lreatmenl to appreciate Ihe differenCl' betwl'en a f!\"C'l'- running. frieticm-free mO\\'ement and one thai, although invaluable method wheT<-oby students can learn to per- bdng full 'ange, has minor resistancl' within thl' range ceivl' diffl'rent beh,wiours of pain, and th\"i, appT<-oci- ofmo\"em\"\"t alion of Irn,s., varialionsof pain palll.'J1lS will mature as this type of assessment is p,aelist-'l1 from pMient to When dL1'icting a compliance diagram of the forces palimt and ch<-och·d against the judgemenl of a mo\", applied to stretching a ligament from sta,t to breaking experi\"nced physiotherapist. point. thl.\"graph inc1udl.\"Sa 'toe region', a 'hnearrcgion' and a 'plastic region': the plastic region l'flds at the 'breakpoint'(Fif;Iln'Al.I5}. Wh\"n a physiothl'rapist asSl.'S5eS abnormal resist- ance Presl.\"llt in joint movement, physical laws state that then' must be a degra' of ,\",'Sistan\",,' at the imml.\"- diatl.\" momenl that mO\\'emL'llt commences. The resist- ance is in the opposite dil\"l.\"Ction to the dil\"l.\"Ction of movement being as~'l1,and it may be so minimal as to be impo.'Tceptible to the physiotherapist. This is the 't\"\", region' of th\" complian~ diagram, and it is omit- tl.\"d from the movement diagram as used by the manipu- lali\"\"physioth\"rapist n,.. section of th~ compliance graph that forms th\" mOV\"mL-nt diagram rep'esents the dinkal findings of th~ behaviour nf f'L'Sistance \",h\"n examining a patienl's movement in the linear region only (Figure A I, /6)

Movement diagram theory and compiling a movement diagram ........ -f1gu~ \"LIS Com~..1'« d'loSIl1Im F;gllttAI.l1 -\" R, 'I, 1'bs!1I000\"\"i!oIR, \"',(IV.Rl....- ...... fitu~\"l,'6 -~ld\"-I'Jl(llI,\",l/li\"t'OIl'pl'OII'lft -~ ., dOil9ram..~clontdtttla\"9\"\"'r.n(.l.BCOJistllilprlftoflllf: o:ompf...I'«\"0iI9...... 1\"\"'1t\\~lm4ofthe_llfOil9...... use'CI for .tpmenlillg3bnormio1 ~(R.R,OI R,R'I \" abO\\e '- R~ is drawn on COlo indIcate lhoot il is I'l.'Slst- \\Vhen as.w5Song for I'eSlSlaro.ce, tM best w.lly to apprnci- ance thdt limiled the range. Rz does not I'll'CeSSiInly ate the ftee runnIng 01 a joint i~ to support and hold mean that the physiotherapIst IS too ....eak to push ~y around the joint wIth ~ hdnd while the othl.-., hand harder, il represmts the slrmgth 01 the rlSIStance produces an OKillatory mon''fJIrnt back and forth through thed1osl:'np.athofthe.ange If thIS mO\\'ement beyond whIch the phy'iotherapist is not pll.-p;tn.>d to IS felt tobe friction fTW. then the oscil1.alory mO\\ement p~. \"!'here may be faclors such as rheumatoid arth- can be mO\\ed nwre deqlly into the .an~e. In this way the tot..1availabl(' r.angec..n be~. \\\\\"lth (\"pe1\"i- ritis. which will hmillhe strength represented by R, to ence, by compolnng two pati('f\"l15, and also by compar- being moderately gentle, 1'lMTt.fore, as with 1'2.0 Rl ing a I\"'henr, right side with his left sid.., the nl'l'l1s 10 be quahfled. 'The qualification Ol.'COs to be of physiotherapISt will quickly learn to apprcdat(' minor two kinds if it is gentle (e.g. Rl (IV-, RA)), the first resistance to movement. I'oint 1(1 is thl'l1 I'Stablisht'd indicating its strength and the 5oCCOr\\d IndlCallng Ihe \",ason whr the move~1is stopped even though the and markt'd on th(' base I,ll(' AU {Flgl\"'I'A/,l7j. sln.'l\\gth is weak. When R~ is a strong resislance (e.g. Rj (IV++j), its strenglh only n<'cds to be Indicated (Figml'Al,lS). l - WHERE, l - WHAT -\"-'-'-- The joint movement is Ihen taken to the IImil of Ihe The next SIl'P is 10 determin\" Ihe beh\"vlour of the Tange, If resistance limits movement, the range is asses5Cd and marked by L on the base line. Vertically resistancebetwee-n R, and L,that isbetwl~n Rland Rl. l1le behaviour of lhe re5istance belween R, and Rl is

452 MAITLAND'S VERTEBRAL MANIPULATION - -,., ,\") ', t,l71\"t,C ' DtLLJt A Y. R, 'h Y. L 6 A Y, Y, RI~' B (~) Range R>nge Figu•• Al.19 Spasm-I......i'l.\"\"\" IdJ .esi5lanCt may Ix' fl'll. Such rcsistance might bedcpiclt.'d asinFigurt'Al.20 MUSCLE SPASM Figu•• A1.20 C,.pilUS There are only two kinds of muscle spasm thai will be con\"ide...od here; One that always limits range and assess<.od by mo\\'tmenlsback and forlhin the range b;>t\"'cenR, andL,andlhelinedepictingthebehaviour occupiesasmallpartofil,andtheot~rthatoccursas of the resistance is drawn on the diagram (Figure Al.19). As Wilh pain, rcsistanct' can vary in itsbchal\" a q u i c k c o n l T a C l i o n t o p ....vl'lltapainfulmov\"ml.'llt. iour, and eX<lmples arc shown in Figllrl.'AI.19 Whdhcr il is spasm or stiffness thai is limiting the Theforegoingresislanceshavelx..,n ....lated toexlra- range can frequcntly only bc accurately assessed by articular structures. However, if the rint is held in repeated movemtrlt (I) taken somtwhat Jxj'olld the such a way as to cumprcss the surfa<xs,inlTa-articuJar point at which resistanre is first l'1lcountered. and (2) performed atdiffcrent spccds. MU5Clespasm shows a power of active n'Coil. In contrast, n'Sistance that is freeofmus.cleactivitydoesnothavethisquality;rather it is constant in strrngth at any given point in the rang\". The following e_arnples may help 10 clarify the poinl. If a resi,lance to passive mOVenK'llt is ft!lt betw..\"\"n Zl and Zl on the oo>e line AB of th\" mo\\(>m\"nl dia- gram(F(~w·I'Al.2J),andifthisblockis'resistaIlcefree of musc1\" spasm', at point '0' bi:'tw..\"\"n Zl and Zl (A Zj Oz, B(FiguFl'AI.12)), lhest~nglhoftheresislance

i .\".... f\" T I ~ I, h liB _ z ,figuroAl.21 \"'\"\"\"la..... lO,....,w_~I~It~WffflI. t---- II A Z, 0 II figu,.Al.22 Oltf.,.nt,alin9,osiltan~tromspasm will be ~~a('tly lhe 5.1me irrespectke of how fast or ....'.----' slowly a mOHmt\"'t ;5 oscillated up 10 it. Howc~cr, if the block is a muscle sp\"\"m and leSl mon'm~ms all' Tf,S,l 'I} talo.en uptoa point '0' \"t differ'l'l1t speeds, the strcnj:th of the res,st,,\"\", will 'ncre.lSO' and be greater, \"Ilh S'llV-1 IIlCrt.\"il5eSmspo.-ed(figun'AI.ZZ). ..... ... AI!iO,lIny lJ'l('JNS('m5lrenglh will bed,rec:tly pm- port'OOolI10 !he deplhin range, n-gardll'SSoftlwspeed fiqu.. \"'.23~~_.SptiIoI with whICh the ffiO\\ ement is carried out thot b. lhe ~feh.. onepointm nvwement\"t11111wlI}·sbo.· The gr..ph for !he beh;o\\'iour of spasm ;,; plotted Ie!;sthontNtfehlltllpointdeq>et'in~ .....ge bo.1weo:n S, and S:z (figurr AI,]J), It will be found th.It wht.'Il muscle spasm limits rill\\~ it always reaches its The fil'5lof thll'twoJoan.o:bofmu-eIt-<;pa.\"\"' ....illfeel ma\"imum quid:ly, and thU5 occupil\"S only a s.....11 p\"r1 liJ.e II sted o;pnng and will pu!>h back \"SII,nst the tesl- of the range. lhercforc it will alwilYS be depicted asa ing ffiO\\emen!. particuLul}' if the test ffiO\\t>merIt ,s 1W'lr-\\'ertical Hne(fi;,:\"rrAJ,Va,1ndbj. I\" >omcca:;e\" .'aned ,nspeedllndmpo6itioninrheranst' whm the ioint disorder is Icss Sl.'\\·crc, a lilllcspasm that iOCTNst'S slightly but 'wver prohibIts full mO\\'emenl s, m~yb<.·feltjustbeforelh.. ('ndofrangc(Figun'Al,lJc) Teshng Ihh k,nd of spasm IS done by ITOO\\ Lng the ;0.01 10 the J'OlIlI at which spasm is first ehoted, And 11\\15 poInlLSnotroon ~oo5elineuS,.Furthe!\"fnO\\'enwnl is then .1Iternptt'Cl If mA:umum intensity is reached bdore the md of range, spasm thus becomes a hmillng faclor, l- WHERE, l-..;;W\",HA\",' _ Thi, limit is nott'\" by Lon the b,'sc line, and S:z;s marked \\'('rtkalJ~' \"btl\"e L on the line CD. As with 1'1 and RloS:z nt...'<ls to be quahfied intermsofslrength andq\\~11ItY(\"8'S:zIV-, wry sharp).

MAITlAND'S VERTEBRAL MANIPULATION 111<.' S<.\"COfld kind of muscl\" ~pa~m i~ di....-ctly pro- MODIFICATION portionaltotheS<'\\erityofthep<1tient·spain:mo\\l·... mentofthejointin\"aryingpartsoftherangecaoses There i$ a modi!i<;alion of the baS\" hoo AD that can be 'iharply limiting quick mll.'iCUIM contraction. This usu- used when the significant range to be dL'PKit.'d OCCu- pies only say 10\". yet it is5O\"short of B, The movement ally occu,,; when a Hlry pamful joint is mO\\ed without diagram would beas 5hown in fIg\"'\" A 1.25. and when uS<.'<l to depict a mOH,mcnl the rangebetw\",,'n Land» ad\"\"lu.ale care. and can be completely avoided if the most be sidled. The ba:;.e Ii.... AB for the hn\",nnoo,l.. jomt IS well supported and rl'I()\\'ed gently, ThIS spMm jointmonmenttobedepietedwouldbL'Iht'\"\"meu is rclIex in lype, cOlll'ng into iOClion n'T)'rapidlydor- that shown on page 175. w\"\",\", graJes of lTlO\\ement ingthelestrl'l()\\L\"fl'lL'ntA\\\"t'T)'similarkindofmos<:u- ~rediscussed.and the !ra,\"\"of themo'\"erJw/'fl1 diagr~m larconlriOCt,oncan/XClJr.1$a ,oIunbryact,on by the would be as in figutr'AI.26 J>dhent.,ndiahngash.1rpino:TeaSl'inJ>dIn.lfthephp'jo. therapisl'arn5thespeedofher\"leslrtW)\\-ernents.~ H.1\\ingdJscussed~tlcngththt'j.:'.plungolthe5t'p' wiJlbeablctodi~tInguishqoicklybef'\".eenlheA\"/lex ~raleelcmcntsofa nlO\\-ern<!ntduS'.m. ,lIS now noxes- spasmandthe\\'oIunb')'sp;tSmbeo:aoSol\"ofthe~ sary to pot them together as a whole ,...th wluch thr sp.um /XClJrs - A\"/lex spasm occurs COMPILING A MOVEMENT DIAGRAM more quiclly in response to a PTQ\\oking mO\\ement Thi$ bool pl.tces grwt emph.tsls on the ltnd~ and than does n)/unbrysp.um. Tlwsecondkindofspasrn. brha\\'ioursolp;tin .. theyJ>\"i'S\"\"lwitht\"\"diff~t wluch dOl'S not lIm,t a range 01 nlO\\ClTll.'nt. can usually r.mlJ\"I(»·emmt<. of disordered )OUlb. beaH\"ded by careful h.tndling dunng thr Il.'Sl. 15 01 \"\"\"tor Torepre:sentlhlSkindoispasrnanear-\",rticalli_ unportanceto thep;tllenl, and lheIclorl'ldlo.o\"'$Pl'MXlt)\" isrlrawnfrornaoo.ethebaSol\"hflE';llsheightandpor>- ,hoo on theb;tso, line will 5lgrufy whetherthespa!>l1'l is easy to prmole.and \"\"Il abo g \" e _ indlCalHlr\\oI ,ts strmgth. Two e:umples ue drawn 01 the exlrt'rnes that may be found (Ftglltr'AI.2\"\"' and Ill. r~~] 1\" -. .~-'.,. Figor. A1.24 Spasm tn~t (Ion 1IOll,mll rang. of mov.m.nl Figo•• A1.25 Mo,j,fi~_......td,agram 0, Figu ... Al.26 F.. m.olmo••m.ntd,agramfOfnypermobil. joinl

M01Itmtnt di~!Ir~m thtory ~nd compiling I m~mtnt diagram 455 in tN- exammation of joint m\",·emenl.1l>e following ident,flCSwher-e thatp06,hon ism relation to the roor- demonstrat how the diagram is formulated. When mal range, and I'l'COl'ds ,t on the baSo!' line of the mo,·... \\Jl'SI1ngtheO/4JOUltbypostero-anterior~re(ltl mentdiagram aspomt L(frg,,\"A.U8) thespinousproceso;ofC3{forexample),theroulineis ~fol\"'\" STEPJ. L- WHAT STEPI,P, Forthth}-pomobiIejomt.thenexl$tepi510~~ GentW, tnCn.'ilSUlg pre!i5Ure is applied wry ~Iowly to therncn·ement ..·;I$stopped ~tpomt L This meanstNt the rtXo1minel\" hio5 moved tht joint;l$ tlras!ohtlS will- tN-sptnous pl'OCe55 of am a pll5tero-antenord,n'C* ingtogo,butshehi05not~,tI'Ndl.B,H.a\\'ing tIon.UMlthepatientisOblo:.edto~wlwnhefinit feris pam. This point in the range is noted, and the decided WHERE Lis. the l'U1IUTOrr h.u to deo..k .. hy $hechoselostopal L; WHAT W;I$ ,I tNt pr>t'I'ented he!\" plW~lOI:heraput then rele.-s 5Qme of the pressure from the SP'oou~ prtX.'e!lS and performs small 05Ci1L1· INChing 8? If ...... -..me, for the purpose of this lory mm'ements. Agam s/l@asksthepatient if he ~ls any pam. If he does not, theos<:illation~hould then be example. that it \"\"i\\lj ph)~l teSISt;lnct' free of muscle spasm that pn...·.\",ted movement be)'ond L the point carTiedout5Iightlyd.·qx'fintotherange.Conl'~ly, ifhedoesf....lpain,thc05Cillatorymo\"ements/lould where the \"ertical lint' ab...\"\" I meets the honzontal bewitlldr.. wnintherange.l:lytheseoso:iIlatorymo,·ol- pro,ertion CD is marked a~ R: (f;81l\" AU9). The R2 ments in different p<,rtsoftherange,thepointat whkh needs to be qualjfied u ing words or symboli!i to indi- pain is first f,,11 with mo\\'ementscan be identified and catc what it w..saboutthe n'Sistanct' that prevented is thcn rt.'COrded on th\"ba\".. line of the mOl'cnwntdia' the c~anuncr 5tN'tctung it further, for I!xampll! the gram as I', (F(Ii'lrr AI.Il). The <'StimatiOl' of the pus- ihoninthcrangeofP, isbestachie\\'ed by pcrforming the()!;CiIlationsatwhatthephysiotherapistf.\",lsis quarterfange, then at one-third range and then at half range,Bythismeansl',canbe\"\"ryaccuratc!yaSS<.\"SOJL'd \"Therdol'l'tho-reareMo5tt'pstoestabIWungP,' I. ASlJ1gleslowmmemenl 2. Small O!<Cillatory mOH=en!S.. STEP 2. L- WHERE -', RqII ;C) '!.iI',1lS found r •• the ph)~apbt should con- \"\"\"\"1.28 Um;loflM .... tmuefur\\htrmtotheranV\"'iththepostero-Mlterior mmements unttl she lNCIwsthe hmit of the range_ She I ------\"- \\'\\V,~, ;c,V,P, 'I) LV. RaIvo ;C, RqI F\"ogu'eAt.21 I'olnlalwnlChparnisfir.;tf.11 Figu~ A1.29 S!la~m.free ~~\"Unct IIm't,ng rrIOYtII1enl

456 MAITLANO'S YEIlTEBRAL MANIPULATION patient may have rh<!umatoid arthritis ,,\"d 5he may watch;Ilg lhepat;ent'shandsand face and also by ask- Ilotbcpl\"l'p<lredtogofurlhl.'r(FigurrAl.29) inghim, how the pain bchav,-'Sbetween 1\"'lIld l'lor belweel1 PI and I\". In f'lct, it i5 beltcr 10 think of pain STEP 4, P' AND DEFINED betw.....nl'landL,bc<;au~atLpainisgoingtoberep­ resentedasl'lorl\".Thelinl.'Tl.'p~'J1tingthebchav­ The physiotherapi5t thell de-cides the quality or the iour of pain is then drawn on themovo:.\",enl diagram, intl.'nsily of the pain at the limit of the range. This can thatis,thclinel',l\"orbetw..'Cn l'jalld I\"is completed be t'5timated in relation 10 Iwo values: (1) what maxi- (Figlll'l'Al.J2). mum would f\"\"l like, and (l) what halfway (SO JX'f cent) betwl\"l'n nO pain and maximum would fed liJuo STEP6.R j By this ml.'ans the intellsilyof the p<lin is fairly easily dedded,thusenablingthephysiothcrapisttoputl\"on Havingcompleled Iherep ....>SCntatioo ofpain, ....-si5\\· IheverticalaboveLinitsaccuratelyestimatl.-dposition ancc must be conside\",d. This is achieved by receding (figurrA1..30). If the limiting factor at L were I'l-then further back in lhe range than 1'1,whcre, with carefully Step 4 would be estimating Ihe quality Or intensity of applied and carefully ft'lt oscill31ory movt'ml'11ts, the R'and defining it (figurc AJ.3/). prescnceorothcrw;,..,ofany ...\". 'i.tanceisa5<:ertained Wht're itcoml1lt'llces is noted and marked On tht°basc STEP 5. BEHAVIOUR OF PAIN 1', P1 OR 1', 1\" lineABas R,(FigllrtAI.33) The C3/4 joint is th.:.n mo\\\"{~d in a postero-anto:.rior dill'Ction bchwcn 1', and L to d.:.tc\"\"inc, both by i[Lr_'1C R'IIVj 0 i~ ~ t ;ClAYOP, Y, LV, B R3rg9 Figur~ A1.32 B~haviour of tne pain 1.~ \"'C'~~;J\"0, .~'[L]r: 0 i tf' \" A v.P, R, Y, L~. B \\I,P, 'h :ClA Lit, B lC1lafl98 Range J Fig\",\", A 1.31 Quality or inl~n~ity of spa:;m-f'~e ~i~tan~ Figur~ Al.33 Comm~nc~m~nt of f~si.tallCl:

MOY~lMnllliagtam Ih~ and compil,ng a ~m~nt diagram 451 STEP 7. BEHAVIOUR OF RESISTANCE R, R, lm\"ards A if i' is NSy 10 pI'O\"oke. and towards B if it is By mcr. ing thejoml bet...·...,., R,an<! Lthebeha'IOUTOf d,fficult 10 pro\\·o!o:e. \"The strenglh of the spasm SO fI\"O\"oke<\\ is inc:hcaled by the height of the 5plSnl w.... tn.-~istano:..~&nbt~mdpIottedOl'lthe S'(FiS\"\",AlJ.:>'). graph between thejoonl5 R, and R:(FiS\"'\",AI.J4).1115 Thus the diagram for u...t lTIO\\elTlent IS compiled, a!§o.--rytoqwlifyorddinl>R:- showlngthrbeh.a'iourdaUelements.Jtislhen~ lO_any.e..!I<lnstup5~the~foundon STEP B. S, S' thee<anUllllion. \"The .e..bCJnSIupssi\"eadisOnctgude • to the tmo.tmont lhat should tN>si'--' parti<\"ularly in If no muscle ~ It.u been fell during ltus ee.>nUt>- ne/.abontothe'gracJo.·olthe_tment~_l>;-u...l is.whether·pain'isgoo'lgtobe~tedorwhPtMthe allon and if the p;lbmt's p;lin is not e:t<OeIl§I'', the tn'almentwillbedue<'tedatthe~ ph)'$IOtIwnposlshould<U1tmuethr06Cillatory~ an~ ITIO\\_I$ ... 0, but porlorm them mon' sharply and qUICkly 10 detemune whelM illly sp;ISm SUMMARY OF STEPS can bE- PI'O\\~ If no 5p'tSm can be pto'okd. then thereisnothonglOremn:l ... ' ..... mcr.\"'........ldiagnom C(mlpiling a m<)\\·.....ent diagram may Sftm oomph- Howe',et', if with quICk.. sharpt\" m<)\\'en'enls a n>fll'.'< cated, but il is not. It is a \"l'ry importanl put of train- Iype of mu5Ck.' spa.-.m is elicited 10 pf1)t~'C1 the mo\\~ ing in manipuJatin' phy~,othl'rapy, OC\"CilU5e it fon:es menl, this should be drawn on the mO\\'<m'\\ent diagram t..... physiotherapist 10 undersland clt'atly whal it is she in a manner thJl indicales how easy or difficult it is to is '\"\"hng whrn mo~'ng the JOonl p<lss,\\'eJy, Coml111lting pn)\\'oke, This can be done by placing the spasm line tl\\(lsc, thoughts to paper lhwarts any guesswork, or any 'hil-and-m~s' ~pptoach 10 lreatmt'nl. Tablt A/./ tr-~-7::]O summari\",,-.,; the sleps lakcn on compiling a movemenl diagram where resislan.ce lim,ts movement, and the Sl~ Whl'n !\",in limits mnvemenl. ilL-I MODIFIED DIAGRAM BASE LINE A ',P, PJ It ,L 8 WlKrf:th~li'l\\IlofiIYI,lablerarHJe\"~rntrlCtt'd ~:C. MId wtM:n the dcrnct'u r/I tht: _lnCAt d\"'!l__ O«\\Ipyonlya~!iIOUItlpe<ttr'~r/ltht:'u.U. . . . . tht:~t d>agramQn ~ mod,rlCdby btcalung tht:~'irc FigurrAI-J.' 1ld!a-.01~...., j CL2J\"~_O rabk Al.l Steps tak~n in comp,h\"9 a movement dIagram t' I, P,la)lIcw I. P,lalslow tJ lb]cscil!<otory A P,Y. R, 'h 'Y, 8 lblOSC'lllatety 2. l-w~ 2. L-WMI'e lCRange I J. L-w~llandddir\"t1 .\"J, l-what(anddnond 4_P,Pl(bt~\" 5, R, ~ P'ld.r.\"\"j 5. P, P' 1b<:~lYiourl 6. R'(andckfind 7 R,R,Ib<:!l~OIl') 1 R,R'Ib<:haviQu,) B, S(d~fin~] B, S(ddin~) Fi~u~ AI.JS SI'~n9'hcfS!lalJ'l

458 MAITLANO'SVERTE8AAL MANIPULATION When l'lther the limit of ;I\\'ailable range i!I very EXAMPLE - RANGE LIMITED BY SO PER CENT f1/StnCI1Il'd(ie.LisalongwayfromB).c>cwhl'ntheelem- ents of the mm'ement di.agram OC'CUpy only a '-ery Markal stilfnes& WIth L IS a Luge dlS~ before B small perrenlage of the full range, the '-'is of the l\"I«\"!i5itale5 a modified form,ol of the Q>O\\emenl dia- lTI(I\\1\"Il'IIl'I'Itcbagramneedsmodt6cltiDn. This is adur\\w gr-MJl. lhe examplo!o will bot\" restricted Jo.ne,fo f1ex1Cll\\. i bybreahng the base lineas in figolrrAJ..36. lheCl!ntre condit;.;., of 10ng standIng following i fraetu~ The 5«bOllcanthenbeidenhfiedton\"prt'!iefllanyiength. first element IS R and the d1Sta~ bet,,:em R1 and L in an) part of the mimmal full ...nge. When the exam- IS only 12·. I'aln is\" plO\\'olcd only by sln.'1eninll; (F'K..... INlhon findingsareonlytobefound in the last, say, S' AI.J8).lJthe Q>O\\-emenl dIagram ..·eredra\"n on an ofafullrange,poinlAintherangeischangedandthc unmodified format, ,t would be as in Fig'lI'rl\\l.j9 IineAI:l is suitably identified itS in figu,..Al.J7.l1us example demonstrates that from A to B is S', and A to It isdcar lhatlhediagram in Figurrl\\IJ9 wastes 1/4is2,andsoon con,iderabledlagram sp.lCe. and 'l is difticult to inh'r- pre!. \\'lith the same joint movcmenl findings repre- ..~ J senled on the modjfi~'l1 form\"l of the movement diagram. it becumL'S clearer and much more useful f;'urcAl.J6 MD,lLfi~dl;ogfll\"'t-loIl'.r... The modified format of the ba5l' li~ of the dLilgram (Figu,., 1\\1.38) Il'quirell only two extra measurements -,RgurcAI.)7 TheIal.tS-oftneeuttftWn 10 be stated: I. The~uremenlbet...eenLandB. 2. lhe measurement between Rl and L Knowing tNt R, to L eq~ls 12\" male! II ea>;y to ~ that Rl is appro>.\"narl'1)' 'r before P, Bcc.aUSl'of the inm'a.>ed span' allovow 10 Il'pre5ll'llt the elements of the mo>.~t, the btfMtolour also is far ea~1t\"r 10 demonstrate. t,C[~\"\"'-llO' I p'r~) 1 -F;gu,.,At.J9lb. . lir....fdby50ptI'«rlI.~\"\"1t'I -\"-- ...F\"ogurcAl.J1 u.in9al'Wldifoftld..,.am A A, P, L 8 .....\"\"lIlifiedd'i9W\" IlliO' knttl\\uion}

