Maitland's-Vertebral Manipulation - 7th edition

Commyn;cuion 41 Q 'Oorou IDl.'~n you',·., 1>('\\.... had ~ d.1\\'~ 00<:1;· rIT T\" I\"IT'>UI' I~... 1,,11' oJ! l~mh'I,~ lril/ $IIW his \"\",he in ~'our ~fe'\" ~, n~\"m II.V hrlp \"\"\" t\" rrnmnbrr_ A ''10, \",)1 \",~lJr: /~\",g llult 'IIJ;i.hl \"llJrru.w~ /c<t. lOT A\". 'l'!o1 m.lly m<'ll\"~ I\" mr I!lall.. lrm IOb1 A 'I\\ ....AI; 00 tl'Io! Thur:.day: ,,,n.-I!liJlg: SO I m\",,1 da\"fv j/. Q '\\\\\",,~ it achinl; wl\",n yo\" \",<lk\"'lL-.I Ihal d\"i, or did It com\" ,m later in lhe dayT \"\"W.Q 'Whell \"<1u \"Not rcallvn , it \"<1und~ ~s though )\"<'u \",,;y fla, ~ h~d s.:.methini;: A '1 think I w~kenl'd with it y(~, I'm sure I dId bee..\"\"\", J (an \",memocr ..lym~ 1<> m, wif\" A 'WCU, mv back gcl!;\" bli stIff if I doa lot (t/ Far- during b~kfMtthat mv rock was achIng, dening.bul then\",\"'Yonl' has that,doro'l tIv.1T Q And \\\\ IlL\"\" ~ OU wenl 10 ~ the nighl befOfl' f:T ;\\'u.. ,h 'CO'lmg \"\"~. \\\\',,'\" , lW'J In h.,;r j,. I.. \\\"Oll did not llan:~' I, thal .......1 ~ou ~ r{ 'I;fp~ trl;!n11\" tllt'drxm'''!pnlnri\"\" Q 'How ~JIlg does il tikI! to reeon\"l\" from /I cer- A 'Yes. that's nglll\" tain amount of garde.ungr H~ mIght ,,,..11 h\",,, SolId, '1\\0, I don'l think it )1\"'t,'<I A 'It mighl ~ke 2 or 1 d\"l's to gel back to nor\"',ll lik\" Ih,lt\". Th\" '1L'~t qll~..lj'm \\\\ould lhen na'<l to be. aft\"r a whole we<.'hnd in th\" /:dr.:len: '!It:f,,,,' lhe achin,.; bef;dn, did VQl,l h(l\\'~' any olher f,~·I· m!; in I'<mr back ~\"l\"h Js lirt-dtt<:ss or stijfness. or ~\",,,\" £T T!\",r'.' 1~\"'.V \" ...flll ;,'fi\"wali~'l, II I1dl\" mr I\" kill'''' )\",1 bl-m); awa~ 01 \\'Our hack' In Qlher word~, did It U~'QI IJI' ,,\",,*om lokra/r.' rr\"Ii~ I dm,'r wl.ll\"\"j' lu>1 ,n,:\"k up on vOIlllfadually without your \",ah/.'ng II iniri.lt1y~. Ho.- ma~ I\\'PI~. 'Yes, now 1h.o111ool b;,o,,;:k ~I u-hl'tlll'r 1\"5 hid: i5. drl<'Tll'rl11l11S '\" ';'\"\"\"\"\",g il. I Illmk il \" ...._ like lllat' ,/Slie. bIll 1\"\",..... 1;\".. I'll ~ 11m drl'TIIrrlltllwr, [T Tlwl slhat /M'rl''ft11t''1''''''''''''wlvnl. .\".Qllm</ ~ ,,\"li/ W(r- provided Idon't forgrllO find OIJl milch\", I t~'I'J l1t 1M \"\"'~....\", ,\"0];(' It> JillJ \"\"l ,,'iull 1'\",,\\1k.1 il TIl<' fir-I tlrm,t i, 10 II~lkr I:mr l;rill ntttl /ilbrc<Plh,o;Jlldor. bml.- il u'i11 '(uook /I,m! ~\"'''d U~~'/lll'r 1I1<'1'l' 11'/1$ m,y Iril'j,,1 i\"..idml till! \",.,'tIl,,<]ftrnJtmml .....,lIIttolllll<f gllJok 1'It'l;'...... tdlld, IK'r:lIrrM <illri,,!: II,\" ,1<11; 1'1<\"'1' lI\"'lmckllcl\", sis mp'\"\",,\"'rIts. n... I'''''''''' nlJV 0'''11\" d\"ri\";.: \",!~'Jrl\"d, If IMs I'ro:\"\" Hrgmi,,', 1/,,\",, 1'/1 ubl\"'l vtl..... pIIr/s <iftllr 1'.lll\",iIlYII<JIl, lHI4/1 rralfy 1:1'<,,1 'I'rdblliJ'<\"',~/Qr:I\"rs' I\" t'M\" 'lOll' ,;; him' IhlS \"V,'<Idt. h~\",\". HI> illjrilll ,\"s'\"'\",,, \",dimr,,, I um S\"h.S 10 I\"!i~' 1<1 .,-.k ;;l'ardlll1.~IIII,.\"ri\",':' 10f'mftl\"'m\",,,'1'1 n....,.\" al'\\' manv wal'~ the qUL\"'lkllb can m't,>ckkod, Q Did ~ou du Jnythinl>,.1 all On the WEDNIS- DA' th.~1 hurt ..our b.t<::l.. \"'I!rl in \" minor and lhe answer for e,1Ch ,,'til tale ..boul the -aml' Irngth \".,n-. or nutk \\ou AWARE: of \"our b<>ck in of limt' lodctenn'Il<!. n.e folio\\, Ing is ltlf\" hm.' Liken.. Q 'You said il (ami! on 3 \"L'.'ks.l\"';'~. Did ,I com'\" an; 'u, 7' . \"\"SUOOEI\\LY'\" A \",0, I\\'ebcentn'inglo~mberlf[dld~\")­ II ')'1.'5. fa\"lv quicl<l~' ET Fa..l\" qwdlv m,'l.m' ·\"\"t,k\"h'\" to !litl/. ~1I1 it', thing.. bUI I CJn't ren\",mber- ,on.. time I coold h.we hurl II \"o1 pn.-cN· ~,\",\"XI, filr '111'. SO 1\"11 Ilml 10 prill'\" 11\"'7,,'r, LT So \"an·lli,tl\\·I~ r,';;tlrl/~ /II,' 'I'ml\"I\"-,,,\"'g!lU:l<Jrs' Q 'What w\"l'(' I'OU FIKSTa\"\"U'<~of\" rdcrud 1<1 \"/.on\",, Wlli!, hi, \"',lid i, om'Prj,a,,1 II ·It ,,,~I 'I.lTled \"chins\" Q 'Dunng tht' momi~ ,>r the afternoon?' lonmu, I'!n\",ral aeli,·,I,.,:, if 1 rollli\",,,. willr A 'ldun'I~: q\"\",lidtls ,,~iatnl \"'ilk <1('1;1',1,,:;;, Ill' n'r!I p,,>br/ Q '00 \\'OU ..,member-If It (ame on, on ont' da\\'? Ny bl'aNr 10 IrIlSllw n«:wl''1'''ctlv/lruJ Ih,,\"rsrwr In oihcr worth. did I~ not t.a, .. an\\ \",(h~\", ,,~II fV' _ ,../illbk. T\" ~ I\"\", /lb....1 ,hr ,,.,,,. on<' d,'~ Mld h,.,·\",,.'; ache lilt' next day\" . \"n!\"\"'tI<'-... I.:'1tV ·I'mti>;p.'sl\".t r.td_ (j:1t\",...I'. ~,rid 1O!l jiJra II,,,, 1o<,11<m~'I' his Illlm 0( III,,.,gM. Mkr a dday. \\, hile he ponders tl1l' que~lio\", the Th~ 1\"Ol'\\1 question probo:s for Ihi5 To do th\", fir:.l and nn,wer comL'>. th~n l'I:lum to Ii>(' pr«lispos;~ phy,ic~l actiYlILlS IJlI!r will ffisull in dd.'I\" in his m~nl,,1 \",-orie\"l\"ti\"\". It II 'y,.\". I think so: may ,llso n.\"\"ult in ;\"i,.ing out m, ~ rele\"d\"t pk<:<, of Q 'WhJld\"y \\\\\"sth;lt,c.-.n l'<l\" remembcrr inform~tion, which mlsht hd'\" bi~'n on the 'tip of his longue'. >0 10 'i\"\"'\"'

42 MAITLAND'S VERTEBRAL MANIPULATION This ted\",;,!\"e \"f pamlleli\"s q'II'SI;OIlS with a pali\"\"t's Another communication guideline - which i1pplies particularly when a P.lti.,,,!,S respo\"\"\" to the op~\"ing Ii\"e of IlwlIShJ is al1 i\"'porJm,1 c.l\"m'lllliWliOlt I\"d\",iq,,~ ro question, 'When did lhi, begin?', is 'Oh, ag~s ago' - is follmv at all 1;\"'''5, 'mless ti'm is a !'t!r1j ,lrotlS rt'<I>O!1 for as follows; dCpilrliligfrom il ET HIS r'''I'''''';'' i'ifcrs 11101 il did,,'l slarlla'/ \",,'t'k, Q 'H,,\" yl.>ll Ix\",n duing any U/\\,USUAL work on that Wednesday or about that time?' b\"l awl's 011. 17\", melllOti /ila/ will m,W 'l\"ickly a\"\"\"\"bri\"g 0,,1 II,c A 'No' i' 10 prmJidc IIi'\" with 1,,,,, Q 'Had you been doing any HEAVIER work dmr rejermn'I'Oi\"J5 a\",i JlIII,jvrcp 'Ii'\" 10 I\",,,mrp than USU,lJ?' 51\"'0/1(. A 'No,' Q 'Do rou m\".on I> months ago, or I> ytWS ago?' y\"\"Q 'Had 1><.\",n doing any particular work for A 'Oh nO - no, only about 2 or 3 months d':;O' L01\\'GER than usual?' As \"'ready m\"ntion~>d, when inte\"\",,,,\"\"ing garrulous A 'No,' patients, trying to k\"\"p control of the interview is c>.tremdy \",fficult. Dur\",); hi:;to,y t~kjnlo;, Iht:>e IT So II,er1' i\"d a\".!1 OBVIOUS phys,wl arlmly palienls tend to go off at tMgents ~T1d gi\"e a lot of \"'hid' /las I'rollvkedlills aelle. Tlte ,rexl step\" to ir\",I('\\'ant d('Ia,L For ('x~mple. tl\", \"pl'ning '1u('stion i\"''''''lisatf lI'f vtlwr .,,,erlispo,,msfmclors' - th\"re ,11ld answer mighl be ,lS follows: MUST /Ie a rr.'II:i<JII for tl'e \"\"S~I of \",!rh,S 011 IIle Q 'Whm did it start!' TI\",,,,llly IIwmi\"s, A 'Wdl, J was on my way to \"isit an old aunt oj Q 'At Ihat time, were you unwelL or <)\\'ertired, mint', and as I was getting onto, or under ~n}' smess?' Wl>ether thephysiother~pist allow,; him to continue as A '\\\\leU yes, J waS pK>lty tired, I'm O\\wdue he chuo,\"\"s, or eilher brings him ,...,ck to an;;wcr her forhoUdays and we tuwe had tWOII\\l..'Il oifwork sKk - and now you mention it, \",e had be\",n question or gently coaxes him lo answer some of her worting long.,r hours tf\\.~n usual to 1lX'ct a other questions, will d~pend on Iwo thin,\\;s. The Il10t is, dead1i\",,'- I'd f\"'b0lh\" Ihal;a,,\" I \"'as il\"'ol\"\"d how much of his talk is likely to be talk for talking's in a lot oj lifting and carrying that day: sak('? The Sl'Cond rdMt'S to th~ aJ110lU1tO! sponta'><''Oos infonn\"tion of !load qu,dily she might le~rn il she £T 110ft\"\" Wkes quite a Im'g rinte (\",!lid, ii> qj,ilr /l'll- allows him to ~onhnue. Ii it is the former, she inter· \",,,,able) fo, a pcrsml 10 n:lrievc pier:fS of ill/orllla- \".,n<'S. Some \"x,lmpl,,,, of inter\\'~~ling qu,,,,tions th\"t tiO/\" 50, miller tlUlII IhillkillX 'WI'y did'j'l .!I\"\" \",ill e\"abl~ th~ physiolher~pisl to keep control oj th~ say IIml whm I asked you ('{Ir/ie,', I should lliillk, inte\"\"'i~w a\", as follows 'Wpl!, at 11'i/>J ( did'I'1 \",is.<. nul \"\" II,al bil of illjumwliu,,' QI 'What happened?' Q2 'Did yoo fall?' Q 'And that is unusual joryou, is it?' Q3 'How long ago \",as this?' A 'Well, yes, il is. I do have to do quite a bit \"f Such question;; sfwuld be skilfully interposed by gen· lifting, but thto pnossure was r~ally on al that tly increasing the v\"lume oj the words llS<.>d in Ihe porticulor time: qut'Stion SO Ih,lt the p.lticnt'~d\",ughts are pulled awa}' from his current line and subtly directwto that of the ET Tlumk)lOlI \"Very \",\\1<;1\" !hllt's just ,dla! I t!'lIsloo~­ interf'O\"Cd question, The important thing is that Ih~ mx for, NiJW il makes ,msc, Ille hislDry \"\"d II,,, examiner can rrlain col1lrol of th.. int..r\"iew without symptom, are compatible. in;;ulting Of upsetting the patknt. The ~bo\\'e is I\\ot the md of the 'history' qUl'StiOning, Nevertheless, it is important that e\"ery eflort shollkl but sufficient diillogue hilS 1><.\",n p\",sented to show a communication p.l11ern which can be adoptoo. As well lX' mode 10 make patients fed that they are not com- as the unanswerL>d 'So Imlg as J do\"'1 f\"tX~r 'luestion plaining; rather, they should be told that Ih~y are mentioned earlier, the physiotherapist ne«ts 10 know if i\"j<m\"i\"K - 'Whut you don't tdl me, I don'l know'. the\", has been aoy spontaneous \",con'ry Or wo,-,;ening of the symptoms OIW the 3-wcek period, Also, Ih.,re On~ of th~ best waY5 oj ~nhancing the inter\"..ntion an> muny jaccts of the p.lticnt's past history whlch need is to louch Ihe p~tienl (their knee, arm, h~nd etc.) and to be sought. and any question you think of later ffi.<ly to s.~y simultaneously 'D'd you fJIP'. The 'Iouch' has still be valuable, nll'Se WIll be discussed in Chupter 9, as this chapler is conc~rned only with communicalion, the efkd of immcdialeJy ch,,,,ging the d'rLocllOn of their thinking, Some people dislike being touched, so

CommuniCJtiQn 43 lor them still use 'touch' bUI do it through t....\" sI,..\" ... Q 'Do ~oo mean '115 not aching thel1~' (thcrttly k\"SSl'nirls t.... skin-on-skin siltJation); rnau- it A 'That's nghl ' both brief and light. Q '5<> roo do \"'wc SOME stages w\",,\" it isn't BEHAVIOUR OF SYMPTOMS (INITIAL achingr CONSULTATION) A 'O\"I)'aIRightlt.-cha!;I'tI..Lda)\" \\\\ithout e ~in the dlDlce of ....00::15 or tfl,e phns- TiwrrordCm;5TASr rrlJm IUt'J bylli/lmls is ooufUv mg of qUl'!;l1oOS, Ml enor.......... llmOUnl of lime c\"n be \"'\\:'rJ;: tim at:\"'V> Mi,mr,wify\"'l1 1.1ktl In lkt,·...mnirq; the beh.I>iour of a patient ~ s' mp- IT '1J;als new eINT. H.. IJimbtrX pnxn.<n III /,.. \",Id1Nll'I'm! n i l 10 \"Ill <;y'fq'Io~1S .-\" bed toms.l.nfortunatel}', tune has to be!iJ\"\"nl if the ~kiU is 'i' to be Jearnold, for I'lOIItin~ li1i1oCf'1e5 as \" ...11 as ('>:pem.'oce \"The Information ~uirnf, \",lati..., to the beha_ jour at /1,;1.... aU oby\", nro fb>«ilt/rrJ \"\"Iotd.' 0( fir a..,- a p.ltienf.ss...mptOD'b, is, t\",,,, ,\" lririclllllM:llo kJllltl' Ilrrlllll<l'<'TSllIr. At\"\"I Dots tIM' «I... Juring!/w <lory! (alld if \"0. /roo'murh, rrlrv, ' IlJ hoo/. kill!? dot!> II labo 10 1. The n..ldhonship symptoms \",-... r to re«t, dcli>'itl...\" ,llh;.idt7J and pt:>s,t,oru,. 2. Doxs Itt I...... Qtl,~ 11I~I/IrI, .'ifftrr<.s and/or J\"'ill 2. TIl{' constancy, f,,-'quenc)' and duration 01 tho.' all grllin;; (\\l,I of Ix<ipr</III\",S ill II\", momil,s! ;nl~rm'LI\"'ll pain iUld \",missions, and an}' f1uch\",!io\", ol illLen~itr Tv \",aU w,,' oflli, ~wrTt,,'lr,ll\" lJ/!hQlIgllt, II\",fvI- 3. Th~ Sll'gc of SLability of the disordl'T. 1'><1-'ill); i, Ill<' qllC>IIOH asJ.l'tl, ll'ld il ,!lorlili quickly follow hi5 a\"SII'cr', • , il ncll(s ALL do~' The following is 011\" \"l(~mplc th\"t pmvirk-,; a gllldt' J.~ to Q 'Does thl' ,1Cl>e ,'ary at all dming Ih\" day\" the cho,ce 01 words ,md phrases thaI will ~~vc lime and A 'Y<'5'- n..lp tlw' II\",r\")'lsl III \"\"\"id making mislaken interpl'l!I' atio.... alld inc<'r,,-'Ct assumptions, Thecon\"\"rs,lllon Ih,lt ET 1\\'<11,11\",1 <l1>I\"\"'! I,dI' me \",\"c1I, but il dO<\"> I'ro- follo\"-'. is bcl'H\"-\"Il llw p\"\"m;n\"r and the !lo'Ul1e \"\"1\" Plae a po\"'! fro.\" ,,'lwlP 1<) Wt>rk, Tht\"rr orr \"\"'\"V inten iewed ab(,,·c, who hilS had 3 weeks uf b;>cr...clle u..vs I ,olliacklc II\" Ilrrl {n\"/jurslifflI5, &sk,/lIy, Id,~ll :/\\1'11 I\"iuou' I>. '*\"'s 1/ \"\",..,,...115 tlttday n.... t..\"\"t .....Ialel; only to the beN, iourof th\" bacr.:..clw I'rq.:~ ,,,. dtv< II drl'rlIJ 011 PARTKlUAR QClll'i~OTPOSTTfO\"Sht ~lIly ...fopl! H<J:l>ellll IT \"\"rl,\" ill II\" illl\"\",jro,lr 5IIid 11i$ /taet.ldlr :1'<1'; I grt !I.. a,,~-:a'T \"'Q~t quidJ,,' I II lTV IhlS fiTS!' \"'<'If\"'a'Ol !J1Ilt', 'CMs/a,,!' (i:lIl ·rrm.!,,,./Il>r!~ 1_,...of/\"'Wl\"·l)r·Q.Wl51<JJ1/i<:\"I(I'T.tbP'\"'~\" ll> Q '\\\\\"\"t mal...., II worr.er ro\"'~\\Jrrd :Nil. 1M mOlt~\"':UY 51rD71\"'''' fbi.;\" A 11 just grts \"''OI''''f' A! the dol\\\" goes on: 00n~ \"\", !lv,ht filel lloot. Ifjurpri;,;n.~ mm:1\\'T plZl~'$ S<I\" 11m, pam is ,(In''~,,,, 1Irl\"'~)'<'11 Q '00 JlJU IDe.ln tI1en',~ nothing you l..now of Il:5t II....\" PPUl,rd,..!d!l prmr to> 1f'S(\"'.1f rht fiN wltich ma\\.i\", I \"'<'lroe - 11 IU$l get\" ....,..,;e £01\" nooM'ious ... 1' ~1. 'l» ~t•.f«! BIf!, \"f\"IPI~ ,.. ~\" lI«talllll'_\"\"\"\"\".~;pj[h'>5Ol-Tf.r..lJ', Thr A -Yes, chal\"S right.' 'U\"'./t1\", ..Jw.' m,d '\"\" Iilf\"Iplllrm /ITt i'Kcml.\\\"l/i- IT 8«..\"-.... a,<r<.<mnll i. _ if 111m' is 5t\"Itething Mr, To 1I;'t!<J\" \",I;l>t ·,j\"'}'RIIl'S hI> \"SIr rl',<'I,ma,,! '\" ca\" dr:t !h.ll incrra~ his IKN. • mo« It'atl\",S qutSl\"'., nrnls 10 W ~1:bI. It IS /'SM',lMIf IIMt il be clarijW.I, mdI( \"\" 1'lJ>colllll' \"u\"Q 'Is the\", anJth;n~ rou COIn do, ho.\"t\"e and now, b!f10 j.'<I,\" tI Ill,,\"\" po!'ili.... '''l<'lVr IJr/d\",S tllf' which you kno\" \"ill yoor b.lckr q... \"i....t fro'\" !Irr opposi/t dlm:tiOll Q '·\\C th,. stdge, you don', haH' lin} period A '\\\\'1'11 I know that \"'h,......\"1' bet.'Tl Sllllng here when )'00 <Ire without some degree of b\"kachc?' my bael. has .td>t..l more.' A 'No, ii'S lho:!re all the time' \"<I\"\"\"mv£T llr<:au,.. he hm... /tn-JI pufi'rllli\",~ Mlrvlry 1;'1\" rite lIl't' 'fHt'S!;\"'. is loa:J: him if!1t lUI' m,,,acltr If /vforr he arrm'd ll'hicll 11,15 COU\"\"! 11k' ;\"0>\"'--\"''11 11'- U'IIke'I' 1lllri'lg l/It \"iSIiI. !<r\"\"\" ... t!.i~ is 0\" ache. ro!!I\"r. '\" 11> :/\\'/1 as. lit,· ,itrmg /wili.l;; for IIIO$! Hr/y tiwefilr Ilim/o v.- ''!'''I,/om-jrt.'\" mt, 1J'''folloll'lIli< q\"..,t\"m 11I115111<' n,ird' Q 'I low dil'-'S your back feel If you \\\\\"~kCf\\ dur- Q 'Do you \",..an ~itllng normally mak,-,; you illl> the Ilight?' a d... \" A 'IIlIrighl' A 'Ye5, if J sil and \"'~h:h lelc' b,on It ach\",,:

44 MAITLAND'S VERTEaRAL MANIPULATION IT I ~hJll\"\",drr if lll.'n';\" I~\" ,m lICIil~Iy ~~I;cjl \"'ill dOfl'1 kno\"'1 i1nsw\".,. or iI mon: C>pt.~,-.mded. less spe- {rI\"\"\" <1(1\",,-,<. I \"',,, \"-,,.I, !Q b,w' hrJ<I' h'''S IllilL\" dfkq\"..··,lion fi>{ Ihr Ildlf,,';th \"\"tiol,~ /fl illcrt\"t\"f, mul u~\",rr_'r lit Q ·llowlongd......... thesliffJloC'SSla~I?' /Hljll'lyd,lfj{'ully ,,-:,\"lti'Ii: \"\"I oj\"dul1r Th..\",,,,,~ A 'Onlya few minules. I'm ~llil .\"·are of it when 10 Iwqlll'<It(lfI$I!f\\R.'iik \"\"'f!ll m\"no\",';,~,\"X\"rJ- i'Ii: \" .. S<\"l.'trilV u( I,;'; 1'TONt',,~ M lit i$ II\",rki\".'{ II\"an 0'·.... t:ht.- handb.~sin I(> .... ~sh my i.lc\"',bul .woul adllJl.~ u~lik ~lllrlril1,'{ /rkM;;W.r, ii\" n'N\"f 10 by breakfa.llime il has I:onc.' }~lrv.' hIS el,rmll 11~'Il,\\.jl/~ Imd IISk all IJS.<NIIllrJ \"\"\"rnIT \"OO} III 10 tl '1Uf':.I\"''' .\",..., <td',~'''''. qUf\"<lilm mlJrt'f 11\"'11 10 .<mrrll (oral! Q(jn'il,v lrlnd! QlIIl'I'\" lilt ~V\"rr/o1'f$;IMI (ll\" t'l' /t'l .. \"tiJ Ll!n h\"l \"ull.. II d\"\"bld rrrlh/ bv \"''''R if difr\"\"''' ocli,'i/if\", \"la1;r ~\"y di/frr....cr I\" 111,' flOlif l1f IIIif ,\"wsf,(f,_ \"', '{rtl\",_~ ilul Q 'After ....~tdting tele\\i:;1011. do you ha\\'e ~ny =Q '00 rou oo\\\"c /IIIf,Jt'xl \"\"\"\"WI,'{ pmblcofl> get\"\"g OUI of lhe cOOi. Of c.n you lmmethately ~tilnd up ~'tTalghl iI1ld walk a'~a' In>Uble ~...'1tm~ OUI Ol bt>d normally'\" I\"\"in the monung follo....;,,1: a \\\"rl\"i lleth\" day' For \"\"\"mpl.,. if )\"QU sank.., III wl\"ekend. d.o yO'Ll. !u,.., more troubl(\" IO'llh aching or sliff A 'No, ill~Lcs mt' .... h,\\;' 10 StJ'.,g!lI,,-\"I1 up.' ness than during the \",eelr IT This ill~;\"'1 IS my tvluatok. Imn.~ it l> In' A 'Yeo.,IJo 1t\"'~m\"'\"Iol\\on~to&fltosleq> I\"\"\"jat:I /hJj fib • 1lT<1)i1ll:abr fUllr'm rfl ..... lwrle ;md I'm qu'!>\" J b\" <\"lJffcr In., 1\"Il,·:-1 m\"nun~.' doo.-drt \"\"\" it j\" ..... tllli 1'r'Sf\"\"Id.' I\" ...nIOI...... £T Gt.uJ -Ihb fil' 1M /VUml rrf.rrrrJ 10 Nr/1iT\" rnuI SlrmgtlJnr> I:~ lud.\\-mtmI ..\"\"\"'II!ft'JItI.~11O>iI. fur iIII' pot:rrn 10 IJt'ftnni, m,.lmSL<\"\"\" tr> .nt..n\" dlofr quNlOtb <1uJJ \"1oUdl f'.M..,..<haJ n:,nlol- 'i\"'''' _IJ:lm!fr:, l\"mIw JDJ< /\"Iah\".'{jratU'l'S fiI), Or so.rh r.qn-llI1.\", IS Some ~ m.l\\' COIbId..'I' lhe abo\\e ..0>\"·\"15 ...., 100 lit' ;#,Vfl fir;I !:dIms good to be true How........., as lhoe ph',\">lMr\"rrsl _\"'r:..\"\"'.f bnf '\" tftr ......i\"S Ho' Ie...... how to ask kl'Y q\",-\"\"MJnS 10 elll,)t sront.~1\\O'OU:S lh./f'(lJ~ ~'ttlr ,...lImg ...oo 011 '\" w..'''SOR'I' III(' 'lIIl1lldNs: .. ...,Wet'S. so IN! \"ns\"er; \"'--'COm<. mort.\" Inlorm.lh....·.Ioo.1 Jo,,>rJ;hurlocffwllm tfrlil. TI.,<;tJf-lrIilVbrmild hoelplul in u~nding both lhe penon and h\"\" Hrlu...w.\"'ld .fIN fur <~y /1)...15 \"\"\"\"I..... probk...... Al u., same IIlilt'. the p.tl\"-\"'I qUldl)\" g,l,ns r' Jus COlIfidence in the ph~'>iothL'raJ\"S1. Also. bo::auw lhe ...1..,1• ., 1I\\'R' 1f'$l,.mJ N /usillllif I~ Ioo:s~\" 'sponl.:m,....us\" a~w\"\", ..\"\"ble ~ accur\"le Judg~ rnL\"Ilb 10 be rl'I.:ldl.-, the i'SR>Mom.....b .ll'C'of gre.~lef \"\"ILK' \".Intl'd IllrJl tllI'1I~\"\" nOt\" II~ \",,,,\",,,,, IItJr41 Ill' for ..\".,..,ing progns>. lolhe ,demng doctor, :{r....h'r ~tIJ lI\"\",fJ w,,1 fer Iorll>'\"- / m\",,' IN: tbr The bd,.lIiour of lhe ralll..,r~symplom of .I,ff~ may .. bo be :.ign;fi<;anl \",1><-\", lhl\"\" IS son.e patholojl;Y il'It\"',iotI In 5HCh ~ 1l'l1lf1b I\" mr, .... '1'''11a!rnJMs ir,,·i,,'·ol~<od. Forl'Jldmpl.... during lhe l'.lrl)' parI of In ..,.......... he't-~~ill\"ll(.Jn, .....ll{\"/Id~\"ld;,.-..'iQ>r tial consultation th\"\"\",mln\"\" may ~llh,jllhc patM'''1 oflll\"qlllfliIVllJuI~rn'oflli .,i/f!lt...., TIltri,.,.. h~s an .....rly alll..yk>o.illg spond}'lili~, lhe «)J'l'~~lion / 5Iwuld m/l <tit '/~!/\"fIr h\",1e <lrf/ n~'~1\"\"\" Xd .\",d Ihoughts may be so\",.'lt\"ng Iil..co lhis; oul ofbo.oJ '\" ,rio' \"'''''''''10:'' n.,. fN.\"JOI i> awll, II mom I', tho\"K'rt Ifl a\\'n\" ION IIIi<, I.. ,rmf o/lIV \"' '1'\" 'Il\"\"', rUlldr '{in'S IfO i,ldialrn\", 0{ilS rrl.ttn... 1uI,,'m\"ltorltrrl,l' 10 I\"\", I'l \"lI\"a~\"rl.I,(IIi$ proI+n,. n\",r.*,rt / <lrtlIll,1 osk lilt qU«li.., \"\",,.,. ,uX\"dll. iT 11I\\I,,11,,1e1l<:r~'iflli5 bIlo.k f\"~s slifJon srllm.o( \"'II 01 /1m in /I\"!' mo..\"i\":i' Ifht 110l\":' /lQ<... ,m~\"!IliJ\"om.~ Q 'When )'ou finn gel 001 of bed in the mommg. \"I\"'\"J,vlili~,lli~ tucle sholiid I'<\"qllll(,lIff;mJ ~ ~b1!1I'{/illfill.[I'.... ifil i, 'WI1'Ny pam/rd, 1I11\"'iff 1m\", dOE\"! it fool\" Jl~ ,llllul.! t'IU \"\"'To' IIrll112 /l\"\"rs 10 IN'}\"\"''''· 1<1 t...,.\"A 'I ~uppo.l<O? \\I'S\" b'l $Ilff, lx'CilUSC' ~lme hi, Ilomllli drgru of li\",ir\"\"IIlI<lI\"lrly, 1\" g~ill 1/\".. diffICulty pUlh\"!; my.oc~ on: \",Ie\"m,trirnlWI mil\"'!\"'''' IIi, ~llsll'..r /11I11'/ 11,'1 Th\" l'\"-,,'l,,r v\"lu., of thi~ i1n_wer is lhJt ii' has used lhe I''rlolmgq\"\"s/\",,,. word 'shff' without bcin~ guid<-'<Ito It, ,md b<-OCilU,*, h\" Q 'How d\"\"\" your bock f.\".,1 ,,'hen )\"Oll fi\"'t !'leI llolS l\"lkt\"lt of ~t,ff,,~~. 1101 pJ;n AI\",,, lx'CiI~ I\", has spo.. tilneously ,,'ported ~l;(fne:;.., which filS a recOj;- out of bed in tl,., morn\"'K\" ni\"'ablc 1'.111\"\"\" Ill' h\" .• show\" tl\"'l hi~ disorder is A 'Not SO good' g\"rll,ine. Till' ~1)()nlil'l<.~ms ;lIlsW\"r to Ih\" unbiaso.-.J queslion pro\\';de-; the e);/>ct qu/>lity ~nd degre<l of lh\" iT if III' 01\",,, I/{/<~' <lllkyl,,,illg sl\"'miyiitis Ii,' ~I'oltld \"ay 1.,_, mrk b ,Iif!, 1'<1, ,1111 a/\\l\"'iaS ~ il-mli,,;.; sliffnL'SS being s<H'lo:l1t. TIlt' 'luL\",lumiI1g 10 lh,s \".~\" hilS </llr5l'o\", I a,k arl('lth,'r facet: \"\". ,kcirkd bet\"\"'t'n ch,~\"inf\\ iI mOil! spa:iftc qUt'!;lion which ~eds only a '\\'cs' or 'no' (m\" Q 'In whilt w~yisn't it ~ood?'

Comm~nication 45 A 'Il's stiFf' Q 'Which isth\" w~rst\" A 'They're Jbout the s.unc ' ET This \"\" ;1\"lcmmt, \"\",) nil st\"le\",,,,,I, n<Td 10 1Jt, mllde faclual Jf rhey al\\' to I~' \",'U for 1Jr('!tlHISI5 1:.7 R'SI,I, tirol's cleaF. Nml' 10 te,1 fi\"\"\"\",1 fI,'x','\" \"\"-<'\"',''''iJll''''I~)S<''' Det\"ikxl de'iCription of how movements shooJd bc Q 'How ,tiff?' ex.\",,,nro is pro\\'id<'<J in Chapter 6. The following text, whife it e~eTTlplif;es the depth of questioning \"-\"luired r\\ 'Very stiff' of the physiother.'pi:;tto know clearly the beh,1\\' iour of the 5ymptom,;, al50 ~how,; the words lhat Carl be Q 'How lonf, d()('S it take for this stiffness to chos.cn to speed up the process. wear off?' The patient is ~sked to bend forward and thm A 'Oh, it's fairly good by ~bout midd~y' return to the upright p<1sit;on. \",,\"iiI<'ET Hi\" joi) nUlY ;,m,!,.,· shift ,,,,rk,S<ll \"Ills! ,,,,1 Q 'Did the pain chan)$<\"\" I/~' M'ff\"ess l\"sl5 for aWY<lxi\",,,tdy.'i I,,,,,,, A Y\",;' Q 'WhM time do yo\" Jl:ct up in th~ morning?' Q 'lVhM happen<x1\" A 'AboutS('verto'dock' A 'The bUllock p~'\" increased' Q 'Did the calf ~hanlte\" ET Tlmt \"'1'111\" I\",'s ,r'fffIJF \"I !e'\",t 4lwrtrs. H,nt's /00 l(lPlgfin /H'y ardi\",Ii'V mrcl\",,,imll,,,ck I'\",I,I,'PII. A 'No.' Q 'And nothing dSt:' ch.,ngeci eiU\",,?' PAIN RESPONSES DURING TEST MOVEMENTS (INITIAL CONSULTATION) A 'No' To ~\",<.'S~ the beh~ \"lour uf the p\"ti~\"rs s)'n'pto,n~dur- Q 'Good, And no\\\\', hdS th\" bUltock pain sub- ng the phrsical examination, some '1uestions re'l\",re ~jJed ba<:k to what ,t was l>t-.fore?' mlKh \"'petition. &\"\"au,,\" of this, (\"\", mnst be taken to '\"-'\"Did irritoting ~ pali~nt by repeakdly a,kin); tile A 'Yes' \",ml\" question with the Sdmc' woros_ If a patient has both loc\"l spinal pain .md rde,,\";! \"\"in, it i, c·:;:;ential Q 'Did th.~t happen jmmedi~tely you started to :0 know how e\"ch is .,ffe(tcd br mo\\,ement. It is dan- come up, or did it take a while h-. sub~id,,?' ltftOus to assume tlMt the beh~\\'iour of thl' referred rain pmallels the behaviour 01 the spi\",,) p\"itl. The A 'It \"nil' flUt't more \",hil., I \\\\'as fully \\Jent wardmg of the questions ShOldd therdort> I'\" well fo\",'ar,js: pIarm<x1, b..\"\"auS<' it is <\",,,-,,,lidl t<l retam the patient's .oofidence, It is hoped th\"t his confidcoce will be ET Tltal', idml \"\"\"\"','ri\"g. 1\"(}i(,ha,,:a ,'I''Y,'oml'lrlc ...m..nccd by the thoruughnes, 0/ the e,amination I,irt\"\", ufl,\"!' Il'e '!fmp/oms 1\"!lIa!',, 11'111, ftmnml For the purpose of the verbatim text the p~tient hJS \"' l'fi<'x~\"\" No/!' Id'~ ,.-Imt Iml'I\"-'115 wilh aUra con;;l<Int pain L'~tL'nding from his nght s.1croiliac Mea Ihrough the buttock and the right p05t('l\"ior thigh to Ill<' IIw,../IIml,. c.w The butlock and calf an: the arC~5 \"fgre\"tcstpain. I '\" ~ssltmro th.,t tl>c\", is no contrdindication to exam- Q 'Now arch backwJrds', which he does, while J ....Iion 01 iIll mU\"ements throui'>h ~ fuJI r~n!!c. Before walch his mo\"emenl ond his nuances, 'and up >\"-ling mO\\'emcnlS, it is <.'SSCnti,,1 to know the st.llc of ag\"in: any pain that time' he ~ympton\",. A 'Ye5.' Q 'Whd\" sl~ndinh there now, what do you feel in your back and leg\" IT TI,c \"'''''''Piln,1 willl'n>l\",bly !m\"\" !m,! ill Il'e 1\",1- I(\"k ,m,l!<Jr Ill!' talf ACClmu-y ~,ul tim!' MI' II\", A 'The \\~h\"le lot.' es>mlial f,wo\", IIml i\"jI\"r\"cr )/,c lmrd, usrri ill Q 'Equ,lly thro\"ghout~' A 'No, the thigh isn't too b.ld' 'Il<eMiOllino: Imual\"\",! t/,e 1''''''. Q YOllr buttock and call are more painful, Q 'Where?' they?' A 'In my bUllock' A 'Y<.,;.' Q 'C\"rl rou show me the part which i, aff<.\"\"l<xI?' (which he dOC'S). Q ')\\'0 CJI!?' A ')\";0.' lOT Now 1 \"i'<~I/1) h,,,,,, till:! llii\":!,,, O'J~, aid '''' I\",,., morr I~,ij/ l~'m)liIg f,mmFd~ OF \"\",n' 011 /J,rPirimli [\\lck,m\"kil\",j tm>, !las tire I\",i\".\"bsh'\"d foIlo\"''''g

MAITLAND'S VERTEBRAL MANIPULATION I/rr:lrmg \",\",hN,ds lIS iI did \"ft\" Jrmwtd flaKJll? On lesting lhe fiflh mml'ml.\"\"I; Q 'Only bultock?' 8talUSf' 1M '1IIIgnlng' Ilspt'd Is« pp 63-64, A 'Ye5: 188-I89J\"'JrY\"'Iu''''mon'OJrrfu11ltottghlJorIM p\"1..rIlIOIlflSlll!T,JlrillllSkilfir-;l Q 'Has lhe bullock pam sub5ldoo agam\" On tf5tingthe slJ<thl1'IO\\·I'ml.'flI' A \")es: Q 'Same?' A 'Yt'S_' Q 'In the same \"\"ar as II did when ~·ou bent (or...anll'\" A 'l\"'o,'I'sonlyjusto;ubsidOOllO\"'-' T1usmodeolquestioninf;~noIon1\\lhep.1ttenl'5 rr 17lIrIJ~\",lOntrIltion_l\",u.sIJ'KOrlI\"I/nd temperament. butaooltis inlelh~ And \"I the ........... ti\"\",\",hl'wil1CQ1n@IOR'Sp«t)\"OU,pen.\"P\"~and \"\"',*llll'll~\"'lISlmskbdorrl_fur8rl,1 cnnsidcrationfor hlSf«\"Iings, Q 'OK! rour bullock hurt more when \\'w bt'nt It is 10 be hoped lhal he IS !\"ammg tus role 10 mak~ bad:;....ros or forwards?' 109 judgernenluboul hl~ ditoniE'f\". A '&l;kward5,llhink: Non-,'erl>al CQmmunt.-alion was d~!<Ol'd In dctatl rr ,\",51\"\"\"\"\"'''''1:1, ·11~;,.k'.IItm'ltl'dlffrrmlrCIIIl'l earlicrinltuschaptern.equahly,s~andprKision Ill'KrtlJ'U\"\",ylll',h11I,\"\"lkllly 1Ilkm for,l\" pro>lde<! by body langu.oll\" is in<aluable, bul lhe Slf\"'I,loms losubsuk m(lunlallhis \"\"SU\"\"_ \";$ examinermusl be al.,rl and p(\"f\"Ceph>\"ifil is tobe fully 'hl!;dr1llYl/~io'l'dwlrlr\"\"\"dml(ba.-kul/lrdsl!li1' uhlized. Perh3F-lhefollowingcx.ampll' helpsshowits l\"mgomgto,,~sm(l5'(/Dst'lydumpg.,.\"tPlr(lll. <31ul\" in rnodifymg the >·.,rbal rommunicahon. Li't us a<osuml'lhalwc\"reSlllllookingallhemovemenlsof Thi~ eJ<ample (h'monslrall'S how much close allen- Iheman who has pain I'xtcnding from Iht's.,croi1i,lC tlOn Ihe pain n'Sponses to Ihe joint mo>'eml'ftl dl'Sl'rve. area 10 Ihe right mlf,lhebutlock and calfbeinglhc To omil prt'Cision in this area WQuid bo: a grave ,u'NSQfgT\"al<\",tpam. m,slaj\"e,CooHrst'ly,Qn<:ethl'bI'ha>'iourollhepaini> eslabhshOO,lhl'lrealmenlt<'Chniq\"lSun~suitablr Following Ihe sub)ccti<e e~amu,,'tion and I;>stmi! forward flexion, the expressloo on lhe patienl's f\",e modified and Ihe appropriale care gi>en 10 IrNUn('f\\1 may mean, 'How much loni!t'r is Ihls gomg on?', or andassessmcnl. 'lfshesays,~Didlhalhurl'-and~Whercdldilhurtr Tho::mlon.ltlClnoft:hepallent's~canako ()f\"ICC mon>,l'U !iorn'iIm' Tlw plwsiOlhcrapist should be e~pA.'S8mU(hlolhephysiothl'rapist,provided..nelis­ alert 10 these expl\\58lOOS and, more importantl\\', IftlSwllh her mind as well as her ea.... Dunnglheroo- should respect them and ad upon them Sometimes il suJlahOn,@'\\'en-possiblead\\anl.1geshouldbetakenoi ise'\\·en~rylob.lLan«'lhclmportan«'ofthe all a\\'enucs of both \\ erbal ,,00 non·\\ etb.JI oommunlC'\" rM't'dlOdeterminetheonfonnahonag<11T1S1tNlofnot 1>Or\\. Thl' more palJmlS one ,\"\"\"\", the quicl.er \"nd the u~thep.1t>ent.Ondt'«'mtirungtNlthe\"'lteris ~xro...tl\"lhe_ml\"rltbl\"t.............. the ~ Imporunl, she could temporarily ......u...... Q -..o...·lctmesee~ouix'f>dIo~ ....rleftSide' !iOI'fM'oftheans... ersand,if,lisqullesafelOdoso. dclerSOll1l\"oft\",\"examU\\ahonloalalcr~She And..., thel\"Umif\\oltlon ronhn~ could ask lhe patienl 'Can ) ...., \"nd y....r Nck. c<lI'\" l1lIl'~\\ilmp~g.\\\"\".,hou1dsho\\o.' how I11SJl'O!6ible w,lh lust Itt..,.- more mO\\emcnts\" Imphing that thos 10 detl\"lT1llnt '(\"0 l'iIw.xrorale inf<>nN1JOn about the isthela!it. pa,n~lOmO'..emmt>...,thoutg\"\"'lexpl\"lldiIU'\" IT lalll_Itl\"~grllm.~lm',,'rdS<llmu~'Ill'a,\"flil omolllrlW\" ........ Jlrtlndk-\"rm iclousl~' 'I IS not alwa}s as straighlf\"\"\"\"ro aslhe mr)'\"gl\\~bul'tis\"\"'arlyalwarsP\"\"Sible l\"ach ·lheprerision. Q 'Juslbt'ndb.Kk\"\"ard~' 501T1(' rah\"nls b<'C<>m\" qUickly irntalt'd by 1x~ng fT I\"msomxIOll'atcIrJt;sp..-tllu\"hrroYlllld.\",tJH' aWllte ...nlCqUl\"ihonsin\"\"'$olIT'ledl.1;l1l1h('rh~~ ~l!gllll\"!'l </ti:1I r{rlrtl\"I({';1I n/....ssioll. nl ;land \";1111'1\" therapist \"\"!w:, is lun,-od in 10 lhe pattrot's noo'\\'erbal communicalion \",ill >\"ry quickly g\"llhis mf5S<1g\". OnI'way around this. will1Qul losing p=isi0fl,is 10 Lei us a..ume Ihal afler bcndm); b.>ckwards 20\" he vary Ih\" questinn. On tt'Shng tile fourth ml>vemenl, Slart> 10 wrinkle the mu~k~ Mound his left \"Ye, Ihe wh<'1l \"skini\\aboullh\" pam re.ponS<'. ju.1 say immlodiateresponso-muslbo.· Q 'UUllockagain?' Q 'Up you come' (at Ihe um\" lime encouraging A 'y,-\",: tl\\l'll'lurnbya,;;;isti\"l:il)

Comm~nication 47 ET I should b'cllrif!dhawl flSkwherr il hurl. AW\",,,S\" Spontaneous answersart'shil,mportant;w I'll keep tanm.b:Il~,m'pfJO\"sis\",,,,,,gtnp,mClI\"e,lhisisa myqueslionsastlon-din.'Cliveaspossible. timeui\"'I\"asllu71lia\",:rlabtn'l',a\"exNplilmmusl 1'1' ,,!/Uk U,,,ll'r t!1est'circumsla\"ccs, ifl a~,m,e 1. Inwhalw\"y? correcllythalilu\"\"I,is/;ultixkthatl,ur/'iluiillbt' goodpolicyloSilytl,isa\"dll\"\",aUhehasfodoisSily Q 'In wh\"l wav is il worse?' '!f\"S'O'o'l...'juslnatlhisIJrod. A 'My butlock has been more painful , Q '1 assume lhat was hurting in your bullock Q 'Sharpcr,ormoreachey?' andnolyourcalf?' A '1t'smoredifficultlogelcornfortablcinb«l: Affirmali\",'nod ET nUll's 1101 rmllya'rs\".\",.illS myqu\",t;I)II, /;ul ,t '5 'juSI lwomoremOl'eml\"flts. then I\"d like you 10 lie down. Ik>nd ovcr to your Idt side. tdlmgmesom'il!rillgpositiw,1<'II;chjortl'ellIVllI\"\"t now to your righr (using Ihes<~meobscrva­ rms<'i\"stoarceplQ$b''''gr''''''gl,arlSl<~7. tionsandqucstioningasabovc). 2 Which pari? AT SUBSEQUENT TREATMENT SESSIONS ET BeC4wsrlwmayllllL'l'llnc\"\"'ro<Jtl'roblellllsJwuld CHANGES IN SYMPTOMS (SUBSEQUENT detrrmm,' if Iris rIllfpai\" IIllS changed, and il SESSIONS) \"'0'u\",u!d IY I'I'lter tv do> I!/ls IJtfo,efirrdiuso\"t Letusassumclhatlhepatienlisagoodwitnl'SSwilh righi-sided buUockand calf pain, and lhal he has IOSI 'u'!ren'aurl'whllofhisi\"cretlw/;ul/ockpai\". allanlagonism he may have had to the qucshoning of &Ca\"selllol'el,iscalfIXli\" IlIls,,'t u'Orser,1'd too, the inHialinterview. The laslIrcatml'Tltwas2daysago lam go>i\",~ to a,ll/'\" quest/all ill a u'lly tlml \"\"lIi,ljI\"errcehimtoS!1y'~,the'lllf!,asbren IT / ,ami 10 drlermine 1IU' effec.l of Ihe last lrealmCf,t ,oo,set\",,' in II\",mo';/irl/o,maliwlluy IlOS.<i/;le. My/irstqurT lio\"ssl\"llIldSf'floulsl-\"'\"tll\",.\"usnyiicsf....-allS<' Q 'Doyoumcanyourca1f?' theyl'rlll'idequalily10 O,e statemCf,tsojfad A 'No,lhal'saboul the same , Q 'Well now, how have you lx-cn?\". Or 'Huw do you feci nOw romp.,r«l with when you c\"me ET Tl,al makes tire allSwer 10> Mlllt I \"'1mted to know inlaSllime?' !'Crypositw<,.1 know Iherea,e Ilm'l' parl,mlar timrswlu71c/lQnsrsi\"symplomsarrlllostlikelyto A 'Nolloob.,d: lun'l' b<>err d\"e 10 lrealmerlt vnd tllllS 11I0'\" inform- alive for mels.x pp. 71-72J,b,41ldo,,'tWllnl to ET T/Ill/te/lsmenol/,inS,so q\"esfio\" hirn ,e<~a,dins tI,ese I!\",,,, times u\"It'SS! Q 'Any different?' ,a\"'lOtgcllllt'an5u'I'rsspotrlarreously A '1 don'llmow whelher lhi>. is usual, butl'l'e 3 When? lx't-\"flterribly tired , 'Whendidyounolicelhebullockwo~ning?' ET Afle\"slthistrlls\",elhathissymplomshaw\"oi b«nsij,'I'ifkalltlyll\"'rsr.lfll...ylllldln-\",hellYmld 'Laslnighl' hat~5<lid so sI,aig!rtaWlly. &Ca\"S<' Ihe ti\",dlless ,an 1'1' related,and I:«a\"se it am beafarxmroble Q 'How about lhenight bt'fo!\"{'?' 5(g\",lheTl'>/XJ'/5Ctohisa1lSwersh\",lidlYasfollows: A 'Nodiffercnlfromusuai' Q 'Yes, il is quile rommon and it Can bca good Q 'Su there was no ch\"nge from the lime you lefl indicator Howha\\'eyourbackandlcglx-en?' here afler lrcillmenl until lasl night?' A 'A bil worse , A 'That's righl , IT Most rCSIXJIISG nlTot quallfymg, /;\"t for 'trorse', 4. Why? c!arifymgisma\",/alory.I\"eedtok\",,,v: CT ltisrsse\"twlthal/nmstmalel!U'palieutjeelable • [nwhalway? 10sayl!mlileft:elsllisin'retlSfi\"I-\"'inwQScauscd .Whichpar(? byll\",I,ealmrnt. • When? • Why? Sum\"palientsan·quileprcp.'redlosayangrily,'You made it worse', bul milny more are nOI aggressl\\'e and do not like 105<lY lhat it was lhc trealment that made them woJ\"s<', even when they feel it was. T~y arc suf- ficienllythoughlful to avoid making theslatemenl, if they possibly can.

48 MAITLAND'S VERTEBRAL MANIPULATION '10 one hM'S the feeling ~ssoci~ted wllh h~, ing DURING A TREATMENT SESSION molde ~ p.lhent worse ~nd being told so, f low('\\'er, CHANGES IN PAIN RESPONSE DURING the<;c ieelings mUSt be overcome; the iniOl'Tl'l<1lion REASSESSMENT OF TEST MOVEMENTS bein~ «lIj~hl j\" rna«\" import.o.nt th.n lhe ph,-'iothera- (SUBSEQUENT SESSIONS) pbt'i \"'mohon\", and it is essenlJal to know \",hill h.t;; \"\"m<!The t\"'-\" mon'fTlC015 on re.ls.;t.\"\"\"\"'-'flt foIlol> the' made the svmptoms worse. llu:: b<:st way to aslo. the Ii des/:ritx.J lor the ,nlh,,1 inlt.\"ft·\"\",·, but with Iwo question. ,,·hich he ('5 10 on'n:ome one's inhibillOfll! e>:\"\"-'Vi, , The fi.,I,,;. the- onl.. lI\\O\\'emenlS IN.t han: ..00 10 m.lk ,I ea\"y for- the !\"\"hent 10 '~W\"ft is to\"a) 10 be t\"\"tr...d aft\" llw\\s<.' 1lt.1t w,.... .1bnorm.ll. Ho,,''''-cr, .might 0\\11:: \",\",'ing s.\"d Ih\", !IOITll.'hm\"\", it \" t'lIJ\\:dS<lr)' to confirm Q 00 ,au think it ,,-as ,,'h.ol I did 10 IOU lasl that parti<:uLor I1lO\\ .:.-menb.,......,h aslunbd.r /Ierion lind \"trollght leg r..l5-ing. are shll nornul The SOl'Cond e>.cep- time'which II\\dlk it worw?' • t,on is that. ,,,11<... Vltt:' I~ (ht!t;;~mga t\"\"t mmement. it is \" '\\01 ll'alh~ bd.. use the ni!;hl befOll' I.lsi Willi \"II right. And, actu.lh; \"'h<.'fl Ildl h<.'1\"C I rell often helpful to know t~ pdt~I'~ opinion of the h'S1 betttr, and I mink I e..en had a better night mo\",~, ......t (oml\"\"\\..(1 \\\\ llh \"'hen the physiotherapist th.n usual: Id,t lot.\"j II b~ lI,kJrlK (1\" TIIPI i; ~ i<'JM QJlS;''\"-'1S \"\"'i\"\",smglro-,,'ll('ll!ul Q 'How d.\".., Ihal feel to you comp\",,-'Cl. with when you CIImc ill for tre;ltrne11t last time?' Q '),'OOJ 1l.11ll'SS\" (all ~, I 1I0W A'ue'!l' 'mt'~\"'''' A 'Dill\"\",n! - \"\",ICr' .I,,\"d \",..kc I\"\", ''''r.i<' lib! \"'gf,I, bu' ,;omdl\",'g ET J 0\",1011101 drro'Cl \"\".~ r/iffi',.,.\"cr i\" \"fIlSO' or q,ml· \"'I'!'/ h\",,,, iI~ '1 \"\"\"...\",,,,,1; >(> I,,~ ,,,,,,m,'111 is ofml<le 10 me Q 'Do you know of anj\" reason why I~st ni~ht PAIN RESPONSE WHILE ONE IS PERFORMING ~hvuld ha\"e been wor,;,:,?' A TECHNIQUE (SUBSEOUENT TREATMENT SESSION) /\\ 'II nuw be lx'Causc I ~Md to <it In an unc\"m- fn.table cll\"i. for two \"nd \" half ~\"\"'Jr' at a II .. important 10 know \"hen f\"\"rftll'ming\" t.-'chnique mc~ti\"l\\ that \"'·''nin~ - m) buttock W,'S quit\" on a patient \",!wI pam \"-~ m.11 be \\.lklOg pl.>c<> \",m:during the IMlhour,' during the p<-'I\"fonning 01 !ht' Io.'t:bnique. \"\"\"'\"' md~ ~ no p:un; or no I'\",m \\(I st.lrt WIth but ~ may occur [r Tlw1It \"\"''' - ~105J 1It/lif\"l. .... the Itrluuque ,,; conhnlll.'d; or while performmg Q 'And how did you fcl,lthi$ moming romp.~n..d tho.' IlXhnique tht...., ma\\ bl' ~ or ll'prvdUCbon w,th olher mominlls?' of the p.lhenrs s)'mplor'OS, ... hod> nlaY bcl\\il,-e in one l'Il \" 'l:l.M;k 10 w\",\"l it h••s bet-rt;lll dl~.' throe ways; (.r TlIIII'; rX«lI,m, TIl;'; i:; \",.'fll i\"~lfiotr to I.,-:p \"'11 )lulgtrnmt t:Jft1k' pr-<sn:t ;;:.wiilty ,0( /;\" di$<lr- drf-. I QI:!O IIIr.'r ~ gll'..i~ ~ /0 110:1' ,,:Ioch ;'i~llr I ,il\" U>r, QIr,1 _\"'!I ,,.,.,} 10_. ;11 I .....\"\"\",,! The I'oIlo\\<\"inl; is an \"\"\"mpk of .l. p.Jtimt not 1. \"The 5yrnptomsdec\",,;.,,~;'lnd dlS\"lpp<'ar (II\"\")· m.o)' ,lI\\$w~ng the qUl'5lion. It is import.ant l(l remmlber 11\\(\"-\"\"\", during Ille f,rsl lo-:eo «<Ond5 and Ilto-'n thor infonnallOn \\'Oll ;Ul.'K'{'king; thi3i is theonh \"\") 10 <kcrease) a'·oidbt.\"1ng kd ;lwaV from the poinl, quire unmten- 2. The symptoms mil)' OOffit.' .Ind go in mytlun \"\"th tionallr,by the !\"\"bent's \"r~wer.The qU(':$bon is ilSkcd: the ml'tlun olth,'IL-d\",,,-/uc Q 'llow o;Ux'5 IT f«>t' (toe ooo-spo.-cific, thc<clOf\\' 1. An \"chfo may bulld up, which is not in rhythm ~ 'IT') 'O)IIlp.1.red with bcfOfl: frida..'s !I\\.\"\"\"\",nt\" w,th the lL'Chniquo: A 'It'!; ternbly SOll'. right m theCl'ntll'.' TIle communication ;\"sU\\,,:> :lS8OCiat{-'d with d\"term;n- This ,,, not ~n an;;we. to tile qu~'Stl\"n, and the phy.- bl!\"\",ing the iour of ,I.... ,ymptoms during the per· i\"lh\"r~pbt rould \\x, led off the t',K~. l'hl' follow-up '1uo,.;!lon should b.'· formance 01 the tc'Chl1ique Me reblL'Clto trying 10 help the pati\"nt understand wllM til<.' difference; might be, Q 'Yc'S that's how it is now, bUI how dO(:S it SO that he can 1;;\"\"\" ust'ful \"\"~\\\\',,r. COMI'Al~E with when you \",mIl' in for tre\"t- nK~lt on Friday?' ET Now 111m JlUI:'\" sMrlr,j 1¥r(iJrm;\"i: Ihe' ffflmiqll\" I \"'1II;f kno>w </mig/,t mm.vll~l,lf is IllIppt:llillg to Ill<' A 'If,abo\"t,h(>same' p<llif>lt'~ wml'lCms.