Appendix 2 Clinical examples of movement diagrams CHAPTER CONTENTS Step 5. PIP' beh~viour 460 J • Hyptrmobility 459 Step 6. R) 460 Step 1. PI 459 Step 7. R1R2 behaviour 461 Stcp2.L-wllcrc 459 • Schcucrmann'sdjsu~ 461 Step 3. L _ what (and define) 460 • The spondylitic cervical spine 461 Step 4. p' ddinc 460 ------- HYPERMOBIUTY STEP 1. PI 'The method is the same as In Ex.1mple I (p 467; 5« thIS ...~ampll' is included (Of the expll'SS pUI\"J'O'K' of flgllrrAl.l). d.anfpng th.to m~lions thai crist aboul h)'per- mot\"lJt\\', ..nd thc.- dl1Kt Influence that some .lll!>ors STEP 2. l - WHERE and J\"'\".lCllhol'll\"l'5 afford 'I in l'l\"5trictmg ,,,,,,tmern Tho.- nwthod is the SoJ.mc as In Eumple Ilpp 471--472; If tho> lnC)\\'e<ncn1 (usang the $olIIW 0/4 JOint bemg _f'g,,,-rAL3). Il.'Olll'd Willi PAs on O. pages #>7~). before .... nng ilo«ome ~,\"ful. ..~ h}llftmobile, the 0050lC form.11 of the rt'IO\\tmenl diagram would be as shown In f'.i;\"rrAlJ ; 1 - tel t' -, figu\",A2.1 Mo....,,,,,,nt dlag\",m for hyp<,mobiit l'aMgt \" h ;~ Figu.tA2.2 P\\.h~,mobllc;o,nl

460 MAITLAND'S VERTEBRAL MANIPULATION -_. STEP 3. l - WHAT (AND DEFINE) The method ~ the 5aflW as in Example I (pp. 47i-4n; _ fiXUrr ,,24j STEP 4. P' DEFINE (FIGURE A2.51 STEP 5. P,P' BEHAVIOUR (FIGURE A2.6) P, .... STEP 6. Rl (FIGURE A2.7) FigII\",A2.5 P'·drlinr,lryp...\"aOUtJlMI p'r~) -,,, 'liP, 1-', RInge;!; f19u~A2.3 L • .......,.hypmIIabiJr....' Fig_A2.6P,P'~f.IryptrmoboIt;a.n1 D~lIY') l·[]f A Y. y,p, 'I. Fl., BL H I RIngI;CI 'II P, Yo Range;c. Fi'lu'tA2.7 Fl.,.II';lltrmobiltjolnt F\".gu'tA2.4 l-what!andddintl,IIVPt'mobiltjoint

Cliniul u3mpl~$ of mowmtnl diagrom, 461 1C] botlom ones wilJ Iu\\e a noonal rang... and the middle one of the fi\"e will I\\a\\-e I slighlly pronunml splllOU5 Pl\"llce55and will be f'l'$;stant 10 the poslem-.anterior p......ures. Theadjacenl \\ertcbrae to the central promi- nenl and s!ilfone ..\"ill hll'ea degn!eof\"'5islance 10 the p......ures thai is eqwil at !he 1\"'0 \\o>rtebr..., and a degrftoistiffneso<that15IuJf...'lIybt.\"\"'........ thoItoftlw ''''0 normal \\'ertcbrae. \" '10 ''\"' P, l'. It, 8l H THE SPONDYLITIC CERVICAL SPINE Rqt ;~ J\\.Ianyormosloftheeiderlypatlli'll~rriernodform.al­ fi9u~.u\"A,A,~,lryptrmob;kjoiool menl of local rervicill symplOmS 1wV1.' underlying ..e.r-and-teardegeneTalL.... c1wnges_ Thesechange;of thmlsel\\'(~sa~ not nece;sarill- ~~ible for the pre-- STEP 7. R,RI BEHAVIOUR (FIGURE A2.e] so;,nl probl\"\"\" allhough lhey may acmunt for some ~Inct>on of movement an<! <l dl'gfl'e of discomfort which 1m, paILent consid,,1\"1 to be normal. This being Tr~atmcnl 50. the milnip\"lati\\ephy~'olherapislduesnolhil..eas I\\ergoaJthen'Stor~lionofaFLJLl.pa'\"-f~rang\"of Hypermobility is nQ! a rontraindication 10 manipula- mOl'lmlrnl. The goal is a 'compromise goal', which tion.Most I','lienlswith hyp\".mobilejoinlS, one of infel1l that Ihe range of movement will bc rcslored to which becomes pilinful. have a hypomubile ~iluatiun what it was before it became symptomatic. and Ihe al that joull. They all' thell'fore lreated on the same ~I ml'lOms will hal'e either 1x'C1I clun.-d or restored to basis as is ust'd forhypomob,hly. It make. nod,ffer' whalthepalienthadconsidel\\.-dlobehi~normal ence whelher the limil (L) of the range, on examlll- Such c,rcumstances occur 50 ofll'll that lhey allon. 15 found 10 be beyond the t'nd of Ihe are ..·orth}ofdesc'riplionin\\(·rmsofthemol'l\"1TK'fl1 aH\"raJ;l.'-normal range (as in the example al'Ol·e. L ,,',IIdiagram. be of an e1detiy man ..'ho has bemg beyond D) Or beflln! 11 (Lbeing on lho:- side> crt B), The exampk\" IiQUghl lrNtment becau.... he 15 havmg increasmg dis- romfor1 in the righl mid<en'ical arell, which he SCHEUERMANN'S DISEASE 1\\OotIaS ..·,thtum,nghi,headlolhPnghLpartKularly \\1.anipulat,...physiolhlY.pt'>!:5ar..-ftequentlyasW10 ..'hen trying to n:'\\erse Iu5car lrNlpallO;\"nts,,'holu\\ebaclp.unrriakdlOtlwst,ff- Prior 10 SoCeking lrNtmenl hP bel..... ed he rouJd tum his head equa.lly 10 left and ngllL and the lnO\\'emenlS nes6 resullong from old. inacti\\e SchnJermann'~ dis- ........ pa.rue....Asi:s50oftCTI theas<\". his normal range of cenicill rotation \"'i1S <.lnly approxunately)5--.W\" ease, The purpoliC of presenbng ~ ~ of Representing Itus on a 1nO\\emt.'ll1 diagram (thai is, as mo,cemenl dlagnms IS to \"\"'phasize lhP '~-fm' durac1enslK of F'O\"lero-anlerior cen.tr;o] vertebral roIallOOfOO'!hewho\\ecen'ic.ISf:'\\Ofral!>erlhanfor OOl\"p.lrncuLu,nlervertcbl'illlel,et).ta hme when he pre!l5UresonaSchrul-rmann\"sp;ne considered thai he was normal the diagram \"'oukl be somcthing ltkt\" thai shown in Figu'fA2_1O_ n- lnO\\'nnml dlagrams only ~I the At the lime when he had had Ius nghl-s.ded cer- l1'!iistance (flft' of muscle spasm) elemenl II is vical pam. the lTIO\\emenl diagram of his Cff\\ical rota- hon to the righl d,ffel'l'd \",small bul Slgruficant wars assullW'd tlul the pt'.k of thecharaetenstic kypho!ios is from theal){}\\'.. (FigurtAl.Il). Th.. diffe~are: al Ll.and llut the p.lbmt is l}'ingprone,\"'hich puts the main \\o>rtebl'il(e) involved al the limil of their I'iln,\\lf of <,,,,tension and postern-anlerior mt)I'o'.'ffiIml (pointAon lhebase hne of the diagram) (FigurtA19). l. l'lP' (a sigmflcant change in the pain M'fl5alion) It may be of inl\"n..\"IIO comment Ihat in lhe young adole'IC.ntiti5~ibletoknow.bythefeclofn.'Sist­ 2. RjRI(thealteredbcha\\'iouroflheresistaoc..) ,,,,,etopo>lcr.,.anlcriorpressuresol'erfiveadJacenl Th<: l',ofFigureA2.11 w;1I onlyrcturn to his 'normal'if q\"rlebra.., that 0>1L'OChonJlilis ('Scheuermal\\l\\'~ Ihe new curved first pMt (endrck-d) of the R,Rl disease')lspre;rntl\"\"rnbl'l'urelheradiologic\"<lIe;.·idl'!\\Ct' bchal'iourofth\"f'l'$islaO~i5clearcd,lftreatmentis isob\\',ous.Ofthefi.... wrtroraereferll\"d 10. the lop and succcssful.the RjRllinewili change so tllat thebt.-ha\\'iour

MAITLAND'S VERTEBRAL MANIPULATION T12; r - - - - ' - - - - - - r R\",1V) ....u..;...... ~=1-l [j] _ _\".;;;;',--,_,,,,L, r.o' R, P,2O\" L 51)0 Figu~ A2, 10 Ct\"'i~~1 rotati,,\" ,lgMl, n\",m~1 m\"\"emtnt Figure A2,11 C.\"'ie~1 rotat,on rigMt, lymptomatic mo\"\"menl diag,ambponllyllll~loP,n.1 diagflmlSjlOtll!ylilicsp,ne}

Clinical rxamples of monmcnt d'agrams 463 of res,slanct' wIll n.'turn to lIS ongmal slr'llght hoe Reilders maybelic\\'e thai it is lmpos.slble to assess such (R,Rz in f'SIIrt' ..1.2.10). PIP' of Figllrt' ..1.2.11 will abo small changes in n;!Sistmee (encircled p.1rt In Flgllrt' resume 10 beIng the PIP' of FiKII\" A2.lO. ..1.2.11). How{\"\\'er, if they .apply themselves 10 the dis- cipline required for compiling D\"l()\\'ernent diagrilms- II lliWrpnslng how prttisc I judgcJnCflt of small that is. doing passive mmements (rihc;.ally ilO<1 anaIysOng wholl they feel, tilthe!' th.tn doing p.:tSS1V'l: rhangein~l'ICI'anbe mm·eml.'fllsbr instinct - they will be surpnsed .aIJWoI 1xM' pnriwtheirjudgm'll'fltsc.an become(E\\'ans.l962).

Appendix 3 Examination refinements and movement diagrams CHAPTER CONTENTS • Diagrams of difft~nt m~mcnts on a patient with one disorder 467 • Varitd indinationSirtdcontact points <165 • 5;l9ittalpostcfo-anlcriormo~mcnt5in combined positions 467 VARIED INCLINATIONS AND CONTACT .\\ll\"diaJly/l~t\"r~llyon the one process. POINTS Various (ombmiltions of tlloesc \"The s.ame '-i1ri~11OfI!I (lH4) in (ontM:t with both pr0ct5S0t5(\"\"hen(3)wouldread'left/righl') TM 11m of 'Illtylng W allCJ~ of inclination and poont As an example of Uus, a patient may ha,\"f' an area of ofcontJct is to find the rnow:tncnl th;It pn:wokcs ltIt generillmid--<:en'icalpa'nsprcadmgaa-ossthetopof S'f'!IptlllM ...hidla~('OIftpir3blcwilhthlMoftM tht'trapl\"ziuson the nght.md read..ng to the top of the p'lotrIl right shoukler. On \"\"\"'ffill'lillJOll by palpation. monng thesptrooosproce!iofCSin ,'.rWtionsofinclinations .nd contact points, the rl1O\\emef>t diagrams rna, be..,; Onpilgesl58-16111\"'o¥.i!il.aledt~tJ\"<1lpiltion(\"l<,lmin­ follows; abon lechmques nt'It'd to be ,\"anN. (t) in tOOt angle of indlNtion by amounb~en~sm.>ll <l5 1- ;;and (2) in I. \"The o;act ....gittal postero-antenor rl1O\\-ement \"\",th thlvcontxt polnls... luchsimi1.lrly ma~be;>s h1tk;os eotehthumbconlM;;tlngo,>;Khb,lldsplJ\"lOUSproce.s ofCS(FiK\"rrAJ,lj 1 mm or Ies5 ip.1lrt. lbe .l1m of tItis e:uminahon tech- nique is IOfind!tIt lnO\\\"emenl tNt prQ\\..ws5\\·mpl\"\"'\" 2. When the ....gittal po6k'fO-<IIntenor mc....emmtis .....phasizedontotherighlbifidp~thediil· comp;uabk' with the IH'tienrs symptom§. If postero- gr.m rnanges in its pam \"\"'porn;eand isclO6E'f\"IO ant,,1'lQI' central \\ertebral ptl'5SUA'islhe mm-t\"I1lenl being·<:omparable't.... nin(l)abO\\-e(figurrAJ.l) be,nll eumuloeC!, lhe sagittal direction Can be inclined' 1. Ceph.llad/caudad J. Whentheconla<;tpomlischilnsi.'dtothelat....a1side 2.l...,ll/rlght oftheleftbJfidJ'T'llC't-\"55anddirecIOOIO\"tO\"'·.. rdsthe 3. In \\JT;OUS romb,nal;ons of these, right, a quite differrntresponse ll5ulls(figurrAJ,J) Obviously this I''SI mOv''ffi,'n1 is msignifi<:ant mm- The point of contact on each spinous pr<>c~\"Ss can ~ p;lTt.'d with th.., pn.\"IX'<img two tests. changl>dfromlhCSlandardlwobifidpro<:eso.-'Sto: 4. If the examination has b.....'I\"l (arri,'<i out in the 1. Onl'pro<:ess \"'-'qU{'f\\C{' R'PTl'S'-'nll'<i h..,re. Ihe thought may be' 2.lligl\\i,r/loweronlheoneplUCt.\"SS. 'Well. pushing on the nght bifid process is the

MAITLAND'S VERTEBRAL MANIPULATION most Iimit<-'d mo\"~ment SO far, and th~ p.lin movement as her treatment technique, she has to Il-,,;ponse docs produce SOm~ spread of pain to choose betw.x.\" th~ following: th(' supraspinous fossa. I wonder what the pain response will be if I mov~ my contact poinl to the 1. A\\'oiding the patient's p\"in and Iherefore using lateral side of Ihe right bifid prOCt->SS and indine the figll'\" 113,3 as thl.' Ireatm('llt techniqu(' PAsay 20\" towards the left? (Figu1l' 113.4). This pain response is much more comp\"rable with his symp- 2. Reproducing his symptoms and therefore using toms, and th(' mowm('nt is both sliffer and has a figllreA3,5 more similar behaviour to th\"t of the pain th.ln have any of the preceding mo\"emcnts C0 5 'I wonderiflhisissufficicntlycomparabletobcused I r~-~-A, as the t\",atmo-.\"t technique? I think I'll just try adding a bit of caudad inclination through the same contact LJj point.' (Figure 113.5). This pain responSl.'. being such a A 'I, 'h 't,R, P, 8 dear 'reproduced pain', is \\'ery famurable, AnothL-r Ra->ge .,~5 L elem('llt indicating go<Xl romparabHity with the pali~nt's symptoms is the simil.uity of the 1x'ha\\'ioUI ',gu\", AJ.3 '>agitUlI postero-.nte,iorrnOliemenl,oont.ct of the resistanreelemcnt to the pain element. point On lawai side ofltft bifld 5piMu,proe<-ssofC5 and dir~Cltd 10\" to th~ right This discussion can be carried one stage furlher, but in a somewhat diff~rcnt direction. J( th~ manipulative physiotherapist chooses 10 uSC her thumb palpation t\"[Jg,,CR,(lV) D I P'(1ocal) !, A 'I, 'h R, P, V, B Range ;C5 Fig\"~AJ,l E....etsag'ttalposttro·ante'iormovement Ihuml>soonl.ctingeachofC5'st>ifld'P'\",\"\"SPfoe<-s~ FigurtA3.4 0 0f.' C[j]'~~I·~1 ,C[1Fl\"~~_' t , tf\"~~ 'h , A Yo '!)R,P, Y. B AR,P, Yo Y, 'v. 1Range cs 8 Ra->ge ;/C<lUI.C5 fjgu~A3.2 '>agitt.lpostero-antenormovtment. Figu,~ A3.S ernpn.\"zedonlorigntbifldspinousp'OC\"'50fCS

l, Takmg a lYaSOtWbIy Sill~ path....ay by U5Ul& r 'XU,.. Ii,-\"BecaUS(' tIw computations ..... mdless, the DW\\Ipula- ph)-siother.pist should br aware of the posstbil- A.l;fbutdoingit~agra<WIVlIIO\"~or~·t'I'1 itie5 a'ail.ble to her and be upablrof e.ploottng them if prugl'C55 is root up 10 Ihee.pectahOr\\S. gOOe IV_, 50 that a \\esl;er degR\"l' of paIn 15 pn)\\'oked SAGITIAL POSTERO-ANTERIOR DIAGRAMS OF DIFFERENT MOVEMENTS MOVEMENTS IN COMBINED POSlT10NS ON A PATIENT WITH ONE DISORDER l'Mtm:J-ant~~l5lJlmll'lbl~pos.tJonslrr Todrawdiagraml,forllil'ftTMI_\",.,.,tc!,r«\\,onsin ~asamc:ansoffind\"'9lht-..-twll.dl apa!Jeltw,tIIOfl(dftcrtIn.,..; IIdptodet(1llllll( pI'lMItothr:patJelt'~5Y'IlP!0I'I5.. TlusQlllhttllxuwd wtudl of ~ dltKtMlm '\" lil(ty to Ix __~ rifK'tNle asatrutmc:nltcthniqul>orprogrtWClrloftrul/lltflt as.lmI,\"\",ntltthnlll,,\",_FurtMr\"l(n.~t 1k ~alue of comblJl<-'C! mon'menls in CXamlrlJtlOn wi.llkt(rm,n(the~ta\\iorWlipbl:lwl'(Qth(P\"'t;(nrS and t\",atmelll has 0C>c1l emphasil.ed in IhiS ~>dHion. si!lnsandsvmptomsandthf:~ntdiag'ilm Imagine a piltk'Tll who has lefl suprascapular symp- 101m that are prmoked by cornpreol6mg type mo\\'f'- -;C5(H11llIltlfll..... lIl 1111 \"\"\"\"IS, such as6\\cnSion, !at....al flexion left, fl)I.ll,on '\"\"' _ _figu~A3.1 ~n.aoinFigun:A3.S;w,l!Ihtacl left, and crntral po;!'tero--anlcnQr lIIO\"'CfJlol!n!S on !he left articular pdLar ofCS' ,nlat(QIf\\eDoftto II\\(Id't 1.Ifthecrnt,..,I~lfl1Qrmo..-.,........ tsa.... J\"'T'\" ; ,'[2[]\"'~'_) formed w,lh lhe pal1cnl'\"5head straight. the mo...~.. f· , menl diagram may be as In Fig\"'\" AJ_6 i -~ P, R, 'i, 2. [f the Silme 5.lglltilJ postc\",,\"anlcnor mO\\'~'Il1~'nt is l 'I) If, 8 performed w'th the hCild rotak'C! 10 the lefl, thed,a- gram will be different. as shown in Fig\"\" Al7. ;C5(lnlltullltlllll'llellancl_1Ilt) l. SagJllal posll'Tll-anlerior mm'emenlS fX\"formed with the head inlilleral f\\e_ion 10 the Iclt \"\"''' ha,'\" F. .~ AJ.8 »gitllllposl\"'H.nlmor~n..w;l!Ipatonlt'. the rn<)\\'emcnt dlilgrarn ~wn ,n rij(r\",' AlB l19dfnl:latffiIllyfle-edlDttw:ld'tlll'dlVtllt(cllDltw:ld't ... If the patient's he.ld i:s fi~t LaIn-i1II}' f\\e:Ited to the Ieft ..nd lhen .. hik- in tlu. ~bon is rotalo1'd 10 the left, ~..nlel\"ior rn<)\\etT\\en1s in this combin- .tion might be as shown in F'f\"\"\"AJ.9 r'9U~AJ.6 ~t..lpost(ro-anlfr\\OO\"m(lV(ft'lttIt<,Wlth pallmt'shitallStrll.oght

468 MAITLAND'S VERTEBRAL MANIPULATION :J--ClC P2($e'<erityj 0 i~~ I-I A '1, ';,P,R, l~, B -') figure AJ.10 C~\"'rc31 rotation to the right i\" the sam. pati.nt asi~ figuffA3.1O .~DC\"I:(s_1c unilater~1 vertcbr~1 pressure On Ih\" lett sid\" of C3. The mo\\·\"m,,\"t diagrams of e~<:h movement might be as in f' \" FigrmA3.1O. i\" Thc three movement diagrams ~rc different from A P, L'I, Y, ~, B e\"eh Olher, ~\"d 5CCing th~t tlK)' ~rc diffcr\"nt hdps in (c) Range,----c, d\"l\"nnining which will be used (if any of them are) FI~UfO A3.9 Movcrntnt. provo~jng 1<11 mid-c~\"';C31 pain. 10) <IS a lrc~tment teehniqul'. Abo. if One is chosen, and C.\",;\"\"I rotatIon 10 th~ 1~f1.lbl EJct.oj;on, (el Po!.terO-3nterior it is successful. it wOl1ld be hoped that all th\"-,,, dia- u\";lat~r.1 \"\"rt<bral pfOjWfO on Itlt sid~ of C3 (4mmj gTams would show Ihl' same kind of impro\\'emenl. If, howe,\"er, Iwn of them did improw and thc third dId not, and also if the patient did nol f~'el he w~s Sl'lling belter, then p\"rlmps Ihc unch~ngcd mowmcnt dia- gram would then be used as tho: treatml'otlechniqu\". There is ono:olhcr importanl as]X\"C1 to be~r in mind As well ~s the three di~gr~ms depicl~'<i, ccr\\'ic~1 rota- tion to th\" right might prove a useful diagram, and be useful asa trealmenttechnique (F,sun' 113.1l). figure,; 113.10 and 113.11 are related 10 the 5tandard phy~iologic~1 ~nd accessory mo.'ements. II bccom{'S more complicated when combined movcmo:nl, are introchrCl'd. How{'\\'cr, whcn rombilX'd mo,\"cmcnts ~rc used as part of tho: examination, diagrJms can be used forth<,m in th\"s.~mcway asd{'SCribcd carlierin this app\"ndix When e~amininga patient'\" movements, Ihere may be three main movements that provoke his (say) Icft mid- cervical pain. Ar.sume that the mO\\'emen~are ccTvical rotation to the left, exteru;iort. and postcro-Jntcrior

1_-----:-----: --. ::.:. . . Appendix 4 Clinical tips CHAPTER CONTENTS • RccurrcnttS 472 lxcrci~s 471 • Muscl~ spa~m 469 Pillows 412 • Oisord~1'$ 470 Beds 472 Draughts 473 Compontnts 470 Wca~link 473 Effects of dr3ught 470 Capacitytoa~umulatc 473 Jointy ptopk 470 Ncvcrclcarcd 473 • Recording 471 • Assessment 471 • MaintcnanCl'trtatmcnt 473 • Elcerciscs 471 Tne conk'nts of th,s appendi~ are not strictly related to musele>, and d<-'Spite the facl that it has oc'Cn .Iatoo vertebral manipulative (\",almL\"'\\. They are, however, thai there is no fMC response from the exten!;Or mU$- de>, most dinicians ha\"e no doubt that musele sp.lsm facto... that are reb ted to the total manaf:Crrlent of is p\"-\",,,nl. Some authors have said that when the spinal disorders, and yet tlwydo not >eem to he gi,-\"n patient lies down, the spasm goes. This is no mOre true sufficient credence or to be adequatel}' appreciated by than ;s the interpretation of the lack of fMC response sorn\" authors and practitioners. The points to be men- The problem seems to lie in the fact that the spasm that tioned are not necessarily related to each nlh\"r and so goes on lying is \",Iat<-\"\" to the long back muscle e,,(('fl- \"re prl'Sented as short !><'parate stalcmenl~. some of sors. and not enough import~is gi\"\"\" to the intrinsic which may be provocative intrascgmel1\\al museles between adjacent vertebrae Th<-\"\", musek'S remain in spasm to protect thl.' joint MUSCLE S.\"PA\",S.;;;M _ from being in a painful position f>foICCli.~ lists of th~ I~mbar Sllin~ a~ ca~s~d. at lust Inte~mentalmUKle spasm can be fett by palpation in Il\"rt. bV th~ m~sd~s \"\"~n when the pati~nt islyTng prone Artides and books have been written about musele The intel\"S<.\"gmcnlal musell' spasm can be f(,\\t by palpa- spasm as seen in spinai problems. particularly those lion even when the p\"tient is lying prom'. Although involVing thl.' low lumlxlr spine. Some patients wilh the load through the joint is less when Ihe patient is lumlxlr pain undoubtooly have an acwmpanying lying. and therefore the joint's need for musele spasm prok'Clh'e list. This list is caused. at least in pari. by is less. it does noltotally disappear as suggested by Ihl' fMC K'Spon\"-'S so far recc>rdcd.