Communieltion 49 Q '~\\ou feelan\\'disromlntT dl all \"h,le I ..m A 'Yes, I can feel \"\"methmg \",lule you'A\" dvlng doing thbr - ,,\"c' A '0. I QUI', feel an}thing other than the Q '1s it \"\"\" the pain pm can g..\"r A 'It's hard 10 Iell,' ~tn'tehing, Q 'Is it a nice f.....mgOf.l n.osty feoehngr IT fbi! <l.lft of ati'i'iN mr; rnm.gt Jar/OJ 'l\"rlf\". S4J A 'I don't kno'I<'.' ;,,\";\"\"'1 lO5t01'lJ\" I ;;'111 R>'J: ~~l/I. Q 'Does your nos:k li~e it Or dislike it?\" Q 'Stdl nolhlng: A 'I don'lImow' A 'No.1 can feel a litl1.. in mr left buttock now' Q 'Does it feel a< Ihough what I'm dOing's getting al 'he lhln)llh<lt IS wrong wilh your Q 'And that wasn'l th..'C\" hen I starled?' neck?' A 'Y~'S il was Ih\"re, irs always lho:re' A 'Oh yl\"', it certainly IS' Q 'H~~ il chang~\"i sinc,· [~t\"'trol' Ouy the la5t dnsW,'T pM'lde:. the infOf1I\\l\\ti..., ncedo.-d, i1nd qu.,.,tio,,\"'S has to conl\",,~ untillhi5 is ochic\\','(j A 'Y~'S, Wsslightl), \",,,,.,,.,' \\\\'''''n you are pcrlonning iI It.\"Chmqoe l11>,ng you. cr WMII \"\"\"d 10 b\"\",' \"Ow i•• r\"'NOIlI/\"!\" I\"i, i. as\"\"l, hand on a ~jnful art'a ,lnd the polhenl n~ponds w,lh 'undcr ,our hJnd:\"\"\",, \\'oo.l5k If he is fe.-llnS \"n)\" .1Il! 1\",11./-\"p;nlO\"\" aellt,'or ,,'h,O..., II i'sPinS 10 thinl;. the \"nrr..,<bl'~respon!jequestion \"hould boo, 'romt \"lUI go' (II Thy/hm 11.',11. Ow ftdml'1\"\" To Q \"'illhc-f'\"\"i'>UA'ofm,\"\"nd... ;\"dtherl\\O\\o..~ nv. ..t \"-oproducrng ~'()U' pamr \"/ilki'll rrr;in' frw hi~., 0.. 'l\"r<IJCn IS /vim' ,,;Mil A 1 drln'l know' '\" curh • uUJI 11131 Iii' \"m \"\"\" of r.m Q Is It on the sutfJa! 01\" d\"\"P ln5id\"r ,1lI1l'11..... ts: \\ '011. dl\"fimlely not surfOl«'.' Q 'Does it rome and go in rh~thm WIth the Of course, if the answer is not l1S d,'Cis,,'e,}oo Ciln lnO\\ement, or is it a st<'<1dy;odw.-r ch,lIl!/;e your contact as \"ell 10 !K'C if II... pain ch.,ng'''', A 'II S lust a slight ache: PAIN RESf>ONSE AFTER A TECHNIQUE IS PERfORMED (DURING A TREATMENT cr \"~l I rO'\"nJ Ii> ohltTmul<' I:; qui<:kl,\" <1$ 1 rmr i< SESSION) :riItfht'r il is going /0 \" ...NIl., :Al'. jkrfl~ ,I;t <Jf To d~termine the ~ffect ol a teduuquc, both Ihe ;;ub!i!<\" tlrr 1«I\",Uj,,(. ,rhtll>rr II ,,~II rtrIf:I/Illlw MIIIt, or ti'e\"nd ph,-siocaJ asp«b muSI be.1SSeS6<'d. The patienl rdwIJrrrltu'i/ldt'rTl\",,,,,,\",I$\" IS a..ked IOsl.lnd so thJt lhe ph,'siotherap;.:;tColIl rea;l;i!'SIS his 1I'IO\\~ls. Befort !\\Stulg the lI'IO\\'ements, tre Afk.,. a ful\"thl'r 10 \",-\"Conds, the 'lu,~tiO\"'5asked' p.atientlS a5ked whether he fl'\\'h ~ny dLff~1 i1S .. A$ull Q 'Is il jusllhoc \"\"me or b ,I,ncn'asing?' ot the kdvuqlJl'. ~ foolll:m. iog ron,t=1Uon shows ET 'fhr IjlleSllOII I, asKed 1111, Imy, btl/lll_e II i, !lOp\"d how tIu-~ c.m boo done qmckly \",,!hou' sacrificing the d<epth of mfurmatJon rcqUI\"-'l1. 11,m tlr~ '!lmplilln, \"\"II \".../\", \"\\l>I\",~ lI\"d tr,~rrf'rr I\"fi\"\"\"'\"1/,. /tr!1,'r III Q 'H\",,' do )'01.1 fu,elllOw comp\"\"-'l1 \",th when J ill( a\"<I,-:r /\"'~'IlrJ5 i,'lhlt I,. lasll\\ad ~'OU ~landingr ,u~ n'll,,~d rat~r II..\" 10 ;<'-/ R ftJY a\"s\"...,. by \"if/utnci\"s if laln,ttI, \"*\"I '< U'Ilnlrd A 'A!xrulth\"samc ET 5os'lojt<:IH,yl\" Jr,' i, \" ••(I\"mgnl~ now lach.d Iii, A 'It'~.lboulthesame: m\"\"\"\"''''''5 Ten seconds larer: Q 'No,,\" belld forwnd. - C01lle up af:ain )-luw Q How IS 11 1lO\"\" was you. bUllock Ih31 HIIlC'?' ,\\ 'It's~lttnnlL' ET /\"\", ,lOll'll thaI lilt ml,gt It'llS 5\",\"\"r,mtl\"\" fur11t, .., In iOOlI~ 10 «<ond,; ~!I,j till' q,,,,hly of/liS \"\"\"l\"ItIt\"l /i.JoUd brUer, Q 'And no,v?' A 11'580\"'\" E.T Tlml\" R~ NiMI frspo'!5<' To l;\"\"w whal is happening in such d~'Pth\" Iule OI'Ie IS pl'TfOrming a tt'chni'lu\" is \\-itaIIO proving the ,·...Iue of Ihe '~\"Ch\"lq\"c lNs n.\"t patient (a man with a tCn:ic,11 problem) was nOI a)loud wi'no;,s~. On performinll the te<:hnique, M 16pooded 10 a 'lu~lion by S<I,mg:

50 MAITLANO'S VERTEBRAL MANIPULATION, _ A ·tt dldn't male m,' bullock an .. WOlrM.' lh;!t If, ho.....,..,r, lh\"\", has bo..'o.:n p~~, the ..sse:;,.mcnt m..)· be made in IlK followinll manner' lln>e.' - -' Q 'What do roo fuel the pcm'T'ttge of Imp«:r.-e- Q ·Andn<J\\\\·thatrou·... upnght.isltlln~\"l)1\"«' ment has boIen (crnp;ncd \"ith whm \".., beganr asa result ofh\"\"ing bent forwardsr Beea...... some p;lhents .re unable to think in tIu'5e A ''\\k)' terms, it ~ ~ . lolldd I(l til(' question- In doin& so. Q 'Before 'OU Nd ,)J'lr trouble with ,-our back. It is better to bOils ttr q..:stJOrt toWards an unf..'ou....vle how far could ~ou MId (o....um.?· ans...er: A 'I think that'§ as far as t could ....·er bend.' Q 'Well. a.... ytlU less than halfway to being com- pletely better\" fT l\\tll.9I b:;I i, _>forrzwnJftfn\"'l$much~­ /tr. bMIug pam is 110 w\",~ prtJt'CktJ hti 1\"..71 A 'Oh no. I'm more thAn Nlf better !hank you-' III(l{It1!lfIrl. NUMJ kt liS $« u<lul /IllS hl>pptnl'd kI lItt'otl\"\",..............,/s And 50 Ihe routine continue'S WHEN PROGRESS HAS SLOWED OR STOPPED tt mOlY be useful, <!SJ\"'Cially if the palienl (eels tNt orMakmg a reilppr'IIS.11 of the eff(.'(:f treatment at .. his symploms ha\"e not chanh-ed, to lISle if he fwts that sla!;e when r~r~s ,s 1'101 <:ontu'un'/; as il should is .., the quan\"tr or quality of his rnO\\'\"\"I>ent has changtod. difficull \"5. or '1lO\"\" difficult 11\\.11'1. ,\\ first consultation The communicatilm a.pl.'(1 is m\"rh the sam.. a, h,1S Tho.'rc Ml' ~Imcli\"\"\" situations where ttl(' \",.h~'r'I1 \"lre<1(!y!J<x>\" discus.<o!d. n,c p,,>/}lelll\" from a \"'arhi\"g starts to mO\"e more fwelr and with more quanntr but pOutf of \\\"'''''', an~ \"\"lImS d<>wn what it is you wish to th., piun is .IJtl lhe ~me. ><l lhe patient eJ(po:'rienccs it find oul. For this reason, di!lCus.;ion is de~tl with sepa· a~ being the !><,me, atthough parts 01 his mnvements rately (S<Y 1'1'_ 78-79). arcchanll'''!; iltn.·ady. Br a,kmg the p.ltient ~bo\"l ()lher a~p.,cts elf lhe moveme\"t that is bcin!\\ te't~.,J. ho.~ may le.1m about this and COIlC<-'Illrale morcOiltht'SC nsp<.'(t~ of the 1l\"S1-llW\"emenf as .....ell AT REVIEW SESSIONS CHANGES IN SYMPTOMS AT REVIEW SESSIONS FOLLOWING A BREAK FROM QUESTIONS DURING A RETROSPECTIVE TREATMENT ASSESSMENT (ARER EACH THREE TO FIVE TREAIMENTS) Rro,;cw consolt~t'Ions iI~ oooJucted 10 assess the changes thai have taken pia«\" during a\" i\"terYal foI· II IS (n.\"'lo.lel'fl)- ~rl .11 the third, faunh Ol\" fiflh lowing cessation oflrNtrner'll II is only the communi· treltment session!! to <rcl;e lIJ\\ lIS~t of lhe caliOfl aspect.1$ il relates to ~.ng changes In the pt'Qr;l\"CIi6 m the patient's slmpt0ffi5 ,>lid sil;'\"6 com- p.1ttenl'S symptoms thal .. ilI be d.5oCUS5l'd here pi1n-d\" Ith tha:;e at hIS fllSl, i:sit. The p.1henl to be rl'\\'K·...ed thesame male pat.....t Q 'Ho--' do ~oo ~ mmpa-t with ~ we ..,110 was .. good \"-Ilne55 and ho had rigt.. bull<xk bq;Mt1\" p.llIl grea= tho.n calf pi1in lie 1MI n!Crived trI\"iltment 10 ciaJ'; ago. Folkl\\\\ ing the introductory p1c.Jsanlt\"tei, Ths qoc-.tkW> is \"\"tremdy \"aluable, bcOlu,;e 1M .MWi!r the questions and \"nswCf\"S talo.e on the more serious en.Jbles ti'M:' rl'}\"Motherapist 10 see the progfC'!6 lit Ib prop.\" pl.~pt'di,'e lI;snol uncommon for II patienllo ,~ rq>Of1 al ~h ~\"cre<si\\'e treatment Ihat he is foelmg bctlt'f, 'Yes. I ~m s\"'\"' I'm a bIt bctl~·. ret al the fourth Q \"-\"\"'II now, how 1\\.,..., p'\" I>eo..-...\" f~.llment );Cf;Sio\", if he is a5~cd how he is compared IT T[)suIl:'<POII1<lr~.slQ'fmml1l~lIpnI;\"g'llH'fr with lhe finn dar, he will 'UID' and 'an' and ilo..-:.it;lte 50 I\"\",tilms .hould b.- NgU(, If> '0 rnrouTagt '0 and finish \"p by !;apng: dl\"SCnb.- 4Sf>Xt$ tIS Jllry ro_ to IllS ,,,,,,d. ,,, 011. A 'Well . rill not an;' wo~\" ~\"'~ Ilw~ !1'l11 a>'~ III JIll! ordrr of impot1QIKf;.. II is fur reason, such as this Ihnt lhe n.:iI\\lSpcclh'c as.~cnt musl be made a routine polfl of ~ntment lJ.~lichlU'S<\"r$lllrm. A 'Beller, l\"m ple,lSl-,<1 til say.' ET Well tlllll', II Iml'l'Y sll1rl; 1\",1 wlmr I \"cl'd 10 drra· \"\"orc;, wh\"t IS /Il'1/~r, in what w\"y \" ,/ 1it'lIcr, hIT'\" \"'liCit I.l IIllC Iv /,,,,,1,,,.,,,1 a/owa\",1 how \"\"\"II

Comm~nk~lion 51 I> \"I)(I1I11I1lrIl1tS rtali\"''!!. To I'~1.~ !he~JelrmJ1\"D' A 'I ha,-\",,'I had .m}' c\"lf symptoms for tIM> \\a:;I: ,rltt'\"'10\", I ,J«J {if\"$1 10 k1w\", III u~\"\" \"\"\",, ITt' hi/!. 'mproved IIIld Ihe in'pro1Ym1'JlI oakrrrd -I days-' nit! if00..' much better ~...,,;;,ll<lfl \".11 Cl>\"\" loll' lOT \"lid I 1raTffl'l \"\"\"n hi\"l for 10 dR.!f5' So TrI/OOuI II t\\II'l ~ltiotlt'dspottlnl1roush; I tID h.r.y !\",TI!C- <tshng hili', ,! ~T> rlra/ I\"\",, /uti /:non rot,I\",\"- ..lor qU61llJrls rrlalrd 10 h.s >ymplt\"'rs llral inS ilf:l7'WO'!t'TT' ~hr()llg/lcllt tilt JD--dtrv intt1T1dl. Jl;; IImJS,/ nat tfuJ...... thIS. 1'11$ a/>olll dJIIInsrs JalII bk, lrr.-inK rrrordnJ 1Ja.m .lId \"\",.w \"\"'III m Il'.lntxJ: symptao./.> 1'011I/5 IMrh ~l'1t'ib \", hl'> lasl tmll\"fl'nl Q .And ,,-hal h,a\" happened 10 the bu!tlXk ;>(hlng M\\d ,ilting 0\"('1\" tt.\" Lut -I d\",,\"\" HOU'<'l'<'T,ltbll«'Sfll\"\"'lilrl/'OUS~I\"\",.lIlr A 'I thin}:: II'S k5s0.1ting • \"\"'\"\"\"\"Q 11wt oounds good. Ten me. in what \"\"y \"J'l! you ben~\"t\"?' Q 'You think?' A \"'The aching dOl'Sn'l boI:her me dunng the dn ha.\"... 'WeiLl don't sir a lot .... eT'\\-- d.a\\, bull the now, ..nd when I gl.'t out of !>I'd in th<> morning inS'impl'e!ioSlon ii's impr<n I don't !\\ave an}' dIfficulty putling on n\" ET TI/15 rrin'orcrs ll~ r;,;'rnol!e tl\",t he i> WlltiIH,iltS ~ksand,;.hocs I\" impll7<Y n'-\"lllrcu~III~ i5 \"alll1ft'inS trmtmml, ~T He 1.ISIl'1 mellrmled s.rui\"Ii\"' ImlI lmlM /ir<1 dar· !,,'\"/nil 1\"11 gr.y II... op1;oo 10.11\"'1{\"\" u~lh Ulis. if'J ,dwl !\" Ifleu\"~ by, 'dotS,,', bul\"er mC ,IIlring Q 'Do }'OU feel \"\"\" !\\a\\\" 111l1'n)n-u tl\\\"nly OW\" Ihe 10 daY', ,,' do you think that most of I\"\" the d~y', I/r!,.,,; $(lid il 'doc\"\", bulhtr' !\",n. >Q rl \"\"pro,em\"\"t came in tl'll! fltSl f\"w J.,ys \"rId that vou'\"e been static since?' sow!>!, U:I tllo\"SI, tln'rt art 51ill S<lrllC \"!i'''plollIS J!<!rsi,IiII,~.lu'OII.1rril11!i';c!IIIUII? Q 'I prl'Suml! you me~\" you slill have SOil'\" n By p,dlmg /IllS qll,'Sliul! ill Jilt' r'l'rliClllarorllrm,,,,, symptom~ during lhe day but th\"t U\"'y U\" dW\",\"II, 1 am dd,!>t'mlrf.v i'!fl\"r\",jllg him all'o.v k'S. ,1~1Il Ill\"} Wl~r\". Wl..,t is ;t that you .from Ilk' arls\"\",r I am ~xp«lillS' do fL\",l?' '\\. 'Oh no, T'\", ~lJ\"\" il'~ ~lill imprm'ing: A '\\1y buttock aches after ,.'\"'~ ~ sitting for a Ionll tun,,: I'-r fr.wi,,'1 chi!i<'lhrs OIlyfurl!,.'!', It s.rt'>l1S arm'\" I,ds \"\"tslill 'I'rpror,;\"g, _IIJ al III \"'~I'(J, 1I1'1\"\"'rs Mlf15frx- Q 'Sitting for how long:>' ,i_,1<!nJ III !lim. I'D pmbtlNlI $Jl~ rttittl-j\".~ l'l1lI A '2-3 hours: ilSl/in '\" \"PJ'rtrn'fTJltlV J u'<'l'b' wirh lIlt Q '[)o}OU !iohlllw\\edlffk1.1lly gemn)l; O'IIt of the \",.~ior1s 1M! Jr un tdtplrot~Q',dallied ~\"I'PO'nt­ ci'1urr ism\"'\"l1'.m/ if/It wnptonl5 cw rlttn \"\" mroy rolW m A No, not now: if<rontT M '!l'pS rmprJ<l1t;:: (II\" 1lvr5mS. H.:lOl'r.YT. \",,'/I <n' rr#rIhrr ,lit P\"'f\"l'\" uf /ri, Il'1fI ....,...\"...\"ls Q 'Andismatall?' If \" ~ It iriI1 mJJI~ tJr ...J;a:!\"-'f' pros A Yt'§.,' 51rmglltm tin; J11w1.\"\" mwa. IT \\\\~lJ.•/1IIl1< 1II'~<U'mV 511ill1g, lit ~ itl pm. Without nw h.ning kI \"\"k, bf.1 I \"lIlY IIffli ttl CONClUSION qUll,'rfv .t 1l1..w. wft7. fo.:_ I \"\"...1 \", wm /~ MptI\"''''~'1SUVT5 ,.. Ill\" Although tIllidi5cussionabout communiulJon \"nd ,Is If''t'S~ \"\"~ rrl4,('S ttl probl....... may sc.= length), II rrot.\",,'ly touches lhe \"\"r- '1II1[ pm't II«' <>11m- rrl41t\"i ttl a'hm I~ gaiJHvJ I~ I,faceof the subject- and II mu,1 ~ ,~nizl<d!hat \\hi,; all il does. :\\Ie\\erthek-soi, all 0{ the main issues have ,,\"PIVI¥7n,.,rl and u.~~111U I\", I;; eM/mllmS to been mcJuded. From the lluthor's romt oj ,'iew, th<> prim.K)-of the ,ubje<:1 will show on reading the section \"\"pM\", 1J... In\"ff \"\",1.1 pror>r 10 k InltH,V. .., on 'relrOSp<'Cti,-e asses,mt'n!)'. II Is hopI.-d that, if the foregoing has been understood and nbsorb<.>d, il will U'I\"\" elmr lip rl\", cal/fin;!. make n..'!rospedive asse,;,;mc\"t. a p\"\"'\"rful tool for the mnnipulnti\\·<, phy,iOlht·r~pl,1. eqllippinlS her to be \"n Q 'Ilow,stheulf?' ('Ssenll,,1 consultant in nssesoLllIol tllC pali\"nts' musculoskelelal disordcrs. A 'O~, that's all gOl'e' fiT TIIIII mrst' ..., IIWI' make a5ki\"s abollt ;p':mta\"eo,,~ rm,,'l''Y \"T~J/, C'Sl'rcially if lile j\"m\"\"k amI coif <yrlll'loms ~n' IlmYtly linked. A 'When did th~t go?'

53 Chapter 4 Assessment CHAPTER CONTENTS AsStSsm~'1 d~rin~ lhe perfOl'mil~ of a treiltment lech\"ique 75 Li$Un and !!diNt 55 After the teeh\" qu~ ~ ~n perlormed (to As~sm~nt ~t initial tlQmil'lJtion 57 dete,mi~ the immc(l,ate rlfed of a t~nlque As~~nl throughout t~atlTll'nt 59 iilnc' Wilke iii judgement ,bout ..holt ~ld Ix AUtrim. GO Components - 1 6\\ ndone MOW) Components - 2 62 Communication 62 Asscs'lmrnt atlhe coMplet,on of the tre<ltment Beh....iour of pain, rrsislanc( and mu~clt spasm 62 sn5<on 78 Behaviour of il1Iin 62 AneSSlT'ent rNer a 24-hour fM:f1od 1fT'..\"edLatdy Behaviour of resistance sa Behaviour of muscle spasm 68 fol'o.... ing the last treatment session [bernus.e this Identifying normal and abnormal findings- IS often tte most important inform<ltion period) Wl\\u is norm~17 What is abnormal? How can lind subsequent 24-hour iX'riods up to the next Ihey I>l' ddined? 69 treatment session 78 Ideal spine 69 As a retrosp~ctive assessment (so that an overall A.V\\\"ragc spine 69 assessm~nt can b~ made over three or four Abnormal spi~e 70 treatment sessionsl 78 Ne'N/oid liss<H' manges 11 Example 8Q A'l5eSSlnmt 72 At tht beginlllng cf ud! trut~nt At the completion of treatment (to make judgements on prognosis 'nd prophylaxis) BO stSSoOfl 72 Assessment assisting in d,fferential dj.gn~is 81 Analytical aSln5ment 82 COnclusion 8J ()I.e. HI<' }\"\"Th, \\ arious d'31i;<lQ5e5 h3\\-\" been put for. mon'm~\"'t i~ not ,,\"'-'(! to its f\"ll\",t adv.m!.1!:\". Huw ward by manipul..~tors ttl <\",'1.110 \",fI.11 th,,!, art' <lomb much b.>lh\" off ,,.., ~nd NI, patient> wOl.lld be If pas- with thl' mom, spinal pam ~j'I1Jn)ml-; they IIC\"l \"K· SIH mm\"cmcnt tr.:.ltmCIII Wl'rC 1.lS<.'d \"nd wlltmllcd hy C\\.'S,f\"lIy. M.ln~ of th\" sugg,-\"t,...i CM'ses of the pat;':,,!', problem. Me not whoU)' ,ICc...'pl,'<l by the medic,,1 prof\",r i<s><'Ssrncnt '\" thai its nl1\" '\" the a,-crall m,ln- pmfl.-ssion. and ron\"\"\"lul'11th tn... tnwnl bj' pass;, c .ll;t~l1<'nt or Ileurom\"_cul\"\"k,·lctal problems could be Ieamed.

54 MAITLAND'S VERTEBRAl. MANIPULATION During th.. Ia\". f,'\" years, pas;;i\\e mo,·t\"m('nl h& E.>,caminalion ;\" dcs<:ril:o..'d ,n Ch.Jpl\"r 6. Howe...er. for the purpose of Ihis cn..l'tcr on .>S6eSSffieIl1 il is......,.\"... )}'Iin•.'d groo1l\"r \"-\"ClIS\"'tllJn as an •..ffe.::11'\" mnde of lre\"l- SillY 10 elaborate on CC'l\"lam pomb, becaU5e ,,;!hour m ..... l. Furt1ll!rmo its us.' as a SOUro! of informalion accura0: aoo dct.1il U1 ...-amm.:ol\",n lhe proper \"---~ n.'garoing Ih\" 1:10- , iour of joint d\"\"\"ro...... has l;ooeoen reali7.ro by ~doctorslobeof gn\"o'Il' aJUI' ifd1ol' IOinl tnents Cilnnot be made. lfI()\\i'mi'Ots ..re ~ accuratell- throu~houl IlNI' \"'edinl dli~nosis onIyd'~v..otflit mobollla:M;lr! or .0ml'Ol. \\\\,Ihl\",t ~I. IJn1tm.....t ~lv an 1\"I:I\";~:l1ation COJId II( a lIe,I1l'Il'I\\1 01 moitt hlf\\hn drlililnl ~\",,,,\",lJOnof _rnents is e..5C:nlil to ;tpI>llCiJhOn ()/ ll.'('Iuuqueo ladjI>g guideI~\"-\"~ drtrrmir>e the eun <fIoN:t of t~almmt ...·ilhin the ronOel'l h.o5 been rdMn:d lO in Ch.Ip~r 1 (pp 4. 12-131. 11< ....aJ identity lII<l\\. mon: n.\\ldi.I~' be ,,\",'n by rclt-rwoce 10 f~,\" 4.1. The,• • • 1wo1lWUlg proce5S6 on ...~ The h i s seekng the souraIoI!he ckordllr. a'ld ... -=ond IS the ...-oIlhe~ ,\"~ONE A. The SOURCEIs, of the symptoms I, Name IS \\he poutble $OU\"\"\",,, ot *'Y pl'rl 0I1he peIlenl'••ymptOms !hal musr bill exarnned. \"'''''r.)Joints unde<tylng symplOmatJc: f . 'Neura,'supportlve ele......\"'\" lluil JoO'tls Itlal relet ;\"IO!h\" SympromahC a_(s) Into t~a symplomalo<: area{s) ~tJGCUlS UMarIY'''IIIymp4Qmatk: a,ear.) 2 LIII joInt••~ and below the ~\"'\" thaI 9hCUd bill chad<ed (\"\"'en apJlfopna!el: Ara UlBr. any special tests indicaled? a, Neu'OIogical e'ami\"\"lfO(l t> OIt'9\\\" - speclly an_ . ,.8. Inrluenee or aymptoms and pathology on ..,mln,tion and lifst treatment 1 Is lt1e pain _ a ? (Ills/No) Of Iatoo'? (\"\"slN~) GloB 111ft (l)(amp/fl 00 wIlfch !/toI baud. I. LOCJII S)'Tllptom$ I. R.peated MOVEMENT causlng pIlln - 01 go lust bIIIyood f'1 ~, S-rtyolpa,nsocau')t'd 101 Dural\",\" belore paO-lliUbIidIJI; t> RefalTad'\\:llhef syIfl7loms i. Repeated UOIIEMENT CiIolISIRl;I PlI'\" - 01 go fU6I 00y0nd referral 01 pcun . • S-liy of Pl'In so caused .. Duo\"\"'\" betore PMl s:t:>s::tn 2. Does Ihe nature 0I1he d<sorde< 'IdIcalIea:udon? (I'M.'Nol ~ PathoIogyTf,rry - ~dy •. • , Eoasy 10 po-owoli:A ~ or ac:oM aposodII 3. N .......e...,~lions ('lb1llotSpagly C. no. klnd '\" .umlnwe.n I. Do ...... _ ...... wiI..-::I1O bill gende 01 MOderalely llrm wiIh yow l!ICa!TW1aIionolltl8~? 2. Do \"\"\"\" exped a c:emparnbIs s9> 10 be - , . or 10 tIlIllafd 10 ind? Wtrf? ~rn<> no.D. .tJJ$( oll/'lll SOURCE of Itle .~: Auocl8led \".amlnallon 1. ~ neUfQimuscubskeletahnadiclllllldofs teading 10 the cause ol!he &V~ ~I Issoeiated taerors nus! tM aamlned .. As Nasons \"Ily It'll ioont. roo~ Of odl.. Slnll:lure _ becoroo symf*lrMllC anG'O' Obeslly. slitfness. po_.t>. Why the joint Of muscla disordef may reeur'? (e g. poolIu.... musda ombalance. musel. hypennobility, mtabilily; delorTl'llty;\" praumal 01 distal jon, 1I1c.). 2. Tlla ellec1 01 the lisorrler on \"\"\"' stabolliy E. Treatment 1 Which lhort·term or Ion\\l.!elm goals 01 t,aatment are \"\"rsuad? 2. Do you \",xpeel to be traatlng pain, rOOSlarlCa, I'l'8Bknass or inslat>dity? 3. Ara there B\")' pracaullons or conl,aindicat,oos which need to t>e respected? 4. In planning tha TI1t:ATMI::NT (ahar the axamlnatlon). wllaladvlce s/loUd be inc1LJdad 10 prevonl Of I_n fltCUrrooces? \"\"\"\"'ideAt!fIllle<llrom 1W!<J~lelal &arrWll!I_1lIPd RIKXJfl1>ng Guide (11198), ...i1h ~<nd pa\",\"\"OO ol LluMrdale Pres•. Fi~u\", 4.1 Asscumom.: an initill ,ug~ 01 {fUlmen\" ,..-0 roml\"'nmont l~inllng p<~ses. so-ol.,\"g thl: j()jirttof th~ n>Q\\Itmonl diSOfde' I'! ..ell I'! ~king (ho, rou-,,\"'\" tht SOOrtt WIll gu,dr t,eat\"'.\"! proc.dUfO

Assc:ssment SS In Ch<lpl~ 2 Professor Brewerton ha5 giv\"n Infor· mo, emenl tests producro b\\ Pl'l!Sllures on the palpable mallon regardmg rh<.- diag\"\"5is, indicatiolls 300 ron- p.orls of till\" \\'~. ~ all! dl=lCObcd ill ddail in C\"\"pter(,{pp.I50---162). lraindKatlons for momipulati\\·... thffapy. and II J,; ob\\ lOUS th.i:ltdiagnosis'~ \\ Il;l.l before IThlI1lpu1llJ\\e tmitmenllS LISTEN AND BElIEVE undertaken. 'This dia~ ma~' onl~' dlSClos.e thilt the pall(\"rll nas 3 ncurumuscuJosldetal dISOrder, signitv- ~ physiolherapi~t mu'! ~ prep.lrO\"d 10 listen!D the ing that moblliution or mampulatlon could bl.\"~ lreat- patient attenth--..l.y and bell\".-ingl} II IS ..draordiRaf)' mmlof cholce.lf a physiolher..pist is asked to lr\\.'al by how ofm'a docto... and physwtheraposts do not 1J..Jero or do notlisto...., carefull) l'OOUgh, ..nd rert.1mly do not P\"'W'''' mo>emo:r>l. II is u..... ne<:e>.>df) for hoer to list~.....' 5uffK:ienl depth,. 10 their J'dl~b. It is \"'rang \"\"\"m,ne mdl\\·,d~' lnO\\'oI'f'I'Ioerl~ in dl':alI IOmak<\"<>ca.demic judg<menls un \\,hat should bedone 10 help a p.o.b,,\"1 ,n prefermcr to malln~.. cl;nio;al judg<:- FIf'St. and I'l'105I importantly, eumi.....tion 01 the menl based on information the patien! com give, rem- pabml should I'f:\\'eal which particuLu int\"\"'L'11L-bral pl\"red by wholt is known acadl\"mkitUy A U-yl\",r-old health)' woman who had been UI'IiIbk' Iocomb her hair lo!\\el or whIch neural romponffit is rt'Spon$,bk> for hIS Of do up her bra5Si\"\"\" fo, 6 'H'l'k:; bo.'Ciluse of .houlder weaknl\"ss and di»C01T\\tort \"\"S lold th;,t the only q:>bons ti)'tT1f1loms. lind \",hilt .-fleet the disord.... hM on his (lpen to 1lL'I we\", 'rna,..,r ~U'l;\"ry' or 10 'put up with it'. mo'·...~lS It is by n!SIoring lhese mow,,,,-'IIts 10 nor- This w\",; based on gl\"O.'<S arthritiC ch,mgt'S shown on the mal th.1t his ~ymptoms will Jx> reli...ved. X·raY\". She rdu\"ro SU\"M\"ry, pl\\'ferrinl; to put up with il Bccau\"., h... SIster, who 'h,,<1 h,ld ..~\"cth' the same Slxondl,', abnormalitv of loc mo\\\"cment of the problem' wa~ 'cural by physiotherapy', she pn.·ss,'d. for lhl.\" \"\"me treatment. Th~ dialiloo\"is w~s 'osteoarthrilis' faull)' C~POIl<....t should tx. determmL'<l by pa!lSive and certainly ,he had gross joinl changl'S. which we\", mO\\'CmL'IIt I\"\"b, to\",tlng each intervertebrlll joint 5\"1'- l*'\\'ious bulh din;'-~lly atld radiologic311y. Phy5Kally, sho> amld~·. and the ...~amin\"tion mll.>1 dh'ulgc: had a :>5 per Cl'III n.xluetion In r~ng'\" \"\"in on strrlch- \"'So and co\"\"idl'I'ablc dry cn..-pitus during ach~\" mu~e-­ I. Til ... p!'l.~nce and behaviour of pain Illrough tl.... menls. \\\\'hl\"n the .ilould.,.. was m... ed P-U'J\\·..lr with the glenohumeral joml surf.....es con,~-.,j, Cn.-Pltus a\\'\"il\"bl\" r;ttlge \"\"\" increased and discomfort (not pain) was prm·oked. 2, The mo\\\"ements th,'t \"\", restrictLxl ur hy~r­ Prior to till\" on..d of ~\\'mpIOr1\\.'> (, ,,«ls pw>'iously. although shl\" \"\"\"\". shl\" Iwd an arihritk should...., she ,,,,<Imobil.... bd\",\\ lOur of stiffnL'S' dKl not haH> the d;\".,.bilit.., 1hc' 'm.>jo<- surgery' \"'as b.I\"ed on the .adiologkal findinp mh.'f])r\\.>I<!d aaodem- :>. The ,,\"tent, q~lality ~' Sl-\\'en\" a--b plY\\iousI) ht... radiologKal finding5. one would \"'xpccI, would ha. e bl\"ol\"n much the same. (including the rele\\ant symptulThllic responso!l Clllieal!)' he.- proNem,,~ an 'end-of·range' problem ralhoer than a 'through'lange' (grosfi oslf>oarthrilis) during nmvL'II1C.'n1 or alth.. limil of rang.... probk'IrL Her .shoukWr ,..,.;ponded quite satisfactorily. 4. The e\"tt'l\\' and bL-ha\\ iour of mu>doo spa'''' durinS I~ ~ent liste~,ng lind pt'rcepllVl' qu ..sfo~ing lire =rotlal to gJln Infor'TIlltlOn m.t cannot be 1110\\·,m\"''IIt or atlh.. hmit of rang... r...,~~lrcl by ary ctter torm cf eXllminJlio~ IMwvKl\\.W oflhe 5)111Ptomi is Ihl\" I\\'IOS! importanl a5J'l\".\"'I A I\"\"''''-''I'S buly, IdO, alll/~ 11Ilrl. Iltal OJmbmr t<J f<Jml rr, 0111 tell the P\"\"\"'II a\",'S\" rlllllltli'dfl' ,Jjl\"lIlmal!l\"ID find The 'bo:oh.:l\\IOUr' of the <15ped$ lisl:ed. abo..... relates ,,~I by unyform ~f e.mmi\"\"t\",,, olilrr tl,aPlIV irsltflll1g arId to nl()\\'ement5 of the raulty inl\"\", ertebrnl JOint and the (2) askir;s P'''''l,liw ql\"\"li~\",; awl u;;,i:;t !rim 10 \"\"yOrr roncurrent S}'1'I1pt()fl\\i!.tic: resporo;<' al the ti~lI\"J ,f/if Hlillgs lie ft.\",ls Wr\"\"S<'llis <',GlIMer 1M 1~llalcVl7 pIIrt il is) is trealmC.'f\\t. In rdation to tJ., pam~tJ\\'\" structun.'!i 1<,lIi\".~ Ilim, Forn~\"'l'ir, ti... 1\"'$1\"'\" hodylR~III ils disorda) in lhe\\~a1cal\\illand the in~'ertt'bral foraml\"n~,.e the dura, lhe \"'-'f\\~root slee\\es and the llt1'\\e 1'I)(Iol$), ls liNt 10 difftmlMlt r'1u'n''' d':ffrrml bnds of \",r~II,.;.s, their \",O\\emrols must al>a be ~ for •.Ange IOU.and the bo.'N. ~ ~)\" resuftir1ll; p.oin. ~!laInl\" n'l(J\\ e- mmI .~rntt11 need. to be..-le of the neural s!n>C\" tuft'S. Also, in 1M dailv managl\"mel1t of ihl\" n'rtcb.al dil\\Qr\"d«Q. it b ~t ..l to lno,,\" the Slilte of condu.... bon of 1M ner>'es in dto;;e pahenls \"'ho5c symptoms indiul\" invnhemcnt of the rol'1\"\\-e root. Many !e'>b Can be used to assess the joml rJ\\O\\'ements \"\"\"nt;oll,-d 3\\)(1.·..: amons the pnnapal ones are the Assessm~M IS the k~yslOM of dkctive, informati\\'t tlutment, wit~O\\ll wnid'1treatmo:nt ~UC=les and treatment failures lose all value as lurning expemnees.like tne keystone, a,,,,Slment i5 at the summit of treatment, Ioc:king th~ whol~ together

S6 MAITlANO'S VERTE8RAl MANIPULATION Figun 4,2 ~.... of;he «l'Y'ali ....\"\" of , 7~.... .......a~ Ct:MCd 'p.M. Th~ «,.,;a,ijl-t 'l<:UtVnl_~tllllltno;n Thtft oS ~uitt rn:lrUd artt<OOt\"\\IIo 'tllln,~ C4-S'\" th S ~hl ~n:.rio, S..tllwc31<111 of (4 on !;. With flh on !tit.. \" 3bo,nlt~or \",bluJ<lIMn \"\"'llWi\"\"ofCJ C\" 4 Th... \" 01 .lIlh. ,nIt<· _t'ltbc,1 d'\",,~ tltlow C2 bUllh,s is \",,,,,I p'O\"OlJn~.d'l C5-6 'nd C6-7 Ostt<.>.uhri\"<: chang.s u/ .\"ide\"t '\" tr.t un~rt\"'r.ll jO,nt~ !>tlo.. tilt ~ofC2 b'd,ltfl1ly.lh.r<: il tncfO.dlmtfll on tho ,nltM'1tbral lo\",m,,,, on Ih. loft:Wel. '1 C2-3, C3_4'~d C4-5, CS_6 \"he-.: 's \"\"\"'. ,')',.,,,,rt\"1 01 tilt Solpm<lf fxrt of 0, tillS IS ~iollya=IUnUd forbJ rotnicn ..-dlllt <:urnlw,\", ofl/>~ «lYIt:3 >j>Jt<. ~SNm~f1\\...... dIa\"'JCS'~ lht~'f'1Il'lJirt~~Wnt\"\"'lt't'/ ~.;~ju'y' mrd i/ is good '1>,,,,,,-,,,,,,,r tons! tiU' 'l\"\".<tkm. 'I,; it tll~ rllill,~ of the C('r\\ ic\"l spino: Is ~ho\",n in r':~l\"f 4.2. SI\\(> is 73 II••, i5 \"'1DlIK ,,~'r,,'r, I' ,;0\"', '\" i\" II j\",1 I>nli:<oillg !J()m~ fro'll tmJ/lfll'f1l\" r\"\" . . . old. \"n<! for mo\", Ihiln n }\"c\"r. of her Iif\" sh., h..s Ano#~nullrl\" u 1lCfi'1l PfllrnJl ,1«11' 1.'/\" '\" braNt' /(J not h.,d any s'gn of ,my sympltlnlS, nol C\" l'l1 oned.'yol' arUIII IIml In'\" bW.. if; 1t'II\"'t hi\", '\" \\\\'t Nil, agrw Ih.ir \",-'d, slirrn.,,;,. lSy la' dppearalKf' of her X·r,,)'S this _r\"\"\"\"\"\",,III, Iwtbrlln.l>ul .fIO\".ofot'Sousl.,f«I Ih.ll \\11'/,11 ret\"\"nil)' ~ po!Oible, it is so. One must be can.fuI 'V\"II\".....' \".tflllln!t brlln; \"\" l,oll aN.. lot'tpJolin '\"-t II aboul\" hat OOt.\"doe.. w,th thtoreliaJ kno...\"'...tse. , II.I dutsIol frri /trlltTr. I\"fanowt_ rtro1/\",1 /1y 511('1, ~\"'hI ,..... m.od<.> both from <uliKIlU\" and br!.'1:i\"sql~\"- ... rngll'\" mrrol im'dlwNt illliJm~'J\"'n. ~\\'t fmm ph)......\"II!'Ymin.olion; thq. n'qUI'\" lho> pallent'. co-<Jpl.... t>on ilnd 1110\" \"\"\"miner' sktll in inlerpm\"'g smm'\"msillStrn. QnJll'1\" nmst Ih« patient'. ,effi,,1 \"nu r>on-\\l~rNlI ~ignals, of whi<h Ih.,,,, a\", alw,ws miln}, n,., mJnipul\"h .., ph~'siolher\"pi51 musl be f\\llly ~'<lu.alro in Ihe Ih(.'<}n.'h.,,1 aspecl of dt\"l':nosis nnd Inlcr~srn~ly, as lrtiltmenl ,.aches say the Ihird \"\".ltmenl, bul she Illu,;l be e,'en \"lon: nh,c<1!ed in lhe Itssi\"\", Ih. p'lient rtaliz<\"5 thai ht Is bl',ng tducatell dil\"llcJI pa;sibllilks, TI,e hum,on body has nIl cnormou, n III how to lhin~ ,nd ofW.....l to take notice cap-,clly 10 \"d~pl ,Ind 'lCoommodatc lulhe insults and disca\"\" inflicl\"ll upon '\\.,11Io:l lh« abo''t' ladr is a pl'ffoct e~aml'll.\" of th,!;. Sa ab;o is the l\"d\\' w~ radiugraph

A>~ument 51 1ne palientlS then able 10 lll.lk.,> \"er:- pt.\"l1ull'Oll aOS\\H'fS TI:<'rl' a~ two d;fftorffi: kInds of ~\"\"'nt: I() quo:o;.hons. and ~ ~ I pm<:\"\"\" becom~ ~ uod moceaccuraIL' 1. Ii.: 'nlt!al cxa\"\"r.ation of a pal ent 2. \"\"\"\"'J'V>tIl ~ t/ft:~nl ~te; at tile bfglnning Jt IS ,mport.lnt fO'\" the ph\\'Siother\"plSllo reali:re th,1I of ad! =5ion. dJ\"llCJ the ~ of a the polloertt \"\"Ie 10 'feel.. far lTK\"Jn' thai tt.. marnpulati...~ ~..q ..., afie- ~ t((ll'*l\"\"' hzo; btt\" ~ at c:orrpletionrrfil ~atll1fl\"l 5a'>IOn. onra 24-hour ph)\"SOo\"ltt.,. ptst can \"'.\",. do,.'1ent\\lne b\\' a.mtiIlanoo - hl~ penod i......ed,ale '( foIloW'''9 t~e last t~il\"'erl bodyc.on ulfum, hIm of' ......- finl'cNns~, and it ism ~Ioo. not~tNely. .....,'Y t~;rt!ffuurtll ~Ion, respon';i1l1hl... 10 listen and.xknowled~e_ Therefore, il i~ afle, a b'.i~ f,om lnonmcnt, at the (Omp!Uion of treatmenl ~ ~\"ilytic~1 ~ument ,mportantlo say the fal\"'''in!> al lhe time of the first ASSESSMENT AT INITIAL EXAMINATION consultation: Thl' fi....t of th~ IWO applKllOOns ;s di,cuS5l,'<l 0'1\"\",· 'WhM )'00 don't lell mc, I don't koow.' 'Yom bod}' \"here III this book (Chapler 6), but in reLlllOn to this can tell you thing, which I C~I\\I1\"t d('t.'rmine by dl.lpter the\\';'\" one ,mportanl aspect, whJdt;,. e~nmininli you. so ,f you <101l'ltell m('.1 don't find OI,t nboul il- and that mi#lt me,,,, I miss out 00 A-L-IKi...C FEATURES FIT_ n:le'·.[I,t information.' 'So \"00 (an~, rou can't lha COl1Cl'J\",making featull'S fit', comes lllio e\"\\1:'n' a'f\"-'CI of eumm.:lhon alld t'l'atment,. and miD \",en> I('l] ml' I\"\" much, but >\"01 can ten me too little,' \"\"P\"dOldSS<.':iSmcnt 2, 'llll!fl< is a big differffice betwcro ~not mlJCh~ tlalirg fl'itJrtS fit is one of Ih~ ,...ost e=nlial alopttlS (w ...'.l1 \",f\"rring 10 ~rmptOlm) and \"nothing atilW: of ~=,ment The rna~ipl> .. lil/C ph\\'Slothe\",pi\" will 3. 'You mu.1 not fe<.1 rou a~compla;ningwhen lell the ~t,ent that his probl~ ,s \"\"e .. j;~-\" PIlule, rou 1C1I1l1l.' about the >ympt(lffili or whal CilU5<'!i and it is ~er job to m~ke 'ill t~. plCCes fit'. She \"\"\"ds hIS help 10 do t~,s, anod II,s he, ability to mmmunicaic lhem. You must feel. that)'ou are m'imllin)(. not Ihat male, Ihe dIfference tlctwcen her bring $lJe~\"ful in helping hom wiln ~is problcm or nOI con'plaming' .. 'Yoo m.J} IhinL of thing>. tholt '00 dO'il t'--d art In trukUlga dial;fUl'>l~thl' h'SlOrYoflhe onset' imporl- ant. and to ma~ an olCCuratediasnosis the onset mUSI rel.,kd to >our prol>ll'l1l, or i1'\" ummportant. You FIr, that is, be rnmp.lt;blt with the objo.'(:t:J.,.(\" dctcnni- \"\"lions found during \"\",minat>on. An \"\"\"mr~ is mUSl tell meaOOut them; let ml' bt.. tl ... judge.' gJ\\l'tl in the S«lion on fuston t.lking.. \".~ a man W<a5 \"\" ..w1~' disa-hl\"'\" by I sudden ansct of ............. pain 5. 'Can you\"\"\" wNI an importanl role you ha' e ill when all he did \"\"as I() te..ch 10 lake a cup of tt.., from lho' lrealment of your disord\"rr' his wife The- disabilir. doesn't 'FIr the storv of lhe onset. Therefore. t~ HAS to be <JIl\" of two kulds of In mllnipulath'e physiotherapy, \",Sloss\",enl has lI\\itn} re\"'son bcllind the mlllor -,nodenl\" and the ma\",r du.- faCe!l;,llll of which will ~ d':.(Il'lSt'd. Il(l\"~\"'\\\",,r, th,,~ ablhl}. Either Ihl'\", Wl'n' pl\"\\'disposing factors of a ph, _ie.,1 natun- or the.... mu:.t be some di\"..,n:;e-I)\"p\" \"re IWO dlffencnt kmds \"I ,\",'lOSSll1ellt thllt <hould be processdS theund\",h'inS diagnosis. The ability I() >et'k ddh\",dfj\",t Out the answers is the bibi, of sIJcccs:.ful aSSCSSllll>nl in thi~ Mea 1. Dum'l> the mltial \">.am\",~li,'fI of ... p.ltient, ~n assessment i~ m...de of: ThCI(' arc other pmbJ.. ms ns>oc;att..J with cli\"'g,1(l'l'. For ...';\"011'10', lin i\"it;...l dinSnosis may nl.,;,d to 1'>.' a) The diagrlO5is, indudmg lis hisroll in I\"rms 01 ch.lnSl'<l In rctrospt\"Ct\" h~\"ll it is seen how the p;ttiWt's the Siage of me di>Orcll'r and .ts p~t st._bih\" b) 1ne ..·..n; in \",hid! it atfl1Ct~ tlte pat\"\",t c) The:o\\ nlplornaotic ... ~ tolt\"'lt lTIO\\ em\"\"\",.... being the ~t p.ut of a tot.1Il?oOlnunahcn. 2. l'hroughout treatmenl \"\".....h a\", made of th,., change> rhat ocr:ur, and lud!-..,menb arc m.ld~ as to their dO\"gll'l\", their n~k\" ..ance. and the influ- m<o' lho.r tw,-e on mo(lifpnS treatmo.>nl and mo.JI· fymg ludg<.>menb of dlasn05i5 .md prognOSIS. On r«hecklllg (i.e. a;;~inlt) the palu.\",!'s original abnormal mo\"ements, it should also be J'OS\"ible Itl interprl't the \"alue 01 Ih\"l Il'Chnique aj applil'.1 10 th~1 particular joinl III th\"t pMticul .. , ,tilk of th\" dioordcr. This is the\" hole purpos.! of i\\s,es~ment EVALUATli\\'G THE EFFECTS OF EACH TREAT- \\-lENTTECH1\\IQUE.

58 MAITLAND'S VERTEBRAL MANIPULATION symptoms and slgn~ alter with passi\\'e mo\\'...ment signs howe remained unchanged. Unckr tllese circum- treatment An example will clarify this, st~nces treatment should then be applied to the gleno- humeral joint in an effort to elL,,, its jOlllt sigus, SO A woman was I'l>f,'rn.'<:l from an orthopal'Clk surg~'On, who nXlucsted manipuLltiyc trNtment for 'disc prolapS<' gaining an impro\"...ment in the shoulder and arm pain. ca,,~ing (7 nerve-root symptom~ and compressive There an' many such !.\"Xamples of combined joint signs', On examinallon, the thr<-'e cervical movements of inmlvem~nt to explain the different p'Wl p.1tt<.'n\\S m,d eXt<.'nSlOn,lateral flcxion to the left and rotation to the left ,yndromes that oc~ur from p.,tient to p.lti~nt. were all markedly r<-\"Stricted ill\\d all \"-'Produced tingling in the patient's fm\"\",m and hand, She had diminished Another example of mllitipl~ caUSL'S for a patient's \",,,,\",!ion in the p.ld of thl' terminal phalanx of the Index pain is SL'en freq\"ently with patl~nts having p~in in fing...r, mark<.'d weakness of the triceps, and a dimin- their back that radiates down the fulllen;;th of lhe k'g. ished tria:ps reflex, She WaS III conwferable pam. In relahon to l~is an',' of pain, phy~iother\"p}'sh,denis Tmchon was the treatment chosen, and bv continual m\"y fjnd themsch-es in a dilemma \\,.h~n learning der· a\"\",,,>sment over the first 4 days noticeable i\";provement matomes. Confusion is rn,derst.\"\"d\"blc wh~'fl one dia- W<lS \"pparcnt in pam, cer\"lCal movements and neuro- logical changes, She only reqUired ID treatmenls, with gram may show the LA dermatome as stilrting in the moblli'A~lionand gentle manipulation being added for low back a,..,a and spm~ding lhrOl.ghout the bullock II\", lasl SL\";sions, Atll\", conclusion of treatment, there and leg to the lop of thc foot (S<\"t' Fiswe 6.4), while Wati complete =overy of cervical mOVf'ments and ~Il another Olav ,how ttl<' LA dermalome starting below ne\"rolog,cal changes had rt'tUrlll..,j to normal th\" kn\"\" a,;d r.,dialing down the shin inlo the foot. Therf' is g[)\",J r..ason for each of th~'\" pr€s-ef1t\"tlons. After r~~\"xamining the patient, the OIthopa~..,jist nle1\"\\' are variou, causo-'S of ,..,ferr~..,j pain fm'\" pres· apl'nxiab:llhat the pati~'Ilt could not ha,'c respondL'<:l <ure Or irritation of a ner'e root - for ..,xample, there SO quickly if the original di,lgnosis of disc prolapse had OC'CIl COlffC!. In retrospe<:t. he con,iclered that the may be a prolapse of thf' nucleus pl.llposus, or the pnr symptoms were caused by synm'itis or infbmmahon tapsed material may be in direct contact with the nerve of thes}'no\"ial joint \"-><:lucing the diameter \"f the inter- root (~nd not thedur,' or nerve-rootsl\"\"..e). Under these wrtebral foramen and thuo compressing the ll€rw. circumstances the pain will orlly b\" felt below the knee. An important point is thai if the pain is felt only Clinical not~:. pati~nl's ,ym~tem, m.y ad,. lrom from th... kn~'C downwards. and if it can be shown th\"t mere than on. SO\\Irc~ [e.g. a sh\\luld., ard a ~~rvi~al this pain 10 arising from tho: back, then the pain mosi 1:><: compon~ntl. whkh have both to b~ addressed in due to irritation Or compression of the nerve root alone. t,eatment Another example, which is fnr morc rommon, is the A furlher probl,o,lll related to making a diagnosis is lhe bet tho,t somf' doctors consider that a patient [an have patient who has a diagnosis of LA rd...ned pain cXk'f1d- Oll€d,,'gnosls only, n'ereare lll~LancCS,however. wh~re ing from the centre back arN through the bUltock Md caref\"l a,5CSsment and skilful planning of pa,siw: leg to the topol thf' fool. Th~ I<'ason for thi, m,ly be th,l! rnOV~lllent t,,-'atment will show that a patient ha\"ing the extruded disc !l\\IIterial is Irritating olhf'r p.lin- p.1i\" (,...y)arlsingat the ba5f'ol lh\"n\"\"kand radiating to sensiti\"e structures In the v~rlebral canal, such as the the shoulder and mid-upper \"rm may haw J shoulder disurder cau,ing the shoulder and Urn pain, coupled ,,,,(1po:;t~rlorlongitudinalli&'I1\"-\"t, th\"Jur\" the ,,,,rvl~ with a c\"IYieal joint dtsord~r causing th~ neck and sc\"pul~r pain. Ex~mi\"\"tiOll of Ihe joint signs for both root sleeve. as well as the \",,\"'e root. Under ttit'S<' cir- theccTvicalspill€ and Ihe glenohumeral joint shollid be cumstance~, wo: may have four contributory cau,,,,\" for accumtely assessed at the initi\"l examination, If joint the pati~nt\"s pain signs are found both in the ,houJder and in the appro- pri.lte Inlervertebral joint, then ideally treatment should II a p.,tient hati pai\" radiating from ttit' buttock be appli~xl only to the cervical spine at firsl, The joint down the le-g: to the top of the foot and he complains signs in th<: spine may imprO\\e. resulting in the pati~'nt that the worst part of the pain is III the tow~r leg, then losing his neck and ocapubr pai\" but retaining the shoulder and arm pain, RL'-C\"\"min~tion of the glellO- one can confidently assume th\"t the nerve root is humeral joint may re\"eal Ihnt the glenohUlTl<.'ral joint's involved, particularly if spinal movem\"nts reprod\"ce all of this p.lin (and in p,uticular thedislal pain). \\Vhen pain is I\"lt from the lower spine to the foot, Ihe di,;<; and ~djacent posterior longitudinal ligamenl ma}' be causing SOme of the pro\"imal pain and the n~rve root and its slee've may b\" the SOurc\" of the distal symp- toms. Therefore. mOl\"<) than 0\"\" factor is causing tl'\" p~tient's pain, From the foregoing it is ~asy to s~\", thai there arf' many problems associated w,th diagl105is, and the'\" is still much moll' that medicin\" has yet to ullIavel, Howe\"er, the problem musl be taekled, and

Table 4.1 Taking the history flo\",' 10\"'] h.\"\" vou had it' Im;ly n,.d to follow u~ with 'Haw king THIS TIME1 How did the pre .. ot bout b.g,n> I bpont,n.o\"\" <omm.nt~) Gr.d~al [<Iorin, ,udden or9'~du.1) I I I WMt didI you noticet\"t? InLid.nt No i~<id,n~ I\"\"\",ily) qul(i:1y Ir -\"-I_,I Ir--~I_--,I From p'edi<p<><i\"'l Fmm inc,Mot I\",o\"ity Nut 5t~(k Stuck W,k.o,d Ou,ing vmh am/pm adi'fiti.s, .t~ Of why r.l,ted) I PREDISPOSING FACTORS t. P'e<!i'p<)sing \"tio,ty: [~l unu5li~1 (b) he\"\"\", kI5~I~intd pM:ur~ 2,Vi,u, 3.0,.\"1I,,.d 4. Cold, d\"mp, d,a~gh1< 5, F~milial 2. Relate '.-<fity 01 intidtnt to d'9'\" of d,,,,b, il'f for romporobility (\"\"iou, p.thology) 3. History of local paio. hi,tory of rde\",:d p.in (Iim~ ~;n upw..ds Or downw~rds) 4. Prog\"\" \"\"'\" initi~1 pe,iod 'lillleo,lIing off 01 'ymptom, r,.viOLtS histCf)' 1 Fir<;t btlU! in ddail' C,u\", Duwion l . .\" l m . , t 2. Succ\"\",,,,, bout<: Frtqu.n<:y Ea~. 01 cau\", R.CO\\I.ry: rat. (Res!, f\\ \"c.I l M.dic.lhi'lOrrl,nd,ocio--~or>omic) in the meantime when a d;agn05i5 i5 incomplete th\" grealest dewlopmenl in manipulative physiolher\"py abilily to m\"ke the proper \"se of 'lwo-comp<>.rtment' in ,\",-'Cent years, ~nd ha5 become Iheone arm th~1 pich lhinking make.; it possible to use manipul~lionwithin 'the wood from the trees' among manipulahve phY5io- roul;ne medical C~I~, and lhe treatment i5 made safe therapisls. The aspects oi asses;;menl which have and informative by ,'i,tue of good .,sse;,;menl ,hone through us bdng lheoo ..\", providing finest value Heinlhearea50f: ASSESSMENT THROUGHOUT TREATMENT 1. Communic.ltion This ;5 an arc~ of multiple compl\"xih', c5peciallr in 2. Beha,-;oUI of pain, stiffness ,md muscle spasm interpreling the f;ndinp. It is one of the areas of the 3. 1'h\" comp\",i50n5 bd\"'~\"'o norm\"l ,md abnom\"ll examin\"lion finding5