DISORDERS j./elati'·e to the lumbar spine. there isan 'old wives' tale' that such propl ... should weara'rro fJannelbdt', There are three points to be made under this heading and thel'l' are patients who have wom such a belt to advantage. The important point,; are that· 1. Components. 2. Effcclsofdraughls. The belt dOL'S not have to be rro. 3. Jointypeople ThefJannel should nol go right around the person'Sbody_ COMPONENTS 3 The warm nannel should cO\\'l'r the lumbar It i~ po5~ible for a JOInt disorder to nave a ~ub<.:linkal areaalone,suchthatitkeepsthata~awanner aclivtdtgenuati'll' prOtt~sineonjunctionwitha mechaniCalCQmponent than the area immediately aoo\\'e and below theb<'ll. Many musculoskdetal disorders that the manipulative physiotherapist is asked to tn'at are not solelymechan- - - - - - -JOINTY PEOPLE ical disorders. They have a subclinical component People who h~ve ~ymptom~ from many joint~ are that is inflammatory in nature. This subclinical com- ronside'tdto~'jo;nty' ponent maybe an acth'edegl'nerative pWCL'SS of the inter..ertebral disc or an osteoarthritic process of the This title rclers to patients who fit into one of thn'<' zygapophyseal;Oints.lnother words, a joint disorder categorioes. Th\" title i!.>elf means nothing mo\", than may h.wea subclinical aclive degenerative pl'OCeSll In thaI there are groups of prople who have symptoms conjum;tion with a mechanical component from many joints. One rheumatologist \",fers to these people as ha\\'ing 'acute joint awarenl'Sll' Thcmanipullltivephysiotherapi,tcan imprO\\cthl.\" symptoms arising from the mL'Chanical component, The first groupconsisls ofpalienls who seek treat· but can do liltlcor nothing for the active subclinical ment lor pain in, say, their lower cervical area. The component. Instruction in exercises and 'back care' symptoms are usually locally situated. though they may play an important part in lhis arc,l spl'l'adaround the immediate area. Whrnthcscpaticnts gain impro\\'ement from the initial mobilizalion treat- EFFECTS OF DRAUGHT ments, they comment about pain in the mid-thoracic arca.1f this area i~ treated as well, and it improves. ~Iit'll'patitntswhosaythatthtifneckpain~ganas the p,llients then comment about symptoms in the ar=ltof~lecpinginadraught 10werlumbara\",a.Thcsepatient~arene\\'ertotaHyl...,., Not all peopll.\" tTcating musculoskeletal disorders are prepared to take much noticc ofa patient who says of some awareness of symptoms in one or more of the that hi, nL'Ck o.back disorder is aggravated or pro- !hn.\"'an'iIS. Mobilization helps to lower the l<'velol voked by sitting or lying in a draughl. Some patients symptoms at the time of an exacerbation, but they will even say that thl.\"}\" are affected by the rold air from arepatienlS for whom it is valuabll.\" to teachanothcr an air conditioner. Most clinicians have hcard a patient member 01 the hou>chold how to mobilize gently spe- S<l),thatthecurrcntcpisodeoflowbackp'linbeg'lllas cific SL'Ctions of the spint' (swimming is also a useful a result ofsll'l..1'ingin a draughl.This is to bebelieved exerci5C) The fcatul'l' is typical ofa group of patienl$ who:;e The>L'Cond group of people havc intermittent joint symptoms are casy to help but difficult to prcvl'llt symptoms in many periphL'Tal joints. These symptoms rt.'Curring.lftheproblcmliL'Sinthecervicalspinethc do not form any rt'gular pattern of joint in\\,oh'emenl useofa scarf is extremely valuable. irrespective of They too can be helped by mobilization, and again whether the weather ishot or cold instruction in home treatment by anot!ler member 01 thefamilyhasa plan' in the total managem,'ntofthe symptoms. The third group includes patients who ha\"e a cOm- bination of the first tVo'Ogroups; that is,thcy havc invol\\'ement ooth of the spine and oflhe peripheral joints. It is thl' leaslcommon 01 the groups

CliniCllltips 471 RECORDING lhe floor as he pushes his body upright WIth his arms.. The n'\\·er.;eof this procedure 15 the method the palienl ~ pmcm of fftOIlltng ,pp1les to ,ny form of wouldlJol': taughllO UlOC I01'NCh IN> lymg pos!bOfl from ptIysiolMnP'l'inttlW:ntoon 511I1ng.\"thefoll\"\"'·ingS... ll........,tsare~·anttothis: It hasboeen ckoarl) esIiJbltshOO thai thi=is, need foe' 1. When;ll pabent has lD'\"t'iidef\"abk> pam m his lo\"'cr pa!K'mof m:on:I.ingln'almel'lt. Thepatll'm used mttuJ back and has d1ffinllty gettmg up from !he I}ing booI. fOI\" r«onJmg manipu!.oli,-., treatment can;also be po5ItM:Jn. he will USlWIUy find hi>. own method llSO.'d fOI\" anyOlherph)'5ioIhenpytreiltment that maybe f o r g e t t m g u p t h a t ~ 1 Z f t o n p a i nl f h c i s gtvt.'Il-Fora..mp\\t'.ifultu-5oundislObeilddedaspart unooble to find a so.bSfactory method. then - ;md of the treatmenl5l5SlOf\\, 'I should be I't.'COfOOd in the onJylhen-shouldihc,bo\\·cinstruct--.slJol':pv-en SilJTM' manner as tt.... manipuJ~li\"e U'Chnique5. lIlCludlng to help him. ,11 of the symptomatic ~ during .md aft~'I' its applicatlOO(Tabit'Ml). Whm exenises are lObe p.ut of 2. \"the patient's method and ~ 01 d1ffinllty the treiltnlolrlt m~\"\"b'emenl. the dk\"CI of eOl(h type ahibiled whde getting on or uH the treiltment should also bt' S1mllarly.lsses5ed for p.:lln responscand couch is an In''aluable -.nent 'asrensk' recorded It i5 .'n'fl mo\", important with the recording I'atients will not causc hann by therrstruggles to of ...>.en:is•.'S th.,n of the ultrasound. The d>oi<:<.> ~nd dfl'Ct get off lhe lrealment couch. no matre!\" whal means of an l:wn:ii\\e should be aSSCSM'd allhe lreatment !heyuS(',andtheassessmentvalUf'cannotbeov'er- session.andlhes,lmeassessmentsshouldbccarrk..tOtlt emphasized bythl:P.ltil~llw,\",,-'flhcpt'rformslh.eexerctsesalhome. EXERCISES HI.' should record lhe Symploms and ranb'<'S of mo,'e- E>ccf(iSC'lshooldbcintrodu~singIV.lndrelsscsscd 'net\" at hi~ I\\omet'xerciscsession;firslbcfore,thcndur- du,i\"9lhctlcatmcntscssion ing and after the session, m the same way as lhe l1><-n.>arefi'emaincalegoricsofe>.ercisesforwrtebral rhr~jotherapist. It is only by using this ~trict rt)uth\", problems.. They consist 01 that thelreffl\"Cl can beassessed. I. Stabilizing exem-. ASSESSMENT 2. Mobilizmgexm:isocs. Piticftts\"'lhlowbat.plIinfi\"\"~.owrl~of J. Exm::isestoincreasemusclepower gortt'IllJU9M1dllownfTomatldmthf:lylngpmltlOn. .t. Exemse;toincreasol'the\"fl'-\"l-'doillCtionolmu.<ldt5. S. &en:isesto~lheenduraOCl'ofmusck' n.iscan~ ... if!YilllRblc~t~ltrisk ~. Dunng a treatmenl SOI5MOr\\ fot palM'nlS wilh low b.oc:k For the lumbar spu'M', I~ are two othrr factors in srmploms._ph)~piSlS~ethalpaIJenIS relation toexen:ise: the USI.' of ~1Qn \"\",erUses ascorn- pared w,th extension cxerru.l\"'i; and e~ertising the must be bU!VI1 a roulmr way 10 lie down and gel interwgmcntal muscles as cornpan.>d with the longef\" up from lhe ll'Ntment couch. For e>.ampk'. lhq insisl muscles. which spread mer many segments. Four lhat \",hen .. pah~l is asked to gel up from the lying poinlSnt.-edtobem.:od... po!illlon. he should tumon lohisside. f\\ex his hi~ and lmcc:> 10 a ngllt angle and then lower his legs lowards • In principle.exerciS<.'Sshould he mtroduced singly and they should be performed at a lrealment TablcA4.1 Examplcofl't'COrdingultrasoondtrcatmcnt session so that a romplele I'\\.'«)rd of the effl'Ct dur- ingand aftertht.'irpcrforma\"ct'cM,bcasscssed Co\"stant US 1 Waltcm'O\\I~r IaOmo,'mo\" lflhe pilli\"\"l performs lhe('x('n:ises ilt hom... he arlrcula,pIHa,C2-. romfortabl~ should be tilught to make th('S.:lmeasso.'Ssmrols. O/E Rot' <!l. »mt ,angt localwlrmth. but no P. now. • To increai\\e stnmgth or 1'Cpt.'titions in exercises. 'Soothil'lg' allow 4S hours mmimum belw~\"'n inc\"'mt..,,15.

412 MAITLAND'S VERTEBRAL MANIPULATION • If mobili~ing exercises an> 10 be gin.·n 10 ...'.I.'''n such disord.,.... The SUI<! of disc damage. the stage of lhe range of l1'I()\\emenl of pamful anhnhc or .spond\\lilic jomts. Iht'y ~Id be pe-rfol'ml'd on a progre56'Ol'lofthcpat~vorthepresenceofacon­ non-....ight beanng or penduLu po6llK)n. They should be ~ fn.>eIy, slowl}'and p.Jln~l\\ hnulf>g subclinlGll acl1'''' p~ may prohibll an I'J(cr- • L'ndel' mast CIrcumstances it doe ~ mailer II cisl' programme, At Ie.ost \" .. !>hould be a,,'are NI ~ise5C'ilUS<'loa.ll\"'inwhiledolngthem.but'l'\" essoenlull tNt the s\\'mploms should subsldt' \\~ ~~ can be harmful. \"nd!heu\" mtroduction shoWd quickhona'llwexl\"rClSei;U1'firush.cd 1i'1lCJ'N500 li\\'mpte:wnsCOOMut> for more INn half an hour al~ lhereforebe progress..... illnd CilnofuJ1\\' monitcnd the ~ programme. the t\"'~ INV be nn.onlbr question is often asled. should e.....-cJ!ICS ....'ducro. n'l(xhflt'd ordlSCOl1tmued Wltil a later stag..' ... ,,~tensione'<t'rci!;ebe\\.lSo.odmparncu1ar51llldtiorlS s..·immLng is ~I as 11 US<'S aU fi.... Cilbl'gOrieS of ~Caullonmust be U5il\"d irutialll «) the 1\"'1;,.\",1 of 10\" lumbar d~ dISOrder? The od..... ~-resull doesn·tO\\·erdo,t.For<;()Ol('()ll('Ul\\dCCUStOfT\"'-odto~1 of a in\"atrnml programme for the poatiml ~ thai he ~lo-I5minu!l3issufficientforthefir.il~ shouId.beablctoperform$lrong\",,~forboththe f1el<ors and the l\"ltensor<o. bomeIri<\" \"Xt>rct!oeS in either d,rection IlJ1\" Ie<6 harmful IIwl ISl'lOnK e:>.en:lSeS beeaUS<' they imoh .. ''''1' htlle jolnl QlU\\etnml; ....... cr- lho>Ies. inlrad~..l rJl.\"osun· dOC'> o.ncre~ during the exercise. Thereflll'\\'. when Wsc p.:1thology cause; pain, any introduction of f1f!x'l-.n dl'milndscaution. PILLOWS,- _ RECURRENCES Many arhell..'S. books and p,'mphlets haw b;...,n writh'n Wh~,tvI'r prmibl~, fccomm~nd fUlh~f pillows for on this subiect. and the only pUTJ>OS<' in mokin); the fol- pititn!';withncckp;ain lowing points is 10 r\"i'le !iOme i5Sues thai do nol 5(\",n' to be adcquatdy considered EXERCIS:;;;\":.... _ Some pah\"n15 have <x:rvlCoil d,sorders in which their pillow is a source of irritation and of continuing symp- 1\\:01 t'\\ery pilbenl WIth a \\~ebral di<oOrUer. (lnI;C toms or 1'('('Um.\"I1Ct.'5. In r\";,lt,on to the pillow. the two rclJe\\·cd of the symptoms. should be ~uw-t an ewrcise prosramme intl\"l'ldro 10 be carried oul on a \"\"Sular most import.lnt a5pt'Ctsa~' 1ong-termb.sis.lfrt'nJpatierIlis;oskdtodo~ 1.ltssizereL1II'·.. lOthepoal.......I·.\\>pot;!on> 10 p\"..·enll'l'Cl.lrrt\"l'On5. ourjudgemmllS poor \\\\e mn 2. Its contenl relallve to the imtabilJI\\ of the find later thai thofopabmtonl,.-dKi thcl!l<CTtises for palient·sd,sorder. 2 ..«lsand thcn forgot them.. yoet he dod nothan'an) troutHc w,lh IllS bolek for 5 )ean. lbr pcrcen~h'\" of The pillo,,' heighl !ihould i>Upport the head and the proplcwho ..,Ucootll\\.... with~~-onalong-term ba:sas is small; rt'IO>t .. ill ~\\C,up within the first month. ned, full,. ..nd in a neutral po6lhon. The content of A~toltlwneoedIodoe-xcmscslSbctter the ptllo\\O' should be sud! NI. If a hollow is made in detennoned ,f 'I ~ \"'~rlillned to the pabml that e>:cr- \",ththe pillow ci5esma) prmo;>l..eaneucerbahon. therefonolt maybe a fl$l.Of1CO' the fISt is ....moHod thehol- brIIcr ror him to be taught 'back care'. and 10 Iea\\e low should rcmdIn. lbr quiclcr the hollow disllp- e><ertises unhllt can be seen thai he is $US<;eplible 10 pears. bec.lIuseof the nalu.... of its 'i'nng) conlenl.the I'('('Ur~. If he has a recurrence ina short s~of time a~ the .......u1l of a minor incidenl, tIK.., not only IS worse il; ils effect on a n«l. thai is easil) dislurbed rrone.I'ahents should ~ sJ«>p it more purposeful to do rrophylachc ex..rclSt'!<, but 'I bccauw In thlS posi- is more hkely that he will rontinue tm, exercise:> tion the cen·i£.aI mlerH·rtl'bral points are pul on full beo;auSl' he is con,incoo of Ilwir pos,;ibll' \\'alue. 11>c word 'possible' is especially includl-d b«ausclhestJte streich in one d,nx:!ion. of lhe pllthol\"l:\\y may be such as 10 pre....ntthcm. BEDS n.e pout that excrciSC!i can play to prevent n'(\"llr· UndL'T normal c;rcumsunces. til.:: ral11<'r firm, fI.. t!x'd is th\" best choice. Howen·T. p~t;enls' requirements are ...\".l\"la.'S In low lumbardi5COg{'f1icdisorders r\"\"'.'dscarI'ful 'cry indi .. idu~1. If a patient has a n'ry broad pelvis and narrow thorax and chOO!>('S Iv .k\",p On his sid\". 11<' thought ExercIses should not be gin.'ll ruot;\"..ly for all may be mo~ comfortable lying (In a !iOft\"r bed than on .. hard bed

CliniClillips 473 \\\\'hen I patJent has low lumbar symploms, il iSorom- infn-quently. the spinal sliffl'l('55 and oldung moo thaI t'Ilher ~ \"'ilJ be comfortable.md all'!>- continues after the\\'irus has resol\\\"ed.l1>e5(>s;gns SIOflunromforuble.or!hl're-~.lbeIUll'lb<lrspllVcan and symptomsCiln mImIC Mll'p\\'Klde,and may bcf\\cxedore>;lI.'ndedwhilethepalientliessupineb)-(I) respond 10 manual trNtmenl. hanng the k'g::s out straIght \"1m a small support under the lumbu spmoe (\"tension); or (2) with the hips and Pat>ents shoukl aoo be told that their weak link j,. \\..ooes fIe\\N \",thout lumbar support (flam). How· lnO'A'~tod.tm.ltgebythet.h..... \",·.\",tsli.~ted e.lT.lllSliu~foJthepaticntlD\"\"onwhodVi\"\\\"('fsode aoo..·e .II lime when they are O'-ertm~d. genenoUI ~fintb nu;t romfortable.md 10 plNtion thedt-greeof unwcllor UIlod.er physacal or mental st~ hip.md knee f\\e>.;on that enabk5 IUs lumbM spuw to re>I inthesulteda\\lmdedorlle:<edpoi§ition. NEVER CLEARED As w,th !hl' cen·i(;Itl sp......, the prone po6lhon il; rom- Molny pat>enls haw ft'CUmng ern ica.I or lumb.u monly a bad pos,tIon for I patient with low lumb;>r srmptoms that §llIrte lIl<Inipulator!l CMI fret' in one or s)mptorns. Although there are some p.oh,-'l'tts ... \"o a\", two treatments. When the<;e patll\"llts rome to the more comforbblc in the prone position. till' majonl) marup\"la!i\\'e physiothcrapl t. a dear assessment havcgreatdi[ficultyintummgon\".,ftheyha,eb..'en should be madeof olllllll' ~ moo,·emenls. pilrtlcuLuly aslet>pin lheproncpositl00 those in\\'olving palpahon of the .-el1e br.te. A \\'ery high pcrrentage of lhew patients ha\\e their recur· DRAUGHTS rcn<:es bceaUSf! tr\"\"tment is discontinued once the pallenl i>asymplomat'c, yl't th... interwrtd,ral joinl is This has been discusst.-d ab!we. bUI lhe poInt is an not lotally cl£>ar of joint signs. With such plticnts, the important <:onsidcral;on and is worthy of \"\"it,-'ration. joint signs should be demunslr,'l,-'(\\ 10 them and it should bee~plain,--d Ihat ifit is poss,bl\"to 'clear' these WEAK liNK jomt ~igns, ll'Currences will be more widely sp~ced ~nd 1t.'S$ S'-0\"\",.,. It sl\\ould bc understood that not all II 's imporlanl for a person to kno... thai if h\" has had juintscanbem>dedelrbceau!ICoflhestareofthedis-- symptoms of ~ufflCient S{'\\enty to require Irc;ltmcnt. ord...r.butiftheyam,tlStothcp.:thL'I\\t'sadvantage.ln tlk.... 00 IIldtt,-... \"o... SU<XCSSfu]trcatmentmaybc.he ...i11 lryingto pre-'l\"Ilt re.:urrences, thtS IS one of the ll>Olit ah>a)·shalea·...eallink·.('\\·enifitisasymrtomilrir_lt important points_ It is a point often negle<:ted by those should be pOInted out that if the chain (the ~rUle) w\"otTcat\\\"ert£'braldisorders ISgJlentoomuch ...orklodo.itwilJbcthewNlltnl (the intenmebroll joint) thaI breolks denvn fir.l MAINTENANCE TREATMENT CAPACITY TO ACCUMULATE Prople who hal-e dtiOl'ders 01 the lund referred to oloo..-e a, 'subclinical' and 'acute joint a.....reness· are It ~kl also be e...pl.iltlned th.at the .......lenrd struc- pabents who do gam benefil from m.1Ultl'l'W\\Ce treolt· tun> that hascaU$ed thrdisorder has !hl'cap«lty to menl. Thistre\"trnenl rna)' be done Ul one of two Wa)y- iKCUmul.Jre dlrnage ~mptomaDc..ll)' until it reaches tho> staK\" whom \"omdhing nunor boecoln<5 'the bst 1. Asmen!ionedbefon>.othl'rmembt:rsofthelvNse- straw to breal !heume!'s back'. n-.-pahents should hold can bc taught t«hnlllUCS that can be per- therclore roIli..... tholt i\"\\'en when they 00 ol '\"'gorous formed on a regular basis 10 keq> the symptoms al ICIl>itythat doX\"i not ca\"\"\"iIJly 1JOubU'. they should a reilsonable 1e>c1 for thepillll\"1lt.lhe rnanipul..bw not fNlth.:ll this means that their problem is cun..-d and ph~\"Siotheraptstneed onl)' 5l.\"e the pilhcnt when an that tht.-ycan goalll'ad and repeat it again aod again. e>;..x;erb.:Itioncannot beclea\"\"\" Itliohould bee:l<pl..ined to them that the things mQ5t 2. There Ire other p.:ttients for whom one treatment Iile!l'toC.luSo\"an..-eurn..'Tlc..arcthoscthat\",volve: sessione\\·eryol-Swcekslo..>epstheirsymptomsata belterl'-...·c1thanwouldbethecas-;\"flheywercnot • He....yltft\"'K-e!c. gi\"enmaintcnancelrealmcnt. • Su,tai,,,--d ,1cliviti,-'5 in a position ne~ror~1 th... In b.llancing out whelher home treatment or limilofnrange. maintenance treatm\"nt should be inslttuted, the • Sudden,\\lnc~p'--et,--d,ungu~rded movcm;:nts manipulat;\"e physiotherapIst must h,,-'P in mind the • Av,ms,Aviruscancausethe'weaklink'IObc re.llityoftheoft-quotcdphra!oe,·lelsleepingdogslie'. ~\"ull\\(.'1\"~bleto;njury.n...,injuringmoleml\"llt mlybctridal butpreroJed bya \\·irus. More

Appendix 5 Physiotherapy for animals (with a contribution by T. J. Ahern, BVSc, MRCVSj CHAPTER CONTENTS Ctrvicill~rttbrillmobiliZiitiolllllldtr lIniitsthttic 480 • Training 477 • Case history 477 • Spinal mobiliution thtrllpy:with particular rtfl:ftncttoccrvical~rtcbralmobmzation undCfllnacsthttic 418 ThIs chapter, mcludmg lhoe contribution by TJ Ahem. III a gentle, stabil~ing manner owr the horse's mane I kor right hand i5 III a sImilar stabilizing. comforting aimslohighlightth.epotenlialscop<:'oflhedisciphncs spread/)\\'er the horse's forcl\\o.'-old. If}\"OU \\ook at the fin- ad\\\"()C,ltcdwitIunUusconcqJlratherthanprmidmg gt'I'SofAmanda'srighthand you ...,lI.-the5ilmewrap- a romprcllens'\\'f' le>.l of animal physiothenp\\ 1llIt ~\"ills of non-wrbal communication, ~StI\\C.'l'iI, J'U'g. sunoundlllg feature of an ideal physiotherapist's _ l a n d rna\"'pulationlechn'qUoC$ill't'w,xhly hand. and the partKUlar ernpNsas is;ogain the comfort- Iransf bk- from the human to the anuNl woriel 1llg.~\"'TappmgaroundtNt gin'S lhe horse a fee!- mgofronfidennoand comfort. !iavE'alook at her right 1be t tmenl of ammals, therefore ..-'l!un the field thumb and)\"OU can_how Anw'w;b w\"'5luckyenoug:h of physiothenop,\" 15 no dIfferent from the ImliUnent 01 10 tw'ebeen born ...;!h a thumb idci111y shaped (lhedis- po.>ople '01 ..11 phyS.«her\"prsts, howe......., an.' good at tal phalanxofthethumb) fof a ph,'5OOdleraptst. E,..... hn- non-\\,em,.J rommunlC.. ho:.... in its !;lrnplest form. When ~ are '\"ftY romfQrtingly l'rl,'ftoping the lucie)' hor.;e's head and n«k.. Her fare IS full of roncmtr-abOO 'n'ating arumals. il 15 unportant to almost instmtly establish a Qnns rapPOrt w,th the dog. cat.. dum- and can' for lhe anunal and It 15 ptrf«tIydniousfmm p.U1zel\",horsc.-,1ltC. thehorse's~thatitisfullof5ilretvandconfi­ 1I;s for this I'NSOIl lh.ol the photograph of Amanda Sulton and the hor>e (Frgl\"~ AS.I), with the gt.\"nl.'fOUS denre in whalE'\\~ Aman<b l5entka\"ounng to actlJe\\·e. appl'O\\oll of Arnanda and theCSP rrontli~Editor,jarw If .....ery person woostarts on a physiotherapy train- Tonkin. has been mcluded in this Icxl (Sutlon, 1996) F\"\",/I\",t' ,~ the magazine of the Chartered Socil'ty of ingOOUrs<'ilSastudffit hasthcseqlL<1lit\"~in both PhY~lolherapy, and Amanda Sutton worthily won the hands and mll\\d, he or ~he w,lI fimsh trammg with as Frontlineu.cclll'nn'A\"ard.11lereare .....\\eral n'a.'>Ons many of the ideal qualitiL'$as it is possible to haw for wanting to includc thepholog:raph. Havingll\"lid that, what stnkes you most? T1le horse. using non-H'rbal commurucahon,. could be ...~ying'goahead,Amanda,whal('\\\"('ritisrouha\"e Look at Amal\"lda's eyes. They are semi-<:I\",c.od 11l1d to do. I ha\\\"econfide'lCe in the way you are going looking downwards. ghing the whole of hcr f,ICC the about c\"crything',This photog:r,'ph shows so many of appeararlCt' of being dwplycorocentrating. Now loolat thequalitie;; that areid('al fora hands-on Iherapist lhal what you can S(.'Cofher left fureann, wrist and h.~\"d, and you \",i]] \\0<'\" how the, are fC>lingcomfortingl)', wrapp<'d it had tobc indudro in this chapter To treal animals effccll..dy with manual lreatment itlS~nlialtogamth('irconfid'-\"T\"lC<',11lesp\"--edof