60 MAITlAND'S VERTEBRAL MANIPULATION LKh of tl\\('5(\" need~ 10 be discussed in d(1,\\il, but As=Sftr'1 of dII\"9es '\" t~ palltnt's W'ftP10lft!> bej~ th3 is donl.\" an ouillne ut 'olS5C5ISmCfltlhrou¢l- 1ICC'IIf!.1hr\"\"\"}houllllttr~lm ... tproct!.S r ....outt~..t\"\"\",r wiD bl!' .... ~ 1. Ir1li<1l u;ol\"n;l!M)rl An Import'lllt pilrtof .ISSl'utnenllS tho;, abili1r kl n.\"('- 2. At ltI< bl:9\"ning of tac:h lmnroffl ~ ogni..... p.oltern.~ of ~~\"n(/romc.-- \"1<0, ,t is 1lC'C\"SS-.n to 1M' aware of the ~tent of Imrron-mmt ' ....1 rn.l\\ bl> 3. During p..-'or,urct of .. 1o:c:/lr1iqut nchW\\'ed ..,Ih tn'alml\"rll Tho:! ool~ way kl gaUl this 4. Aft\" pt;r'o<marct of i tfdl'llqut pruflCl<!IKy is by e1mical <!Xperience t>ased on accu..,t., 5. Aft\" compltllOft of t\"'illTtnl session 6. Retrosp«iM iSRSsrotnt .. l t<tdt 41\"'Slh critical ;lSSl'SS1TlffiI. \"tml.'d wIth this competency. and as:l member of ,I h:am, It\\(, ph~'Siolheraplst can offer ,\",armtnt stSSlon curbtnJ<;ti, e ,uSS\"\"ljons 10 the ref\"rring dOCtOr 7, At C'Ompl~tIO\" of trt3tm~nl \"'!larding the physi,,,l sid., of Ihe miln\"gement \"/Ih,; patient. Achie,'iT'lg Ihi\" competenq is ,1 ~,ow pn>ress pro,,~n fach thl'y \",,11 cnd up with a w..rl('rof ralher \",i~hy·wa.hl'kno\" k'<lllc which ;~ofHtllc\"'\" in the \"nd is not to be r\\J~lwd. Miss J\"nnifer 11ic~ling, ,1 diffclL'fll .itu.ltio/l' \"h'clt come ..Ion&, phy~ioth\"rapi,t of nOle i\" tIllS fielJ in Engldnd. ollCe li<1id lum,,: A~nt of cha~ tIl the p.'1lie\"t'~ ~ymptoms dnd ~1p1S Iltn)u~1 t\"\"\"alm\",,1 is ,\"\"de altho! follow- Manil'ulation dl'Jl'<\"'l'ds \"pOOl clarity of lhought and inlllimes: cnllcallhought. reople hane to bl!' trained lit it in a 1. AI n... begumi,,!> 01 each t...atmenl ~IOO (so th.ot \"'''v.mOlSt det.1i!ed It is ,;a\";\";\" I\" adtie\\'e Ih~ \\\\ .th a Judgt-rnent can be m<to.k- .., 10 .. hal ~Id bc donelucbv). undergraduate sludmb tM\" \\\\ith pcslgrad....le jX'Opk because lhe lalll'!' h.l,P Sol min ~ h.1bll of 2. Dunng!hl' performIng of earn tmltmerlll.'Chnique lhml.mg in otht-r \"iH~, and it .. <hi6cult I\" undo (to be aw\"... of cn.\"'b\"'> the lechniq_\", h.1\"\"I: on the p\"ri<.'nl'~ symptoms\" ltd.. II is l><.:intl; jX..fonnedl ~h.lbils. 3, Afl<!r the t\"\"hlll'lOJe has be\\'n performl'<l (10 dt'll'l\" This blJSirloe.<~ crf nK'thodicaJ. critICal ttunlunj; mme Ihe immedia~crt\"\"l of a tl't:hniq\"I' and mdkc \"jlldgcmenl nboul w\"\"t should be dOl'\" now), \",'SUllmg in addIng bnc~ 10 b<1C~ is terribly import- ant. \"\",'ice. mIr>t e~jX\"Ct k) get fewer \"\",'Ui1S m(1I\\' AI the mmpktiUI1 \"f tt\", t[('alme\"l ,;essiorl (5Qlh:u slowly Ihan the c:q>Crien«'d pcr:;on. and titer mu~t the I'''''i<'nl df~\"Ct of the whole IrcatnW!lt Sl.\"\"inn is ~nuw\". a, distinct f((lm whal m\"y oppeM!() h~,,, Tl..~tlhe Il>mplallon 10 !I)- ~hort-<uts changed with c'teh I<'<:hniqup) NO\"'CI~ need to dearly ul1dl'r~tand thdl e\"en' S. (ft'\"r Ihe 2~·h()ur perioJ immediotd) followm& little bit of di,,;cdl ~nO\\\\1ledll\" th~r g<'1 Oul of ~ thl' lasl tl'l\"\"ln>Clll Sl5SIOO (becausc this i. of'ten 1M most important infOfmllt;'.., period) pal\"\"\"t, pW\"id<>d !Ill')' MI' '\"rla;n aboul wh.11 il i. 6, As a n'lnl>f\"'C!i\"e r.lSeSSment lind what th\" re~nlts M'(', adJ, up to\" brick which I> a) At the begtnrung of e\",h fourth Of fifth I..,dl· lI1t.'f\\l sesinn (ohct> 001 01 ;n_1 done 1<> con· dcar\"<:ut; a fact thai I,. not only useful for thaI finn the dav-Io-d.lv ~t) pall\"nt bnt abo forolt...r P..tll\"lllS lhey must meet, bl \\\\\"hen thedmounl or \",\"'of progress has ~Iowcd r..... ,-\",amrle, iU1 I\"XpcrK\"IlC't.'d ~ \",ho is PI\\.\" or st\"PP'---d (to determine the \"'.bOAS and pt.1n lh.. \"\"ioo~) pa~ k) tak a cakulal<,<l cha\",\"\" not m an ull5C'nll)U- c) Following a\" ;l>6<'s\"mcnl b.....k from tl'\\Sltll\\ellt (kle<>L,bl,sh lhe pl.tee of further tTe.. rmenl), 10us <II' unpmfcssiOl\\ilI way bul menlally, \"WI\\\" ~o 7. f\\t the rompIL'IIOl> of lreatment (10 IIlil.l<c ludgc· SlI'i\\tW>1 for a particular t«hnique and say. do lOu- 1n\"\"ls un pr'Ol:n06;5 .. nd prophybxis). tlOO to lhe left iL5 .. V, right al!hc bcginningof I~al­ ASTERISKS mcm•.nd..nem.oy get .. quid \",--_ltO!her.; .. hofL'\\\"I Itw;r way into it might flllillly rome w Ihl'rooclll>lOIl Ikforc discussing as!Oessmcnl undpr IhL><;l' l>cading~. the use and \\'ill\",; of .hlerisks (0) tIl the Il.\"Cnt'.:!ing of Ih.lttru:. \\' IS ......,.\",<at'}, Dulll might taLe them si,,(W :;en:o lreatment:. to K\"tlho!re It i, much bo>t1Il\"r 10 ha,'., taken sri or \"\"'1'1'1 tn\",t h.J\",mcnl5 to g<!t lhef'e and to JU\"'hfoed all ttu. way nllln~Ihe h\"\", lh:!1 rot,'Il,,,, is the right choice. and that the dCb>ge i, the ngll! one. To ;m;\\'c allnc \"\"'~I!l by gUP:§l;work dot'S ,\\Oth\",S for thc nu\"ic,,'s future good rn:u\"'gcml'nl of m.mip\"!.,tlu,, I;\"\"'-'fall)', wheR'a.' Mrh-ingallhl' right n\"'llllllll'>R'<lowlr. ha,'ingpronod til her f;/ltisfacuon Ihe COrTl'CInl\"\", uf ,,\"cry step alll\"!; tl\", war, ,,-ill pay hands dow\" i\" the f\"tuT'<' Unk\"S\" no';C(\"I an' prt.-p.1n.'<l tu Mlrt out lhell' knowledge as r.... ;'lj; po:o&;ib~ inlo lhese c~dr-(ul

examinMion ,'nd treatment n('('ds explaining and pll!- COMPONENTS - 1 ring into the prop<'rmnt\"xt, In ord\", to p'l'<:is (success- fully) and C<lmm,t 10 paper both \".,amination and For each pJlient, astcrisks should be used to identify t~\"lm\"nt finding~, one is forced 10 be de~rer th\"n the \",ays in\" hieh he l\"aws h\" i~ affected by his ~pil1~1 would be the case if recording w\"re not done, The disorder ('subjecti\"~ ~srerisks'). From among the a~terisling nlll~t occarrie<:! [}l,t at 111~ tim\" of recording point:; he menllons, asteri\"ls should lJ<' \"ppli''<l to the l·ach pit'Ce of information ,iuri,,!! th~ consullalion, and notldlllnlil the end of Ihe wnsultalion. HJYing been folto\"'ing thus enforCl'd. tl1(' '1<')d ,Iep i~ 10 sek'Ct out of the l'ffording those sllbj<:.:the and physical finding, ItMt Any functions he b unable to perform \"ormaHy and mllst imp'o'\" if till' patient is to be made well again whICh rel~te IQ diflere\"t wmponenb pfhb Ji~>;n,,­ This asterisling m\",;t b\" carric·d Ollt at th~ tim\" of 'tis, For\",x<Ullpk h,' may nol bt' able to walkM briskly \"-'Cording Neh piece of iniormatian thought to be worthy because th\" inc ....·a51\"t strid\" len~th \" ..qui ....'<l is lim- of on asterisl, throughout and dllring thO! consllitation ited by a 'canal' component j,t'<' p, 000), i.\", limik'<l (nat \"t the end of the wnsult<llion). 'denlif~ing thl'S<\" straight le)o; raising: he m,1y not be \"bl\" to st,u,d main a~\",~,m,'nt \",,,rkers with a large, obviou, asler- e\"'-'Ct beca\"s~ of a discogetlk component. which isk not only enfon:es a commitment bt,t also \",a\"\"'~ may be totillly lmrclatcd to the c>\",al compon\"nt. To rctrospt.'Cti\\'e a~5<'S5ment~ qllick\"', easier, mort' com- ju,t mMk one of these two\" ,th an ,lst\"risk could plete and Hwr\\'fo....' mpT\\! ,\"aillablc. [('Suit in not apprl'<:iating thJt, although one com- ponent of hi' d\"order (as he ,ees it) is improVing, A5t~rish are an invaluabl. ~id in a5\",ssm~nl. Use ~n the other is not. ast~,is' to h,yhl,ght lh~ following in Ih~ f~c<lfding If he h,,, \" 'positionJI' compon\"n! (11,,'1 is, he is • Primary sympl~m~ or d\"abil'lits/acti';ity limi13tions unable to Ii\" on his right side) and ~ 'mo,\"\"mL-nt' • 5ign, th.t r<~rUliuc< ~ pali.nl's symptom~ component (he h.~s Sharp sta.bbing pain wh<:n • Oth.. information thaI is impot\"tam dionbing .. ladder), eaLh must be identified with ~n • K.y iss,,.s th.t n• .,j to bt f~lIow~d up asterisk fo' the S<lme reason\" )o;1\",>n in (1) There are thn~' l,:,·l'!s of distinguishing n\",rke,s; \\\\'h'.'I1 a pati\"nt h.,~ mol'C than on\" pam, at Icast one 'subt\",t\"\" a,terJsk' ~hould be u\"\"xl for e~ch pain. 1 A~terisking it\"ms that th,- pot,ml i,kl1t;fie~as being primary sl mptpms or diS<.l>ilities Some p~tknb' 'ymptoms ~l'C only of an intermittent nUL\"\"n\"\" qtMlity. It mav be difficult for them, 011 first 1 Ast\"ri,king informotion that the clinici\"\" oonsid,:,-,; bt'i\"g 'luestioned, 10 rrO\\'idr a rcli~ble <ubj<:.:ti\"e to 1x' aspects of major importanee,l'H'Il if Ih\"I'\"ti~.,'t \",t\",;sk b,\" which progress m~\\' be assess.ed. Under does NOT ,.~: th,>m as being mJjor (e.g. tingling such circunb,ances the point must be pursued: pins and needl,., f~11 imcrmittL'Iltly along the later,ll border of the foot). Q 'H(\\w \\\\'ill ,\"\"0 be able to tell if von, Ilffk is 3. Kcy issu,-s thdt must be followed up because of impro,'in,:;\" - doubtful di<,,,nosi~ ,md the possibility of e\\·o!\\·ing disca\"\", Thes<' can be mark\"d \"'ilh an a~terisk A '1 don't really know' and br also 'highlightin~' the ,'ppropri,'le written SlXtinn Q 'How <;nn )'OU find out' - 'I\"'hat priJ\\\"nkcs th,' unroll1fort\"ble fedi\"g?' A'terisks an: a rnNns to an cnd, not an end in them- selves; tiler aT\\! not jargon, neither l1('C..,;sa'r to nor A 'It ju,t seems 10 come of it:;; own accord: f\".'Culi\", to maniplllati,\"e physiotherapy; the'\" a\"\" n~,\"er­ Q 'How often does this h,'ppen?' lhele,;s, an ;m\"aluJbJc aid in ~ss...ssnwnl. Th\" ~st~r;\"ks A 'Oh. it's not rL'gular: must be wriHen into the record JS th\" infNmatioll is \"'CordLod. By doing it this way, th... lh~,ap'''t ,ewl;\"'~l-s Q 'How long can \"ou be withemt it\" whdt is \\~orthy of an a~tl'rbk mOT\\! <juickl} A 'Oh I ha' e \",mething e'\"cry day: Q '15 it rcallr e,uly in th\" da), 0' at th,., end of th~ day:' :\\ ·It's usoallr there when I first get up in the mo'ningaru::l thct1 perhaps\"t the end ofthed~y.' Q 'I, thl>;\\ fairly ....'gular p\"ttem?' A 'Well, J\"\", I SUPI\"\"'\" it is \"OW th\"t ypu put il that way'

62 MAITLAND'S VERTEBRAL MANIPULATION nus isan Olkampl\"nt u... mental disripli\"\" It><.- \"\",niru- As l~atmenl progres6l.'S. thca;.l\"rish-d ~1mptomsa\"d <igns ,,~Il change; S<)I\"fIC rna) go, some m.'y dlan~ in I.,twe phy,.ioU......artSl must \")\"'R:~10 Am\"e Al lhe \"1.01 rnar\"\"\",,\" and \"\"\". one5 ma\\' be 1'.l...eIIk.-d_ \"e'''~ lhmughoul In'a_1 tJw subjecti'\"t' astl-\"I'isks O1lbl issue-11M> pomt cannot be glO!\\lied O'er match the ph~!>icaJ Aslensb. this is another example O! '1AKNG FEATURES FIT COMPONENTS - 2 Although II is not ....ithout value to 1,'0 through the In tho? physICal eumination, some N\"Ie,'am tests o:obif.' proce5IS ol ~I as a mechanical process, illacks ql.l.1hl~; il IS rJ<lI>odi\",rimll\\llloo' and lead> ~t to one component 01 the patienl's di$<Jnk.,. olnd oIlwr nowl'Jen> HQo,·{'\\e..., if lhe findings lire relatOO to the lests ~1a:e ro other component>.. lust as ;t!;lerlSb at\\' ...-pectahoru. of lhe 1n.·atrr>o.\"'l tt.'<\"hmque, tm- diagnosis ..-ded few different components 01 the su1;ecb'\" find- hi5to~· ..00 prognosis, and lhe possibilities in the ings, '>(\\ are ~. equAlly ~TV fur ~ diffet\\'TIt u...\"\"\"lablhly of sclechon of loIdu>iq~, a5ses&Dl,.,.,t components of the php;ical eJGIminatm finding$. This bccrJr\"\",. ,{'p, d,SCf1mlllillon', m\"lu\", .. nd ,·aluabl\". is m<l\"t ckoarly >«II Il\\ the ex.Jmple of a palient 'dw 1be paths for'lc\"mmg 1.....1such.l pl'<lcr'5S of assessing and 'making fmtu,....\" fir an.'m/inll., And if the p~ hitS pain ToldialinS from his bxlt down to his foot, is carried into the reAlms of spe<:ul\"'ion (sn pp. 7-8), Ill<' mental. pl'OCt:\\>'oI.'S h,,,·>! ''''' oouud\"'ies_ It i5 in this \",h\"re t~ i~ diminished sem.alion along its lateral area th\"l as.>eS/iment wange'S to ~nJlyll\",1 as>.es&rr>o.-ni- h/I,'\"OOrd\"r. An of tlw follo\" ing should an asterisk: EarlIer in this chapter, th,' following \"\",as \",,,reslated as ocing th\" a\",a~ofgn.'illl'!>l gn,wlh 1I1 :ll'6l~m\"\"t 1. A mew\"m\"nt th.,t pro,o~\"s shack pain al()l1<!. 2. A movem\"nt thai reproduct'S Ih\" \",f\"rn.-d p~in I. Communication 2. I3eha,-iour of p\"in, mist~nccnnd muscl\" spasm. a,J. A Illov\"m\"nl «llCh ,Iraighl leg r~isinl;) thaI 3, Identifying normal and llbnorrn~1 finding\" il,dieaK\", n.'Slricle'Cl canal/foramina mO\"em\"nl as COMMUNICATION OOnll\",...'.Cl with inll:'rvcrtcbral joint m\"\"\"menl Thit; subject has Ix\"\"., dealt with in dl.'lail in Chapler 3. ,'I'4. A pailHhWlIgh-r,lIlge mO\\'<:'nwnt ,1S compilre'<! with \"nd·u/·range pain (1I\"'l is. a mn\"cment BEHAVIOUR OF PAIN, RESISTANCE AND that I, unly fcilio be p.linful at the CI1d of ranlle) MUSClE SPASM lho.~ at\\' I1Mny \"lherlinds of rompo\",~,l>. and, \"'h\"n BEHAVIOUR OF PAIN 0\"\"mon.· th.\", can be id'~lifioo m a palient'~ d~\"Jc.,., Pain OiIn be~~ in • variety of ~ n \"\"\"tiomhip til ........,,,,,,,rl, _nctudlng ~rv pa .... Il:ka51: pam. I'ach should be m.uk<--d by an aslen~k. t~ttnt P\"'n ~nd ~tttr paIn 0 ffntnl pain, can occur tn d,f'ntnt mO\\'tlJltl\"l~w I~ tht samt pil ntl Following the physical e\"\"minallon of Ih.: p..I;\"'flt<,s Pain is A subjecti\"e experience. it is influetlCl.'Cl by an mcn-aTlI.'flts, tilt main findmgs should be ldenllfied ~ etlormous ,ariety of factor<. and il presents in IThlny differenl ways. It is the mOSI common \"'''SOil for a f\"->t- llsterisks. HO\\\\~X'I', itb importanllAallhe\"Ol' ~uld blo son \"\"\"king.. or being ref\",rrt,'d for, mmupulatin' physill- therapy- Rol'~ Imming can leach Olue-h about P.1in, but -.:l«ltd findirtgs; not \"'-e.:\" itnn i$ wor-Jly of an aster- tu cXp\"rien~ p\"in o\"'-\"sdf, or 'ft\"I' it vicariously with ('mpathy, is far \",ore '-alunble. Trlblr 6.1 m('nlions the bk. To us(> aslcl\"isl<s indis<:riminald\\ dostm'''s darilV il\\fhl(~'c~ of p<>·choe.!lCil..l-(.'C••nomi(: factors - ,uch jnfi\"\",,~.spali\"\"l.\" ishlng III pl\"al><:', the ,ariali\"\". and indkllre.. bd< of ttoinlang_ Asierisks shook! ~ ustd to idft)Ill)' and luJ;lilight the dIfferent rom- ......\"IS 01 a ~tient's symptoms. Tl\\t foIlo\"ing lire t.'....mples 01 diffemll components, some or aU ol whICh may .\"isl Cl>rKUrJ8'Itly in a p.ot~t: 1. A\"af\\;\\1 llo:J1lmmajoinlsign_ 2. A 'st\"\"ch-pain· ~Igtl from 11 'compress-pain' sign (_p_II\\6). 3. n '''n.ogular-p.ltlcm'mcr.crnenl ~gn 10 id''fllify II From among a rollect>on of '''1;ular·pMtl'm' O1()\\.<ment signs (sn' p, 136). 4. A pain-through·rans\" O1m'ement sign 10Ide\"'lIfy it from an ·I.'lld..of-range-pain· 010\\ ~menl SIgn when both arc fuund un e~\"nJ1n,'lIon(51 p, 188). 5. When a pal,,-,,,t no,s more th,,\" Oil\" co\"'ptu ,t 10 jlls p.~in, I' mon'lllt.'nt thot pro<!ucest.','l'h romptll,,-'nt sho\"ld ~ identiiird with an astrrisk. An \"xample of thib i, when cen'ical roLolion 10 the ri,.;hl pro- 'ht<\"CS only scapular pain, dlld lateral flexion 10 lhe nl;lll producl.'S only tingling in th\" ind\">' finser.

AsI~llm~nt 63 in patlent{ ps}chol~i(cal and ph\"Mologlea] p.lIn e\\du.;wlv with elderl,' patients. Whl\"l\\ lhe spin<' is LIlkn to ~ limit of anI of the mo' ~'Tl\\mb sug,gested thr<-'SholJ~ ..nd pOlIn\",,\"CC\"l'tano']\"'L'!s - ,,1101 \\\\hich abo\\\"l' and '\" l!T-pn'SSUn' i~ aPf'hoo, the mo,·..,m\"nl mal' be qUJb.' pain free; howe\\\"l.'r. 111'1.-' Ins!.mt lhe patn,nl ,aT) from pc to P\"~- .>.sse5slng .. pat!cnr'. st.,rts lhe n-tum mo' .............1 sh.lrp ~ l\"l'l\" moment,,,)' threshold of paln , lX' ..>o$isled b~' firm!} -trelching p.lin is e\\peril!llITd. Such a -.ponsoe <hould be dassOO one or t\"n III th., patiomt's IIl'nJ!iII jo:nt'i;lnd noting \"\" t>elnlj, abnormal..ond tredlnl'l.'f\\l .houkl boo .aimed al dminatingit- their ~_ Kl''l.'k-' (1967) statn:! lhat n J'I-'r Cl'T'l1 of Latent pain po:opk Iw\"ed ph~~iologic.l.llo\\,·F\"'in Ih~d. 17 \"'.,. cent Iw,... .l. h'ilh f'lm 1h11\"Shold,.md 60 per cent Iw,,. 6ec.l.US<' mOSl t\\1\"\"> o'lat<.'t\\t ~~\"'rtom,ame from dis- .on .., ....ag\"'. nonn.>l pain Ihl'C5hold. For thoi! dinid,n, orders which aR'diificulrTO Ilt-'lp. \"~\"\"\",,,-..mcntlll-'eds to b<' pn~ to deled SlTldlJ ~q; ] p<'r .....'1) ch.l\"b'= lilt-' ~ Il\"lIU.I\\.'Tl\\l-nt IS to lJ5kn, 10 beIK-\\,. ;mel bl' Thl..... aA' m.Jn~ ,-\"riM...... of latl\"Tl' p.lln -a.... to ~ unJl'....t..nJinl; ,,!wllhe p,Jlienl is tl) i.ng W \\, ram occurring when ... tot mlwcment ,s su.tained_ For \"\"\"flIpl\". a pallenl rrt'-..;.,,15 wolh p<l'\" in h;~ \"\"p~ If the m,ll\"pulative phy,.iottw!l'3p\"\" c,mnot 5<':Jpul<'J and triceps a.....,~_ On \"\".llTllnation. the rou- tiTlC cen-;ca] let mn,,'mcnb MI.' fnund to b<' full !I'''''learn to do lhi:>, shc.oould up b.>fore ....\"\"tarh II ran!:e and pain!.\";,,. I-Ill\"\"l,,·,,r, If cen·k.. I ..\"lell5ion \"\"'st..,,wd (for ,.\" 10 \",\"'Con,b) while >Qrne 0\"\"'- !he P.llic.'nt 5<lf', '\\I~ ;lrm (a-.ls h<-a.-v' ,w, '~h back pr'<'5sur(' i, al'O maintained at the limit of it> r,mge, the p,lin m,ly bl' rcprodUCl'{1 onl}' ~t the \"\"d of le\\...s as if II'S m.l ,·ic.,', accept lhe sl\"lemen!. tre\"l him 10 St.'OJnJs. 1\\1'0, wh.,,, the patil·\"r, h\"\"d is wllh sck-=~ lI.'Chnl'1Ul'S,md Ihrn. 00 standing him up rt;tufll,,,i to the upri!;ht p\"\"itiol1 ,t m,w I~ke som.' «'C(1TWS for that p.ain In 'lJl'~ide. Thi, kmd 04 to.lSSeO»o th,. effect of !he tcchruque. ask. -How .. th.>l behaviour is .. \"en' ,1ccuralc ml'asl!ring ,ock_ If tn~ltlTl\\..\"t 15succcssiul. t....... susl,'ining rime \"-\"'l.uired hcavln.,,;o, no...!' 01, '110'\" is th.. t ·,·k,.\" fe.-11I1K, no\",7' 10 reproduce the p.,in ,,-ill \"lC\"-~l5e. or thl' lime Lll<cn fnr Ih<- symploms 10 .1Ib>..dl' \",ll <k'C...\"..., If ..... uw Iheir words. they readily r''''ognLt.e III<: qUl\"\"- T1lt' ~oal of t\"-,,,tInt.'f\\1 ... to adl ...\".. <\"mplom-(ree lioll;, nIl.:! call ,,,,~\"-,,r ,m,m, .,Iuably and ,,-e c.. n ma~e mo'emenl no mailer ho'~ Io~ ,h<- .,~t'.'nsion ~i_ I,on '\" \"\"\"lained. i\"nn if il i$ \"ustained \"hUe a mOre fO<;Ilp\"K,f .,_'Ssrn\"n!. If til,. patienl'. tl'rll\\in. awhing '-f'J\\ Stl\"Of\\!: \",cr-r\"\",ure ol\"KY ~ .. nd l'ol,'onci.,ti\"n) Me used, the assesSlTll'Tll is 2. r\"in ocCUlTUlg 'oQOli\" <e<onds alter a sust.:limd resl OlO\\·c::ncrt.tbre....lSl'<l quichr, In\"O' atf\\,rately translated and gil'''\" the 3. 5umm.ttion of p.lm eillwr ..\" ~t 1:loJ' 1!llll'Tll> art' patlel'll a fcdin!: of !.>ciOlg understoo.:!_ A p\"'i\"n' tl,,,-,,, continued or \", .. tc.\\1 po;;i,i<\\ro is su5!.lir'll'd_ It can .. 1~ occur \\\\ith repctiti,,, o.ciUato') 1rT\\(l'\\'.......... not h., e 1\"1'>\" ~1\\lpid ttl ha ...• bizarre symptom •• alld it is iniqui\\(>l\" 10 label h\" <h.-or(ler a~ 1'\"\" \"h\"\"\"o\",llc 4. A \"urg<' of pain occur1'inj; .. rter a 8l'O<JP of tc.\\t unk-\"\"S it I~ I'n)\",~, tn b<! so, To repe~l a previous st~«:· mo,·..menl5 ha\"e been pt.'I'fonno.... This sUJ'S\" of pain ;\" a n'dSOl\\.lbty fn\"qU('llI find'ng.. .mu ,.... l-;<;l'nple menl, the p~henr~ 11\",,,he is innon'nt until ptt..-en will help f<) l'~pl.\"n il_ A P.llIi.-'t\\t rnav h\",·., pam m h\" ltfl \"\"\"pula radialml\\ mlo the b.>ck of the SUllly, not the o,n'T'.'.('. upper arm, Durin~ the e\\~mination of his Ct.'T\\ icaJ lTIo,·emt.'J'l!>, all arc full '~OlKe and painll'SS. How- The prescntJtlOIb 011(1(.'11 and refern.\"<i p.l\\ll\",,,, d, .... e,-er, imnlooiatel\\\" following the (',<\"minalion of CWl!iCof in detail in Chapt,.... 8 (PI\" 183-!12j. l;>ut !.home his mo,'('ments, the p.'ticnl m.l)' h.\"\" \" ,urge of pain mlo thl' scapul~ ~\"d Mrn_ WI\",n ,his occurs areothet-\"'luall\\' Important fdC\\\"tsof pain which n'luiR' the firsl time, it \"'ill not bt: po;,:.iblv to lo-t\",,,,,, hich of the tl'Si mm·\"\"....nlS has ~timu]<'led Ihi.~ ]a!<'nt \"\"P\"ral., m~..,hon ho.>re. pain. TheCMmin\"\",hould ....... thi. phcnon....non as a Rtcovcry polin In this calo>j:on. the.- poll:\\{'Ilt fl't--'b polin as .... bnnp h,. bod} bl\\d. 10 lhe uprighl ~taninll position iollo\\\\ m.: IN mo, ,'m'-'Tlb FOI\" ....... mple. dun~ ......m'naf1Qn .,f tht-' I\"\"nk nlO't'mt-nl~ of \" polDent with Iral low b.>cl: pain hos lnInl.. o,.\"iQn is tested. The fanse rn.l~ be full and 1'\"\",1\"\"\". ,..,t,,~ he rt'tums to tU upright J'O'\"\" ilion from the full\\' fk>.ed pos,tion II<> '-\"'peri............ I\"\" bOld: pain dunnK an an: \"r tht-' ....turn m\", ..~n,. From \"n .,..,.........ITI'-'Tll \"\"1Il1 of ,-il''''-. if. folio\" \"'!: Ire~lttu:f\\1 the pain fell on th.c rL-'tum mo\",menl to the upright p\",ill\"n dfh'r n,.\"ioo i$less s..\\\"t'r~.orif the arc OOctlmes smaller, lhi!l inJiCl\\tl-'s irnrron,rnenl. Release pain ntis phcnomc\"'>J1 ,scommon in thecervk~1 sl';nd~nd solTlelime~ the thur.1Ck spi,,,,) \",ith r\",t\"tion, ,md III th\" lumbar sl'''''' wilh I~t('r.ll fl('~irm_ It occurs .. Itnns!

64 MAITLAND'S VERTEBRAL MANIPULATION \"ammg to be ger.11<:- \"ilh \" ....mll...tion InO\\ emenlS roch IIJ,.... The first I!> hmmg !hl.'on>;eI of l»·mptornsand and do f~'\",,,,,, of them. Ii l!>l\" p;ltio.....1 5-lb lhe diIlllJlJSh,njo; of s}\"mptums ,n seconds; tht ~ i~ quietl}\" withoul mo. inK hl~ head, Itus 1a\"-.,..Il4lf'l;\" ~ tht Si:'\\\"ffl1V cI the svmploms at tho.-'tr ~Jt.; and the rtUrd is a»!'Wng quabi} of lhe .\"mptOfl15 oi paUl will §lJb:.«lc lho.> Jenglh col hm<' t.>L,'fl £or calJS(C't,l n...\"...\" I;ost Iwo ..... po=onal judgement:;.,. the e\"-\"C\"erl>a1Joon to lol.\"ItI,: .. i1I ..~. from p.a1i.....1 \\<) I\\.\"Iu'''\"8 rn.u.imum arrrecialion t'>l the pallelll's ......... palK'nt. but \"'ill becon_ISlenlw,th anyone p..II''fl1. .......b.ol communlouiQn 1lJese th....... jud~...... muSI ~ is .. noth\", e\"3mpk ,,'ilL.,.. lhe lIme IJ ........ f.... ~ intima lei\" hn ....od 1\"lIh th\" caUS1llS ~I mo'..emenl Ih,: wmj>l<Jtl'b to ~ub\",J.. \" \" ,·\"llLibk ml'.\\suring or pos,tion -thai Ll'. w;lh j\\5 stn:ngth, .mphluJ\\!, sus- ~licL) When Ih.\".., 1<.\",1 mo\"..nenb Arc r<.>pe,lIOO, Ihcy 5-hould bt· ~,,,mln.'ll III a ,lighlh ,h(f..,....,,1 tainc<! lime and dural1on, and AnV Pol'\" \"-\"'pollse occurnng during H\", tC'>!. m,mncr to elicit Ihe exacl \"'-'ha' lOur of Ih.c 1\"'111 wllh \"ach dln.'Cti,m uf m\",'emen!. Ll'l l\" I,l~., 'After' pain _ examin,'!ion 01 eN' ',,11 l\"tcral n..,ion r...,,1. This &\",ausc this l\",il1 le'S!\"\"'\",;\" ocCllrs ·afler' the cau':lt', ow\\'c,\"c\"l .11(\\,,1.1 be IL\"'IL-d lowMds Ihe side \"f some \"-,,dl!rS may link;1 with latenl p.1in_and \"cronJ· pain. and if no pain i. foWld al the lim'l of Ih\" ing 10 lhe dicti<mary def,n,IKKI of 'lat(-'l1\". lhe word can ranb\"', O\\\"'1'''-,»ure should \"'-' Jprli<.'<1 If Ih\" mo,~'n..'nl I> \"hI! PolmJC'>!o. tho., p<J5,tion should be be ~ lod<\"'<.\"riN- Ih,~ '.. fl...-' \"\"in. Howe'·«, beca..- su.tou...-. d for a .hort lim~ ,\"\"'\" 10 'i<'<:ondsl Th,' 00.:\"\", ..It doeo.rmt p.lhent's h<.';td .h'....kl lilL.,.. b.., return\"\" W lhe 1anr'lt.lgeduring the I...at\"\"-\"I ......• uprighl J'O\"lllon. lll.l p\"1JI.\"I1.1 i3 Iht:n ,,~ to remam Sl-tting for 10 or ITIOJl> second\" 10 del.·nn\",. ~ and ( importantly) bccauSie II '\" a deC\",i'\" \"ilLother thcr-e I~ an~ \"''''''lllog surge of poln riot. l.11•.,..t pam, from tNllIll'Imwnt. If IIloerel> no pain ,...til)' thalc (J('(lll'ln Il'SpOOlSO'tolrea.lment, lheentity from !hi!; resl, then rotiItlon t<;n.Aro,. the l>Ide of 15\".,... n'IIdJ!,' rcmetnberoJd and identified if ~Ien a pilII' :;houlJ be I\"\"'k'd III lhe \"..me 1TIolTlIlO.\"l', ,,'th C\"1l' belng tAL..,.. to Allu.. fllOUgh lime f\"r Ltll:nt ~atl·l1d.. paUl 10 show up If tho.\"\", I.:\"t Il\\OI \"\"\"\"'Is r,m c . After' piI,n IS .. pain l\\\"<~ thai rna, not OCCUr negati\" .., ,,11 oIher mOI·Cm,'Il!:> would toe Ic...I,'<:I (~l unhl ....aki~ on the morning follm.·lng tl...• day of in ~ c~lculdlcoJ ...'q\"e'....\" Jnd {1>1 wIlh sult\"'iH'l1 ~Atmml, or \"'tlhlll lho: Ii\"t hollr 01 so of gelling OUI lime fOf i.o;urdle M!0eS5m~'Il1 bctwl'('fl Nch I~\"'I \"',,'·emco!. When the pmticuLlr mOl\"ml'flt pn:.. 01 bed. PAm thaI comes on 24 hour1I or mol\\.' afler liucing lh.. blenl pdl\" I' dcler\",in'-'<l, tl.., nexl ~I\"p ,s to dlSCQl'Cf how much mOl emen! is t1~'t.\"d..d tv 1I\\.\",tmenl is a \"\"in response of th<:' \"\"me ~\"\"d, bUI al produce how muen 1,ll''Il1 pain. i.e. Ill<> \"'I~'f\\.il}· ~nd.:uN of r~\"'· Th.... 1m.... ta~en /Qr the larenl pain IhM time inlcr~,ll it i:j easiC'r and dWI\\.'r I\" aS6l.~ as l\\J subsidesoould al>o be.- nok'd. These fine a',.....\",· ments of the bl'hal iour of p.linurl mo,.'JIl(~lt 01,1)' bo'ing a reo;uU of lre\"lmL'1J1. Wht'll. il ocellI'!< Ihe follow· \"\"\"\"\"' tediou> And tIm.... consuming. They are ing m\"mlrlf;, it ib l<-s<; \"asy to uoderstand II and 10 \"'-' Important. hm.,'\"\"\" and filmiliaril}\" with the dif· p\"'parr.><'I 10 \",;\"te Hln on(-\". own lrealm,'''t. Ilo.....\"\"r, f\"\"\"'l way'\" pain ,an belwl .. ,,;th JnO\\cm......1 it is nol M' \"n\"lInlnr\", lMppen\"'g. Among many dlf· m.Jk..-.I\"\".....,mi\".,... dL...1r'oll> in c.arryUl.g them out A!;'C5l'>mI\"IlI '\" madcollhc time \",J,.\"n for the surp' [..\",nl on>(15 of spilul pain 111M pat;\"nt, h'll\"\" Irn:,re is of pam lO occur, lis il1ll\"llSil) .. I its ~al.: and Ihto lime ..,bon for il tu I\\.-'CO<.(.,.. one particular hi\"lnry lindmg thai OCCIln; quite oom- S. Lmgc.--ing p\"in. which 1Yl.l~' take from 30 se<:\"\"d~ 10 monlyand prm Idl!S proof thai the 'after· response Is a 5 .ninule> IV ~uo.ld\" dll,:r \"'-'''I); producctl b\" m,,\",.....lity. A palK-'n1 mm'\"\",,,nIS Or sU51alned positions towards thl' ..nd of a d\"y's phy',,\" 6. L.lI..nl ..xac.. rbatiun f\"l'\" thJt appl.'a\" in .11t kal work. feel a ~i¢'1 1\",,,,&,, of pail' or Illsi a blight incn:\"\"'-'I1 form bel\" .....n 30 min\"tes and 5 h(l\\l'~ ache, but the Sl'ml'IOm ~ quickly. The nexl morn· Mter !realm\"nt. ing, 00.....,...-_ lhe pilbt.,..t is \"naHe to b\"ct oul of br..'(/ A,,~ing chang\", in the fir:;! fi\\'e types of lal~'Il1 p,1in dl......riOC'tl aool'e I\\.\"lUIn.... Ih..... judgements I\" 1:<0.' made bec.>US<\" 0>0\\'....,....1 ~AlL<e5 !'e\\'ere l\"'''' Rel.,lInl\\ llus 10 ~r, iI's impart.'111 to point oul thai 1......lment ~ iid,OGItcd in dI\", ......1 \"ill not prm'okc ~ \"00.',, dt.-g~ u~. Nr:erthele». the 'after' I'e:>fIQR;O.' ha .....lil1· and m\"\"\" bo' \"--'ft1.\"\"be.-.,d when one L5 plan· lUng an,1 car')lng oullrealmeJlt, and in asse.s-ing the effl'Cl of the last lreatmenl. During any lest ntu'·(>Inl'l,1 Ihal Ul'''''. pain. the mO\\·.... menl and Its polin re;pon.es should bt: asso..'t«'d fully ,l\"U wilh care 10 allow a~Sl'S>Ulcnl by \"\"\",,,,n'II1,,lion to show if Ihert hn, 1x\"-\"1 lIupro\",'n1l-\"'1 f(,llowing a tTl'M,,,,'nl t<.'Chlliqll~. 1'1'1''' if Ihis Improl'ement is only inlh\"order of I pl.'rcent.An exarnpl.. of the (Il-plh of dl'to,] reqllired;s ewmplif>ed in a pal~nl who f~\"\"ls

Assessmenl 65 pam on the ...-.f1 side of his IW.\"Ck at lhe mid-cen'ical 2. The ;ld1\\~ rangenf rot..hon .md its associ~ted polin IN\\' be uncha~ but with e'lell W shghte5t lenol. Du~ the o,anunallon he IS asked 10 tum hb OI·.......pressure ~pplio.'d to !he m<J\\'cmL'flt hi> p\",n head to the left unlil the s~ mptoms .lIe Iir5t fell T1us \"ill incre..... more ~n al the tnill.lllesl. r..\"u i5 C'5tim.1led and \"\",ortk\"Cl (for eo:amp..... 70\"). As the first use of the Wchnique is '...-r)' ge<>lle, ~nr The physiolheTapist then guHJo the lTIO\\\"nnentthrou¢\\ wor......ing of thc ,,;gno \"ill be minimal and noc h.lrm- ;l further 5\". arv:l judges ho... the pain briIa,..-s \"ith Uus f\\Jl and the chang<:S will be ;nforma!i,\"e furthr.-!\" lTlO\\'~enl If !he patll.'f\\t rTports that the pain Two or mor~ pains ~ not dungN, tho- m\"'TmeflI t, lalu!n further.......\"\" to the extl.'l1.t of over-pl'l5O>UrT ~t the l'fld of the a,ail\" Thi'R' i> ret another pl\\lblem a5SUCi.,tL'<l wllh can.'-ful ~b\"\" ranS\" of mO\\\"l.\"ml.'1lt. Tln, furth•.,. m\",\"ement may ~S\"'-....melll of a pali,'nt's mO\"cment a,>oJ hi>. I'ain. A p.lt,cnl may have two or more rains. One mOlemcnt r..-sult in .. marked incre,,* on the left ru.'Ck pain. Some ('\" d group of combined mo, en\",nls) may be (OIlnd Il' reprOOlice One pilrticular part of the pati\"n\"s ')lmp- r\"\"ders (1M}' doubt th~t sud, detail in ex\"min.Uion i~ Ioms. while a differ<:111 mo' \\'ffi\\'!'lt rcproducesn second n(X\"css,lry. The answer to these doubts is tfl.~t th\" find- nnd dIfferent part of Ihe pilhPnl's pdin. This is P.1rtl(\"u, ings s:ive the physiothcr~pist I' !:\\,ide .1S to the treat· larly importanlll weC~1l i>CCl1't thal il is lIm UJ1CW\"'_ mCf11 I~hni'lue to US<'. while IlItn'id\",!: \" ,'erl' fine fUT a p~he\"llo ha,,· mn/\\' Ih.ln one kind of pain. either lJl the \"\"\",,,aWaOr lJl a do:sel)·Jinked iIIW. It is Import- rne.,.ure by whim theeffectil\\~of lhech~n treat- ant for- ~ rhp>otherar;~ to b<-'- fully aware of!tlesc J'OSSlbi.ilies iL.,,1 ditferenc:..-s be mISSed durmg \"\",ml- menl t\\'Chniques em be a~~\" For example, MXing n.th.... For examp...., It IloC'Ommon for 0 patM.ntk>com· made the irutial ~'ru.·..1 of rotation as d\"\"'iled pI.lm of Iwo dlStinctl\\' dJfiWrlt ~Inodsof headache. The ..boll'. lhe ph~-siotheraristarries OUt a 5Clected In'~t\" ment technique. thefl sits lhe pabl'''' tv re~ the pall.,.,1 must be .1dequaldl q.....\"tioneod to det....mine rotarioo, Uking noll' of I\"\" lhroe faMs of the T'Ot;lI>On till' diff~, and e.tCh p.lln should be eum.incd, tre.l~ and asso-ssed irl(kp\"nd\"ntl} \"--\"<t. fa.ou\",bloo dwng.... of lhr abo..........mpw would be indlCaled b) an} of the foIJo.,.'ing findings Patients h~ve many de:l('riptions for p~in... )'\\.'1,t IS ,urprising how often till....• U~ ,l1n;l.1r terms, mOISt of 1. As till.- patient turns his head 10 t.... left he f...,b lhe which an: \",.,dlly rI)COI;nI7.,ble, This ;s so even with same pa:n lD hedW:1alI.... lJllh...1teslo. \"'--p11'§§.llJl' 1'.111enls on dIfferent countrk'S and Wllh diffe~nl cul- IS opplk'<l. w,lh the \"\",ull tlu-t the lllO\\\"ement can be pushed further w,lhout inrn>..,;;ng the pain. tures.11 is probably stilting the ob\"ioll' to S<'y that, if n 2. II till' p..li\"nl's ..cIi\"\", \"'''S!' of roI~hon 10 Ihe left l~ \"aiJl changes to an ache, the ch.lJlge is Ia\"our\"ble '1 f.....1rm ~tandingslraightl'1\"', or'l feel more \"'-'Cure'. an' unchanged although il bt.'COTnl\" S} mplum fll..•• (J\"ou1\"~ble comment>., wh\"\"'as ·It f\\'Cls dehcatc', 'II ~I,d Ihe rcspono;c to U\\er-prl~\"ru is as il \"\"as ~t the ,,,t!f('j>b r\"-'C1ous' or '11 k·d, unsofe' urua\"OIJrable mitt ••1<!x\"minatLon, the f\"rlth~t heran tum arllvelv romm\"\"ts. .\"t. p.lriem U\\~ng. 'II rt'C()\\\"en.'d moll' qUldJy after rennls than f would han- e~p.-oct<'(r. i, without pam indicatl\"S impw\\\"Cment ' anotMr kind 01 r.nou\",b~rll.lnge. HOlv\"\"\"\"',a patienl ;\" OIlen able to ans\"'CT the question, How does 'I ft.'Cl 3. When the patient tlilm hi, he3d to !he left he fL'eb 1lU\\\\''', onl~ by SOl}ins.·1 don\"t know\" I 6nd il Nord to no p.:lin. nor does the fin;l gc'f1tk-' OIl'l-prcs.sure pro- npla.lll.lt',\"\". ibIUSldi{fernU'\" lhequ\"\"tJO;>n.1s ita I'ol<> any polin. \\\\1th firmeron'r'pre55Ure, },o,,\"(.'n.\"1\". fnourable difference or .... unfa'-ourab.... di~\" pol'\" ~ as 1l dId In the IJ'IitW IC:\\I:. These find- ShoUld iol!ow automario.lly, and the paoc'fll (Ml tngS...we..te S\"\"'1et' unpro'l'emml than (2) obo\\e. ni'drly al,,\",,~'S make ~ CleM distinction. l .... l'fl though the P\"ha\\1 srill ft..'els the 5olID<.\"d~oi neck ~n \"itll the >otrong....- <l\\o?r\"r~ \\\\\"A,-'\" a55e55ing p~.lhe phfslOlherap<s1 !ihoold be al\"rt to .iluatinns\" h~ implll,,~meniin symptoms ~\" If the f\"'til.'flt CAn tum hi ~ \",;!hout p.tin \"I>oJ signs donot occur synchronously.lhere .11\\' hnws, .mel the Oq\"'\"PressuTC also dOl'S noI cause an} pain,. p\"'lio:uIarly if th\" p'.ti.:'nl h.15 S\"\\'CTC p\"in, when the the paluml's .:l.~rde-r b olll'iou.;;lr impm,\"ing Sil:l'lS m~y show improH''Ill~nl withoul the patienl lx,,,!: fa\\'ourably able 10 appre<i\"te an)\" dwnge in symptoms. Se\\'ere n\"r\\c\"root p<,in fits into this C~teg0ry. In U'be \"tu' If the tl\"t'atml't,1 I.....hnique is of roo help, the signs ali\"\"\" tl... slight ;mpml·l'm.'Jlts in the movement fouoo on r...\"\"amin~tion will nOI hal 0' allcred >lSns indic~te Ih~1 lhe liame trealm.... l shoI.lld bE.\" Should the tre~tm{'l\\t I\\,<:hniqul! ha'·... mad\" Ihero,'- dilion \"\"D•.\\-(', Ihen \";th,.,., l. The l'dtlenl's ce,\"\\'ic~l TOlarion 10 Ihe lefl will be slighlly mOre limited and rain\" III <tart earlier in thcrlUlge,OR

~-66-M-Al'TLA'ND:'S V'ER'TEB'RAL'M'ANI'PUL;AT=ION=======------------- l't'fJ'eol~d; impro·.....m ...m in the.- 5\\ mplorns Wlll5<lOn bt· c~__ P2ft\".onuY)]' notiooab..... CCJflH,'f'5Clv, circumslilflCeli mal· a.\",.' whe... the svmptums imprrne quite drollNlically but prop:n.>ss ti, In the joint s.igIl\" b not 'loU r..\",d. The ad~1 di~ k\",1Oll1S a good eumpk-of this phenomenan. If ellher' I lhe sub,.,rn,\"e or tho! phl'SI(;/I1 ~.ent sho>\\~ Impro<emenl,th<.\", il c..n be COr\\SidO!rW, ,,;th one I CT) •;--\".~\",c.--c\"~,,-,,,t;-.- ,\",porlanl \"\"\"\"Pilon, Ih.. llh<! doorder is impT01·in~. ' -Figu.. 4.3 Pre\\~nlition of ~~in felt \",itll cervical 'Ol.tion to Th\\.'\" Imporlanl I'X'l.'P\"on to th~ rule concerns theldtooMood.V p3hl'1lk who h.l\\\\' >('1<'1\"1' ntn.,..mol pain ..10 IlI!Uro- , - '.':l l..gic\"l ch\"ng\"\" Th,.....• l>.lhcnt:; 6houlrl be \"\"\"rnilll'ci Fi9~'\" 4.4 Pt.~nlin,on 01 \"\"\", - n'pclrtw '\" ·\"nchi\"!lro·- Ilcurol\"I';ically doily br lhl' I'I1)'slOlherilp1st. \"\"d ,lUi f.lt witn c(\"\"cat '01iticn 10 lhe kfl on I'IcdnesOiV W\"T\":><Clllllg of nc\"rologlc'll ch,lIlg\"., or Ihc \"ppeardlKe of ,,,,u1\"l1logical cn\"\"!;,,,, 111.11 \\\\\\'1\"(' not .1pp\"retll bd\"rc, di\"Srams. F(,<'«( LJ would be th,-, p\",-'s.mt\"lion of I\"\"i\" ~houlJ be reporloo ,mn\"'(h\"I\"ly 10 th... dodor. It I, common for ~lI<;h po~ticnls t.. rq.or1 dr\"mallC ImproH'\" felt wilh Ct'nicill rot;lli\",n 10 th... lc't on Mon(l.lV and Tn\\'1I' in srmptom~O' er \"p\"riod of 1 or2 d\"l''', ,'1\"('\" to lhe I:),lent ofbc>roming SI·mptom free or alm\",,1 sy mp- F',~\"re J.4 would be lh<.' n.'P\"\"\",nlalion on \\'I,-.lno.'sd .. )' t(lm free. In lhew C........ pain does markedl\\ and rap- wilen he reports it being 'unchang~'<:l' iJJy lC§OiCfl, .... hi)\" the nt.'\\Irolog:K;ll changes l.,t1~ appe.u or worsen (()IlSl,J,:rabl) As has aln'ady b«'fl The,;econd i~ lhal, at the beginning of a lreatmenl ..tlled. the referrin~ doctor should bI.' notifioo oil one... btnll\"l' the patit'nl ma\\\" require im£lediall' SUI).\"\"t'l'\\ ~'\" t.... pallenl rna\" y thai his ~\\\"fnpl(>mS ha\\\" \\\\-hen .. p;!ti\"nl h.ls re<-1ri(tiT13 local pain aminl; r>nt d1.angt'\\J becau<;(\" mo ·n>enls or a f1\\O\\'emcnt 1Il.1}' ho.,.from the ,ertebr..1coIu'TUl, ~ m..\" 5<l\\\" Ihal hi> pIIin w\"\"\"be just as p\"lnful or> .... 1 Ile beg.on lre..rmenL or as I............ere he h;Kl hj<l.u;ltrealrnt.'f\\t. Hoo-·.....·.....,\"\" \"'IS nol Ch..ngL'lf .... he U.til,l1 un~bl~ to s\",~\" goIl club. The physiolherJpisl :>houId then dvxl \",thi.·r <=;\",Oilhoo 0/ the p;!mful mo>enwonl. impro'·l.'ment \"\"\"'risk,'<:1 ~igru.. II may be Ihal this pilti<'nl can l\\\\lW b,ma~' be ind ....tt.,l tho- bct thai ..... uncl\\lm~ pain lurn in bo--d wilhoul pdin Wh\"r\\',l~ it Wi\" implK<ible bt.-foR' In other wonh. til<' gr\\',lIe, demand (Ihe j!;olf c;; in fiKtexpenena.'<l Iat.e'l\" in lhe rans\" lh\"n al hisl\"st ~WHlg) lias nol ;mp''''·,'d, btll Ill(' dlsonJer is in f,1(1 \\'1.>it (fl~'TI\" 4.5). or th.~l h\", FIRST aW\",,'Ol56 of p.>in i\"'r'o,·ing becausc tl1\" h'S,\"-,,' ,-k\"'and (Iu,n;,,); i,\\ b.'d) h,l~ in'pro>\\',:d. Mmor ~~f\"'ds of\" p\"li,,,,l's wmpl~int wilh ~ 161 mO\\l.'OTl<'nl is l.. leI\" in !h<'r.1Ilgt' (FJ:I:\"rr ~ 6). U~Il\"lly i\",pmH~ [xi\",,' lhe m,'JM mmplaint. E,·en when both l'O\"itiQn$ ha,·\" impro\\',-od anollh\" pat· Assessing changts in pain l<.T1l of po';o during Ihc m\"'\\{.\",n\"\"t h.l~ ,11;;0 In'Pro<',,J I(d...rencc has l'lX'fl made to ascessin!' d>angcs OIla~1 pilln \"00 ''''n<b of POIJOS', oolt~ a..... two olM-r ~11u· (Fi~rJTf4.l). till.' p.1licnl rna)\" still >a)\" that hb~}'milioms ..loons ~I t>Nr recoo-dlfl~, hav\" not changed [x'Cn\\IS/.' lhe inl...,,;;;tl' of Ihe pain IS 1hl- firs! IS th.i.t a pallenl rna\\\" n..-\"ort. at the~.. unchang<'d. His statem('nt is corr('(l and sho\\lld \"\"I Ill' ninS t<f .. 1Ie.._ t SO'>rSion.. lhat his symptoms ~ ,ugU<.'<:1 against, bllt allheS<lme lime c,,-,\\min.'liol1 must undl.ln~ hlM......l......... hen hIS m,,'.-or..,nls a r e - t thequ,,\"tyof .. particular m\"'·...mcnl IJ1d)\" \"ppl'\"ar fro\",!\". bI.' accurat... cnllllgh for Ill..• as.sessrnenl 10 1'I.'\\'cal Ih,- In bet I.... p\"1i<.'f\\1 \"-....Is U/lCh,lnged OOI:.. us.: afll.... lia~. IUn,mg his t....oId -15 10 the k.1I, ho· Can go no further favourable chanK\". bee\"IlSO.' of p,l;n. the \"'kns,ty 01 which (and Ihc po6l' linn \"I which it occur< mIll\" r,m\"O') is IhI.'\".1I\"\"as ,II his lastlrl-alm('fll On mo.... d\"I~I1<'d \\.'\"~,l1l,in.lI101\\ it may l:>c that pain felt bt.'lwc<,\" 2(1' and 35'· is much I,-':>/; liMn it was at his 10M IrelHm,'flI, Ordinary local pams nrc ,Iblc to change in man)' fal\"ourJble ways. ,uch a, thc abo,,,, withoul Ih\" p .. l;enl ~rilr being a\"an: \"f lhem. ReMting 1m, ~bo\\\"c ('>..ampl\" to mm·crn\"\"r

AsS<'S~m~t 61 ..... co '\"\",e •.~ Prt...\"~tc~<>f\\l\"d':~\"9~·poinfdt aft< ~\"\"'}t i ...,th ~I ,Otlll<;ln to I\"e left on Wrd,,\";rt 1 ~ r , .'. -F\"ogutt 4.1 l'I'...n~liona\"tr:rlm~1 \"\"IIIfti1 .. th (ttvKlt ro:.tic.o to tOe le'i. on l\"J~d'~ manq.,\"';10< j~ ~ _motnl cli~9l'l1m ~ tit ~.ampl., 01 impro.~m~nl of which tn~ P~l en! m~y tit unaw... .....,. Gelling u~~d to p~in Fi~..\" •.6 l\"tnf:\"lJl On of pi'\" r,m f( tat.. n \"'''S\"'':to On il,......\"ing ch.lng(-. in ') mpt(Jm~, pilt,,,,,ts quite fre- qU\"ntly .... )'. 'I thin>: iI', just th\", ...,me - I thinl< I'n, iu,t cervi<:.1 rot.tOll to I\". eft on \"'Ifflr~y ~<1ting u<ed to it'. Du.ing till! roml'lrdh'c\" short tim..' pilt'''nt. h.we trealment, they 00 '\\JOT '1;<1 USo'.\"d lI'Ia~\"g.dIa.in~;>to-t\",'1 ~,'§(lof to pain; the rcspon!il' lh\"'\"Cfore can boo.> <K'I:l'l'Irtl .... an \",diedho\" of slight lmpmn:m.:nt. rrio:¥a'l(t to 1l$6S tr\\.~ in d !o3bility n in ...... ' IV and q...nlJl\"/ of ll'lM'IT ....t Weathel chang~ RelJlIng themo.>\\'-\"1WI'l1 d\",s,arn to the th ..... \"'N,II;(W\\~ ha.,,,Patic'ub \"\"110 'joint di5orcler.l ofren ronsider S\" ...'.I'Il1bl,lH·,.:lnd l.I:Ilng F-gun'44 aslheorigin.ll presm- laoeHl.the mo\\\"rnent is stilllimlll.'d by tho!' lI,rerunh\" of fho<m\"eI\\e< good OOror'l\\('\\o.--r.. b«\"auw tho.-\" 5\\'mplums the kx\";ol ~in but the positions of P, and P:lLj h..~,c ch.onge ,vi!h chang~ in the weather,.md dli3 hi fuct. no/: cha\"l;N, as lIb<l has the bclw,'iour of lX'''' bl'hh\"'\" PI lal\"U\". The fact thai some pl\"OI'~'SSnJ1rlmnsrncro.-.:>sIl' and 1':1- rust~u..\"ealt\\.i>fcham;o,,,hik~ch.mg.'''' f'.>(u/Y> 4.4-1.7 n\", all \"Mmp.\",; of irnpro\\l~menl of the Weil!her changes or immedi.llcl~ following the whll:h tht· patl~'11\\ ll1.ly bc 10Iul1\\' unJ\"'Me. Ewn when cn..nge. ma~e< ~smml d Ifhcull II\"\" ..nr. the hdp- he is awnrc of II\"\" changes, their signiiicancc will ~ fu1 f,alun.> for ~t is that. ~1though the pt'TSOO'~ inlerp\"'k\"l ,hffc.,~,tl}' by the paliel1l aoo Ihe mampu- lali,-., phy.iotllo,'rapist. 11 the manipulati'~ ph\\'.iothcr- joint s~'mptomS ;n<n'.l..... tn.,. ilS<><XIilIOO movement apisl re,,1i~c' Ihm tht,> impro\"\"m\"nt is of ~reat<'r \"&'1-' do NOT I'\"<hib,t an,' pmportlonal chang<>. 5i&nific~n<:,>to h\"r d5.essmenl thall docs Ih., pilt'';'''l, il will help h\". in he. allitude to,,\"ards him. T,eatment so.eness and disorder sorO\"~\"'\",- _ P.ll,ent:s often reporl .'I(lreness /ollow\"'g a pre,'ions trea:ment 5C>.io\", ThlS 111\\l51 illl-t'IV~ bo.> c1anf,,'d, Is it the <li\"\"\"',,r th.ll has becollle \"or\\', '\" is it ju>ct \"'-'''-~1~'''5 from the m\"nual h.l\"dli\"S of Ih~ lre~tmi!nt technique? 'Is it a $urface brUl'>l'd f....·I\"'f: frum my h,me!, or i~ it \"the thing\" th,1t you hal'\" gOI 'Hong \",itn you which is !oOrC?' (this is another e~amrle of an 'm\"'l~-diate aulo- m,llic follow-up' que-t,on).