476 MAITlAND'S VERTEBRAL MANIPULATION Figu't A5.! Am~nd~ Sulton ~nd ho~

l'Il'(iiolh~npyfOt~nimaI5 477 mowmenb un.dt'1't<llen mu~, bt-s!o\"', sl<'ady ~n.d gen- the author and the publISher fOf\"their permission to include il in full in Ihischap'...., tle,and the lher\"rl~1 needs 10 respond irnJnedlately '0 any rK.....·erbal m~\"'ic~ge the animal is ron, \")'ing. TRAINING~ _ CASE HISTORY In many rountnes ~ is no need for 01 o;p«io1liZ1ed A6-\"I'ur-old!hllrl;ltJ9~brt'd~lall\"\",lgd~ u'llrung C()U1'\\C 101\" am,\"\",l physoothef\"~They may 'lllmn'lImtly ' - in both fofdtqs ~ a 3-ynr prriod. also\"l\"-'dan~bnIOl\"ananaoesthetist_Ast.isliln«'is not requIred fOl\" snu.ne.-.anunaIs such as dogs. bul o.agnousandtnau..:nt under !hew cimlmsbnces it is e:<trefMy helpful Lf thr Hoof~iJnd~lIaYlClIjardl5ftso:~ _-..eo-ispre:>ft'taswanimal\"sronllo:lencf'canbf diagnolcd.thoughnoleions_dt1.fdnLl~!r.I--a<bal1¥ coffinjolntllljKtionsof~f3tJrdtog~adiniQl gailll'dlTlOft'qulCld,- ,\"\"\"\"\",,\",\"Anatlrmp1to\"lCfu~theh0r50bodywrigh[ m,Thr IhinK ,IYIIIY,'\" found IIIO>t in~K in with~;Mlilabilityolgr3lnfffdhadreurtedinthe ~lof~mLniIlSBWttbpnortoelClm>nabOnbyttc ....or~ Wllh Dr Tom Ahem is !us USl' of mobIlv.ong author, TMhool'~led .. th.tv\\lICIl·~~an·.and (nwupulalmg) ~ The changes rt'Sulllng from the W35eonstantl'y loh,ft,ng ItS weoght from OM formg to the rna\"'pula,,,,,, harpm as quickly and drama,i(ally .loS they do ....hen 1n.'.1\"ng !he same ,ariety of disord~'f\"!> in athl:r.ju5ttl1t~lofhoof~ltTlWaHooughto~' humans. Ahem is In the pr<1C1'S5 of wriling hIS own bool<, th<:l\\of)f'vioIC'Ill:htntt.fnporl~tolattfaldigitalPfl:55U1l' l'ass-il\"'t Motiml Thml'1lf, regarding repair in noo-splnal ..~notgaugtQaltllttimt.thoughtntrr:sultsWl:n:S«Il ;omll; and soft hstiue(lt'ndon and lig.1mrnl) injury. lobtpr~d~tablt. This allitudelIad rtSUlled from Il'ptated noof uamination5 \"\"er Ihe p,~joo~ 3 years. The ctNical The thoraoo/lumbar spine of the horse is a ~Ia­ li,\"elyimmobilestructure:th\"great<'StraJ1geofmo'·~\" JOints w= palpaled. and a SIgnificant p\",n rtSjlOMt was m~'Ilt is present il1 the lumbosacral ioinl. This area tliciled in the Il'g'on afCl.C2 arlll tilt k!wtf ctrvical joints. lends ibell to ~tanding techniques. Ahem directs most olhis\"tt('fltjontotheC('r\"ical,\"ertebraln.~'-;onasthJ.~. i ActIVICiIl manipolatiorl ur'ldl\" anaesthtW W35 ptfformtd Ihe\"reanflh\"spllleoftheho\"\",whichhuthes\"\"'t- No athf'f form af mtdoeatrotl wa~ admlNsleml. arlll tht<-t eot mherent rang\" of mo,'ement wt.--e oofffd or mvironmtntal changes ill5l.,tuted. Withtheu\".,ofal\\oll'»thc..iaintheprocedu~,thc Ththorst·scond'iionimp'~gradua!ty.andlrywttk Ilor;\"o> is II\\Qn' Il'la\\ed and Il1OIl' stable. Ahem ch~ 3adlSlillC1unilaltfil(nghl-Sldtdllame~wl$prc5mt 8'(wtd8tht~~mildin~tothalat to repeal the procedure after an inwnal at 10-12 wed 3. At ml~ lime i second man,pulaloon ullCltr ....f'I'l.s.but It rnaybepossibletoproducea:!-Spercml a~Iht$i~~perforrnt1I. faH)lJrabledJffenonceb) treab.nghor.;,o\"\"no1shol1;>r Tiltfollowintcbyttc/lorw;'sC'OtId'\\JOn\"-lrq~ periodoftunelllt'reha\\ebeennohannfuleff«tsby In-ahnKhor<.e!.alshorterintL·.....i1 .... .t.o..O..M..a.f..an~l.r_rlu_c·dtlaSnlotiptaollWt'dJgI'.rjabdllu:talnll3y1lMfoRrtlhome b Thr foUo.... mg quotation b from ~l rorft'S- folIowinq6cbys.,andbycby~thellooY·~CllnIfiIJon pondence (Ahem. l'JI96j\",1h kind pennl!6lOO; WI$,\"\"JbrlothalpnortothtS('(Otl(lmlft,pu~lJonullller a~a.8yclayl.thtrtWJSno~oftht~ 1I1prr;t\"l11 ..... \".-\"\"~II.u'-lm\" l:t~andthe~Il'''''rnedlolhtlXlllgsublts2 aIOlhnu.lIl\"l4wrmd\"'I!\",iJ'lIJr,,'distd/orrlunb wttkl;laln'.~tedw,t!ltherqrewonaf~~ nbnllll)ClIr!ll\"'JI.r,jI'''JI\"iodrftzoo!l\"'~.I\\'llrn fiTSlpm<'frlnl\",,,,,IR'ri:sIlgO,thtItorstUVS'lIClllrl,, was 1ft incrn50td willingnns 10 tuftiw in t/'>t pi<IdIrl.. ...\"..·\"nJ\"\"\",\"\"\"\"\"\",IAISOntopt.oon.8tnlIl~rf Tilt horSI: wtnl on toriKt. and Wi~clts.rnlH:d bybolh \"\"\"0\"'\",1 n'itlli Sp\"'tlms.oon Il'f' Ikndtd ttl t'a'ntrindr~l$bt,ngithisbtstl$rtil~ladaf IIldl=t CVMUA. /;.IgllllA'ds rift\" thtfirst limm=5incrht_firstri<lr:!enasa2-'lO.-okl.A5in CVMU\" IhtrondillOfl had improml by 8Q%, \" early 3~rr:ar---old. lilt hoTlt hid bttn I~YOIvm In a mi~ap.liehadbttomti\"\"\"'rtel!andtntangltd.and $I'Cl.\"J llU. lit..\" ptTformrd, onJ tu'Oums 101\" lilt tlCUtmt dfort,,; had bun nCtt~~,.,. to utricne lhoe 1\"'IS<'''OWOI~lf'dT$c1\"\"cllllynormlll animal (Ah~,n. 1995) ,o~lIn1ttll\"tnruSI!u\"'f'benlabnornrllll'\"..,u,t OiKussian or I..\"\"\"\" ill t!'''I~(j\"ily \"'11\"Cfn~coll'f'rtrlmw lamtnC55 that appear~ to defy diagn<)5i~ i~ na, uncommanlytncounttrtdintqulntv-elellna,.,.medidnt. Ah\"rn (1994l wrote ~n <IItide. which Wil~ \",,\"i...w~-d ;11 thel(>lmJnlof[qlli\"rVrt..r;,lorySC~\"cr,onmobili<!<1Iion oftheC('I'\\'ical srrne und\"r \"n\"e;thesia. I \"mgratt'ful to

I~ fi~ i~sta~c<'S. f~pl'at~d diag~ostic wortups fail~d to Condu,ion ~Iucidat~ tll~ cauSl' of lam~MSS. On ~J<OImination. all fiv~ Th. elimination of chronic fo(~limb lam.n~ss by a two caSl's pf~SI'nt~d witll significa~t c~rvko-spinal pain t.catment ~rvkal manipulation und~, ana~th<'Sia cllfO~ic lam~~<'Ss and d~monstfabl~ lamina, eo,ial p.otocol wonglv su99.st~d a mo,~ dir~ctlink b~tw~~n c~rviro-,pinal pain, r~duced spinal mobility and th<: IlVpl\"a<'Sth<:siaofon~Ofbothfo~hooves.Anegati~ lam~n.ss ~ing inv..tigat~. Th~ ~duction in lamina. conal hYpl'ra.sth~si .. which acrompan,~d tll~ .~~,i\", '~sponSl' to anti-inflammatory mellkation sugg~st~ that appeared to ~xplain th~ low~, limb compon.nt of the th~ origin of th~ lam~n~s was not an inflammatory lamen.ss. Th~ sympath~tic n~rvClU' syst.m was th~ most rondition. Th~ ~xc~ptio~ would hav~ «~n caSl' 1 at p.obablelink bctw.~n the high~r ..nd low\", eompon~nts of th~ lam.n.s, ..~d th~ alt~.ed gail5 p~~tation ob5l'rv~d.l'c,iph.ral trauma and henee pl',iph~,al n~u.al trauma had not bun ,~rord~d in th~ hi,to,i<'S Hypl:famh~sia, hypoa~sth~siaandallodynia to cold obtainell. How~~r. examination suggest~d that and me<:llanical stImulation af~ som~ of th~ clinical c~rvico-spinal \"~u.al trauma ..~dloralt.'ell findings associat~d with sympath~tic disofd~\". ccrviro-spin ..lncuralbiome<:hanks.withdi'e<:to. Hypl'fa~sth~sia, fath~, than allodynia to m~cllanical i~d '~ct involVl'm.~t of sympathetic trunks. was mo~ lik~ly to Ix th~ SOufl:e of alle~d Mu.al stimuli,w\",choSl'ntod=fi«th~f<'SponSl'tolloof tra~smlss,on t~st~, Pf~SSU~. as tllis P~SSUf~ was ~ing appli~d across 11l~ inSl'nsitiv~ horn and not dif~ctly to th~ Sl'nsitiVl' SPINAL MOBILIZATION THERAPY: WITH lamina, corium. Mu~h of th~ PfUIU~ was the~ ~ing PARTICULAR REFERENCE TO CERVICAL VERTEBRAL MOBILIZATION UNDER at>so~byth~horn ANAESTHETIC Manysugg<'StionsastOlh~cauSl'ofSMPinvol~ T.). Ahern is One of the prime mover~ in the introduc- th~ id~a of a vicious cycl~ of ~~nts. Th~ cyd~ is tioo of verteb...1 mobilization to the \"et,·rinary world thought to ~ Sl't up wh~n pl'riph~ral t,.uma What follows, with his kiod jX'Tmission, are excerpl5 involving affe,~nt nern: t~,minals occurs. The aff~r~nt from a paper he was p..,pa.ing for publication in 1997 activity arisi~g from th~ damagell n~rv~ is transmittell to th~ 59lnal cord. wll~f~ it is PfO~ that it lllis was one of the tl>clmiqu\"S u>ed to attempt to resto.., the mobility of a joint .. nd neurologic..l com- distOl\"tsnormalsomatOSl'nsoryprOCt:=.I~adingto plex. It was a form ofach,·t' motion therapy, i.t'. where .x~siVl'aC1ivityinasc~ndingspinalsystem, motioo was initialed by and was und\"r the control of lhc therapis\\. Slow mo\"enwnts we\", perform,.,j with eon~rn~d witllthe transmission of noci~ptiv. direction, amplitude and pressures being selected by information. tnc therapist. ~au~ the therapist was al aU tim\"\" in control of thl'SC movements, inappropriate forces w,ore How.....r.th. possibility also ~xistsofa mO(~ not applied. Movements could be maintainl.,j at the \"~t.allyoccu ••i~g dis'uption to 'IOmaticand end of the av.. Uable range of movement for extended .utonomicpathways. Thi,couldocN••ithe.by p<-Tiods of time, Joints were nevc, taken past the limits. dif<\"d~~uropathologyorvi.disturban~in\"'Ufal \"'I''''Therapists using high velocity thrusts, which biom~chanicsofth.,ympathctkchain5l'eondaryto typical of manipulatiw procedures, we\", lC5s able to \"rvico-spinai pai~ and ,.duttl! 5jlinal mobility. control thc amplitudt' of joint movements. Thrusts ini- Th••~ has b••n dcar docYm~ntationof widtsPr~ad tiating mO\"ements p.~st the inherent rangc coutd havt' creall'<! rathcr than t\",ated spinal traum.. patho-anatomicalchang~inand\"our.dth. Mobili7...tion was achieved by initiating mo\"ement sympath~tic tru~k and ganglia in human~ C.rvical in a single joint complex or by applying pressures ,ympath.tictrunu\".also.xpost\"dtome<:hanical through a series of adjacent complex\"\", The size of lht' trauma, In whiplash incid.nts in monkeys, damag~ animal and the ability to locate and palp.. te indi\";dual to th~ c~rvical ,ymp.ath~tic pl~xu, had ~en structun.'S t=ded 10 dictate which approach was USl.\"ll. otlSl'rn:d. In th~ fIVe caSl'S investigat~d h.r•. Small animals often provided the opportunily for the ~rvical manipulaHon und.. ana~th~tk was the tflerapist to locali7.e and treat individual spi\"\"l joints, only fo.m of t~atm~nt utllil~d. Slat~r and eo-wort~\" (l99t) consid~r~d it impossible to mobilil~ tll~ ~rt~bral column withOut m~chanically aff~cling the sympathetic tract 0' symp.ath~tic n~urOn, in th~ neu,axi~ In ca5l'S t and 3. th~ t.mpo.ary ~lUrn of overt lam.n.s, afte' th~ Sl'cond c~rvical manipulation und~, ana.sth.sia may w~1I hav~ bun a p.oduct of this eo~,id~ration. Re<:~ntstlldielofth.innervationofarterio~nous anastom~ in the ~quine foot were u5l'ful i~ furth<:r unde\"tandi~g th. functio~ of sympath~tic Mural ~nd transmlSSIO~

Ph.,.ioth~rapyfOf animals 479 whilstthesameformoftherapywasdiWK;uJtloach....\"\" thethor<lCOlumbarspin\",Bolhdorsalandlaterajmo,·~k in large ammals. With small animals the thL'l'ilpist would oftl'fl initiate mov\"m~..,t by applying prelsure mel1!Sw\",\"\"p06sibl\"inct:rvicalandlumbarregiort!l. throushthedorsalspinouspl'OCCS<lCS,partic.-uJarlyin lWo major contradictiOrt!l wilh this form of therapy were those common to most forms of spinal t~rapy,

480 MAITLANO'S VERTEBRAl MANIPUlATION The5C wen.' vertebral fractuIl-'S, particularly in caS<.'S of resent 5.lddle, girth or bridle pressure, grooming, non-union, and vertebral instability secondary 10 gcneral handling kSpt'Cially by the loudcr and trauma or degeneralive bone or joint disease. Vascular more aggressive handler or rider). Bucking a\"d disease uf the vertebral artl'ries was a major concern in rearing we\", a fcw mo\", dangcrous acqu;K..:! trailS. the human species. but appeared to be of k-ss signifi- Symptoms of claustrophobia (unwillingness 10 cance in animals load inlo a lan or starting gates) occurl>!d. with apprehension prior to rushing throu);h doorways, CERVICAL VERTEBRAL MOBILIZATION UNDER etc. Thcre was avoidance of contact with other ANAESTHETIC (FIGURE AS.2) horses (Colrs b.lck or hindquarters raif'l'd 10 warn others away); these anImals wCrt' often found on This procedlln.', which utilized anaesthesia, was the outside of the herd or on their own and were designed specifically for hor>t->S. Some significant unwilling to race bctwc<:n other runners. changt'S, mostly as a direct result of improved spinal mobility. we..... reported as early a:; 1-2 weeks artcr a R<--rognition of the existence within the animal kingdom singlc trealment. Problems included: of abnormal conditions that result in \\'arying degrees of spinal and rcdUCl..:! spinal mobility has providl\":! I. ReducM cervico-spinal ROM, resulting in altered the fll'C<'S&lry stimulus to mo~ thoroughly in\\'~l1g.lle gailS and a reduced ability to under·nex, bend lat- spinal and ilSSOCiiltl.'d anomillics. Australian human erally, collect or change gaits smoothly, occunl..:! as re;Jean:hen; in the field of rrmnipulativc thl'rapy Wl'rc a dill-'Ct ronst-\"quence of reduced spinal mobility. rcg.trdcd as world leaders, and with the benefit of their t'xpericnccand K'Sl'ilrch,a base for thl.-Vl'lt'ritkll')' appli- 2. Behavioural changes OCCUrll-..:!, mostly due tocxag- cation of such principles has bftn laid gerilted respon.<;cs to touch (hyperat'Sth<-'Sia) and pressun.' (mechano-allodynia). The horses would

Bibliography Refefl-\"I1Ce.canbecho>en and lGed IikeSl<Itislks; lh.ll is. .-..-gimented self-criticism and tl\"lChing. It is not an aCJdcmiccxcrcise,tOctext of which isjuslified by J thc)<canbes.:ll'CIe<lto..aywhal}'Ouwanlthl'mlOsay. 10'\\11; list of modem rdeN..'I1Ct'5, The references h.:t\\'c Somt'wrih'rsofn'\\ieI'l5 place emphasis nol onlYUIl ~n'leI'-'CledforlheircHnicalN..'lalionship.Thl'yearof th\",,\"'m!J<'rnfrd<:I'L'ncesquolL-d,bulalsoonlhcprox- publication is unimportant, but the clinical signi'i- imily in liml'which they bear to lhe artidcor book canct'is Oneoflheoc'SlboQksonbackachehasbeenwrill,'\" bl,oing rc'i..wt'd.Such p<.-'Ople, on rL...·i..wing the 6th ooi- b\\' a world-respoxted author on the sub,,-..::1. The b<xIk hon of this book, may makesuchcomments.llowe-·cr, this book ~hould be rt'ad as a c1inicaltt'xt b.1st..o on is &<koclreby Ian Macn.lb. and has oob'bliography. fI1OIl' lh.1n \"<J )~'iI.\"\" of clinical \"\"perience bound by AL.\"'-lII.A L(l97\"),\"\"\"\",\",.wu~UII MIefJo' - rotabQn \"'l\"'Y Pn>cMJ,\".t>cf/N AIOt\"\".... Ll1ITIbfoe;,oc,aknllnrichund;hn,UinrdorlkdrutWlg ,.,..\",.\",....... ~.211.211-228. lb><JdM\"\"'cfN~.12.1\" Bo.'lUlL...... (t'1iBI·Thrl......... ?yg.aporh'-'jolnIS.Theit A1tu.\"\" T J.(I'l'n1 P\"\",of!ip\"\",I<>rip\\(P\"iOI.Catn., IX, 6-17 ....Ion\"andchnical ..~\"\"\"\"-I..~cf ~.\"'-'Il«t\"\"\"'.Swd>otvAIIU\"\"\" ~_TJ(I'l'M1CenI<Cll'ffb.>bn.lm0bW7\"lJQnundoor ~tC\\~ILA1;ph)\"\"\"\"tIwr~\"\"thotrN_ MnbaoI\"\"'....1kulL...... (I9l!011.l..mbvdon.1lr......u)-ndromo'. ...ofcrn-i<'o-1f',,,,,I~ .,.j,,,,ffne-,,.,,,..,,.,.j~_ c f A w , . , . i l . . .r , - S 4 t II.;UIU'\"N.(I'lIDJIn.. ....tomr'\"\"'CI~~oIl~ Vrln'...\",s.v... •. H '4l'-\"4~ b.:-l<hgbilit\\·lboUtl,,,fl/IM,...,,-GN</...t.e-.ontttr.. A1mt!<.. T, 1.119961 Rdbs, ...polhchcdystroph)'S)\"Tld_ A-Wrnor,J6,2-17. (ilSOS) a.npW>:I'l'gIOI'illP\"\",S)-nd_-I)~.I....... Ilo..UJL\", N (I987j,bw-..oon,f\"I,nl\"'\",\",\"\",and \"'P\"ltu<po\"\"'''''I..,''''f''''''\"PI''C!I'-.J-.....lol[qUItW ~oIp.unprodloOdion.ln.PIntsuln-.,., \\'etrnnu)'~,,,.~ cf/Nt-Bri(L T. T\",_andj. T.}'Iot. M>L 0>. 3. AJL,u. M (lO7'l) ..,J'e-omiaot..... London '''''hum. £donburgh;o,wdulJLi>-.ngs!One lh·.n.. . R..an.! Ga,-or... J. (1975.0). \"-tlnn, </11\"1\"\"\"\" \"'*\"' .......IkUlLk, N (l99-l.o) C,.. icalcau_oI~and Tn_.......,\\'ulll,I\"P.I5-17Califonu&,M..tarublic.l1On.. dm·Jness.ln'Crirt...' ...t.,.\",.\"\".,..2ndedn., 1I ...'DlD.R..ndGRJ'DB.J.(I9'75b).ThtSrrllCl~\".cfM>x..-. pp)17-332-F.d'\"b..'l\\~.0'..rchillli,\"'l\\Stont \\,~, 1.0..2. l'ak,Alln,CA, Scimc1>.r><t flffia,iour Iloo4, II<x;AJll... N.(l<i94b).TI,.. l1ACf'<·.llOl\"loilhe\"'l..r\\'ettebrai B~~...,G. (19tlOJ. M\",\",.ni N.rwrr. A Nr<msIlry U\",IV. dilo<S.ln:Mi>J\",~M\"\"\"\"' ITIon\"\",,,,r\"'VtrrrtrnlIG>lum,,, pp.17..'18.122.1.<>n<!on:l'oola\"\" Wedn.O.Ilu)'lingandNl'al.l.Wllla,edsl.pp 149-/61 8u,\",,,,.r.• WII>l,.SW.andRan<'Mt>.R.H.(19llO) \"h~ri,.,mldem}',·I\"I;rarhyandlhcid\"\"'I;nc.lion,,1 Edinbutgh,ChurchiIlU'·ing.tonI' a\"\"\",al\"u~lumbo$.>cral\"\"rverools.Areportof...t·o ra......nd ...v;..w \"It\"\" li\"'.alu\",./OIm\",l,rjlll>'lt.nd/oiIU 1l.:,x,uuk,N·(19971.CI\"\"r\"IA\"\"t\"\"'.I\"fl\"'l.JIml>orSpi\",.nd Sw~,~lA,I203-12al .\"',rum.3rdedn.Edmbu'l\\h ChurchiIlU'Ul,..st\"\"\" 8, ...\"''-.p.•rolMr......,j.(19'75j.Mechanisnuinn-r1'bral lk:<~l\\!~, N .• nd \"T'.>1)'\\lrv, I T. (l9'l1). CI\"\",.I \"'\",lon/v\" k,<mnsin lraum.a 10 high n'r\\,kal porboo of the \"end>r,,1 'I\",L\"\",\"\"r~p\"\".W,..Jn. Ed\"\"'.. r~I,,Church~1 U''''ll'tone ll.:,x,uut<, W., W'l.'<J\".,A S and TY,.AN, W (19ll2). The human lu mb.>rd\"\"\",lrami/\"\"null cfA\"\"''''''y.I),l,383-3B7.

482 MAITLAND'S VERTEBRAL MANIPULATION 6R\"'''. R. (1'l57).Thetrcatmentofpain. 501lih Afriam Ml'd,cal Dt;BcJr,;o,E.(J9S0).Lalero/Thi\"king.H,urnondsworth:Pelkan J~II\",.1.31. '173 Book•. B....lN.L.andlV'LKL.._.M,(I967}.C......C\"/SpoMylosisand DI: KIIYN. A. and N'ElI'o\\'£.-';HliYSE.A. (1927) ~~~:;::'~<'1'SVflheC..\",iealS/,inr. London: William Schwindelanfalle und Nystagmus bei..mer N.>stimmten S\"'llunl;desKopfes.AelaOtoiaryngolog'ClI,VIl,IS5--1S7. BREIG. A. (197B), Ad,..\"..,..T\",sion m Iht'C\",JOlI/I;m'Olis SysJmo, AnA\"\"lysisilfCaIl><\"and E!ftd. EMl4bjlFllncl!QllII1 Do; P..u.t.., A, F. and Rom......\". R. H. (1970), The 'nltrormbrn! Ntli/USllrgtry. Stocl:holm; AJmqvist and WilkselJ; London: D.... PhUadclpru.'S.'ul1d~rs ChuT'ChiIiLiving\"\"\"'\" DI'SfzE.5.(J955), L\"\"altltudesanl~lgiq\",,~dan.,l.sdatique B.B.L.. (K. R.A. (1'151:1). Manipuiationin themanagt'ment of discor.diculai\",commWl<'.5<wl/,,,,,,Ho/,ilaIParls,JI,2291 chronic low b.ck21che due 10 lumbo6acraJ strain. Lanrt'J. i.20. DIll:YHJSS, P. MICIt.. El-'O.... M.and FtE:TCIIU, D. (199~) Atlanto-occipit,J and la\"'ral .tI~nlo-axi.ljointp.in BRE\\L\"~R. R. A. and SiMJ'SON. M. (1959). M.nagement 0/ paUems.S,'inr.19(lOl.1J25-JJ3J. hunbo6acealsteain. Lanert. ii. 949. DlJRIt[u.S.(l996),Expandingll><'orop<'olphysiotl><'r~py BRLW£ItIOO,D.A.(l964).Co\"\"'-'1'Vatil·etre.trnentofthe chnical physiotheraprspe<ialists in eonsult.nt's dinics. painful \"\"\"k. ProcmIinsso{lltrIWJIIlISociftyo!Mrdici\"... M'\"UIl!1\"htrap'l,1(4).2Io-213 57,J6:l---165 DwvER.A .. APIllll..C..ndBooGUK.N(J990).Ce....icai BRJ:....£ItIO'J, D. A. (l986).The Doctor's Role in Di.gnosis.nd zygapophyscal JOInt palO p.tkrM1:astudy ,nnormal Prescribing Vertebrai Manipulation. In: V....lrbral mluntl'<'fS,Spinc, 15(6),453-157 ~7';:~~~';;:~::~:~~;~~~~I\"\"d. ed.). Ch, 2. Er:o;;AIl.M.A.andl'''Il~.W.M.(l974).lnducedpainp.11t<'mS on pas.ivc slraighl-I<'1l raising in lower lumbar disc BUlUJl.D.S.(l99J).Mobili,.,IIonoflheNnwllsSy\"\"\"\" prolrusion,joll\"\"lo{lkmea\"d/oinISu,grry,S6B.65Il-667 pp. J.-JO. Edinburgh,Churchill Livingston\" B.c.EJ;>W~.os, (197'1). Combinw mOI'ernenls of II><' lumbar BtflUJl. D. S. (1999). -nr\" Dynamic N\"\"\"\"s Systrm. Adelaid\", NOli\"\",;.,; spinc. e,amin,ltion .nd dink.1 signifk,mce. A~SI,alian jou,,,,,lofpl'ysiothaopy,25,4 C\"\"\"\"lJ'Y,J,(1951).Octhop.edicsignsinthedi.g\"\"\"isof ED...-...OS. IlC (19M), CombinL>d mOl'ernenlS in lhe C'C\"\"'kal d,scprotrusion.umert.i,l86 spinc{C2_7).Their,\"lueincxaminolionandl«hnique cMire.Au<t\",lwnjourroalo{Physiorhrrapy.26,S CLO\\oI\".o,R.B.(l958).Cl'rVk.ldisrography:tn:hnique, EIlW\"ROS,II.(1992),M\"\"''''!ofCo,,,bmI'dMiJV<mt7lr.,London indkotionsandu'leindi.'gnosisofrupturedc\"r,.. k.l Churc/lillU\"inS't<:>ne diSCI. Amt7ican j\"\"'llIIlo{Rofnlsmol\"ilY. 7'1,563 E'w:Y,R.L.(l97'1).llrachialplcxu.lc..... ionn.\"'tsandth.c p,tho-on.tumical \"rigin \"I ann poin. Pnx:mfings,>/ CLO\\oI'AJUl,R.B,(1959j.Cer\"kaldiorogrophy.Arontribulion Mulli-l),seipi\"'''''II\"t'\"\",ti<maIConfrm,uon o\\-\"\",ipula/i\"\" IOtheaetioiogyandrnechani.mofno><:k,should .... and Thrrapy,M,IIJoII,n'. AIISt,,,I,,, pp. 105-111. armpainAn\"\"lsofSllrgrry.lSO,J052-J064 ErHF.U1,'.C\"S.• ndRuSI\";DF..j.(1952).M.llmntali\"nof l\"mbarspil1lllroots.ndsnealhsinlhec,'u\"\"tionoflow C~n\"u~::;~~~~:~.~~~t~ :~g:~:::;t~': bacbchcandsciohca.jollnu>lofBo\"t.\"djoinISu'X\"\"I. 346,442---446 syOOro\"\",. /v\"rnal ofNeurol\"ilY. Nru\"\",\"rgnyand EV~NS,D.H.(19S2).Accu\"\"JIofP\"lpahonSkJlls.Unpubli\"\"\"-d PSy<hwlry.ll,312-326 thcsis,Sou,hAuslr.lionl\"\"tituteoiTechn<>logy. COl'[, S, and Rv..:<, G. M. S, (J959). Ce\",,·ic.l aml otolith Ev\":<s.D.H.(l'1'.l-l).Thcreliabiblyofasscssntentporamerer: vert'go./ournaloflJlrynxo'ogyandOlolaryngvlog'l. \"\"'ur.cyandp.lp.tiont<'Chniqu,>.ln:G'in...·.Mvd,'\" 73.113 M,muaITh£rt1py.2nded n·U.lloyling.ndN.P.'I ••mnlla. CoRIuGAN. B. and MMTU.!'.D,G. 0.(1983). Prnrrira! eds),EdlOburgh:ChurchillLi\\'ingslone.pp.5J9-5.l-6. OrIIlopaeJu-AWJiCJ!~.London:Butterwortlls E..... :-IS,P.(I9'l7).n,.,T4syndrome.SOm~ba.i(dinical CRISI'.Ej,(I960).Dlscl.t'sionsa\"JOrhrrlnlrrwrlrbrnl .spc<:ts.Physiorhl;'rapy,83(41.186-1119 o..\"\",gemmr, Trmll'd loy M\"nipu!alwn. Tnulion a\"d Oll\",r F\"RP\"~, H. F. (1973). Mrcho\"iull DooroUrs oflhr in\", IlIlck, p,5-I.Phil.ddphia, t.e. & Fcl>ige•. eon.em.r\"\",M,'lwds.London:Uvingstone. CS~.,(=)p~~:,~~~r~:~:jJ.,M\"nage\",,,,o,fAcul. FARF\"''', H. F. (1975). Muscular mechani.m of tho> iumb•• spine.nd IOC position of pow.,,-and elfjcie\"'-\")·.Orihopalie CYRLu. J. (1975). TrxlbookofOrl/wprldil: M\"1o\",,,... Vol. I, 8th ClinJCsofNorlhAmnica.&,135-144. oon\"LondonBailhcrelindan FmJSTE1'J.B.. lA.'lCTON./,,/..MEliOS.R.• ndSoULLElt,F, CYRI..x. J, (1978.0). Tnlhooko{O\"!wpaM,e MNiicme, Vol. J, 7th (1954). EXp\"'rimrnt5on p\".in referred from d\"\"psom.tic tiSllu<'S./ou r\"\"lofBone a\"Jfom ISu'S'''I,36A,9S1-997 edn\"p.747,LoOOon:B.1ilh~\",nndall CVltlAx,j.(I978b). TrxlbootofOrlh\"l\"\"'d,eMl'dici\"r. Vol. J,6th edn .. p. 709. London: B.,illie\",nndall. CYRJ\",;;. J~=: ::=~,~~~''''rdicMrdic''''', Vol. 2, 10th ev.JAX.j,(l982). Trxl!JookofOrJ/wpruJic Ml'dic,,,.., Vol. 2, 8th edn.. p. 281. London. Baillicn:nndall