68 MAITLAItO'S VERTEBRAL MANlf'ULATION Wrong t«hniquc On lhcocca~ions\" hen 1IlSdt'tlTmined thai a patient's S)'II'IptOll\\5 ha\\e Mn dgJ;fd\\dted b\\· tho? rn.\"I'OUS trrotmerll, it is 001 alwa~~ thdl the '\\l'on~ t~'(:hnique was USI.'d - it lTIdy be that II \"<15 Pfiformcd too ..trongl.... w'lh too much mon·.........t,. tor too Iong.../W in the ...'~ pll6IborL Therefore. an clTort must be IlIilOfo Ir) ~ if ttw p\"'lient ;§ ,,,,..'\" of wtwl.t w.i§ about the Iedlmque thai \"a~ the cau>t\". This i§ particulnty...-k- 'ani., pre\"'lOUIi USol\" of the- techruque hdd1J,;.(,n produ· on~ ~al prog.-.. BEHAVIOUR OF RESISTANCE ResrsIafICC to IrI(WmImt \"\"1 man;fcS! Ii I loss of tllc 1'---r--r--7;,c,.=~CI·\" fn(tlo1-f~ f«ling Ihrou~h the 'ang<: of s\\lHn05S, 'n<:.e\"'\"g 'I the mQYCment i5 carT,ell furthe, into \", 'ange ,h Considl'r now the diff,',,'n(('S >n Ih\" N,ha\\\"iOHr of ~}inl .Iiffnolss, In the normal p.erson, the mo,enwn! \"~I Onl' \"- Jllinl surfllre Ull it. wmpanioo\\ is ~ rompletdy (ridion- fA-'C mo\\\"(m'l~\\1. Howe\"\"... \",~\"min.lt\",n of a p;,til'Ol's joint togu\", 4.!I 1'ICJ't2)t n ~I ffno~ ol P\"l pmportion.llo may ~how that while the range is full, r,>t on osc,ILll('~y mG\"oICI\"\"C\"lt\"\"'\"'Ih ra...,e 111O\\~l.'f1ts through 1'MIgt' it I.1cM this Feel 0( fncti<\",\" fn:oe l~nj:nt. With C-\\p'-\"rience it i5 ~k' to red a BEHAVIOUR OF MUSCLE SPASM slight ~t't.ncekllIIO\\.,...,.,.,1 as descrit>eod ablwe, e'\\'en rho\\Jgh the r.>ngc IS full. Th... ,e,,~bntt ma\" be .K'nllTl- \",ooqMuscle SjSdW I\"lay be fdl d'S • qvid: rdlu ~ ponied by crq>itus. although Ihis is by no ll'Io<.lI'IS alWlly~ kll'o',n\"';il; a i\"\"\"\"'ntary plotectM' the C3!>l' II is imporUr11 thai ph~~rlpistsde\\~ the ~ldl 01 \"-~,~ tht;, lad of frictioIl-frft' smoothness. wnlraWon When a joint is lirnitro b\\' s1Iffne..s. there d~ 1..-0 There are two ~ ca\"'l;ond of mu,dc spasm lhat common Wll)'S in which ttis relS~ IIUI ... behan' can\"\" found on \"\"\"rnll>lllicn ollOU't UlOwment,. and 1, In the fir<l rart of !he- joint's mO\\'MM'nt 5liSht thes..ared'-\"'Criho:l in detAil in AN'f\"\"d'\" 1 \"\"Stn(1IIl)n to the fndwn-m.e mo'.-emcnl IIUI) be f.elt through a 1a~ part of the 'ange. and it onl... The firs! of thcooe is a mll!'(1e ronrraction that comes uo<:reas<s tni\\l'kOOly in slTe'l'lgth at the I,m\" of lhi' Inlrl l'ffeo:l as a \"'flo.... R\"\"Pl\"~ to pain P'O\"oked by r..nbc If,S\"\"~.B} 1TlO'I•...-nent. The p.lin mar be pmmlcd oc'Cause the movement i;; jerkily performed or boeause the joinl is 2. ~e-.i<.r..oce md) be: fell [,,,i)' in the r\"nse and rhe furlJl\"\", the mO\\\"'m(mt is carried into the \"\"'!>\"e the ;\"mtpoorly supported. Ho\",c\"l.'r. if II.... is handled w('il. §tronger the ....i~laI1<.'e ~ , unbl a romt IS R'll(h..... ,,!'>ere me physiotherapisll$ '\\OJ1 pn'pared. this spa= docs not mJke ,t;;.elf Db'I',ous.. i'\\('\\'\"rthdc;s. to ~ln.>tch the joinl further. In other ....·ords, lhe r\"te when ,t does occur, it 's~\" ;\"dic,'tur of the intensity of \"f inCl'(~,'..e of ~Irt:'ngth of Ihe rL'S,~tanc.,,, propor- tional to the mo\\'emrot thmuSh range (Fisurr ~.~) the p.lin.1tcan be diffcl'CnliJwd from a volunt.'I)' muscle contracti\"n by \"irtue of the 5p<.'Cd \",ilh which il i~ Tho: physj\"thcrapist must be Ow\",,, lhilt tho.'SC laria- i\"\"\"ked by th\" provoking mO\".,mL-.,ll; Ih\" refI\",~ spa~m ti\"\"s in joint stiff,..,,;s can and do \",x;st; proficiency ill contract,; mL><;h moro rapidly than till.' \"ulunwI)' ~pasm. as&.'S.~mo'llt of lI>eir d,fference.< will come \"\"ly witr. clinical ex~r~l'I(e.

As~ent 69 TIll' sernnd c.JIl'gOI'\\' at mlNie sp.tsm 15 tcl~ted ffi()f(' to\" hat is wron.g with ltIejoinll'3tho.·r than berng dtn!dl\\ rel.<led 1(101 pIlin l\\.'Sponse, It lSal\"\"},,, ,trong ~tfaction of ,.... mu,.dl' fibn'S, 0100 mOSI communi.. is the limiting factor in II partlCulM dir<'Ch.1O (Ii mon'- m<!1l1 of a joint. r...,r II\\ose inl\"n'St,><1 in till' 10m ~m\"\"t di\"l:r~nl rep- 1'I.\"'<.'Iltatkm of these two sp\",,,,s, lhey ~rc de,;crib.-d in App('r>dix 1 n...\"., \"' ,moth\",. t}'llOt of muscle ~portS<.\" thai is \"h,,,,)(Xl...>iimes found one is examinim: joinl JnO\\C'- men!,. ..00 this is \" 'holdIng' ralhef than 01 <pasr.'_ Although\" smdll mioorily of p.1DenI5\" 111 \\\"ollmldril} cmlrMct Ihcm~ thaI support thejoi\"110 Pl'\\'\\cnl its bI.>ing mon'd, thl:!i c.m ,-en ell-..rly- boo s<'l.'\" ...... 'olun- toll)' mUKULu oontractiun. No romp.1I\\.'\\l \"\"llh tlu5, the 'holdmg' is~t II;\" 001 a \"udden muocul.lr..rnon. but r~tlwr an inab.hl} on tlx! \"\"Denl's p.lrt to be ..ble to Ict th.. muscles 1t'11I\"- P,lhl'llts \"dlibilin!: lhl~ \"holding' arc USIJ.llly lotall> U''''''Ml' oflheir urlrcl\"\",-d state 60lh th(' musel,- 'p,1<Ill Ihol limit. ranh~ and tl\\(' 'hnldil1l\\' musele reslX'~l\\'\\'cal impm\\em..\"l ,hJ\"~'''; Figure 4.10 Rodl\"'l13p11 of «\"ical ',,,nf of a 76-~e31-ok! by 6hvwing a d,~\",,- in intl'nsil\\\" and an ;1'\\C....a~ in Worniln. lho... '~ con~n;tll fulion tx:lv,.~n sc~od and ,~ird !IVc:il1 \"\"[,,bra, C~I'J!'M:Thrrt: Isa CO\"QCMI fullon of lhe ran!:\" found on e'amination_ Also, lt1 \",I\"hon to C2 a\"d J C6 and 1 a06 Tl.'ld 2, F•.<ion\" gOMly I,,,, leIl, BOlh 1>oIdirlfl', impmwment on f('-.t':-amln;ltion ;s demun- CJ-\" iN.rvertctral ·or.-il\\il a~., II ,lilt narrowl'd ~rc is r:ygc\" lal drt ~ t\"t ,~ltCl r ~I a\"' ..... 0( C6-1 strolro by an impn\",eml'lll m thequ,1hl' of Ihl' JnO\\e- nwnt through which the> musek- hol<b.. IDENTIFYING NORMAL AND ABNORMAL had an,' ~,-mpt S not (''''''' <1 da\\- of \",il\" _t,ft\"\"\"\"or FINDINGS - WHAT IS NORMAL? WHAT IS ABNORMAL? HOW CAN THEY BE .on\"\"';, ~rb>ng from hol'r l\"Il'Ck,. up to the Wl'\\.... pnor to DEFINEO? the film N'\\llg lall'll Dif/l·renli.Jlmg lht'l\\'lelant from U~lul hVjlOt~,ical calegories art: to l~ink of l~e l~ine as(x:'MQ: tl.... 1\",,10\" ant findinlr~ 1~ t/>('rdon' \"en' dlfflCUll • 'deal - normal in e\"\"ff'( rnpttl n... follm·,ing de/ill<' Ihe 'id..ar 'pmt!, Ille 'an'1'''I;e' • a~a\"\" - d1S3d'arlagell but II<ll OI'erttv ,pine ,lnd the '\"bnorm\"l ~rine, Sl\"\"Ptll'l1a:ic [if dir>ialfy sent! • abnor\"'\" ~ d UdvJ~tfp lind sv\",,:ornaltC IDEAL SPINE [I is~edasbem.::normallD han-\"\"\" kog urooeann \"J'h(' 'id\"\"l' Spill\" refo!l\"\" l<\\ ~ \"'-'T\"ies of tnt,..... ,ort!.·bral ~ihhtl\\ shortoer than the other, wt this is in fact ,loom- moll bcG1uS(' lhey art'<>synml\\'1ricalln J ~hJo;hll, differ- \",,'111m <t:llJlleflb fie, ml''I'bod .. and t\\'gapnph}!;e.l ent vein, J person rn.1\\' hano an i<!i\"P',!hIC \",,,I,,:,,,i,, which is OOYiously ;,t..l<uJl1al, yel h~ m,,;. not ~d\\e dJl\\' joint~\"11h all thelr 'upportm~ligam('flflOU~il1ldmotor pain arising fmm 111(' ~ptn.', Abo,.l p,,~m l1t.ty l\"\"'e m..tslructul\"-\"'> ..-hi<:h ~n> nnrm.al in l\"\\'l'f)\" \"''Sp«1: mark\",l spondyhtic or Mtltril;\" changes in Ihc spin.,] is, \",\"nIS y<'1 h.l\\'(' no po';n, Fi):/l'\" ~,10 is lhe radiOl;r~ph of \"\"ynflnl' i> di>.ld'4I1tal:,:d Il1 olny' b~ inl\"'-l)', ...........00 theO'r,';cal spw of\" \"'oman ilf.'ed ;'6 who h\"d \"\"'-l'r Iftr, <lll1Ctural iIJlOIn.l!, or o.li,;c3Sl' _ ..ach motor seg_ menllSrenect AVERAGE SPINE The '''\\'.. ra~e' ,pme is nOl 'ide,1!' 11 doo.'_' nOI consisl of .....ri<'5 \"f perket m\"t\"r ~\"l>\"'c\"ts. One or more of them is \"b\"\"rmol III ,\",me \".n, C\"l'n If Ih.\" ,1'\" not e<1lhlnS am ~..mp'om• ••f ntdjoT ~...en\"e,

70 MAITLAND'S VERTEBRAL MANIPULATION Although the 'a'erage' \"1''''''' h.u been dcf1no.'d a~ ~ tobo- so\"J'ho> spirksofpropk-m the first.sub- h.... inr; roo s)\"mptomsof majorcon5l'quence, this Ol.'t'ds dilisionareonl,·'dlSol(h'anlaged·,MaUSf.'IIl\"lIother qualifICation. Some prople han' roo symptoms wh.atso> \"-'S\"nblht',ndl,lduals..-gmentsfittho.>'ide..rglUUp l\"\\et\", \"hlie others h.a\\(' mulOf symptoms of a J\"\",d Elderly peoplt'<ummonly ha, .... ~uchonin range \",hl(h ttM:y accq>t;l5 being ·nonnal·. Thc thrw Io.tnds ofmo...\"\"\"\",t[mo'itnotireable\",iththen'lQlem.\"Otsof of unpene<:bon in the aU'r\"!;,, spme al'l' exp1amed ilS Cft'l'IC..1 rotahoo mel ....tens>on) WIthout I'e\\jUlnng follo....s: trNtrnenl Th~ slatement nl'<'ds some quahhnbon I, CooSftUtaloracqu,rodMNClural.mom..llics. \"\"\"I\"and e~pallSlOr\\ bcciluse il applies to 2. lJrLogenerati'echang..... J\"'h.,'fI\"'- ).Diseasep~orch.;lngcsl\"C5uJtingfrom The \"kk'rly po..'fliOI1 who tw; no Cft'llCal \\'mptoms ,rauma l'l'Ihasn.'St~t.'<1rotatlOn',\",llfl'l'idl!;«'mforllftn.. mo.....rncnliSQn Ih.. S,dt· to which it ,s,lri'tdlCd. Th,s is perfectly IlOrmJI provided that. when tl.... ~t\"\"lch i:> Jppli,-d in th\" oppos,tc direction, th., di!oComfort i~ Congcnita!or acquircd structural anomalies as\"io fclt 00 Ih\" side to which th\" h\"\"d b torn,-d. Thcre are peoplc wh\"\"\" ~pine i~ d;';.ad'antag~od by a llow\"vcr,itmaybetholtwheotherotdtioo's~t....tchcd toonesidc the discomfort is felton thc oppo!i,lo.' s,de congcm'al or acquin.od structural anomaly. Ex\"mpk$ \",dude- a bifid spinous process th.;l, lacks one of 'b 11I.i.s is \"<juan, norm\"l. plUI·id.-d that when tn.. strekh pr'IX...,..;,es,aspinousp~lha'inclinestoward~the IS applied in the OP~II\" din.'Clion it too ('\"dUS<':> dIS- lcftortheright.orcongo.·l1ltalfusion~·\"\"\",thl.'5l'COOd comfort 011 the oppt itc side \"The eJl<lm'''''tlOfl fimhng .and Ihud '·ertebr...... ,,'hKh ~ not uncommon (Frg~n' that is IlOt iIIC«f'Io'd o>sbemg norm.tl IS wilen the dIS- ~ 10). Such anomalJes are of lhem§el\\e.s pam~, but rurnfort is fdt onll' 00 0I\"Ie side \",'he!het\" the rotaliOCl is Uwy do mdi<:al<' ~thct\" .as\\\"mmctry, or tNt \"\"\"\" stre... ~ pbred on ad)aO\"flt \"'tl\"Oertt'bral segments. Strl'tdlN tgwards It or \"\",al· from it. Aflllolhet\".ibnor· mal pain Il'SpOf'SCIS thl.' '\",leaoe pa,n\", \",hKh IS felt AnomalM'!> of IlCUral ..1t'\"....\"b must also be' con- \\\\hen'O'ter-p~un'·toafllO\\emmttsn.-Ie.l!ll'd $Idcred_n........arem.tn)·,,~inmcdicalli\"\"\"atun' Thcquahtyoftn..sen>;ttionCll'atcdb)SIl\"i'khing the ;:en icll rotatl(ln ;as discussed in lhe pn'('f<ding gi''''s C\\id\"\"\"\", of difk.n'nCl'S of \"\"\"\"·...-root (>rig; paragrdphshouJdalsobl-slatedsoth.1I't\"\",\\'a:>s>stm from the spinal ront \"nd ,heir c~its from the, ert,....\"l a~<;(\"'ISIOgthe d'(f\"ll'Oti..\"on of normal from abnoI'Tn<11. Col\"\"!. Such anomali\"\" mu~t be' taken \"'to conslder- Who\"n the \"\"\" ..mt.'fIt is >Ill'tch<.-d, discomfort IS norm,ll and \"hurt' ma)- be norm~l Or ~bnorm~l (d\"!'t'\",,I\"'K on atloo\"hcnassessingtheO\"S'Jtiofap\"hcnt·srd.'r~ pain. Figurr8.1 i.a good cMmplc. Ihepen;on·~p.,inthrt'Shold,pall1 ,lCceptance, p\"'\"\",n,ll. I'l\\'fi\"ed andpo>t·fl\\('d pl('~\"\",-'Salsoformpartuf ;ty,c1c.),butwhcnlh\"personexp\"'ri\"nc~'Sa_llarp'bit.·· the anom\"li('S 'hat ('\"i<;1. According to Br,lin and I1fpain.lhisisnot'lOrmal Wilkinson (1967), 12.1 f\"'r 0'1l1 of people hal'c a pre- fi\".-d brachial plc\"usand 107p\"'rn.\"Iltofp<.'Oplch.1v(' DiseastproctsStsorchangtsrtsultingfrom ,1post·fiu\"CIpl,,-~U5. trallmil Thc.... are other cl<\"mlll\"tion finding» thai should be' This group LOdlldcs peopk- \"ho;;.e !>p''''''' ~ho'\" el i· COfISldcrodo>sbl-\"'Snorm.ilorrommon,ore',m dcnceofjoonlch.1ng~,:>ductod~a\"\",ortrallm.l and .abnormal, I-et do noC \"\"lUI\"\" I\"\"\"lmen!.; I.\\l.an)~a~unablctotouchtheirtoe<,and \"'ho hal\"sI'mptoms for \",hid> the-. ma\\ or mal root N , ' t \" l \\ a d a d e q.... l<>tre..t m t ' l \\ ! . ) · e t \" \" h o . K a \" p t t h e ; ; e tru,.dpplieo.r.l'f\\toduldren. sl'mplonts oIlS ~ng thcu\" normal dcsplW the lact that they LOt..nen.· w,lh their normal !if... On \"\",mUl.ition. 2. DlffeM'ltbod,typesh.11 .. differenlroonn.ol thrir joint mo\\\"l'ml'lll an' pamful when ~In'l\"wd .antl palpalionfindmgsan.>ob,ious. ran\"\"\"tJilIl(l\\'emeRl ABNORMAL SPINE ~ On e>.>min'ng the rango.' (If fIlO\\ement auibblc inlhe'er1ebralc.a\"\"lsltvcture.s(lheslump~t \"'I'f\\,lescnbed 00 p, loWl, SQr'Jle people, the \\QUng. ha\"ea marh-d I'l\",tri,t;on \\\\ithout\" ll('C(\"iS,lnlycaosingp.'''' l1lc 'abnormal' .pinc is a .I·ml'lomatic SPlI'IC for whICh Degtntrativtchanges tllep\"'rsons.-\",k.lrcatm'11t_Ot1examm..'hon,~iKnificant romp.\\r\"ble s;gns will be p.llp.lbie at lhe\"I'prt'l'nat\" Th~' first (If th.. thl'l,(, subdll'l'ions 0,0.'. congcni1.l1 \"r inle\"\"'rte!lr;,IIc,d.l1lctitlc·abnormal'iso><.xltn,igl1ifr ,.Ct]uil\\'d struclural ,1nOmJ!leo;) is quitc diffcrent ii' an abnormal d~1ln.'C of s}'mpfoms rall....r tl1.>I' ,lh\"\"mlal kmd 10 the other two, ..ndsllOUld bl-thoughtof and joints,which.ilSho'lSb'-'(11_l.lloo,llldybctot.1UVp.llnl(\";.s

This w.e.lling into \"omup5 IS 11(It J f.-.:riIOUs acl, II ;,. \",If>.lble Ii$\\1'\\' chang~ \"'QUId not haw:' beeft as 'old' a re.u,~t1( Slluation and h'6hlighh Important dink.JJ a, those in tho> pair>-~ ·a......./:.·· group. Diff......... l;.. rnnnt'ctIOllS bctw~,\"\", S\\'mptoms .md e\\.a!ll\"\"'hon ..hon ~-wn u..,·new' and 'old' ,\"\",nses under the:.t.' finding.~ lholt c.m be~. \"The ,.\\lUI\" of the dil'ti'O\". ornunstant:6 b much \"1Ofl'difficull. ~TlI ~r,ng5lies in our ~bilil\\· to roerogn...\" thedifkl- eroc<\"o betw«n finiling> 11>.11 rel<lt\" 10 ~ palien!'s The abnorm.1liht.~ sought b,' palpation a.... ot tho> 5pTlptorns alld those- lIul are \"'''I \",-~nl} ~\"'led. foIlowi\"S kind$: Such d;ften.'l'lri.1riolL~c~n Ihm;oh,o b<> rel.:Jt<>d 10 In';ol- menl .,'pectaho\"\",. For ,·>.amrl,·, (t is ~ible to n.'«>g. t SOtl·II'suechanl;l.... lll~\", thn.lugh lhe inlt'Tpreta.tion of th., findings, Ihal 2. Bon\" ..\"omalo.._. Ih,· n',lli'tic Iolwl of lrL'alm«'ll m\"y be n minimally 3. \\lnH'mlTlldb\"\",mJlihes. sympl\"nl.ltic 'a,oo..g,,' ,I,ll\" 0' ,I pain·fn.... 'a,,'ra6'\" SCft-timu.· Ch3ng..~ stal\" rMhcr lh.w an 'ide'll' St,lt\". Unforiurlaldy, very fe'\" p\"opl\" ,n',,, th\" age of ,j.(] Till\"'\" ch\"n!;e. ;lrt> to be f,,\"nd in th\" Ii~ar\"e\"tou~, c~p· ha\"c\" 10t,,1 wrnplcmcnl of 'ideal' inlcncrt\"br,,1 joint>. sul~\" muscular and c(>I1,1t.\"ti,,, l~\"\"\"l'!i as Ihickening or Mo>t I\"-~'Ple, for one reason or another, fit inlo one of lIlu>cle sp,1>m. Pdlp.,tion Ii th{'m will 'eveal Il'tlderr\"..s:.. mth,· 'a'cr.,sc' groups. If\" ~;roup ~(}.rcar-<,Id p.·opk' Th\" abMrmalities .~f 'fl.'el' in hgJfllentous, ca!\",ular \"ho h~\\<' no pa,n or disoeomfort and ron:;ider I~.. neels 10 be I\\Olll'IiII ....en;> ,\"'Jmlllt.'d b} palpdllon, and CQnlll'<:ri\\'t' li\"u.\", d~ tt\"'l the older Ihey ,,~ Ihl' abnormahl,\"\", would be found In Ile.lrk aU oi them. '\"\"-\"q,*\"\",ion is,. \"hen _tlCh a p\"......... h.u.1 sponta\"\"\"\"~ han.J.e1- lhe,· feel. and the more \"\"'lTlt Ihe\" aI\\.' Ihe 0f>!Iel of\",-\"'(].. pain.md seet..s treatmenl for It. how does ;,ofter I,,\",~: fecI For ,\"'lmrlc, p.>lpaling oli capsular '1>0' e\"\"RUI1I..,. differenlLuc bet\\,cro I,,\", fmdings !hJ,1 n~I;1t~ 10 !he p~1 probk'nl dod lhe fiodings tNl thlCk1Un~around lhe J'\\-gaporh,~~1joinl \",U be 1oJ,.,- ,,·c..... p~'1 \"\"for<\" the ;;pontanoo~ on>eI of the IlIId< pa.in' A .. milar difficull\" ..\"\"eo, ,,'hen altempliJl,l! 10 rn\"~,r,:: J.;.Jinst IeJI!M;I. the~ are •••..en \"~ria!Klns in dRl...... ,.... lilt' d~'g\"'\" of diS.lbLli~' thai can be allnb· uled 10 a l\"\\.'C.,nl,nlul') and Ih<.· dcgrw Ihat is ,Ittribut- the NmJ1('!;; 01 the leather) 1'1,,,1- Thico..rong from \"l.>I.. to) p~.,.i~lu1g rei painJ~~, .~, ..mg..• joinl finJiJI~. g\"\"\"roOA' rea-nt,;~\" III a!>Oftcr or SJI'O\"f.\"\" fccl, NEW{OlD TISSUE CHANGES m.J,-\"h\"h \",...-tie.m OIdt.T k.lt\"\"\" iM. lln.:I.e;'ing wilhin the mll'ICU~' lissue is usually Ob\\'iously If an jnter\\'ert,>br~1joint ~uddl'l'lly sta't, to r.lU!>e p.lin for 1100/\"·\"),,,, re.\",.'\" sometlling mu\"t h,nc m<'rl' dlliuse dnd 1l4'\\t.'l\" feel>. like hMd leather. :'\\c\"(1\"- 1I.1PI''-''''-'lI 10 II, and therefore ~ ...... changes of \"\"me lhel..\".\" when thickenin~ i.> pre..cl1l'l ha\" a slrill~}' fed t\"\"\"\"kind will be present II reaTlt \"--.sue ,1ta~f\"> ha,~ oo::urred m an il il ~ 'old' ;md .. ,moother Noel if il is 'new' 'idel'll' joint, I,,\",onh- fi\"d,,>t;:5 th.ol \"ill be d..-:ti\"d by Bony anomalit~ palf\"'h..... e>;.lmi\"\",lion Wlli boo oi the 'Ile'\\'\" \"\" '\"\",,,,,1' \"'nd. ~ with,. for e;ympJ.e a 'P'~\"ll'd anUe L·\"dN IhlS h,,\"ding Ihe fe,ll.,m thai (,In be det....minl'<l by I'alpdlio\", Me: \"bnormJJ d\",·ialion of ~ .pil1l!ll_ 1£ ~ recmt tt\".sue chang..'\" ha,e occurred in an pfl>(,'SS from Ihe (\"\"'Iralline w;tllo\"t (Or with \\ \",t,obr,,1 ol!iymptomali~ ·~Hr.U;e cenic..1 \"\"nt then on \".....m· illation b). palf\\illlOO ~ ,,,II be Ill'\" Ii.\"u\" chanSO' rotittion; abscfIC€ of une pnxl'S§ of the b,fid SPll\\OUS sUl'lY'in'p'''''''' on l\"\",oM,,,r 'a,~rase lb,U<' chang\"\"'- process; abr,om\",1 \",...ilion of Olll' ce,,.iCilI,,crk.vr.l reI- nri\\'~ 10 its nL';ghbour; and the ostt..'(,.uthrilOC \"\"tl'Ol'h)\"~ StKC\\\"'<l '\" dilfeK'Tln\"ting boe1w;>en lilt' new and old fcmndlion of lhe margIns oft~ zy~pophy~l jomts. d\"\"\"\"l.\", males progno;;i.>. n;>1.-.tcd bolh to the 5\"<:C~'!iS of presenl tl\"t'Jtmenl and I\" Ill.. 1Il.elih\"od of fUlure The .lbnorma.ilie~ of d... lalion of sp\",ou> prol't...\"i!i n.='I1.'I\"',-,\", l~\"il'r to J\"\"\",,s. and po>.Il0R5<>f ,....nebrae,..\" bt.> (Onfirmal by X-rd'''' If\" Jl'O\"'itional finding IS IongsLlndmg. Ih<-\"Jup\"ot' lhl' If till'S<\" n\"enl liS611t' (lI~nfl •.,. I\",,\",, occurred in a lbslJCidtl'ti \\-..rtebrae \\,,11 h.l •..., changed from Ihdr 'y\"'p\"\"n,ll'C ',werag'\" ~!;meT1l, tlle!\"l' \"'ill be 'recent\" ~~ mmri......l 3PJ't'i1r..nre 10 .ocrornmoda'\" the chanlo--ed ti\"\"., ch,'n!;{'l; ~uperimPW<.'d ,)1\\ the changes 1r..'1 \"·\"n' pos't,uns. all1.'.1d\" painful \",hen stl\"t'telled 0' p.1Ipak'll. Bt.\".m....' the pdlk'tll \"\"d symploms bclun' th\" \"\",Kerb-,li\"n. I~ The articuJ.IIr pilJ~r abnormalities thai ind'cat\" OSk'C<lrth\"llc (0' os\"\"\"'rlhnltlC) find'ng> ..'\" \",ad'ly dctennined by palPJhon, .111(\\ Ca\" .. L.... be cunfirlUl.'d b~ \"·rays If the dldnRes 3re '\"Id' dnd lotally inaCli\\'e, Ihe bony \"\"'<gins of lhe e\"OI';I~ will be hard and clean withoui any sign 01 soft or leathery \"\",·\"nng. Mo~cmtnt abnormalitit~ Thl''''' abnormalities COt\"'st of Ihc following: hyper- or h\"pomooiJity;abnormdl qualit\\· of nllwemenl th ....u/Sh