Blbliog.~phy FIt....lo4O'fD.J W, !'on./'.. II.,COSJA'7.A,M C.n.l. 1I9@(l). /m1l\"'.... E. (19'11). PnJgIto<.. \",MUJ<1lloJSrl'kll'llniu'Y' Epidcm~ic Sludl601low-boo:k pair>- Sp\",,\", 5, ~~=='!Ml,...,...london ~19-423 1lIXJYDl.8..-.d f\\om..G. R.1l9571- TlItIOnther;op)~asludy GI.o\\u.J.R.(I960).B.locljMin.ondh,~\"\"\"\",,, \"'~!<lrrei.pn-Ioonuwt)·rtpon ... anrwmdhodof i.\\165 1uDlb&r1r~\"-\",,,\"\"\"Sw~.'J3.llll ew.u.J.R.(1977).~_oIlooolindp...o.. 1lJU. G.. (19S41 ~wn.\",.ity 0I....,u;a) ro-om.... oon. A 1n:~I<t.V\"'iMt_<:JjA-\"\"lortiorln..r.,,- pm..........'Y...pon. I'lv<mIUlgi AfTM .. '-- lid: P.m ( .... A.~andJ.S.Tobi<,ftI<).p 1JS.~.IL.; ~c.Tlw:Jn-. 1uu..G..Boall.\",-N.andMAllSLA.'IO.A/l9ll8).Theaceur«y ~.JE.-I\\\\'u:n.DG.(I9flO)..EpodmuoIog1c 01 ....,UOJ d\"'S\"\"\"'\" for cen..w zyppoplw....I ,.,.,.1 Sl1.>deoflow-hKkp.oon.Spr....,5.419--423. p\"m.'~ronM'.AfahoIIl<*nItJ1<:JjAIIloI ....... 1-&8.233-236.- Gowul§.E.llmj.11or~PImII\\Gn.I. Ho.nnond,,,,Ofth; ~wn Boob. juu..G.. Tuu.o.\\~I·andVEJ:SN:l.G.I,<I<I)1 Man..... GaAS1.R.{td.)(Ige8).Qml<'J\".l'fry.;OlTIwoty<:Jj1ltt ~min.Jtionofspirw1joinb;isp.oitlpoovoo.tionam¥>o' Cn1\"iaI/ __ .,..\",.., s,..... \"'..... \"....1<: Olurchill d~CUI'ford~ioro' PmtMlurpll{l\"E~ Pm\".Bint\"ilII~<ft1wM\",,,,.../oII\"\"'PlI)-I~ \"-:trVtiorl r:fAIISI\",lia, pp 4042. Li\"onptone K.u:Aw,:u.5.,KAzL\"Hf;A, l:,Tu:Al...,.1I. Y.naJ.(1996),The lAAAT.R.(I994) Ve<1l'bra1art\"')JI\\S~'acl\"'lGOl apparenlpath...Y\"oIdi\\l<.'O&ftliclow.o.rkpa.... \"\".m«1 proIOCOIforpn:'-lIW1JpuLotionleotingoftt....<ft'..'ical cfBi\"'u\"d/o,\"15\"~,n8,~12. sr\"\",·In:Af<!dmoMII\"II4IThm>py<{IIorVnlt'b..ICoIu\",,,, KArA'0l~A.j.(l974). TnmkarrdV,.,.'''''''''Coiu\",,,, Thr 2nd~\"'n.O 80yhngandN Palastanga,eds),pp.71-1 I'IrJl'i/l/<lgycflllt}<>int., VoI,3.2ndl'dn,l.ondon Edinburgh;ChurduIlU,ingstone G\"'Y\" A...'''''')' (1961). 36!h O'dn., p. 438. Edinbllrgil: Lonllm.ln. (hLlJ'ChiIl--l.l,ong>roo:\". KHU. K E. (1967). DiscUSSIOn on fL~afCh inlu pam GREV>.Dnnd/OVr-T,R.{I959).V<I$CUla.accidrntstotho! P,,,<I,'iJ,wr, I'm, 287. brainSICn1assoclaloowithncckmanipul,'ion,!olmwlOJ/ Krt'<;RfN.I,H.(l93'l). On lho!di.tributinn of pain arising II..-A\"......... \"Mtdl\"\"A6M<\"..tit\"',170.5 from d\"\"P,om,'ic slructu\"\", CIII\"(&/ S€imu. 4, 35-46. GIU:D:. G.) .. 1l.\\ljt1'. B. and ORuKJW(,J. (1990). N\"\",'oS and KIL'l:Y,J,LandHAW'r'.R./.('975) Drivlnllolmoto< v\"hkl............l factor for 1ItU~ t...nu~ted lumba,. inlcr- A\",,,,,,.,,nerve rlc~1-lSl.'Sof the human \"l'rlebraJ rolumn. vrrlroraldisc.A-.....\"\"\".\"\",I<{£podt>rrllllogy,lD2,6J-73 /I1unuJlI/A.../mny,IM,282-2%. K\"'EALL~.\\t..RL~'AOI.tl;ondEL.u.R.(I9S8).Tlv: GuQItSO!'o,G. c..nd LucAS. D. B. (1967). An in,vlvostudy uPf'O'\" 11mb l<'nsion tel Uw SUI: oIlhe ann. In. CI,,,.ors '\" of tho!u~1 roul\"\", of tt.... human tlMwaro-lumba. ~pltlC PIoyoi<:.f ~<fl\"'CmUf _ n.-nr s,....... V\"l17 ,.,..nw1<fIlotw •...s/\"\"'1 SU!J\"Y' ~9A.247-262. (R. Granl. old.). Edonbuopl; Chun::lull UnnptOfR KI:o-.--e~.B.(l968),Abn<InIW...anll\"\"\"\"\"lofthe .......... GU\"'E.G. P,(I980),C<tm... Vn/rlonr/\",,\"I~UlN\\orl IUmN. and firsl--.-al \"\"\"e WIth\", theopinalanal \" \" ' - \"e-..... G rC198I).e-VtrltIJnrIJoo\"I~ Joo<,..,o(Bo'....\"J/\"\"'Is..~.50B261-26S KJ:t.HD.B.andOUL.ul.H.(I'MO) ~-t-il EdU'lburgh: Churdull U\",ng,Wnr dlStribu_mfarcbonfolloo,'me:duropraoctlC(l!nical \"\"\"\"\"'.2nde-.-(;oan-r.G. r (1'J88,o), VnldonoIjlvtl manlpulabon.'\\\"\"'O\"\", Prr1aN\",gs. S5,3Z2. o:<irLEd~Chu«hiULi.~ e-v..G.P(I'l6llb\\.~~PNcIia.f,7.l-n e - -(;Q;\\T_G. P.(I'l89) \\'mmar~.2ndoldn. Edinburgh: 0wtdUlI U'~.p. 473 lA.-.cr,/.\\\\.(lm)AkIorn_\"\"''''~Ir:fH-s.:N. e:--T.,(;. r {1997j, ~\"\"\"1011w EdiIof.Ma....... '\"'\"\"\"\". 2Ul,lo..l07 Stholdn.Uwodon:BuItrlWOnh-Ht-onnnann e.-::.c.,Gj~8AlJ5'. B.-.d DauQu.I.(1990l. Mon~and lA,oo,A. (1994), T\"\"'P\"'\"....... 1$Ul1l by manipulati'~ .-.~pln..... otthehUJTWl'~rolwnn.A_ ph)~.-..\",~Ie:anuna_.fn:G '. /ot<,.,..,tJ(A_.I88.282-2Ill. M<Wnr \"i.>,,\"\"'o{IM \\'mt'bnll CoIwm\". 2nd n. H~~ R I.•nd MAl:->.... I, (19S&), Stouctural <Nnll\"\" in tho> O.8aytingand/'. r~iHtan8\".N~).pp.5-I7-5~ lW11Nr inll'f'-...n~ob\",1 d~.\"\"'mMcf Bo.....nJ /<If'\" Edonburgh:ChufCIuIILov~ S~'l\"\"Y,J&8,J04-J22. H\"\"\",---.,.c..l'-Q.lJ,l..o...B.•ndMlllllt,M.(I96J~The UltM\"\"'i.J. F and BItL.......... G, D. (1958). A deo..'i.ce for the ~pp1kat1onoilwavylumbartractlO<l.A,rf\"McrfPhys.tatl analomkal~fOfk>\",backpam.lkl.OrthopAr'dlOl Mtdicl...., 39. 696. Sn.-nJi....l'irQ,33.1-17 HOC~A!)AV,J. M and I'IIHTn.C. IV. M. (1967), I'dttermof L(wls.j., RA\\IOI, R. and GRUK A (1m) CNng.... In mech.~nic~llcru;iOllin the '\"'-'<li~n \"\"\"',.: possible .dcm,J pain in lh\" ,,,,.ma] subf<-'<:l. B,.in, '.10. 481-495 Implications fo.tt.... upper limb t,...,.ion t\"\"t rhyswtllnapy, s.1(1t). 254-261 L.oo!.fMrf. K.. Ktv.FT,G. llV~'''!''1., 0.11. (1951). FOCCI 1''''''-'1.VT.andSAl'1XRS,j.B.deCM.(1<J44).Reftol'l'l'd .ynoviiJl;mpingm....ot-ar\\l'Wcooceptlnlhf.eriology<>f pOln from 5kck.'tallltuClu\"'S. JeuI'IUllaf Nrm>uJ and Mtnlalo-s\",,99,~7. lumbar \"cncbral de.anll''t1le01. SUrxtr\\', Gy.UI<'C<lO'ogy.rul (»slrlri($.'H.4J9

484 MAITLANO'S VERTEBRAL MANIPULATION I.JUIT. S (1%0). MIrsJ,oX\". Moo\"rpoJ.I'_1PtlI T..rt.... Mt:.,-...ut.J.r-.k-\\t.{I%O)I:Io<tP\"\",~\"\"'T\",,'''''' Conn«ticut:LM:hL U~ _,,..,tol\"'\" r......,-.!-.don: Chutd\"U U!lI..L(I%5) Falal ....... \"\"'lcotd\"\"\"~· ... a§W1mmer \\ '.... ~.IS,675. ~H.(I'176).r.t\"rpno\"~a<f\"-\"C'Sand~ f\"\"P\"\"l_oI vm.bro-.l ....1jo<nI (0-11· AcW LOal.\"Y(l97'3)~IIOOl_oIlt-..\"\",..., ~\\' ...~s.-...tiJomiooUI1lI9-)l). lUno-*'n...tKtWrtl''''''_,I1.Zll M.uo.J-(l9i8).T1otIWv,\",-\"\"\",__ London.~eap.. LY>lIu.E.ll969) \\lo6<Jnollt-.. ....... \".1 opmo'.Nto \\~TY.V.andlh.\"'''..... J-{I'l'i'')_l'he'-.~~ OrllqwdnSornJ-... Surrlftnmt 123 au..:.lOrtlqwd.... _ItrlMtd~_IJ,I~ 15cl. MM:lX%>.AlD.R.(l970).IlJiJ..--IcM\"\"\"'I.p74 London,CoU,... ,<lCIlUoI5CJ', ndMo.m.J\\t.(l%-1).ln.·' me;o...remt- ol ...t<,.,hsc:.lpl\"eS5u\"',\"\"'_'''' rOOt.l\",,6ool<s- ~·,.jlo\"',S<t'i\"\"V.%.... I0'77. M\"\"\"e.l,( I97I I,\"\"SalhedIKe,plorati\"n.Ananaly.bof N.........\"LIUl.5\"To\\lU.lJl~\".K., T.... ' .......... Y.n~1 (19'16) 'Theapp.renlpath....y.ofd'''''ogenicl''... -backp.>'n rh\" .... u>elof\"\"',..,·erootin\\'ol\"~mL.\"linb8pati\"\"t •. e.'.lualionofL2~pi\"\"l n<'\",,'.. inhJtr.llQl'l, /~\",,,,,lr1&,,,r lo~\"'.lofiJc>\"'.\"J la\"'tS~rg\"y.SJ\"'.891-903. .\"dJ\"j\"tS~~'~.78I1,~12 M...u.\"•. 1 (1977) Bacb<'ht'. l\\o.ll'mo\"-\": WllIi.ms\" WilkiN N...TH,<...,II andl~u\"\"\"nJl'.\\l..(197O),Angulat<'llc<>u\"\",ol >pinaI ......·eroot... \"\"'r\"\"'Df,\\\"\"osu~.1.:w9-,~2- \\1\"IT1.A'D. G. D (1957) Low Nck I\"\"in and .Ih,od iyrnptoms. and tn...tment resultli Medi<:al }tJ~\",,,J of Onginalarti<k(l9661 Pa,nintJ...ne<:kand.rm:. mu1ti<:enUetrUlolthc~oIph)\"si\"'IM'P').BnIt>h ,.4\"\",..I... il.851 ...w.r.l/l»tnMi.l2JJ \\hmA>o1l.G. D, (19&1). Sonwob$<or.alM,nU., 'sciari< I''''T'''TA 5.(1%0) Funl:bonah~~sdgooupllJ ./Jeo-entfDn,sol\"\",mmalwnmU!oCb\"\",_#{ >COIm..·.AU<lraJ. .II/ootntalaf~ItmIpy,7.Sf-87 ~1\"\"\"\"'!.tS2.250-Z'O. \\hm\"\"\\}.G.O.(l966IM.mpula~lion. P.......,.WA.(l97SI.~\"\"\"'t.-yIlJIlttSfnot·T1orS,...., ~Jornpy.S2.382-385 V\"'.I.~So.........\"pp.I9--41 \"\"\"\"\"\" .............\\Lvtv..-.v,G.O_(I\"'Go).\"\"\"\"\"\"\"'M_ipo<W_.2ndtd... Pr..~L(l9'1ll~'onnaI\"\"\"'emmtsol ....... ical\"f\"..... A _ j o o I.... <f\"'-'I.~llOttIlI7~326 MUTU.\"l>. G. D. (19itI». Apf'lOlaon 01 manipulation. PHD........ 0.aoon........,..,.L(l9911.~ofl\\'\\Ml....u PlrylmtIwNpy.56, 1~7 d\"'gno:>is ... ,th.di.1g\"\",,,\",,,b~by.,,n,I..\\'cl lumo..rspinalbloc1<pruct...Ju..., 8th B....\"'.IC\"\"/rrrnuof MMTI........ G.O,{I978'\\.Acu.. Ioc....... oflt-.. .......·><aI'lJI'If'(' MPMProanl\",,~.pp.55-61 AI/StnOJ_\"\"\"\"af~.2~103-109 I'IlILU.... D. R. and ·!\\<.'OMn. L. T (1996). 1\\ comp.\"iSO<l 01 m.nualdi~lln ..~i:iw'lh Jdiagnosi ....l.bh.ht-d by., unl- MNTlA'U.G.0.{I9l!Olo~T1wh,·~ol..dding k...·c1spnulbloc1<rroaodun.o.Manu.IThmlpy.I\\2l.82-87 (.'Oftl~.. \"\"\"nam\"\"n8.nd t\",ating~Y\"\"'..1 1\"\"UJJ\"i. II. and G.aI(\\-'(,C. 1'. (19ll61·\"'\" lhcwacic ....tk'l \"\"\"ts,/<turll1ll\"'OrrIlcJfletd.ic··nJSpom~Tht\"..v .yOOrotN'. In; Modnn Man ...1 Thmlptl (G, Gne.e. edl. 01.35. Edll'lourgh; Churdu1l U'ingstone 1.7-14 Plt.n-ntot.tAS,. H.OO IlIJ.u. K (l'H?). C......t...Il.1<.rod M\"m\"'ND.C, O. (19801». MO\\'l\"\",-~n of p;o.in_\"\",\"V<' spinal'njuriel. ftcTdu rorracl\" ....llIpu..\"\"\"/OO<_/c{ 'lructu\"\" in thc \"\"nd\".1 co\",,1 in. group of 'Ir~AW~IA_I_.lJl.9 phy.,oth\"c.pyslud\"nl•. So\"tI,A/r''-.II!p\"m41af 1,~\",r/rml~,36.4-12. .\\ND.c.M..m 0.(19821). E~m\"\"'IO(ln,,flhc,,,,rvical~pl..... Aust1lJ1..n/m<\"\"\"ofP/tvsMHh\"''I''I.2i.6 \\!..rn...'''.c.O·(1982bI,P.lp.ounlt minat.... ofthcf''O''\" _CO\"n'.ic.lsri,.,- I\"\" Ideal. .\" S\".nd abnonNl A..\"',./.... /oot...,JII(~.:z:s3. \\INTl....'-n,G. o. (1%4' Can.olli~andthrir~floraon'\" t\"\"\"tmoI'lt ~PrDaN,,,,,tJ(,.,~s.tcPml ~~,·\"\"\"\"\"_c{A_.-I•. Mthoo ...... Ql\"\"-u. J. {I'lll'll. ASl\\dyoluppeo-lunb~\"\"\"\" ~~foIao.....o..flnt-o..bdra~di>ni.a\"lp\"Io\"-\"o:'Url _iudo_ ppll9-lll. ofEh-..yBnl'oIr/oJtl.... #{IUIrtI~.:z:s-'Q3-~U \\1..m..'-D.G.D·tl'lll6)·Vtrt....,Miorrlpoolot_.Sthodn- ou.d 1Iu1~Hnnmwv\\. \\t...m...'-P.G.O.{l990).I'mf4mtI\"'~/aI\"\",.3rdodn-. pp 1~S--I56.london:SuttJc-tworthf. RaA/.IIo.\"l.U8J8j lttt'W tnl«rtotF..fO<C'. 1.74 MAC.U:n.\\t_E.(I'IlI6)Tlwlinttt'\\'.>tmenl~.11\\­ 1l<.llA.'IlDl.5.D.!I966).\\tol oflt-..lurnb.>r 'P\"\"' .. ,th ModmI Mm\"\",T1tm>p¥t!{I'\" VtrttforolCol\"mn (e. (;n,,,,,. Santd,,,,,,,,,,.,sJ\"'Ci~ltl'fererl«!(ItJ...~hnngeffuctofJ'Oil<......\". ed.).pp 661-672. Edinburgh Chu.dllllUvingslOl'll' tUsion. Aehl Or100,-dle. SUpple\"\"....t 'lO MCCt.Ll.l.W.,PAn.,WM.ndO'llIlJE'.J,P.(I979l.lnduu'<! R\\....'.GM.5.aooCOI'l-.S.(19'i5).C\"\"ocal' ..rlig<.>,/.Jl\"\"tt, paon merr~t frQnl poo;l<.\"';or lumb.cd\"\"\".,,15 in no<m.1 ii.l355 ~ubi\"\"b. Spi,,~.4,441-446 R\\MJ,G..nd CO\"I',S, (1'i'i9).Cen'ic.l.nd ot<>hlhwrtlgo McKThzo;.lt A. (19811, TIlt L~mNr ~I'\"'''' Mrrl....it'\" D1a,\\~\"\"''' /oll,nn1 af'-\"ry\".'(O/\":<.V.\"JOM,'Sy.7l,IB .fIII Thmlp1l. New ZNl.1nd Spi.... ll'ublicalions. MJUNX. R.•nd W\",u.P (1984), ThrCillfU\",lI\"crfp.\", 5u\".':>''''''.5.. lI..url, R.•nd M[\\-'[I, J. (1%9) V..ncbral.rt..~, H.>rrnonds..-orth~jn800l.$. rom.p~,ons\",C<'\\'\\ic.I\"f'O\"'l,loI;is.~ru\"\"\"n,1096ll.

- - .Bibliographv 485 SO.... 'llT/.G .<'dGu,.n.) (19561I'oft.mor\",r.,.io< 1Ot'I...-,·erteb••I\"rtt.\"'Y.A\">I\",I..~ RJJJf<liogy, 19, «'r'ri>rlLa,.rrerysrnd_olWelIenburg;an.\" :~;t('h<;maruPULaI..... ArdurnofA\"\"\"\"'MNI('fW, \"..\"\". 5o\"\"\"\"zu.A.. .v\"\"C-;andllcGlL\",'.(I'J1\".il.Thr \"T\\o'(-...cn, L~ndT\"u~J-(I99-l)Thelumb.>t5f'tt'l'; >t1UCtu\"\",function..l!\"ch.onll\"Sandph~~f') .wcrodwl:JOInl.ndriumlclowNd<po.... 5prfW.2OIU. ;~~_\"\"'mal\",,,,,,,...,,IttTaPV.J..biIH iM... 31-37. Scrrrr,a.O.(l'K~I.Aun,\\...,..)traet>oofra ...... andlumlwlr nw.onL(l9'n)AnalOmyofthr\"\"\"oal'f'U'O\" \"'-mlillp fl/1Itr f..w-.- f'*\"-t_ fIIOH\"\"\"\"'''' Ma\".. ~A~.... \"'''''--',\\1td.ocifW.1,.258. n....,.st.(S.r...... ed-I\\.,I.lJSAlI'O'-fT Stlw.J.tA5r,1(..LAmwo-.ILWl'~L.ndCou>,L(1 TWtJ!o(£\"<,LT.andT..n£a,J R(l981)n.o.lwnb.>.Sf\"M< ~Nd<f'<O'\"andphp\"ClIItt-a1\"In\"\"\"\"\"\"'~ _ _~\"\"\"\"'followins\"\"\"\"\"lm.>RIJ'''''' tl(JItr'-fld(L T T~.ndJ R. T........ C'dsl.p3Ol. 'Wow'-rrl:OIurdW1LiH~ \",...\",'\"11tr\"-\"'- AWnI ~_. 2«,1.3. n.o...n-,LTandT\"n~JR09'n) r .. thoioKYoI Sololr1<TO:mnIDIIN_ry ... H-.oi~3fdnln wluplash.Prorml'\",.a(IItrIIUmOllI..wr\"\"'_fI/ OrI\"\"\"\"'i< ...,.,.\"...IaIrt\\\"~.(S.P-.ed).p84 o.Jord.o.Jon!Un....\"\"'.tvJ'reoo.. V.illJSA:lFO\\fT SN..l.All.D.C-,IU'olXl..WltandFAl.lXl'<IJl.\\l.A.(1'Wl) n...........,LT.ilndT.mo-.IR.(t'>b)(199ol)·PftyoUlT7tmtprJ _ _n.o.tnl(on~ri>ralIi&,, .~oI\"\"5\"\"'\"uJ tflltr'-'&tdr,2ndedn ......\" y,.,LCh.. n::hill Li,'Utg\"\"\"'\" po.n Jttu\"\"\"of8DN ... \"\".,'SIf'X\"'Y,JOB.515-~21 Su.n.. II,(1991) Ad,'ft'W ,aJ Icnsion in 0... s,mpotho::ti<: V..\" BAA\" M,E.. 1J£ll(JI.j and llo';\\\"IlJ).W.(l'l96).A s\",,,,,·yof?hysi<:..llhe,.'?ygo.ll.~nd ,nrc\"'enho\",fOI ttunL ..nd •..,\"po'.......,. int;oi\"\"\"'po'n.j\"nd1'Offl('S parl\"\"ts ..... ilhhack.ndk....~p.ln rn'l'\"ol1Mrapy. 1lI,:I3-42. P\",MI'\",'r'of'ItrC\"\"r..tnNof'''''''''pul.-l''''' WftD:.H.(11l941,Spi\"\"'\"pdalt!ThenalU,aJhisroryofdisc \"\"\"\"\"\"1trup'ffA~,,,,,,,AIf>l,,,I,,,.p.214-219 ~~;U'ldlheinA\"'-'f1Ct:'o/inl(>.r...n!i\"\".Spi\"\".1911'11. SM'rn.K.A..ndl',r1UllU:.\\lN,(1%2),,,\"e,,roIogical Wuu>,l~ E.(1986) Enm,nahOno/IMp<'lvic)\"ints.ln: complk:~riron!l\"fheadandneckman;pulatioo·lolfnullof t~ AmmrlfOf MrdlrQI A•..,...,t\"\",. 182. ~28 M....... \"\"\"\"\"'\" n.r..py ofI\"\" Vnf...., Col\"mn Ie. G\"\"'..., SMYTlI.M.J,a\",IW~x,tn. V.(I95/l).S<i~hcaandlhe nl.I.?p.~Ed\",b.. rgh.OI11n::h,llLi,m~ WII'n.AAandP\"-\"r.... \\! M 11m) CI\",,,,,IB-.:lwnoics ' ftnlt.'I'\\·~,!~b,al dr>e, An ~,perirn<.-n!al ,r\"dy·IO~'Ofal tl(1\"\"Sp'''''l'hilado'Iph'''Uf'J''nron Bo\",r.\"J/\",,, tSIf'S/'t'1i.40A.1401. ~.C-r.(1%5).SI\",n,l'f1\"aJlJBJ'O!Itffl,p,67.L\"nd\"\" WORUl HE..,m 0....\"\"\"...\"'0 I.T1IrrI\"'''-'\"'-' ~\"\"'fl/I,.\"..u-n\".()o\",ohId\"-.I~ r ,... g\"in1luo~. c......-.a:\"l-fO. S~~II~=~n\"\"lofO>ln:JP\"t\"i<:T...-\"niq\", World Health Orpnwotlon O'l97l. /CIDH1. I..'.....,....., SI'Ol:Jl),W).A.0969)·\"\"\"\"\"'ofOM..,...,hi<:r_,io\".Wnd<>n. ~_tt/I~.AIr..I... _PmiciJ-l_ HllldUttlonMedicalrubliQOOns.- &w-JrmttfttrFitWTnah. e-r.a,WHO SLTl\\.'O\\,A.(196I>1Anlm.Uthenpistsrunlo'-ic\\ot')f_II,•• W_,A.(l995).H'~poo.I'\"\"\",pu\"'n,..,lIwn~ .....·iewolpotenb.ll .......rophlooolop;al~ '-'20.1\"16 AUtr\"\"'71srnIpIf.I(SI,Il-I6. TA.'U. . j.R andT....'...n.LT,(l<l'l3).,\\cu\"\" ... \"\"\",,\",Il.(I976).n..lumb.uspww.-fb«Lp.>Jt\\.ln: ~~ri\"\"l!oan..utopsy\"'aoi'.oI\"\"\"k'P\".lJn.s,. I'. ........~Aopfr,..tI('-8odh,\"f\\1 J.oj ..... ed,L T\"uo<') R.andT...--.. LT, (I99ol1.AnaIomyolinjou.lift. Pf'l~2S6..''''''YOlLGntlW''51r..non \"'-In \"\"--'~fl/IItrC'.rm<al_ru->cs,-,2.-t za..J,(ed)(I'18l).AT\"\"\"\"~.s,.\"\"\",,~'hM\"j,,,,'/ l:trllron.p.l':i9f',...... YorLikuftn('t'·\\lueI edn.(R.GrInl.f'dl.p.21 ~~Own;fUll £uo;w\"\". M. (1\\165). I!<'.1rppra,s.alofaf\"\"'PO\"'-'\" nnoro- T1IrrA~.(1'llU1.2IA~ rhj~a1ftlt'd'1..>n.smforlhef1'IO<\"fofl\"inlpoln T.~\"'.l [)(~(l IOm ... 'stNcLpom.ndilSJ\"\"'__.... \"\"thpo\"\"iyejouun'l(\",e\"\"\"'lli PltY\"\",\".m'I'YPnlrtK'. 1.64-70. An\".-_oIthrp<lOilU\"'l\"m...lOfy ..ndm.....-uLa,f-.n., togeIhn\" .. ,thllvproblnnoftr.n5mI'~rood~k. ArP'1td[~..... '.207-214 TlIoc\"l',J DG,H...:o.C-A.andO.........\". ,AE.Il96fl) M,~uf\\'l'll<'l\\lIIof 0... wilmal mobility of the lumbu 'P'\"\",anJ hl!\"'-An ..\"I'of~IMrdi<'''''.9,:nh.121 TI..~11 S.~nd I\"IRRnT,L V,(I975).Tht' tomy .rndt~di\"~)·\"/U\"'\"'fYic.I\"\"l1d>c nd!he

Index Ref\"\",,,,,es to m~i<>r mentions of topics are in bold, whil,;t re~ to \"\"\"-textual matt~' ~uch a~ Figu\"'\" or Tab\"'\" are in ,tQlicprinl Abnormalspine Age o! pall''''' a,'eragespine69--70 assessment 70-11 d<genc ra ti v e c l u n g c . 2 4 4 beg~!;;:'lll'atmenisesslon palpati\"\"\"\"\"minalion 153 diagnosis 89 bonechanges,ocw/old 71-n Ac<e>SOry mQVements Ahem,T.).475 \"\"rvka~:r~~9qualified a.-\"\"\",t definitIon\",',) An'IYlic~~_menI12-13.14. c\\inicallips469 Aexion, lurnba. spine 384 Anim.\" conlinuou. ana l}'1ica12,4 PA1VM.s« PAIVMs (passi,-\" physiotlwr.pyfu....... d<.>ftnJlionxv I'hysiQther.py, for animals diffell'~~~iagnosls,assislJngin a<U\"SSOry;nlcr\\·crtcbral ffiOVMnCn,s) Ankyolos,ngspondyliris 19 example SO loca1iztod.ching217 Idealspine(IJ in parl of range f\",\",of listening/beli..v ing55-57 '~zablepathology'l07 musclespa.m.beha\"iourof6S-69 Acth\"c m::~::;,m/ort 2ffi-206 Anterior ,uperior ilioc pain (ASISj 409 neurological changes 66 AllI<'~:~riote<xcygeaJpf<'SSure pain_Pain au>.iliarytcstsa'-'OCialedwith prog\"\"\"isar>d85 neurologicalcxamination 136 Alllerof'C\"leriorunil.'leraJ\"ertebral quaJifie<l,cerv!cal.pi\"\" HS-H9 referred pain 137~138 pre;,;uIl'278-28J n,asscssJJ\\l\"l1t,painn..'<ponst\"S «',vi<;alspine2.15--237 Allxlelyslaleo;21 chang,-'54S combine<! 13J Arm pain 133 n:sistanee, b<.-haviour of 6/1 functionald\"monst,al;onlcsts Ar~~~:~c spine symptoms 94 1l'lr<>6f'l\"'ri\"e7S-110 127-128 Iilillory-t,'kingJ20 compromis<'tl'Sult.SO p.lltemsofmowmcnr 133-135 localized aching 217 estabfuhing pi\"\", of fut!her rht,umaloid 19 irregubr 136 sul>-<:linicaJ,afldinflammali<\", 103 lrealrnenlSO reguLorlJS-I36 zygapophyscaljoinl$« fOIlU:::~:\"\"I-b\",aklrom ph)\"'iologlcat\"\"\"'cm,,,,lS 128-131 Zygapophyscalj<linl qu,,\"lionsduringSO Ac':.':t:::~~:ormity 131-133 arthritis/arthrosi, wh\"namount/ral\"ofprog\"\"'\" ,,,,.rmcnl,,,,,,mpl,, 427---128 ~~~~;~~~~~rioriIi.l< I\"'in) 409 .Iowe<l/stopf\"'d 79--80 Ae1io1ogy abnormal spine 7(}-71 sP:':nornul.17ll-71 defined 197 analytieaI12-13,14,82--83 aslo:risk.<.use/\"alue6O-{>2 a\"\"\"'&,69-70 Aftcreff\"\"t alinitiale\"aminati0ll574'>() defmedlOS 'A[t<\"r'pain64-65

=488 INDEX ~1(l'O'lIJI polp.>I.... ..,..m\"...\"OIl 154 bonyd't.aIlgft/p060I.... Iests256 d,,'f('!oon01 n>b'1OI1134 \"f':~;';JI \\'~.p0601_1S4 nr..:ionU7-268 Ilo.wd't.allgft c;,~V \"'puLob(lnm-29oI .....,,,~, daM\",\", (imfnNiali'- Lotnalfln dooutg 1M ~questtons)3b thoracic:tpiM312-313 Loll'falflo.oon,\"f'fttittg 2lb9-rD '1lraIllChiIdol~tv',..mniqUl\"as ph)~\"\"\"- ~.nd_I/\"'T~ ~,ln-176 ~bonsl87 2H\"lUIprnod~ 1OUb(ln27'l)-VI foiIo,o,· ... IaioI-...on78 1lfto\\\"'Y ..wd\"'l!sklllsJO C3--0' ...... ~'l1 .pplol>onol~21~, rnrnllwmod2S1 115.216 'Bnck ..aII·_~~ d.-dn-Iypr ZJO--211 ('bnd..-alI'j ~oI-..n-73 ,.\",.;;wI<;,IortirollDW-428 f\"dol80-81 1Itltln.o..-od 114 f\"dolSl.'SW<ln78 (;lItd~I~ZZ pam\"\"\"ula.\"'ll CI-2 (<<n'oa.! spm.)lOree...ic.1 foIIo¥,l/tIt«hruq.... n-7B \"\"\"' IodJns ~2S-l2'J sr,~CI·2._ \"\"'Sr;IIu...pam ..mulahns r-fonn;ol'lCC'oIl1eduUq.... 75-n tI\\I'otlghoulS9-60 Q·3{«n·olsp,no:) .... een·io;al 42-4-427 ......... m'ng sr.- C2·3 .\",;\\! ...\"....,.rootpain41~15 - , -.Nl)\"IOlloMeS6mcnl82 O«1p'I.lpa'n,shootmg42'}-4JO C2-7 (ccn·Ic.1 spino:J .... een·i<.1 :wrommuninl.... eTTt>r'!I srlt\\(\"C2.7.~ asrSUpr in.>IU5k'ndIJUIuS,p\"m Mt,.\",.k$.u,;c,/\"\"I\"\"\"\" Q.4 (~\",kal sri....) .... Ce.\"ical simulahng422....24 sp,,\"',C3-4'n\"'\" c.duding~~sour«>oI.h<>utJc. \"umin.'lion 100 Atlanto-a ..ial .......s(ccn;calspine) C7-T~(lhor;\\fi«p;....)Io«Tho.\"\"ic .ympttlm.2~254 spinc:C7·na.....s bofly,,,\\()mali\\'S 260 e.\"'I1>''''''Sfr hlcnsion (n''''lc,,1 G.ad\"V .....n'p..l.lioll293--m C••Ji..-disea,., srinc ) ::~':/::~~~l p<I,nslmulalln~ ~21\"\":U nc\"ionI<'tFk\"klIl(re,,\"icalspi~) ooft-li..,~cl\\an8\"\" 259--260 C•..,h,.I.,..... , h.c;>dachcs lumhac<f'1\"C' )'fl--4f(l w,lhn\"'''<olromponc''\\l 92 \"'............,thoracic:s:puw,lrealmml..,..,mrle _ .... liac\"-1>'IOI1oMl7-409 ....Beds ~n\"\"73 l'-anc~ .lD-m ul'P\"\"n.,..·\"\",I~i\",,91-92 UlC;.Ilmml...-urnpl..,4H h~232-2l4 . .- o r d \" , ~ l l . ~ J O 1C1DlI (,ntr.-rn.1tM1na1 \"'-ifi<:atoon Ilo!al«al~,..,m,br;d Couda\"'lu'na.d....-18 C..... lal\"l''''''~~ oI;mp.>'rtnft\\l<,di<abi.li~ \"..,... «n\",al'f'l\"\".rnobil::i;ubcnl72-27) an\"\"\"'J-_\"\"'Loter.I ....\"\"\"'.1 Loll!!ral ::....Nnd:.~ 92-93 f\"\"\"\"'tl... 27S--281 \"\",,'\".\".'... ,..,01\"\"\"1 __10191) 1ongI~\"'I\"\"\"~272~275, ~1)oI12J+-2J7 Bod\"d n -''fIMlilil'\\l2-18--2~~ .....--\"\"......... 2JO,211-2l:! n:omrd lnl118 bon,onc>rnaI>e261 .~I\"\"\"\" .... AI1anI~ _~I~_21b3 BoJ,~26-27 boLot.,. . . I ~ , - m d n 1 SoOft-l_d\\anse> 263 ~~'-71 Pft'Mtlf1'27S--m \"\",'l'menl.bnormal,_71-n m.>nIf'uLob(ln(G..... \\'l:!93--:!99 p.>in\"\"f'O'b\"lln CH_ IioOfl-hSil\"\"71 bonr~/p<ll'ilion_:!S6 -\"\"\"'~JOlN(n>bb(lnl\") llony.r>Om.:1H~ ........ \"\"C2-3. d,ffnmhaOOn oI-')mpbm ~icalrotaoon293 \" ' . \" l e a l . p , .... ,nten..nri>r.ol I\"\"ntl (C2.7j atlanlo-axi.l ..... 259 lw.>J\"\"hHfjll Iow('••\"\" 263 rolalion(iIlSlIlmg)2tl6 \"\"-'\"Ot.Up,lo..,Ulanlaljolnt midS«tion 261-263 rot.lion(supinej266-U,7 sllboropl\",I.re.>259 C2-3.~.lS (IonS'lud'.....III1O\\·emenl} b o n y . \" '...... 1\"\"'26O .ndCl·2,d,/ft..,..\"\".tionm \"'-'\"oexip,II)o.llanl.1 ~)int(n)lalion 1\\.) sympt\",\"\"saris,ngfrom l!A 29),,294 1><'\"d..-\"\"'91 oex'pilO-allant,,1 ~\"nl(unila\"'ral i,ldicalion\"rlindings26G-261 nl(wc\"\",nlobnormalili\",260 I'A thruSl I,,) 294 \",fH,ssuechange<259--260 urpo... \"'''·ical;O;nl<,oexipullo 0-70\"\"';' bdak,..lfle:ione,tenslOI1 268-269 C3(lr.\"\".·c..... lhrusl)295 mid·\"P\"'\" 21O,261~263

mobil.....bOn272-2'J9 ,\"\"\"-~\",arle<ylesli\"8 lum\"'~it.l ....lmft'ot\"\"\"\"'P\\o> a,,~uru.later31 po5lm)-\",,~cmlr.I,-crtd><al C\"\",b\"wd n'IO\\ emml> I3J ,flWbral~\",278-m \"..,..,.~\", C\"\"\"\"\"\"\"\",bOn D-51 btI.I. ., u l ~ _ .'roml>Irwd'lIOdvUqut'rJ6-U1 ..IN!dqucstlOnSl08 ,·nttt>r.o1~278 \"\"\"\"~ C_m..niocali.., ..nun ~unilo\"\"'.al,~ Iollooo.tJpq_l08 n>ooth,-ruod281 mu~277-21l:l \"'-ry.WUIf\"OI\"i-.dsogm 2~ fInJ<ln{«n'i('a/JW-28lI _U l \\ l l W d . . l a t e - - ~ ~ \"1n'~1n...\"\", 285-28i _ ........~Itototoon(\";,.]~) blg>ludJtwol....,._m-V~ ........ImlN!d......~ ~1d«'YD'f'lO'M2SJ.-254 ~_tft\\tnI,~ ~~lI<lNll2 Jnit>al_It.>_ _ lrubal ~V\"\"'215 .......\"_~_2JO,236--m \"'\"\"\"-.........1O'Wintt 2Il-?:I ~uniWlIon1 _oC~\"'plllom2Jl-ll2 ~...'OfdolJO. .»-J\\I ~pmAInOU1-Zi8 mu_283-28-I d~I).... 2JO--ZJI ..........,~JOo I1.IS h.-.y m-m .rod boW\\-v>« S-~7 ...tnIn>'_ _ ~.I\"..,..... \"\"\"mwntd>&grilmand+l5-+l7 281-28-1 ~1...-....... ll2 ~\"';;;'_~\"i<Jutll2 .....non-~I26-27.38 ~~t-1,.... :z.n.-ll7 it'w_~R....-_\"\"\"\"\"\"'\" .\"\",I..ry237 ,;1umrh\"'l 2~ k'<J~ofroml>om\"8 2:H-2~2 ..,...·L.. «'t\\.....I'luad,anlll7 §l\"-'Clfkity~ ..Jump 251. lll. 253 l.... t\"\"\"'I_SUtr:M><j......,tt\"'~t\"......,t. undcrcomr-oon 241.245 uppc1«>n\"kalq\"\"drant2311--2.J9 Tn·.t\"\"\",t_ ,mdor.l ca\"\"lfin'mobr;ol t,..niunonT'i\\Cli<Jn(c o..:al) /or-..\"I...... 2~9, 253 tr~n\"'L.\",.,.\"tl<.-br~1 p \" ... ,·\"rbal26 ~l'\\'al\"\"'234 \"\"\"~:.. ~tl\\''' (0--6) 2~2 ·u.nijd..rivat\"\"\"'l\"\",ard\\'31 ocril\"ltC7.~\".....,,1OI1 271 \".,rbatim ..xampleo J4 35 o'cr-rl\\.'SSurt'(().P)H>,236.237 1\"'~1\\'.. lWXt._\"yinll'l\"\\'L..-tLob,al c;;'':'~~~~:'~I'oW;~okillo Il\\O\\,....,,--nts(I'A1Vl\\b) 2~25ll uppo.'I' 229,2Jl,1S8-261 1\"'!O;\" .. ,a\"S.. <>fph)'si<>logical otl\"\"I0-\",..I • ..,.,,2..'9--261 .,;,sumlf\\g34 \"\"\"·L-mmtsofsingle dlffffo.ntlal..\"'ofs)mplnms., mLSOnterp\"\"mg31-33 \"'l<.\"r\\ ..rlcbral;ornt>>«~nJn .nslnlf (O-3fCl-2) \",-....bcotundq-.nns 33-34 I\"I'1VM.(~,,·.. .pnrh, 1'0tJllli 259 Com\"...... f'hl\"\"*'8 i a 1 i nK'n·<.'1idIr;a) <;rad~\\I nlp\"\"I\"'\" ?:I3 _......def\",,\\>Onw ~91-92 C_\"......~_,_ \"\"\"~ts) '-dao;hl-;ard91-.-CJ2.229 r--~_I44 .,..,..·oc.-l'f'...... 2U,24.'!i ~bo=4'_~\"\"259 physocaI ........\"\"'lion2J4.-271 Ihonacspuw 311 ,~:-.ylcsbng Consull.>_ upprl\"\"f'U'\"'25ll-2:61 1fUd~2:61263 IfUtW~2-16 irutwl«lnibalconoullWono Ccnttaond\"\",-.m·225 .:.:..:..=.~..2_l>W4m-2.l7 .,..W_J_}'noL!\"Cmlb,aau,ospei.nmr;Thnn<ic hYf'\"'l\"OWdy22.....ns Ouual .........~ ~14 \"\"\"~Ift.~ ~prubWtno6--l.1~ n&ab\\loty224 \", canol,,,,,·ftW'k;dIor;muno n..>mlNlIOn 11-12.1~ 1is1eJlm&1ll-1I,IS 2f9,m thoofy,anclchninllknowledge 8. 1~ ,ad~lcl\\an5\"\"m---224 ~-_2.loI W<><do.ng~1O,1~15 '-..rtIJJ' 22~ p\"tp.ot>on2S+-256 C1inicaJhps C.,.~ .......... ;ory~ ._t~75 :::::~:,t~lrt'\"\" n ;;:.~.. (PAl\\lMs) dl3Ordom ~77 Cncothvrood \"\"\"\",i>o ~77 ~, .. pI'l,1Iiologico1 ml/lClcspOJm 469 «'t\\iallllp....... mulNli.<.obnn281 !\\'roNin/; ~7lI \"'It..........-tdlralm<n·emenlll RlCu~~77 Oo:/onnity (l'I'I\\lMI}2li+-271 .ppllc.tiono!t\"\"hniq\",·.21l> CInW~N a\",a~ di\"\"¥nkdi\",,roen 216 pl~n.nint' 2J.I q\"\"Jif....J Oli6CSO\",,-\"'t 2~&-2~9 .ih'of~ympt\"m. 112 Itt olso \"rot\"\"I,,·.. dc-/onnity COCC)'gOOnl. ~\"Q':o~~':::\"=2~2 o.r~21 ~hotJldl\" ~ymrtoms 253--254 • lum r l\"\"I251,252.253 h:Stsll7-m

490 INDEX Dermot\"\"\"\", pain'7:;;:',lruclures/patterJ1S Iraum.,1cllowiog 10li,107 siteofsymptoms iClS-I09,IW,lll lypc98-1oo palhol~~c.ldiSOrders/injury192, Di,'gnosis <crvic.lspi\"\"~231 age of pali<.,nt 89 prol.ps<.<lIOS lirslqu~'Stion 98, 100 sequestrianlOS lumb.>rsptnc 338,3.19,340 ~C~~fo~:I~;m<1l1S 199 surgcryiooical<'Clwhcrc210 lhoracicspine 302 Di'.ziness dcfir>cdl'n _.J\"\"whiplash injuries 105 and cervical !>pine 2~>'-247 dilfe....~~a...,.,.mcnt assisting in Disrogenic disorders Doctor,roleofindi'Snosis/ Discogroicdisordcrs disorder dinic.lfe.lures 191 prcscribmgI7··21 be....vio...r!l6-a9 dclo,mity 216 caud.\"\"luina,di\"\"• ..,18 hlSlory-takingl20 Org'lnj~.::':':;,rs1'~I~n\"oIVing - \" 'sl.bHllyS7-8ll low<>]'cc\"'ic.lspinc 230 painllJ,1l4 prcS,ulllcyl8 sl.ge87 sul>tecti\",ex.mm'lions 104-105 psychologicalf\"\"lor:s 20-21 doctor,roleofI7-21 .....I\"\"Disc.inlcn·crleb.al spinalcord,disc\"..,18 DiSQrd\"\", 'crtc>!>... I.rlcri<'S 18 familyh;\"lory 89 vcrtcbr.ldi\"\",..,_Ver!ebral g\"\"d\"rofpallent89 ~::~~:~rl~ g\"\"\"r.lhc.lthofpati\"\"t89 di\"\"a... int\"\"'''rtl.'bral disc/n<>]',-e root 199 com!X\"\"\"'tsU6 Draughis473 ligamenlousandcapsu1atstrain/ c...rn:nlknowkodgc 187-196 OUR/nerv....root.k..,'·e definition xv, xv; sp\"\"nl99 diagno:si.87-89 as,,,,.S,,,,-,,,ISS n,l1\"rcofinjuryS8-ll9 discogcnk .... Disrogcnicdiso<dc~ pain.\"'7'~ti'·CSlNclures/pattC\"\", ocC...palion01 pati\"\"l89 dr,'ughl,clf\"\"t.476 pa,n/98,I99 gradUlllonsetlOli \",fcrrcdpamlQ.l hernia~J~::smialeddisc192.. p\"\"\",xisting>igl\\S/sympl<>m.89 Edward$,llrian 136 pre;en~:~~~yron'pon<'r\\t dis< 192, 19~ Elwy, R. L 2~9 \"'-'urologicaldlolng<-'S 223 problems rbric\" waU') 6-11, If progn.OSSK>n rale 19~ End'::;~~p:~n prc>gllO'i•• ndS6-90 \"\"lati\",,\"'ip.l95 slructureoonsid\"....'d.lf.ull8(>-87 st.bilityofdisordcrl~l95 mO>-CmenlS 188 1<'Chni'l\"\" selection 196-199,204 injur), 192-1% vcrtcbraclSS hcm;':f~;cmi,'ted dis< 192. P\"\"';\";\"~;~ility romponenl mythms 178 liga\"\"-,,,ts 11J1d capsules 19>'-1% .houldcrsS 7.yg·~~:~~ii';;I'r1hrilisl whiplash lOS lho,acicspinel711 ~~:::::~I~~C.PSUI,\" lQJ-lQ.l Erkk>on, Miiton 25 Diagnosticlitles Ev.lu.lion_A\"\"\"\",m\"nt jointypeople476 Examinatiun 97~170 probl\"mswith6 cltnkalevidellce 11-12.. I~ PhYS~~;lconsiderati(>llS diagr.msof differenl mO\\'CmcnlSon Diffe....\",tiali\"\" c:;g;;painresp<>n>e 188-189 paticnl withoncdiso<dcr467 dcfinitionxv int<-rrogationwilhempalhy 100 pain-sensitiveslnlCt\",,-\"S/pain lleUroJogicallJ6.-138 Diffe....\"'ti.tiontestsI62-170 palpatIon .... wndn Palpahon p.ltcm~ phy.ic.l_PIly.ic.l{\"xammalion dc/inition12 sa<:nlCO<X)'geal.ndintcrco«yg....1 dura/ .....\"·.,.root,l\"\"'·el92 int\"'-\"erlebrallevels,sympl\"\",,\" inlc~:';';aljoinlstructUrt\"S \"'!lions ~1l-412 sagutalposlcro-antcriormo'·{\"mcnt. .risingfroml63-164 ncrvcroot/.>SQCi.l<'Clnen....'SI92 rcfcrredpainl90--192 in <X)mbined position. toint/neu ralslnKlure:5,symptoms vcrlcb.. lcan.l/for.mina 192 .\" ,-yg.pophys.,.ljoinll90 SUb~~:::::J~lV{\" lrom 164-165 'rccogni'.1blepaihology'l07 'labtlity87-8ll.JOl ,,\"ried~ions/<onl\"\"Ip')inlS fromneuralano:lmusc...loskc1<,talsoun;es, stage 87.JOl ;~:ms 165-166, Exc\",iscs dinicaltlps ~71-472 radiogt,'ph~ 169-170 !>p'..... /rrS~';;al joints, pain from Ihor.CICSpl ..... 313 Disc,intcn·crtd\".12<»--211 diagnosis 199 hemial<'d/hernialtng 105,192.. 1~195,22J less se\"e\", symptoms not ~~;;':inghght\"\"Otk

\"\"\"'1ftnClIS4711 Cr.lhorn,DrJolm24 ICIOH (inlemolioNl ClaMif1Cillkln of C\"'Y' AlIo1_y6 r...!<'nSlQn (\"\"\",,,ical ,p,.....) impounnml:<, d ......l'l..,.aw;l ....... lwondicillp» bila'~ral 268-26'1 e'tension-<K<'<'leTationi\"luries2'l9 CftVocaIIrKtion28S-2ll9 ccr>ocaIopme 92--93 oo;ip\",-ei271 E>ctensoon(lurnborsp;r.1 \"'\"\"\"'\"<ftV>Cal\"1\"\"\" 91 ~69 dri>lbW1nll;Iowbac:\"~~ ul'f\"'191-92,229 wilh\"\"ural('<>mI'Ofl'.1l1 92 lli::I\"'\"\"\"\"\"\"m'naI1On 152-153 p.ttionIk>t..d354.J86 Il.... rtd ... pft'-...I ......lIUNtluo>34~ di\"\"'lpre!l5I1\"'0I'I4Qo4-4(l5 l\"'in \"lah\"'42I~Z2 mmblrwd ........\"\"\"'\" let> l52 l-ItnUt\"'8/honUleddlllC 105. t-. ••ImllM'di.atlO-\"\"\"P\"\"'!oeq......tions lS-J8l6 E>c\"\"\"\"\"\"(1ho<Kicspi.....j in.....loonoul... 191-195 physkale,aminalk\",30':1-310 dlK 192. 194 non·''<'tbol~38 I'I'IV\"\",,, 314,316 netut>Iogr.ol~22l ~'.---'d0nfru>8J6 ~ ....r..194 ouhtKtn.d>~J6-37 r\"\",\"r \",lalKJnshipo195 \"\"~l_to:r;_ hunb;o~1'Ola.oonu....g 'lobiljlyoldi5Ord\",1<l4-195 lhstorytoling Inflammollon fl., palm \"\"\"hod or1tuiticdison;lmol20 p.oII\"\"ion151 in'...·articul.ord'~lm =r_n:~lll Fle>:... (............al opuv:l Inhe\"\"\"e')1'ilbiliti\",,01 body 15 Loa.nl2!l6-2lI7 larnily'-Y,-.dd.- I'J fnl_fill\"'Swith,ymplOlnf copoocilyload.plll c.....wV<narlIf\"'W_m 101,121 apo.<'1lylOmform14 -\"\" ..mo-b'llI:~S~~~ n\"n'ical spme In'l,aJeon.ultabbn>4O-l] 1nrti.aI«JNW_ I\"mbar.pine 341 342 f b i o n ( l u r n b ; o r > p i ..... ) qlleitions ll~ ~\"'l1ng4O-(J ~;;~tiont1112J. ~\"\",,·ftnen.3M pun-==:r:L7 Cfti,....... ~2.n-m doebtJJl.I''''3 lowblod punC<lftlirun& NmNr\"l\"\"W 341-J.l2 .ymplOrTls.beha'iourof4J-6S -=iIiac~402-lOJ h>ili.I\"\".minal>or. \",,_IObood386 thoracir$pi..... J05.-106 LoleulJ86-387 Il'Chn'q......lI'Cnon lW-2Ol ._mml.157-«l lhor.>cic:spincJ05.-106 1nIlboJ\"::\"'387l1ochniquc381-J8.1 1tt~I-/SIS(hittory.,ympl0<n5and _'\"l\"lury a~tIOtI,Cfti,i<a1 ph~l.,....mi\"\"'ionJ.l+-J.W,34~, sip) 346.347,348.350 H....\".\"..~-.:l\"'P\"IttHSS _ _~'-noolldd rombinold mOW!tl('n\"estl (ho<tory••vtnl*-a'>d HerruabnsJ........leddoK 351-35ot . . .> IIoop,toJInnJon3ll8-J1J4 Iipmmto/apAlla. 1<15-196 in5Wod\"'l!3S0 fri<•.,...frwluetionrouchlll9--J93 whip\"w. I(r; Fle>:U>(~opWl ltSS(hblOry,>ymplom.and.lgntj I\"'lab,lity curnmurlic.llon 24 \"\"\"lr.indic.tion, Z24 c..-V~_:u9-JJO definition ... Loler'alJIO,JI4,31~l17 \"''''hniq... lI<'I«tion IntemolM:O'\\olOl~llOnof pftYl\"C\"'lnanunonon306-X19,lIO ........hl5tory IW-:ZOO irnpoinncnt>.d\"-'i_oOrId PPlV,,\",.3J:}-..114,l16-317 hmdoaptlttlClDH Functi.on.old~mon\"'r. .i o n ' ' ' ' ' t I \"'\"ow-200-201 C..........t>onaldoo5Ji<o_of irnl\"'\"mo:nto,dlNbi!>_iIln<l 127_128 l~lmmf\"\"'llnglO 12 h.andicil.,.l HypermobiJily In=.:.::~~ernp\"lhY e--,~L>fV 174 c.,oo..,.olp.tbml mnlr.indirot\\ons 22+-2:25 1ntcr>\"<'t1t'b<.ldi\",_o..c. ddinition ~v d,agn<llli,1'l9 moye\"\"\",ld\"gr.m -I6}-467.466 inl\\\"n-enri>rol Crad\"\"ofmo',.\"\"\"\"\" lIypomobility ~ft1I'br.al\"\"\"\"\"\"\"\"\"\"_lof mO\"~laI>nortNLbe$n,l55 tuhniquct.',I7S p.un-sonsobveRru<turft .. Cradualor-tofuanienl 106 140-149 In.......ntebr.I!''D'.. Cra<k,V rnanipuLtoon <:t:r>ic.l.pinc29) .........lfle..ionlv29!l rolallOlllv293 u.,..00<~m-lJ2

492 INDEX ImerveMd,r~I;oints«tmIJ) Latcntpain6J-.6.1 l1exion_~lexi(\",(lllmbar.pine) Cr~deVmanipulalion{\"\"nIJ) Latcr.10e,ion Ir.,n,versclhrustc!osing2'19 histol)'lakingJ.lI-J.l2 l,.,nsvcrsc Ihtust opening 298 \"\",cc\"'ic~I\"Pi\",, 287-2S8 U/5al'<'as3J.8.340 intcr\"'md\"aJdi'\" 189--190 pain LS/Sla\",as338.J.IO bil.llcr.1437-138 longillldinalmow\",cnt lig~mP:II:%:.t~~~psular insidious 419--420 poorlydc/i\",-'<1.ymptoms 42tJ.--421 (mobiliz.llion) pass,veph)'5iologiealm,,,,emenlS Lig.mentsancleapsul .. 2ll-I-209 usingOflCkg 381 161_162 us..ingtwolegsJ80-J81 cnd-<:>f;;;ge/lhrough-rang.. p.in lower abdominal pain rdcrrl'd <NalscPPIVMs(pa<si,'e physiologicalintervert\"\"ral injury 1'6-1% from 116 mO'lements) p,in_SctlSiti\"cstructuresl90 lowlumbil,p.1Il 94-9S paS/;i\":''':~::-~l'Clmlqtl<'S. m.m'rn;~t)fl (Crade V) 394-397, pooilioninwhkhmov£ll\"\"'l Group I (pa;n) 205-206 mobili,otion 36S-J97 Interwrt=:;:2lt2-203 Group2(stdfnc:s,) 206-2fJl d..-bilitatingluwbackpain p.,lp,lIion ..x••mirutlion 150 \"\"\"lining paticnl to b<.\"<! crou;;_<;;;n with ,lifl\"\"\",) J8.l-386,J85 Imer\";,,wingsk,JJ,28-29 flexi\"n38I-J8.l lmr.-.rtkula,,,,psul~rdi>ord.c.. Grot~<.;;m\"\"Ilt~'Ypain) longitudi\"\"lm,,\\'ement 3&}-J.81 I\"\"tero-antcriorn>ntral'·ertebr.1 subj..di'·.. \",amin.'tion l()J....l().l 5tr~in/spr~in(diognosis) 199 p\",\"\"ureasrombined Intr.dis<~ldi>orde... 1{)4 5«Q!5lJPeriarlioulorstructurcs lsomctrkl...i5 Uslening ](}-1l,15 mo\\'ement(la~ra]flexion andbel;\"vingS5-57 oclivc~nd pa,sive 121 Longitudi\"\"lmo'emcnt nght)369-37lJ as.~mcnt 01 ,rm and leg musd.... cl'.,.vk~lspine 2n-2?S.296 postero-anteri\"rmovement386 thorock.pine.Ul-J32 poslero-anteri<lrunilateral J39-I-I0 Lowb;\",kpain eonliningpolie\"ttob<.'<i384-3ll6 ,'\"rtc-braipn.'SS\",\",,370-371 Jefi\"-'J'~,Eung 86 po.ten>-anteriorvertd>ral Joints ,,; extmsi\"\"W,386 pres,ul'<'J68-.369 ~~';;;;:~noix~i\",ements I~ fl\"\"ion3ll6 mtoh\"n:Jl!.l ~~=i;;:;:od 393 difierenti,hoI1t<...ts16ol-IbS Notional Clinical Standard. GrollP in~\"'·ertebTal_Jnlerv..rt\"\"ral;oinlS :;:~::I~g387..J88 locking..I\"'atmenl ..xampl.. US......29 \"\"trcdtmenlexample 430-431 physicaJexsminalion 125--126 transJ';I~;.;ertebrOIP\",\"\"llre 'pi\"\"/peripheraI162-165 LUC:~~i:':~\"'397-lOO SltuCluresl64-165 palp~tion :J.5S-J5S zygapophy>eal dcbiiil~~~inconfimn8patlenl 5011 lisoU<', OOnr tiss\"\" and .rthritis/arthroslSl'.19 c,lcn,ion384.386 pa'n·seru;itJ'eslructu...../p'in Oexion386 position 357-3SS rot,llioo3l:l4 ,wC'ating 356 p.'IICm5 19(J disorder type JJ.8. JJ9. 340 temperoture 356-357 Joinlypeople47lJ examples physkalcxominahnn 342_368.343 ju\"enilcdiselesion acutel>ackpain4JI-4J2 functional bilalc'ol leg P'1Il 437--438 lumb'~~\"\"l7Ire.tm..'Ilt cx~mplc coccl'godynio434-43li ~o~=:~ti;:':iniuring jm·cnilcdiselcsion4J6.--4J7 Keywmds JIJ,3S-3'J Llbuttockpain432-4JJ bteralshift 350 low back poin 430-431 luml>arflexion344-349,348 L1bUltoekp.in ne\"·..-r\",,tpain416-417 obscrvahonJ.W luml>arSJ>ine.lrciItmcnlC>.iImple .pondl'liticspinewith 432-133 ::.:PA1VMs 3513-360 =~:~]ocalil.cd lA/S(luml>a'spineJ_Luml>arspine ~;~~~~:\" lA/Sa\",as extension SN Ext<'llSion (Iuml>ar spine) rotatJonJ5() t\",ts (when applkabl,,) J50-355 firstgroupJJ8 Jl'O!'lero-anteriorcentralvertebr.1 p\",\"\"urc(mooihution l<:'Chn;qllel36S-369 asrombinedmov\"\"\"-'Ilt(latc ral f]cxi\"\" risht)369-J7lJ Jl'O!'t('ro-onl<.-rioru nilolc.al,·ertebral p\"\",\"\"urc.mobili>ah<)fl \"\"' hni'luc370-J71

493 IOUhoo In Rou!JOn (Iumbu If>ini'l --S~21&-219 \"\"\"'~dunnp;olS-&7. w_ oond.g.roupl3ll JJ8.....l.&2 18e-1S9 1......... ~-L........ JPi- d~l)l\"'3J8.JJ9.)«l end..:Jf·'MlS\"I \"\"\"\"'5h-nJ>llI\" 1usloo·~.H1-312 or ........pul.otion1oodvuq1ld rest',n:hJ.40 20]-202.220-22\\ \"\"\",18& il,\",:w0-341 f\"\"'O\"~IoIorJ'''''''''emmts ~~89 sp«ialqo.>estlOn!l.Hl symptom ...... J.W-J.Il su,'a,nedMreich.i~.nd4 rrftorrodpain 186-189 \"ymplomb\"h.,'iou.341 t,\"'hn'q.......,sel...,honl86-1Bl s)\"I\"plom. i>I~ngOl'romp\"'S80ng ,In,,ol J.ID-.Hl thorolC~\\';7\"~~t\",,.acic.PI\"\". pain 188 bcl\\,o'iouf.Hi MOIOr'\"l'ply.n,,·,.,.. .,.rooIur'g''' for(M) Ul-l4J pa...'v\" ..... r\"',\"'''t..,;!:> lItSlS.combi.-..d\"\"\"enll.'Tl1S MO\\'i'mMlabnoo-m>JillCll p.lll\"msutMovcn\"~'Ip\"'I1,·\"\", \"\"\"\",... \"\"oer->nJS2 ~dYn8\"\"71-n phy.~>logkalconsid\"'ilions_ «'nolopinr ..,fIoJonJ51-3S2 it~\"larNS:zt,() 1\"'~\";~\"\"'~b tnl.ollrRllIroonIritJ'\\2-:\\34 loowrr.rca2tJJ ~Jac...pon1(1.l LIlmuuonleft 3S+-J55 1nId.....uon26J ,'\"\",\"\"a1can;ol uwrrtrbral lractKJn 3M-J'H ~ubompItaI...,., 259 hypomcbility71.155 foramm.o14\"'.~1 -,,,fnctlOfl-freelr~rouch f'llf'100nI~IS5 l28'1o\\~10~,'''-'\"tolarul It'a,,.,·Cf'5e'·Meb....lf'I't''S'' , MQHm\"\"'ldiagram _ _pb~lnU' mobili2.>lionh.'Chnlq...... chnical~umpl,,\" 4:;9-46.1 3il-3n hYI'..nnooility45Y-!61.460 \"LAI\"\"\",ipvJ.;otionl.lnlloer Scheu\"nnann'sdi!iNsc4(,l ~1181 _81so'C~c...i<.18pioe;1lloI';>CiC ipondylitic ...........·kal.plr.... 0161-163.461 \" ...d,·opasm ,,~ rompiling 454-457 booho,·\"\",.<:J68-69 drilrun.,nni c1,n\"'alhps475 ~\"\"'puLollOn mod,fieod 454 mob,h,... lion.d..\"thof 218-219 ~-OC\"..lspinl'_Crnical sptnI'\" btioluw4574 muftspasm452-&54 ::':;,';~:~'llll~;;m m4'H .....ipubtion(en&.\\') PWO ....7-450 doofiN'dn\",3 p-'~\"\"\"-.:mm1161 H·rt<>br\"\"n>on\"\"\"\"II~.I60 r.angt'bm,le(lby50p\"C<'I'l1458 '1yOlQl'l'll':$ fonNofl71 ~~~<:Jm..,;ck~) ~teofsymptum> 1O'J./I1 lumb.a\"f'I.... _Lumb.aropi..... a.t,'\"\"hingaid/lIIO'aMol rornmunkation44~7 G_l\\abtlnalClinical StantbrcbAd,.-... marupulation(Crad<,Yl MOH'm('fllp<1ttErns 133-135.221-222 ~:\"l>rlpa\",).M) ormob,JUlngteeM,'lueo; 201-2\\12, irrt'guLarl36.m n.'guLarl3S--136.222 inomalid of I'<'llcm 19J n<>-m \"\"'l_olobt..\"\"\"l!d'''I'Chon chronksymplomi III 221-W compr<-'SSion of root impending 20 rhyltu1t!l,d\\anginlldcp.h.<ofl79 di.S\"\"\"'\"199 ,hot;>cocspine5<rThor\"':II.\"Pi ne: ,==:\"\"\"=ction221 .....mple<:JI\"'atmenI414--421 manipuL>hon(Cr.-l..'V) abnonn.lhlieo_Mooom>ent \"\"'7t:;I~I\"\"\"e-rooIpain abnonnaline 'n.. lll'Chruquc-lllQ 5('\\'~=nen'e-1'OOIpa\", ::::;~:=V~-encnb \"\"po'2l11'duuqurlIlO-1lo' leII~s~nccP\"\"\"'ft\\lJng under~(MljAlI81 _rrl\",.lion 01 lO'Chniq,,\" 216-217 bghl: ...-..k211.2U ,enrbnld_19 combinl.'dl13 _ouPP!Y{\\I1J41-14J \\t.luJ'Ui'l\"\".thrRpv ~ Kq~.\"\"\",,,,al~.... 2l9--242 \"\"\"'ft't'en~plI'\" \\llJtl\"a\"... undcrcompr<-\"\"\"'\" 241 liU~,ndlCaloo210 dlreoc:llonol.t<'Chniq\"\",.,k'CIioo 202 t«lmiq\"\"\"\"ktJOn 209-211 paan ..m....ung -424-U7 gradalolS.175 '\"\"',,,\"roolp.lin 1'1,137,192 inl.....\"\"dl•• ljoinl.po6Ihonin ..x.mple 414--415 MNn~ ~:':l217 ...hi<h~2m-:2lU romm...ni<3tion~Jl_JJ c.rviril a.... (..umpll') 414-415 Mob,lllAl_teehniqUd ~~=:.:.\"\"l~';'\"mplPl 41(..... 17 ~\",'i<alsp,ne_Cer.·oc:alSf'IJ\"\" mobiJi1.. hon d,·r\",iIHJnni,4 <1<.,,111.0(217-219 ::;.::e218

494 INDEX N\"\"ralekm\"\"ts netJ\"'P\"lhk116 PAIVMs(p.,ssi'·cacrt'SSOry anomaH\"\" 7ll ·n,-,w·/,old·.ituali<mS 155 inte\"\",I1~'bral rnov\"\"\"\",ls) occipital 429 Neuralsympto\"\", \"\"n:ical.pi\".,256-258 5ubj<:cti\"c,\"'amlnalions 11)4 ;~~~~,~~~' 117 lumb...p;...., 358-360 N:u~~:~<::ng\"\" rcro\\'ory63 thoracic spine 313 referred r.lp.tion oonlraindicalion.223 Neurologicalexamm\"llon 136-138 movemellts 188-189 abnormalspincl5l Neuropalhicpain 116 p,'in·scru;iti,·\".tructurcsl90-192 a\"cragespincl5l NO'Hpeci/icdis<rnle.s2(l physical \"am;\"\"lion 137-138 bonyanom:ilics 154 l'>.0Il-....\",alromrnunicatiOll26-27 j.;KT()ilia<;r<-'8ion 4(l2 c..r\"kal.p...... 254--256 \",lea,., 63.178 O:dpit<>-at1anlaljoint ~9\",\"kJ_pain\"\",ponses bonychange!l/positiont...ts256 f!e,ion/\".!<.\"\",ion265-266 ...,ft·lissucchanges2S5-256 CradeV manipulahOll \"\"apul.r426-U7 sweatinga\",a. Z55 1<\"'gitudinalmo\"em.ml2% shoulder, example 8 diffcrentialiunt<..t>by\"horack rotahonlv293-294 spi..... /periphcr.ljointsI62-165 u\"illteralrAlhru.t 2'14 stiffness. with 207-208 ~nu,,?t:~~~-161 lateralfle.ion264-265 .Ireldting/romp\"\"\"ing; ISS !<.'<:h\"iquesclediOfl205-209 g<'flCralroulinelSO-l51 Oc<:upatiOllof palirnl thoracic 112_116,Jl5 diagnosis 89 through.range ..... Through.ra\"s\" :~::~r~~~~315Q o-~;~~~e:~;;,,) pain lumbar.pine355-35il tolcra~IQ31 soh tissuc. bony lissuc and \"\"r\\'ical.pine!J5,236,237 trealrnCntso\"-\"\"CSS67 position 357-358 ddillltion xvi tWQorm\"\",pain>-65-66 .wcatingJ56 Organicdisor<l\"\", wcathcr<hanges 67 nOlin\"ol\\,ingvcrtebrac17_18 wrongted\\n;\"u.. 68 m:':~:;~I~:~~i\"\"15+-155 Ost<\"'J'hyles.\"\"\"'kal H3 rain \"\"'po\"\",,\" 0s\"\"'J>On>S;,,18 boncchangcsn sacmiliacrcgiOfl407 Ovcr-pr<-'S'u\",S€t().P(o'\",\"pres,;un.-) .kin5wcating/tempcr\"lure 151 :\":;;,i\".,.lowcra\",a264 ~t-I; ..uechangt'S152 Pain \"'mperature 151 abdom~~\"tmcnl example lumbe;;~:~:;~~'';,,=~. ecrvka1spine 255 \"bdominal.lower 1/6 passh-clI\"\"\"ss<_\"yint,.,-\\-crtebral lumbar.pine 356-357 acule431--432 mo\\'ern..nlll(l'ANM.) :~:~pine312-313 'aft.,r'~ \"\"-'\" mO\"\"\"\"\"'1155-156.I58.100-161 position 154 arm 94,I3.l tcchniqucpcrformance48--49 Pa r.lleling behaviourof62-f>8 wording.kill.29 change<in,~ing66-f>7 t\":~~:~en~5Q diagnosis 199 l'as<ivcac~ryinIC\"\"crlebTal disc<lg<'<\\icllJ,II4 rnd-.of-range/through·range disordersor<->fle<S67 l\"'inl88 mO\\·c\"\"-'TlI$(l'AIVM.) ..... md-<;>f-range st't' End..:Jf-range pain PAIVM'(P\"\".h·c~ry grttinguscdl067 initialronsultati0ll45-47 inlcr\\'ertcllralmo\\'\"\",enU) l.llent \"'i,63-M I'us;vemovemcnt xvi;,3 hng\"ring64 ::==.:;inl88-1S'l neural linked mo,·.,mcnl$ 149 k><:aI188-1119 PPlVM• .- rrlVM. (passIve k,wlumbar 94-95 stret<:hi\"g/oornp\"-\",,,ingl\"'inl88 mobiii>.aIiOll,d\"pthoI218 pain·\"\"\"\"~:~l~~nJctu\"\",/patle\"\", phy.iologklllinl.....·ertebral morncntary208--209 movement diagram -lS3-lS6 assessmenl55 mO\"e\"\"\"'l$) \"\"\"\"·...rool st't'N..rv...root pain duraaMncr\\·...root.l<\"-'''cl92 _ a l \" \" r. . .i , · e l c s t s r.ssi'·e \"sdllalory movements in:;~~~~:lr~:~t~a:': .ndmobllizalionlcchniqucs4 I'.ssi\\·ephysiotogicalintc...·..rtl'bral liga,::~~~:capsular mo\\·emenlli(PPlVM.)_ ne\",croot/aSllOCi\"K'dner\"csI92 PPIVM,,{passi\\,e rderredpainl90-192 phy.iologi<:ai inl~\"\"'ertcbTal \\'ertebralcanal/fOTamina 192 mo\"\"\",,,,,ts) zygapophy$CIIljoointl90 Passivctcst.3,138-162 <\"\",·;<.I.pincI44 isomctrk.assessmcnlof.rmaM neur\"I~~~~~\":':~~f9

Ino:k~ 495 p.llll-§ft\"dlu'·\"otructu\"\"'m'·\"\"\"b....1 --l'Ian\",ns 121-126 ~~hnoque3li4. (\" l.ndml.....~••l physlcal.,..,mlnorion \\22-\\2&.114 S\\IlIj«1i..........rninarionl22 -s1ump_367-36lI fora m\"\"~I\\40-\\49 1!>or'Ioc'lp,... 3IHI7 ~andpolif-fivdlO I\"ft'd~f«tors p.o~tIOnI«P.lion \"'F(~\"\"\"\"\",k\"\"\",,,,,)312 ~\"\"mIICO<'C}\"SC.l ....... 90-9, f\"I5iSI'eph~m\"\"'\"'ertft>ral ~411-412 doctoo,\"'oItnd~, \"\"O>~(PPlVMs) ~centraI,~ .._.......\"..'.\".\"...,.,.\". \\49-.\\51) ,,-- ~iar:poin402 \"\"fi~ .........~joints.P-i\"\" cen'icloISf'1l\"C!27S-Vl> cbn>calappbc...... 01~ 1Nllun&91~ r,:~\"\"O>~15 lumN'SJ'Il'C!J6&.369 .~.tedwIoq.... 369--J1'O diasn<- and _~ .... D1agnosto slump_l«-l~ '''lul'}.,,\"lIenfl~109\\ physical\"\"\",minab<lnIS7,I5B,159 r-l\"'f\"*\"l'i f-...90-91 'ltn>5N~nisonsl40-I\"\" IhDrUSf'1l\"C!,IYI(lbW.u,,,,,,, ' ....OIm..\"tt'ff«l9'O \"\"'x'_JaM~~I~/1UY ,.\"\"\"\",l'.thoIop<\"&1 dl-wn...,. DisonIer.i 1«ftni,q..... 31&-319 I'QlC\"\"\",\",\"\"I...-u\",lo!l!1\"al (F~Jeff\"'YI) Ill> .,;:ic\".hOnol~217 I'rofjr~mmed' pain \"\"\"\"\",~...I p _ \" \" lumbullpW\"tn)t;lb(lnLtSUlfl; J86.-387 mobih....h\"\"k'dIniq\"\" 323-325 I n~rmplornbl'haviour \"\"'Iero-anleriorunilolenl'·erte!>ral l'roI.pooedd,,,,,Ill5 \"\",\", Prone kn<>eb<\"I'Id(I'KU)312 bKk,,·.rdllh405-406 p\"\"\"\"u\",, ProIt'cti,·.. d\"~,\",,ily f<:>n,.-.rdldlol(l6..4(l'i' \"\"\",icalSf'inem \"\"livemoH~m,\"'IS/\"'':5I~ 131-133 ren..rticu~'~lfUClurn a and C2 in 3QdcglW tot.lion defmilion wii .u~i'·eCX<l\"'i ... lionlO.l 2n-278 l'sychologIC.lfactors doct<J<,rokeol,ndi.gnoo<is/ \"\"dpher.l\".,...esupply•....,,,..,.«X>\\ IUmN'spine 370--3'1 1~t;:::~IcSPI\"\"321-J23 p\"\"\",\"bmg 20-21 orill,n/or(I') 14/_143 ,·,.,.leb•• ld\"\"\"'l<'20 R2·12jit><>l'acil<lf\"\"\"l_Thor_ Ph~~:~::=;:'~~~: I'I'IVMs (pasoivr pIll\"ioIOS\"\",1 ._................1f\"U\"'\"R2-12 ..... m<n\"\",\"\",,l~ inlt'rV<'l\"M>r.lmo......rnenlS) \",,,\"Ic;o\\\"Pmc~Cervical.pine-. ..d..,f.f\".n.:.n\"a..._ _ Ijj')..110 CI·2(roI.non) diffetenpl.hlaylsilocn.l_eUJ_nirlahon on\"l\\~2btI cuntRandlOl>CJn&223-214 ...puw 200-267 Dd'f~na\"on_ bodvch.utl08 0-1 cenial<pUw,~232 joinI512S-126 dJl'llCiOlups 4lo9 \"\"\"_,.2.6.''-\"2681ri~lo::r.>IfIe>:\"\",e>.btnSi<ln pa\"\"'I115 lumbarspiMItltLwnba.spine: l)\"mptoms.cen\"ic\"al\"PII'\"C 232 1a!l!1\".lfle>:...... <bmg~ tKtvuq.... applocat_ 225-228. phys.ocal\" uon Later.lfle>:-.\"'P\"\"\"\"'« Jm-Z1O -~,~-_I'_, 2211.227 n)t;l\"\"\"210-271 piannln&122-I26.1N C?H(Rn.....))1J-314 ==m6J\"'ntlm,b)'pal_t?!i dmlQlhps 4?8-4?9 woaudi.ac~4lD-4Ol C?·H(fIe>:>on/\"\"Iensoon)314 Rcl\"r.....Jpain C?·H(La!l!1\".1n..,.ion)314 IhDr_Jplnf_Thoncic\"spt/\"C\" ,Un;';.lfNtU,\" 191 ..,....~- C7·HtlO,..\"\"\",)ll5-316 definit;on,vi cen'oal.p\",.. 2M--lTI dur•. from 1Q.l _,,,,128-131 lumbusponl' 36G-36lI ..,ov,,,,,,-,,,I> 188-189 oro.p'to-allanull\"\"'l \"\"in·sens'I,,·rstfUCl\"_/pa'\" \" ' - -driinlnon\",....3 intICf\\~j<>Int!llfll_\\6.2 (\"\"-ion/n·tensionj265-26f> p.lllems 191)..192 J1IO\\\"'topaln,\"\"\"\"\"tolllnJll28 O<rip,w-otlan~ljOinl(lale• •1 -.....-'\" -palhologl<\".ld~cum:nl ~'lor-.IgoellJ7-I8S \"\"-101\\)264-265 O<ripu,<7...,,,'-....\"'\" 271 O,.uJ. I'l'lVMs (paSIi<\"\" pass;,·c~ts149-150 rh)~.lin\\er>·,,\"eb ••l T4·11 (fk>.'on/e~l\"n.ion) 316 T4·1I (l~t..,..1 fIe,i\"n) 3l6-3\\7 PhysKJIImwor.vp\"y\"./'o'''rlol'n)i\"\",I.475-4l!O H·II (\">l~li\"n) 31' Tn-51 caso:hislOty ~n--l78 ,;pi ...lmobill',alionlh.... py.cervkal fIe,ion/eJo.l''1'I5ioo362-.J68 lalcrill/lexlon36l)-.J(,1 \"erteb•• l,no!>iliulionunde. rot\"ion36l-J62 I'=:::n!nm&\"\"\"'II,,·,k 478 rKB(p....... Iulo!lI!bl:nd) 312

496 INDEX K odp;o.in(ro.l!J) w,lhSlr.>lghtlo.'gratstng 379-380 Slumplo..'St 1«-1~9,/46, /47 ph aleu.nun.lttonl)7-138 deblht:,~IowJ84b.ckp.oinronfining ~lul~\",,251.1S1,253 commUI\\IC~l\"\" 2~ .....-......1i..:\"'S\"\"'402 Grade V manipuLotoon J9.1.:H1 lumtr.r-ilpllV 361-3611 phYSlCllI~,\",nahonJ5.1-J5.5 ~~\"\"'tlOn!l of slump e-ibom II.o>\"'-pain63 !loUtion(thor.ocic'poneJ l~l~'l m'ittunsl78 G...Je V lNI\\lpubbOn 3J2-3.n mobil;,~...,leduuqueJ5..J26 Soft·bI!5~~ bet\\;I.\"\"\"oI68 phywcaJexanuruobOn Dl bonedwl~~ 11 ~lCalJP\"'\"' \"\"--mobll,ul>On.depthcl218 M'!V\\t!I 31S-316,311 a~la .... ~260 prog-.. ....C'd!~50 bo'erSOlCt>On::!hl mlOl'pKh\\f~l.q_iofts ~'M\"'al~mIercocc}1I\"\"1 m1dl«! 2ttl ff'gions ~11-412 paJp.t 253--2S6 durins\"'O Mlboo:nr'u.la.... 259 s)\"InpIom~dUfU\"ll;lmItmmt SaclOlhx\"'Sion4llI-4I(l plIlF\"'hol'leuminahol'l15! an.........rsurl'a<'eli,Of\"-\"U\"gm cen·IC.I~ne~256 IwNolSG-.51 caoehLSloryW-IlW t~spilll'3U Rhonlrnl1OOdMl.hnh.19 hLSlory402-tOJ thorM1C'~'lIl'lI2 Rh}Ihm!I'i-6.I76-I79 movements: 403 oo--'atlon 40J 5on..-. t.... tmml/disordl'f 61 latmt\"\"itlrcspons<\"l79 p.lp.t,,,,,401 ~m!'tl'MU$Cle\"\"\",.m \"\"''''pulahonl79 phy~k~1 e,am,narinn 403-404 Sp«iflClty ~1\"riQr.urlan\".ol\"'ning404 ,*~painl78 l.lCrumand ILium, direct pressu,,\" mmmunkallOfl J'l-4O SpIn.1Icord.dl~18 =~ts'i-6 00\"'- Sp\"\",lmubill;eilhontMrapy s,.><'olol?'l IIp.:c:ialq tlOl\\ll4(12 ce\"'dral\\,ertcbr.lmobililali'm symptomn'SpOf'lS(' lBO-llll l!u~c:m·.,., mU\\;ltion 402-W \"nderan,,,,-,,,th,,ti<478 trt'~ling l'fld-ol·rnnge pain 178 tn~1hn~muJ<:kspil.m 118-179 -....-..,~oonaJ'\\.'dS/behJ,.iout402 Spinll tn'.\"nj;pain-throuJ;!1-rangc 178 ~ k. . ~rdtllloiupperpel\\·is .1\",ormal1O-11 ROOICOOIrre56lon.lmpending 20 ftwwardbltolupperJ\"'l'iI! a\"\"r.I\\\"69--1(1 R':\"::~I d,-.\"\" 19 c...·...'c.l_Cervkal'pm<' \"\"\"'mwhmappbable ~ rongenltalfacquilWlsttu<:tutal IlotAryp<>!lll.'l'O\"'lntl'fiorinte\"\"ertcbral d\"oxtplt'S6Uf'l'on.J04----.405 anomah\", ro \".....,.. -,.,...,...'\"~l~_ ......-~m o..generatl\\-edL.angeoro thorK1o(~,mob\"LZahon Sal... \\'''5'''''' 25 d_~1(1 l«hnique319--320 Scapu..... pam idNI_ldealspine Kotabon(cervoc:al>pu>e)283-28-1 lu~,\",lumber5pine lfN!mftlt..umr... ·26--427 IhorKX_~5pine CI·2a1N!i Zii>-1iil Sdlcuocmwm'sd_ l1aumacha\",\" iO Spord}iitis19 C2.1a~I~,21O--271 ......~ld...gnm~1 CndtVmarupulat>on 2'J3 Sci.lticsroU05is. ~-\"ii, 132 . ,loaIWldadung211 Sequestnandl5Ctll5 atlan.....\"\"\"'ljcOnt296-1'I'i Shoulder pain If'O''''I)'hIlCspme \"'lff\\~,......,.N1 MO\\·....-.ld...gr.... -i6141iJ. ocop'.....tUnl4ol,..,.293-2904 .,xamp~ 8 p<lISI~Ift>Or\"\"ila_al.'ft!Jrbral w'thMlfl\"'l'mposedloc.alizro Sluns.....,·\"UX bion~34 \".....,m palpallonexamination 151 R<KabOn (lumbar SJ\"UW1 3n-J.8D cer>,alspJr\",m SpondylohsdleS-l!l 18 lumb.rsp'''''' 356 Spont._onformatlOn al\",\"\",b\\·.,.InfthodJ,16-371 Sll'mlOmc5 rombo~~emenIJ'05lb(lrtS wt>nlmllSkl1k 30 sitcQhymptoms IOIJ,Il2 ,nc:>.h.,.,..--.fromabm·e SUI (.Ir.ight !q;rai...) -\"\"Stlffnell5,tcc:hnique...Jernonfor downwards J71 pain ..·,th2117-208 lumb.1t~pi...... rot.llOfl 379-380. \",f\\c>,..., and latl'fal position left J87-J68 Str.ightleg raise fJrslR(SlraiRhI!eK fromabo\\edO\"'nwards 318 ra,.e) ~;.... I...tlllolO-l-W in nexionand lakr.1 position left St\"'tching from below upward. 378 mobill~.llionlechn,'l\"'-'5• innc,kll1andlal\". . lposilionlefl Structures 101,103-105 from below upward.;, diorogenic:di..m!=llJol-I05 with vertcbral axili 318-3?'l Intta•• rtlCuLarc~f'>ul.rdisorders from beluw upwards and 1OJ-1(l.l 'COI.Ip\"-'d·by using/eTTU,..nd 1\"'1\"i)c386-J81 physaleumiruohon3.50

....\"Ural~ymplorns 104 righl. nlcrior.uperiorili..c ....'Urotogk..lchang''S 223 periaJticul. r l00 radiological chang.,,; 223--22~ Subje<;H,'ec.... mi\"\"lion 98-122 '\",.'m=~~O \"erhgo224 cen'ic.lspincwCervicalspine Sy;::t~:., 116--118 ~~f~::;'~/t:':'1tmenl 21'J.-22ll ~ubj«ti\"~~,\",minotiun =~~:c:~,2J2 dismderlype93-100 frequency of lreatrnent 219-22ll lumbar~ptnt' 341 monipulalion,mobillZillton cen'iClilspine230--231 'programmed'pain 117 fjr>lqulStioo9i!.l00 \"\"\",roili,xT'l'gion402 conlrast,'<!201-202, feMuresofhi.'ory,fi,tingw,th lhoracic.pmc 304 220-221 \",,,'k,,193-94,232 mobili7.allon.,deplh 217-219 symploll'l5 101,121 chang\"\" in hislOI)'lakingllll-12L1l9 foUowingt\",atmentbreak 50-51 :i:I~~C218 hypolhes<.>s m.:~=n~~~~217 d~~,~~:-~i\",,\" 47-48 clarifyingI05-H)8 p..tlcm..... MO'-ementp.ll\"''''' gTadual'l<\\SddisoTd~\", 106 inilialconsultalionsH-45 patholOj;y217 Slag\"\"ofg~neTaling/l<'Sling 99 intC!'\\'c~:t~.'''ds,.. ri.ing from \"\",\"'o/ill!\\22S--228.226,227 ~lruC:~,~ardinglOl. joilll/neur.ISlructuresl64-t6S s«.J..,Rt.\"\",ru. lumb.r~pine .... Lumbar ~pin~' hghlwmk,nolpre\\'enhng21O-211 '''''''rru.'Tlt;>s\"-\",,,\"en' 2t~, neur.ll(J.t subjectiv~~xamlnalion neuralnlldmu~ujoskdel.1ll\"\"u\"\"_,, 215,2t6 T\"\"hniqu.,,; pbnning 102,122 1(>5-166,168--169 R'COrding of finding. 109 pre-cxishng89 appli<alionS«T\"\"hniq .... sit<,ofsymploms 1ll8-116 'lCIIpul.r93 app~cation should::,:~~~g;~~I'Pi\"\" Clow.rda\",as 112 assessmenland ~.I4-IS d~\"\".tl)f\\les 101l-109, lW,111 Clo\"'\",.d .....,,, 112 application of '''''hlliquei 21~, dis<x'g.,niq,..ins113,Jl4 derm,'torneslll8-1[19,110,111 215,211> m)'olom.... 109,112 dl';Cogenkp;oll\\ll 113, If~ dUri;~/ormancl'oftedln;q\"\" s1eroIOffil'St09,lt2 m}'otom.... 109,112 lh,orackpairu; lt2-116,1l5 .I..rotom~.. 1[19,112 followingtechniqllen-7S .1\"\"'i.lqu....liOTl$118 lh\",acicpain.1l2-116,1l5 br.int;hitdofillgclluity',l~\",hlliq\"\" .,age, ~~=;;:~trilabililyof 'lIrgerycontcmplaled 210 te<:hnique ...leetion200,204 a.5,ln-176 Slruc1Ures,hypolh_\"'S.. rdtng lhoracic.pine 304 changes,tyJ\"'Sof~n 101,103--105 upper limb 93-94 ddonnity216 _.I\",HSS(history,.ymplom,;and grad.... ofmo,'cm\"\"t 5 di>rog\\'Tlkdi\",rdcn;I{J4.-105 int,.;:.~aTcap,ula'disorden; .IgMj n_\"imm~'di.teeffed,dcte\"\"illalion S~\"nO\"ial jomlc\"p.ul.... neUTalsymptoms 104 ::~=.a;paillrt.':5poIlSCf>8 l\"\"iattirularSlruetu,,-'SI03 peri.\"tkular\"ructu,,-,\" 103 maniputationwManipul.hon 'Y::,':utll6--118 1'2-12(tho'acicspine)_Thoracic mobili7.aliOllSt!tMOOili.ation .ilelll8-lt6 .pin~,1'2·12a,..,a. l<.-dutiqu~'S tho,..cicspine<n\"Thoracic.p'''''' m\"Vl'1ll(.'T1lj_ uadn Mon'1T\\t.'T1lS TJ.-lO(thoradc.pine)_Thoradc p.inresl\"~durillg<lS-49 subj«ti,'~eMminalk>n ~pinec 'n-IO area~ p.,nrc:5ponsesfollow,ng49-SIJ Subo«ipilalatt'a palhology217 T4-11 (thora<:i<o,pll,cj_lhoracic principles 171-181 upl\"',C\\'rvk..I'pine 259 rhylhm..... Rhythm. Su~u\"\"t'\",.'m<,nl ~pi\",,:T~·ll a\",~. . .c r r o c o c c y g e a l a o d i n l c r r o c c y g e..1 imlTll.'di.''''''''''f'O''''''questiorts Tapl\"\"l o:gi\",,\" 412 37-38 thoracic.pi\".'312 ..crollia<:\"-'Kion404-W7 ...lection\"\"Techniq\"\" ...techOll I\"'m,...\"pt>nses T~\",h\"iquc.pptiC.'lloll 2U..228 lItor<>eic.pine318-333 duringt,-chnique#l-49 rontr\"indkatio\".222..225 _a1..,T\",,,,mcnt;T,,,,'m''Tlt followingt\"\"hnique 49-50 hypermobility 224_225 i...tability 22~ TC\\':hniq.... sclecti<>n 183-212 symplomch.ang,'S 47-48 \"\"I\"\"'t.of '''''hniq.... 201 Supr.,;pi\"\"'uS lendiniti~ di..gnasi'S«lI\"dnDiagnosi. disc/\"\"\"\"erool 209-211 pamsimulatmg 422-424 chronic \"\"\"\"cLroot.ymptoms 211 Sutlon,Amand.476 Symbols 115 Symph)'~ispubis 402 leftam:~;r.uperiorilt ..ccaUd\"d

498 INDEX T\"\"hni'lu\"s.,kd;on(ronld) b\"\"blcheol4()...+jl postero-antcriorn'l\\tralveriebral disc!''''''''''>rO,\"(ronld) ·g!\"':~butionOfSymptoms p,,-'SSure,mobilization tesssev\"\"'symptomsnot te<:hnique318 p\"\"'''''ting~ghtw.,.-k 210-211 t,aumatiegirdl\"p.,in 441-4H surw-oryindi\"a!<.'d21O extl.'Tl5ion\"\",Exlension(thorack postero-anteriorunilateral du'ationof l\",a'm<>nt204 rostovertebralp,.\",;su\"\" ge....'aJaspect.Jas,187 spine) ~:~~alion t~hniquc history 199-200 f1exionw He.-ion (thoracic spin.,) ligamenl5 and c.,psole_L'gamcnls fuooionaldemoru;trotron! p\",.tero-anteriorunilateralvern,br.l and capsule p.....sllre.mobi!iz.1tion m.,nneroll\"\"hru'lue 203 d,lfercnti.tion306, techniqoc321-323 mechanicalblocking2Q.I 307,JOS manipoJation(GradeV) 329-3ll R2·12\"\",a,rnob,1izallono{nbs326 rnobilizing!<...,hni'l ....... 186-187 inte~::,aljoints (0-1'3) roIation_Rotation (thor\"\";c spine) Or manipulation 20l-202 sc.polarsyrnptnms93 m-\",inl<'rv<1'tebraljoints(J'3-lO) sllbjcC'li .... L'Xamination 302-306.303 mO\"emcnl,d',,-'<iionof 202 mo...ementpattems 221 mobili,..,tion 318-326 as.sociate<lsymptorru; 302-J04 pathologicaldisorde,\"\"currenl poslero-anl\"';orcrntralverl<'bral disordcrtype3(l2 pl'l\"Ssure31S-319 history305-J06 knowlc'dge postern-anteriorunil.te,al speci.Jqu....tionsJ05 syrnplombehaviol.lr 304 ~,~m:2~J~~I89 ,\"-'\"costovertd;\".lp\"-'Ss\",,, T2.12a~3:·liontoright pain...ensitiwstruC1o\"\"'!pain poslero-anl\"';orunilateral TJ.-lOareaS,GradcVmanipulation patternsl89-J92 vertebral pressure 321-323 = progression 206 ribs(R2-12)326 rerognizablen>golarpattems, rot.lrypostero-anterior T 4 · 1 1 . r e. . fle'inn!extension316 components 200-201 intervert<'braip,,-,\",,\",,-'S scqo\"\"\",,'84 319-320 ~~::;:;:~on 316-317 .ig\"\" 200-201 m1at~2:ght(T2-12) .ymptoms 200 bonyd1anges312-313 tr\"\"\";~2~erlebralp\"\",ure C<Jrnbin..'<lmoverncnt 31lJ-311 p\"\"\"\"ting204 compression mOVem\"\", 311 zygapophyscaljo'nts« pains1l2-116,JJ5 position 312~313 palp.'tion312-313 Zygapoph)'S\"aijoint p.....ive\"\"cessoryinter\\·ertebral tr::~1~26-329 ....../\"\" Te<:hniqu\"\" movemL'rlts(l'AtVMsj 313 trans,·~';..~~rt'bul pressure Temperature pa:>sive range m physiological upper, traction of 327-J29 <:ervicalspinc255 movem\",,~ofsingl.. uppe'~~=\"iCalsymPtoms lumbar spine 356-357 inverlabraljoints ..... under palpdllOn15J I'PIVMs(passi\"e .... alscCervic.1 spine; Lumbar Testmov..ments,painresJ\"\"'SeS physiokJgicalinti.\"\"'·crtebr,,1 spllle moveffil.'rlI5) during physic.lexamin.'tion 30&-318.307 lhrough-rangepain initial <:onsultallon 45-47 appr.,is.ol308 asSL'SSffil.'I\\t62 function.ldemonstration! ddinihonxvi-,... ii reaSSl'SSm\"\"t4S diff\"r.;ntiation306.J07,308 histor)-takingl20 Th<>ory observ,llion306 int,a.a;~u\"'rcapsul.rdiSOrde\", palpation 312-313 anddinkall<nowJedgc l:l,14 pao;si\"ca<u..soryintcrwrlebral painresJlOOS\"SIS/l 'lhoraci<:out!d·t.'StI49 movem\"\"ts(l'AIVMs) 313 rhythms 178 'Thoracic spine pn'SCnlpain306 shoulders 8 1,,\"1<311-312,313 Traction 19-20 appralSaJJ08 thuracice'tensi\"n~310.31~, \"\"...·i<:.12S8-293 C7·Pa\",,,,,,. G.ade V manipulation '\"thorackflexionJ08-J09. inflexion 292-293 329-330 313-314 h.lter2S8-289 C7·T4a\",as lateral 31O,31~,316-317 tooracicrot.tion308,315-316, ::~~atlre:.:o-~; 290 \"\"\"i0l13\\3.-314 lIexiQn(extension314 '\"posterior rami 304 progressionrnethod291_m t\",.tment 289-290 lat\"alflexion314 intennittent20 roiation315-316 easchistory333-33S examination.ndt\",atment te<:hniqoes318-3ll rnob'lization31S-326 \"xamples .bdominalpai.... / ....gucpain. \"'-'\"

Indf~ 499 lumbarspUl<:38S-:J9.I spondyliHc.pinewith ;w;essment 55 frictlonf\"\"'troctJonCQOCh389-393 ;nvertebralforami\"\" ~:=i~~Ioc.liz<'d t~~L~2~394 movements 249,251 \",,,ve-roal upp\"'spine327-329 chronklumbararn.. 418--419 pain~itivestructures/pain 'Tmnsderi,.tional...,.\",h' \"\",idu.1 intermittent p.in 417-416 p.trern.l92 ve\"\"'lcommunication 31 S<.'Vcrccervicalpa;n414-41S Transvers<'coccygealpcessurc412 se,·erclumb.rpam 416--417 mov\"':~:~~:~~7~~~~ Transver,;evertt,bralpTeSSure :'~=P'in426--427 tests,.,.,rvicalspi\",,25J ~\"icalspi\"\"281_282 abd':;::~~'ins/\\\".g\"\"pains v..ort<.'!>raldis<. ..... al\"'rnati\"e(CZ-6)2112 b.ckachf,-H0-441 ankyol\"\"ing.pon<!)·liri.19 C121J3..2ll-I 'gI0\\4e~~~butionolsymptoms manipulatiun 19 lumbarspi\"\" 371-372 non\";p<-'Cificdison:l\" ... 20 physk.lc..mm\"Hon 157.158,159 tre~:~:,~t~lg;rdlep'in441-4<13 o;;teopo\"\",i.18 Tr~t;~:CksPine 320-321 Tre.tm\"\"t\"\"\",ion. J'O\"tureW rheum.tuid.rthritis t9 dison.iersfol1o....ingl06,I07 beginningofse;sionn-75 rootcumpres<ion,impmding 20 Tr\"umallcg,rdlep.in duringtre.tmcntteehn,que 7$--n root pain 19 c'fld ufS<.-soiun78 spond)'luhsthesisl8 thor.c~r~t.... tmente\"\"mple 24-hourpcri,><!imm<'di.tdy - , ' \"traclionl9--20 Trc.tmo..'f1t f\"l1o....lngm.t .......ioni'S \"\"\"\"\"\"\",\"tduring 59-60 bcginn~~;~\"ach,a'lIeS/oCment\"t Vertebr<:>l>a8i1ar ar\"'ryk:Sting242-248 breakfrom,symptomchanges miti.lqUCShUning246-248 romPl,,~onulcach..ssessmcntat \"'''duration v..orte/>roba:;il.r insuffiCl<-'flCY (VBI) • ndf\"\"luer\\Cy219--22U p.mr($p<>ns.,. !L'CMique...,k'Cti<m 2().1 dUri~~hniq\"~p\"rrormanc~ VC:~~\"io'd\"icati\"ns 224 effc'CIof,andprog\",,\"is9O \"\",.mples ~Treatment\".. mples fullowingt<,<hniquc 49--50 Weaklinks47':l frequency,.ndduration219--220 testm<lvements(during Weather changes histOly,symptmnsandsigns 12 result:s215 \"'• ....\"..ment) 48 and pain 67 \"\"'ti\",,214 24-hourhourperiudimm<'diately Whipla,hiniuriesl(lS subs<oqurntotr'Subsequent f\"lluwing,aosessment 78 w~:~:n~~ls ~QIsoTedmiq\"\"\" st'tDIS<lSubsequcntt\"\"'tment; b\",\"ity30 T'::\"\"'::t~::~~ Techniqu<-.. keywords 30 Tre.tment t<-,<hniqu<-'S _T<-,<hniqu\"\" pa r allehng29 \".\",'k.l .pont\"\"\"\"\".inlorm.hon JO acuteturticolJis427-428 ULNT. (uPl\"'r limb oeur,,1 tests) 249, Work joint lucking 428-429 250.251.312 vertd\".tdi\"\"ase 20 UCCipit.lllp.in,shooting429-4JO W~::k~;ii.1J2 pain simulating cardiac dis.:.s.: ~:~;:'<-,!>roba:;ilarinsuffid\"\"\"Y)242 421-422 X-r.ys pain simumting migrame 424-427 bunyanumali<.'S 154 \" '...· i c . l s p , \" \" 2 4 4 painsimulatinll·<upra.pinatus mO\\'\",\",-'f1t 155-1S6,15Il,tW-161 1.....dinit;,;422-124 org.n~~~~ersnulin,·ul'ing Zygapophyse.ljuint arthritisJ.rthr05i.l99 e><amil\\lltion 413-414 ve~:~':':~;';:es 18 lffhn~UI'se1edion/Progressiun Icgpain,insidious419--420 I,·gsymptorns.poorlydcfintod Vertebralcan.1 pain-sensit,,·e.lrUCtures/pain patterns 190 420-421 I\"mb.r acute back pain 431-432 bilateral leg pain 437-438 cuceygodp,i.4J4-1J6 juwnHe disc lesion 436-137 L1 bultuc~ p.in 432-433 lo.... backpain4J0-431 \"\",,'e-roalpain416--417

MAITLAND'S Vertebral \\ 1;\\r\\1I1LJL \\ ]10\\ This (~text I\\a<i become one of the founc:t.tion tutJ\"for 1I11 moc\\efn \"....-1 thet'<lpo$U. MaitlMld's Conc;ept of MaftlpulatiYf'~.pyis nUlbllShed.-s one of the su,ndard appr~to .nal m;m,pul<lt~t@Chniques,MldMlIrn.nd'sVertebral M,lnlpulation ili an indispen5ablot ancliluthofitatiw guide to thas irPp'OKh tn this new editiol'l i11l1line drawings nave bfton replaud with high qu.ltity photographs whkh, together with the kCompanying CD-ROM of examination and ueatmtilt tedlOiquei\" afford II more in-depth lind lIH'f-fTiftldly upenl!n(e for re~u:Mmi. New for this edition: • CO Rom containing video clips of how to prOlCtke the techniques discussed in the teltt • High quality photographs replace e)listing line diagrams to lhQw tlKhniques clearly • New design ilnd layout of illustrations Felltures: • dinicallyiKcessible ·evidefl(e·~sed • Colour highlightl'd bolles to reinforce the k.ey cOO(epu • dinkal pathology with treatf1'M!nt$ for pathologies made de.' • ~t.nd t,e<ltment of patients cle.Jrly eJlplllined • c.se studies induded This highly improved edition will prove an iovilJuabie reource for both for trilj~ \"\"\"nual tnef-i1p1sts.ro pr.aising diniciam. [ lEVIER www.else,-ierheallh.coOl Thbproductisgppropricrt.tor. JI(~II IlI'TITlNl'R...\"..UAl.l.T.'\"It • manuoltheroplsts • phyNothenIplsts .\"........-....• undergroducltes gnd Iectv..rs ~