72 MAlTlANO'S VEIIH811AL MANIPULATION romsI'; and \\Illf!N.os>, and spa\"\",. Such abnolllu.lIt;\"'S ;\"terpretation of the clh.'d of lre,otme,,1 (i.e. the symp- 10f1bhe fee~).'\" most ..\"IOllbltr. can be dclermint>d by palpation being applll.\"d in \" I, Immo.'<l'dtL>l.,. fotl\",,·,\"K 1......lm.E'<ll II\\dnlli\"l\" lhat prudo«!'! Intervl'l\"tl'ln'al mo'.emml Abnor· 2. During u-.el!lTrling of the day 01 Ift'lIlme111 and m\"lilleof Tl\"IO\\'ClI1CI1t should be qu\"lIfied in terlTb not th.JI nighl ani} 01 t~ available range of mo\\t',nenl. but .. t.;.o cI 3, On fir.;t ~ 001 oIb\"d the folkrn Lng morning. anv (h;m~ ;n the llOI\"ma1 ftec-runmng mO\\t'mtnt ro.-II is importanl not to.lS1: the p\"ti..,1 inili&ll~' this nvthrough the r .. up 10 the end of the .l\\ai.J.lble ranI:\\' information. N<cau«' 10 do SO may block the flo.... of sponunoous commenb from lhe pab.:nt q\"\"-\"itiootinj; This may be dbNrbed b., SIKh fiKlOl'!l U Mthnb( .!<hould be SO pl.lru'\\OO thai the rhyw,therapi51 c.m \",\"oke spontanoous I'<!I1l<Irks. \"hid, It\"\"\" pro...e 10 be ~, stlffneso. ,n suppom:n· capsular and li&,mf'TI- \\.\"\". infonnatj, ,,_ tow ,;tructUI'8,O€ prot..ct\",e mus.::1r spasm \\Vhen asseso;ing al lhebeR:innmg of a IrNlmenl:>e5'- sion. the lim q...-.-stion ,,\",ouhJ ix', 'How ha~\" you An 'old' l\\\\'pornobiht~ h.>s .. hard end,ft..~ ..I I~ \"\"\"\"\"n,.,,,,,,,WtY ..-111 t'<! 'Olludco'\" if 1\"'-' patiffillakes ,I as a b..,.,..,.al n:mark and \",swel'S, 'Fine thanks, how hm!t of the r.. n~e, \"lIh ffiO\\ement before the lurut of a.... you\". Howe\",,!, if tho:! p.1lic.'nt ;;'1)\";. 'Much beller, thank ~OIJ', then llS'--ful 'l1f\"\",,,,I,on I\"\" b.;>en \"\"pressed, the r,lnge bcmg a smooth. fricrion..f...... mo\\tm,',l1 A If lhe fin;t 'lUL'SUOLl proou<lod a valueless ~rlS\"'('T. 'new' hypomobilily. on the other nand, tws sllfrtlC<o/; the \"\">.1 'lul'stion should bl', 'Wk,lIdo you fl\",1 \",aslh\" \"\"rI'er'llXurring effecl of the last t\",.1tm\"nl?', The ,,,ply. 'Bootie\" or in the range, building up In ~tren~th 'Worse', ,,\",-'Cds further clarification. Fo' ('''dmple .1 pM;,;nl mdY, in \",ishill!!: to I'mph,1Si~\" the d<'gT'('t· of his of resl~....nre until the end of ran!;\" i;. reached; tlmt 15. present pa;ll, gi,l' the impn..;;;i\"u Ihdt he is wo,..;e, \",IK'\",,,s on d05tY qllestioninll it may b.1 prowd that Ihe'\" is 're!llSLonn' throo.,~ range. he was betlt'l\" .rltl'T hi,; lreatm.,,,1 until he pt--rformed \\Vh,.\" (\"-\"'Itll~ i~ prr>sent during mo.\"t'Tnl'l1t, it will some activity wluch ,lggTilVatt.,j his pain. lindl\" thes-e (,rcumsI.1no:e'S, t\"'dtmenl hdped ,..,ther than mad\" him be painless;( it ~ una;;.r.ociated with pR'Sl'nting symp- WOI\"Sl\"_ This kind ofinformdrion may bl~g.>.ilK'd Ihl'OUf;h Ihe follo\",ing: qUC'IIOIl.~: loms and rainful if it i, aS5OCial\"\" 'In what W\")' is lhe !\"un w~' (is i111\\Of\"e SC'o'ere, In 'id<\"al' iuints, wht.\" the s\\,,,o,,,,,] joint surf.Kt'S\"'1l' sharper, d\"\"nged 10 '\" throbbing P'un. or has II slro\"\"ly c<)ll\\pre~>edand m~'e, Ihe mm'\"ment will be in<ttased in a\",a.. <:!C,?) p,'inl\"05 (M\"itl,md, 1980.1). There Me d.-.:umstann.\" 'When did 11 start 10 N<como' wooq!' whC'n pain i. cx~rienced durmg a la'll\" amplil\"de of 'Whal do you thll\\l: made: II \"'00'1:'\" Ill<! ran~e, and it 's somdimC'S possibk to hdghtcn Ihis 'Was\" Mill<.-d 10 lreatmentordid vou dosomelhing \"'I;pain by holding Il>c joinl surfdcl'S flrm1y COmpR'SM.'ti which may ha\\e aggr;lulcd II\" \",h,l.. ,no\\ the jninl throogh lhe <.lme amplilude of \"\"\"\" physiotherapist must be prepared 10 accept IJ..o p<K'<ibl1i1y that she has perfornocd a led1niqlJ<' I\"\" th\"TJ\"~. ~Irongly. If a p.1hmt oon]($ in f~hng cross, ><l}ing 'Whdt !'oudid lome )'<'S\\letd.\\y made ..... a lo'\",(lr'5C', Pain rtspOnSC' .he hcginncr is Soin!> 10 feel d '>COIl,-,crted and d\",heilrt- ened. She wHl lind it \"a,i\"r ill a(cept the bllun.. if ,he \"\"\" pain n::;ponse felt by the palienldunng the p ..lpa- can reply,'Good -oot thM] \"'Mted to make you \",orst'. boo e ....minahOO 01 h ...~ues and mm'''m<'I11 i~ ....»1 bUI il shows m<.' \"xactly\" I~t Il) do and how 10 do it'; ,mport1nt, 1'hc pain or d\",.;omfort m.l~ b.1 fdt ('Iu..\". or she may >.1),. 'If 1 can m\"ke you Wllme by too much through rans\" or at the end of ranb\"; it m.:ly be.- fel! or too hed\")' mubi1i~ing 0/ your spine then I should dol'q)l)'.Of it \"\"\"y reprodU('l;' The p.>ricnI'ssymptoms. ,t\"nd a good chancl' of bo.>jn!!: ~bk In imp\"\"''' ,I'. SupeThci.JJ and 00.,:. local p.lm c<ln ooxur m both Th<' seq\"enL\"\" of qUl'ShUl\\i\"g 10 dcl<>rmll1e \"~..:,, dnd 'new' arod 'old' ,!Ioations, Se-.enop<Wl fdlln theP.1tient wl,y a p.1t~nt·s s)'mptoms \"'t'rc \",orse is important. when only rl'o(l(k>r\",le pressun.' is applocd 1o .. soft 105- sue, or JPJ'1ioOO 10 prod....e mo....menl.1Salwa\\'1i 'new', When '\" p.>lJ'-\"'l \"\"s rri<orred p..in thai can b.1 repr0- duced by palpallQfl eAamination. lhe indlCi,hon.\" that il is a~,oooaled with a 'ne....• dt50rder ASSESSMENT AT IliE BEGINNING OF EACH TREATMENT SESSION ASSL-;'~Inpnl \"I chdnl't'S m ,ymploms and s;\"n~ at e,,,h trL'iltmml session \",,-,,-'tis to be carried ool in a particu- lar m~nner. Ther\" art' lh~ time:; when the p.1tit~!l's

AS<l':<<m(:n! 73 The fin>t questions <\"iln toe. 'When did \\'ou ~ il IT TIItII is.m unqwllfird -l..Ifflft',l! ..,W IflU>/ &rron .tlIrting Iu \"omen?', and, 'Do:>}OU knl)\\«' what matk.t !'r1W to .... irtlimmtill'C<>rnpdriso,,\" boocome WOIS<\"r' Q '~th.ln\"\"~?· Assuming lhl.' arlS\\Oo~ be,ng OIOUgtlt,,~ not duti- dJred by Inc, ,,1xn--equesllOOS, till' nnt step, re!<lt;h.... to A '~th.on s\"tutdar. bul then 11u' ..... ·1 been 1fWron, IS, 'Did \\\"CHI .....k\"\" \" ilh it being Won;(' or did 'I doing anrlhiflg: co.ncun 1.llwin theda,·?'. P.:lncntsam U5Uall,' ans\"e. \"\"sET I ,Iill don't kn;)ou. Illorlhn brlltT lhun /JtfM' this. If the a\"\". . .\"\" is, 'Ii \"\"as \"or.... '\" hen I ~t; got out t......I\"\"\"'lm,friJ.:iy. oibed'... nd ,f il ~rs to Ihe momlng following trl'.:lt· menl. lhe posSIbility thoi'n ~~b t\\ul' lhe worsening Q 'How do you fl!1i1 nuw compared .... ilh when W4$ duOl W the lreatment. Th.,. second 5t<:'p. rclali,e 10 )''-'u \" ..re III here ocfore lrealment nn rrid\"r~' '5,,'I,y. ,hQuld be t.lCkled Oflly nfler th<! 'tns\",~r 10 U,.r4'\" A 'Oh,ldon·lkno\\\\· ... ilboutw.;lme (lr .. might be n bit betler.' known TN> purpose oi the ..\"...:-s:;1ltcnl is to detcrmint wh~lh\"r the worsening w\"s due 10 lreatment (which is ET Tlw! m,'t rrolly 'ilrcll'flr·w' J::'\",lllf n'l'fI:'ll'l' I'm ., known quantll,,) or to other faclors. Ii it is du~ to olher faclOr!;, the degn'(' oi th.' cau...• mu~1 be deter· \"IA' \"'r,lool:;\"g.f~r\",Id Ihi' I\",i' (', qUi'5Iioni\"x;~\"o1 gl'I' rnir'l<.>d SO thai il can oc rdall\"d 10 tlu>d,'p,,,,,, of WOIlief>' ing. b)' Ihls lhe dq;reeof ..1..biJitl' of the disorder being ling \"''Y I <tIll dion'l k\"'J'\" IIll'tff«tcrfllJi' lreat{'(l m.. \" be laml.1f tllc p;ohl'nt's;lr\\sw\"\" 10 '''''!>en' Ir....lmml. I Ihlllk I oMll ~ lhi' '/wi O/f is. 'Who:n I gQl out oIbcd ne~1 nlO)r\"TlIng'. thl'auIDlJ\\iloc immedi.:l~~ is, 'Does 11 Ol,mcti\",es lluctual<' 5tJt:lrd\"Y pa71\"\"d )/(\\' if IJwl g;;n, mt' \"\"II m{t>r I:b< this, beln\" b.d ooe morning for no known \"\"olson,. n>aI ..... '0.or is ttus unusu.U\".IfIheMl5\\Oo.... i!, th~isunusual'. Q 'Ynu -.lid 11\\111 \\'Ou were bad 00 Saturday - tt.> quoestion has to be pursl>l'd; 'DId ..uu do anything \",i1ft100 Sarutd.l\\'7' rtstero..), \",hieh might hoI\\(' Jggrilull\"d it?', 'W_ rou more bl'\\\"d I....n usual ,·est<!l'd..11 \",,'ening\"', 'Do A 'I dun'l knO'....• ..uu thml< ,t could be duc to }'E'SlCrd..)·S tr&:IIIru.\"IlP' Q 'Did you \".am ...,.'lin3 bad 00 tho.- Only ~t all of this quellorun& !las pro·.-l\"d fruit, koss C,'n the fol1o\".. \"'& be \"Sklod, 'How did you ft't'l Salutd~y momingCH' \"i>S il Late. in the d.. v?' whro you left here )esterday after trealmenl comf'll\"l'd wilh when you came in fM IMt tr<:,'tm\"nt?'. Then call A \"I don't lu\"\",. I Ihlnk I w ..s all righl in Illt follow. '11o,,\" did \"ou feoe! later ;n Ihe day a{te. the morning, Ilhln~ It \",..S I~tef in t!u'day.' treilhnC'nt?'. And la\"stly, 'Whal,l1d II f....'1 like when rOll Q 'Dld you do ~n} Ih;,,!! that could h~l\"e mMf' il went h.bl-d?,. '!'he fnllowm& is ..n ..\"ample p~'fItl'<ltoshow how b~dr carefully ttu.. que;;h0llS ha\\'e to bl.' ~kl>d to gamlhe infor- 1\\ ':\\0.1'1'1' only been ... ,Iing . ..... lion bl..~ng soughl, and 10 show lhe<.re~'in UlIefpMmg Ihcpatimt s ~The palienl,a }\"o.mg IT He' i; 'lIJ/ IY\", d«l>lI....,'ilh lti5 IlllSleYrs; litis man. had seo,'Cf'l' low bad< p;oin '\" Ith a ,\"..gue rei\"......1 N'GIIV '\" lw.nJ :l'l'tJ::. me\"'to rlghl buttock ..rod rl#>1 po6t.,,-ol.. tnal ttu Q 'l-.lIal \"\"ere you dOlllg during lfwo aft\"fTlQOTl?' /II Ius fir.>t \\isit 1.1\"'- Fnd.:ly. follo\"'in8 • limIted A ·Oh.~bn&: \"\"\"\"',.... t\"'\" he \"o1S !matl\"d u.lng .. grad.. oi lumb.lr l'\\btioo foe suff\",ienl Ii..... 10 prodU(e a change in the Q 'Did~ougetupatalP' 5}'mptoms CIt' 'I~'Tl5 if il \"''''re lht.- nghllaitmque to ..... ~ \"'JS a..mall but dl'finite ,mpnnemenl, showing A '\\\\d!. now ~·OU como!' 10 menrion 't. m, WIfe th.llil muJd be the righllechnique'. did ga OUI about mldd,;;,yand I w,\"\" at ~ 00 mv O\".-n, The phone ...ng four Iimt.~ ..nd I The ~ trNtmcnl \"as on Mood..\". and lhe fol· h.ad to MIS\".... il. That lTIt'iUll bending do....'f110 IOWlllfi is the conYl'fsahon Ih\"1 was n.-q~11'\\\"d to deter- redCh the bClephone b.'G1lZS<C II wason the noor' m\",,, the e/fe<1 otlhe trcalmff\\l. While M;.ing Ihis hoe dem~'tTJIt.'<l hO\\\\' he b~nl dO\\\\'n Q ·Il\"wha'·eyoubc...n?· to the tdepOOne. ~nd thl: ,Kllon (erl..m\\y Jool<,'<l A '11 was terrible nn 5.ltun:l.. ) but it's better ~\",k\"'3rd. now: Q 'Thank )'Oll • IT At la.t I\"Y .~ot I/l( an<\"..... P'\" I ;;}lOnlJ /Ilu il Q littlr r\"r'hrr tobi' s\"re,

74 MAITLAND'S VERTEBRAL MANIPULATION Q 'Was it hdur{) tl\"'t or afl{)r, th,lt rom hack Q 'How Ion!; did It remain better?' worOCllt\"{l?, ,\\ 'Well, I don't rmlly know, because 'lly wlf\" A '\\'('S, it W;lS after the phone calls' drow me home whil.. lIar on th\" ba,k scat and that WJS11't nrr oomlortahle: Q 'How did you f~'C1 on SundJy?' 1:.\"1' At I~,I I hWll', Irs ,1f!'Crs..'lV'].; is /\"A',ll'le, idr~rf my A 'Oh, I was\" bit sore Sundav morning, but it InWnJi'm stallds i\" ,,'Iatio\" 10M, 'y\",,,I\"\"'s, m,,1 I gut bMtcr as the day \",,,nt on ' kJww 1111I'\" 'lilies.' 1fin,1 rilnl hi, 1\",;1 m~,\",Il\"\"r/, m, Q 'And now VOU'f<l about the \"tme as before treatment on Friday, i, that right?' ('.mminn/iOP' nrf IlV,,\"-', I llW:il (0\"1\",,,,' .dlll tI'e roMllm' jor nl Imsl I1Ile more tnwlm\"\"t if I ~,,' A 'y...,lthinkso: gvin,;; 10 ream II, nl[w. 7(, d,m,S\" Il'dlPJiqw'S ET Hilvi\"g got tlwi elmr I \",\"si \".01'<' 0>1 It> my IIl'XI b«\"\",..\"u\\'111d bt'a wnmg dffi,;;,,,,, I'''rt ofQS5t'SS;\"X, ,tage hns \",11 ',<6\"''t~' n:ad\"oJ \",I,m II,~ \"\"III<' aj rol\"rit\", I.y\" Q 'How did you f\",,1 alter treatment un Friday o,mpmL'Cl with befm\" the trro,ltmenl?' \"rom!. ,\\ ') ~rtai\"ly knew I'd 1x'l'Il mOH'Cl rOlUld a The extent and depth of the suhj<--ctive questioning lair bit.' may .eem to some p'-'UpIL' t\" be t<-'d,ous, U\"\"{'(\"l'SS.1rY \"\"d a wa5t~of time_ TL'<lim!S it might \",-\",m, lInl1L'CL'S&uy Q 'Do you mean that )'ou had mur\" pain than iUld .1 w;l>le of time it is not. It is \\'italto the interpreta- when you CJme Inr' tion of thc dfed of t\"\"atmen! to be at>le to underst,'nd th\" \"ffrxtof the treatment in the p\"tienl', terms. It is not A 'I don't think so, I was about the sam\".' tedious, it is challenging and stimulating Q 'Well, \"'hat ,,'en' you a\"'Me of, when you rd~r Ii the vital spontaneous inform\"lion sought is not to knowing rou had Ix'l-n \"mO\\'L'Cl Mo,md a torthcoming, it may bc nL'CL\"lS.lry tu ask the di ....\"t fair bit\"?, qUL'StiOJ\" A 'It iust felt differ~nt: 'How did yOIl I~...l when you got up first thin):; the next morning cornpilf<:d with huw yo\" f,·1t wncn Q 'What felt dilf\"rmt?' j-Ou carne in for the la,t treatment?' A 'My hack' 'How did you f('Cllor the res! ollhe d\"y and lhat ni!,:ht?' Q 'In what W,l!, \\\\\",~ it dilfer(~'t\" 'How did j'U\\l IL\",1 wh\"\" you got up first thing the A 'ltfdt.1bitsore' lIe,t Tl1orning~' Q 'How long did itl,,,t?' Should the~n\"wersstill not gi'\"eil de~r J,s~'Ssment, the phy,iotherJpist may nL'l'{1 to \",k, '[-las your pain A 'Only lor.1ooul5 minut\"s,' ,11Iel\"L'd ,11 all JS ~ result of t'C<llment?', (f the p\"timt has Q 'And then how did you k\",l?' to hl.\"itate before answering, then it is fairly cl~ar that A 'Back to the lIsu\"l' the symptoms muld not ha\"e change..! much, if at Jll. £T Till, lS Im,,1 !l'(Jrk al,d /,,,, ,wi Wllillg lYry fM, If the pJt'ent ..~porls fl'Cling bette .. from the treat· Q 'Dv you \"~m,,mber ttwt during trmtment on ment, it is equ~lIy importantlo dJrify what it is that Frida}' you were lying on your side ,'nd T W,lS ha, improvro and in what way it has improwd. Thi, is twisting your b,.,ck?' p.uticularl)' rde,'~nt whL'\" <1 patient has referred pain. A 'Yes, I certainly do.' At each treatment session, wh~n making the initial ,,\",;LOSS,,,,,,,t of the slIbi'-\"Cti\\'e changes, the m~nipulati\\'e Q 'At th\" lime, I thought you \"\"i<l th\"t yo\" felt physiotherapist must be \"hi\" to understJnd cle~rly the bett\"r: effect 01 the previous trcatments, if the patie!1l gives A 'Y,,~, that's right' gawk'\" Or conflicting information, she mJy neL'Cl to ,'sk the p.,tiellt, 'Tllillkil1g m'l'mll, what eff~t do YOU Q 'Despite the 5 minutes of s<)f<lness?' Hunk the last treatment had?'. It may be nea'S,~ry to ask, 'How did you fe-el when you left here after th\" la\"t t,eJtment in comparison with when you came in for thJt tn:;Jtm\"nt?' - in other words, '\\Vhat do you think

Assessment 75 was the imn\",diilte ('ff('(:1 of thl.' lrealment?'. Such a pamcuJM the pallcnl'Sopinion of ttl(' changes dfed,..:!. commItment frequent!) giles a bl.\"tterbal.ln<:ed ~ Itl~ lherefore ltIilooatory for Ihe m.101pulati,c pnysio- InI.'f\\I of the 0\\ ('rail ..ffect of hNtmml lila\" ,~ dl:·ter- lm-r\"plSt to dP\\·~ lhe Mb,l of beglnn,\"j; the ...ntlen ~rd wilh I\\urds ttut lhe pilhL'flt usei C..bbn.\" Idled if minftl by 8Sking ~~ifw: questions aboul spt.'C1f.< rM.'Cl'SSlIry) to e:<J'1\"'SS HIS opinim of the cltect. This sl.1gesdUril.g lhl.' \"'1\\\"I\"\\al bdwecn lhe two ~ ~lbt be Il\"COrded;n quotation m.;orksso a~ 10 IndlGtl<! ckarl~- NI this is the pat>enh Dplmon It IN} not be Writtl.'n rttOfds by the ~tient lhe m.;onipulali,... ph,~\"'-.,.arISlsoplmon. but It cer- I..ml, ;., the palil!Ot'~. If th<>no b a H1ridncc of Of'imon. n.,.., are hllll!S \\\\t..-n it i.5 no:l'S5olry for d patient ro \"hid> cannot be resolnd, botll opmions m\\bt be IIT\"~ a runrnnf; rommmtar) of lhe bclwliouf of his ~ymptonb. for l\"'.lmpk. patient IN}\" be .. I'en poor \"\"\"\"\"'.C>ccasion.ally a patient will ('Qn\\rI'I('llt that toIlowing hisloridn. in which case he may be ilSked to \\'\\ nle dO\\\\'n how h(- f('('ls lmmediatdy foUO><>'ing tTt'\\1tmo. ..l. ttlc Ias.t lreablent he fdt e~ln'mdl t..~, \"nd p. fact how he feoels Itwlt nihil!. .nd how he fucls on flrsl gct- mdn, ha, I-' ~ for as Ion!; Ib 3 hours.. Thh (!{fuct usu- ting out of bed Ih\" ....·,,1 mornml>. There an! al50 timt'S ..Il.. occurs lolkl\\\\ing the imhallre.ltmMllS. and can be \\'\\h('n III~ critic.lto know pn.'ClseI)' IvtllU happens to a rons,dcred to be a fa\\\"Ourab~ re-ponse to the lreatmenl pa\"t.\"Ilt'~ svmplom~ for lht.. finlt 4 hour> immediately following .. l'''rlkulM treatment. The abo\\\"(' is the ~,,!'i<\"C~i;,. ~nl of the effect of the pre\\'~ day·. treatmenl This 1$ followed by Wlu.:n .. patient is ha\"ing 10 interrupl a \"\"'IU\\'1>'(' of re·to.'S!IOS The pr<>\\'iousJy ,.hm.rm,,1 mo\\'ements aOLl tn.~~I\"\"'nl fur bu~illl~ or ulh,'r ,('a,;o.)n~, it IS useful to ,\\';,;t.....lIIS thl-' qu .. hty of ~\"y chang\" \",-'!>ulting from ask him III writ\" down Ih<.- Ix·h.,,-]o,,' of hi, ~ympl\"ms t\"\"atml'n!. ChangL'\" in thL'S(' Sl~ns will hIJp<!fully a;:(rL'C l\\ ith the findings of til\" subi<'CI\" e ,'S~'Sment, 50 rein· oll'r Ill\" fif)t 48 hou .... from the time of Ihe last treat- forcinl; e~ch otller. This \\l'iJi then make Ih... total asS<.'Ss- mell!. Some ,eaders may f\\'I'l th1s i, enco,,\"allllll! a \"'\"Olt more \",liabic palientto 1:>I:«>\",e a h),pochondriac. bm thi, i~ not Sfl. ASSESSMENT DURING THE PERFORMANCE OF .. nd el'en if it we,t.' the ad,-anta\"l'$ of the '\"Ittl''' A TREATMENT TECHNIQUE re<:oni f.u outw{'lgh Ml)' ~uppo6<'d dls.ld' ..ntagl.... Two points are imrorl.1nt here; one i. the inl<!nrton 01 Whl'n a \\I \"U,,,, \",-'Cord IS u>Cd ••t should be handled the teeruuqul-'. and the otner Is the lind of changc II mdY be rifccting. by the manlpulali\", ph~~iotherdpi~t in .. parli(Ular ,'1'ie§!\",\"'\"t d~r'ng a 1rr:Miquf: >e<jlll!rlO'. • Mgo;r'.;oct.n-nI' I. On \"'Cei'in!: 11 from the patient, il should be • Oars no ~mles.\"'\" ~ 5UIt ~ffect oca.-~ pl<>ced faa do...n. Intc:ntlQn of ltchniquc: 2- The pahl'l\\t should be..,,1U'c\\ to w'e .. !l-l\"fM\"f\"al ;mp~~;on of IN! l!f/<'Ct 01 the last tmIIlm<.\"nt. FoJIo'~iJlS the I-'~amination and a.~nt of the p.ltl\\\"Or. dL...-mi.,- II 01,\"- be the intentiol1 to \".,leel the l. lbe ,;ut,«\"ti'e ol$sessm\".'fll of lhe effec'l of the l..st poslt.on and m,atmenlleclullque that prul\"<lke; a con- tn...tmef>1 should be takn tnrQtl,gh l(\\ it!l omdusion. lrolled d'-1'''''''' 01 his symptoms. Le. point (l) below, Of lhe oppos.te may be theinlmllon.(ThIS inll'fltion mu,t 4. Thc\"'ritlml'l'C'OO.l(ilnlhcnbe~and ..n' ;\\1>0 be rcmember<xf \"hen m,.king tho! ••sSf.'SSments d~repa.ncicsc1.lnneJ followlOg the U5<' 01 the tL'Chni<jI'''') ror ..It I~ not uncom.-non wnt!\\'fl ~ 10 gil-.. a Kind of change wrong imprbSion beouse it is \",ad OUt of cont~1 l'n> pain n.'!>pon,\",,~ C,1O oocur whIle performing .1 tl'CIUlique; I;rsl, i~ that palO ma, he iellln mythm with \"ill, all otl\\('r dCrt\\(\"11b (>I the dS5eSSm''f)t. It ma,' n.'old as though 'ho' p.>hmllS worse. \"h<'mas, bK..~§l' he h.ls not roc.\"dc'd \"\"\"\"\" import,ml facts (not asJ..al for), he ha~ m f.let Impron..:!. So this is ,,·here the manipuJ.lli'·e ph)sinther\"pisl muM be<-omc skilled ,)j int\\'rpretation and uS!' hoer ilStl.'risks from the initial cOllMlllatlon ch.ut. Patient records Afkr C()\"'p1eILon (If the ~ubJl'Cti\\e as>t'Ssm{'nt '1\"\",. lionin!;. il m,,,t be \",-'C\"rdL\"\" on th\" case not\"\". Tho: FIRST \"nt')· at \"'-\"f} trcatmenl ,\",s\"on is alll\"a)\". th\" ass<''!o)ment ()llho! subje':Ji\\\"e changes, including in

76 MAITLAND'S VERTEBRAL MANIPULATION the ~ill~lions of liM.' t~'l:h.niq.....; and >«ond, an act.. the joinl ~Ie, that of the piolmst plapng. con-- rna, de\\ clop during lhe performinS C>f thl! ledmiquc cerIu in OOOluoctie-J ..'ilh ton ordlestra and, 11.1 the .....me time, being a\",,,A' of Ihe compos<'r's Pam (O!'II in rhythm \",ilh the lechniqu..., I.e. p\"-\"-nl (3), may d ..,ng... in lhe follO\\\\'lng ,..\"-~~, emotions. L From a pain-fn.~ .tMt. th... dioorder mar begm to 4. The 1\"\"1 rhylhmic I'~in n.-spon>e i:, wh.·\" II;\" pain hurl in rhythm \",ilh Ihe 1I.'<:hnique. The technique \",orso..,lS as !he tcchnique progres.... and {\"\"Hinu\"'\" ~hould b<- ce-Jhnuco:l without \"n\\, cnan\"... whatso- 10 pmg_. just as much mre is \"'qllin.'\\! under I ....... citnlmslanres as m p) ab\"\"..c. b......\"..\"\" il i5 \",cr oc,ng allowed to to,\", pl.lce 10 Its: n~' to a!jSi'SS .........h.·. the disonkr.,. ~IJmg OIl Spo.'Cd the nuonJpulall\\e ph)'SlOlherapist, 'I don't \",.anllD hI Rhvthm be \"\"\"00 Ilk tJus. please lOp-yoo re \"\"\"kong me c) A~p1itude WQl'l;e', or saying. 'Yoo're mOt mg me too qUIckly'. d) Position in range 'Youre pushing me too f<lr mf() the paonflll t~ngr.' Tooch\",,-e thIS po.-rfectJ..... \"\"lUIrl'S lOt>Il Concenlra- or 'Y(H,'re mo';ng m\" jcrk,h--·. These COlnm<m!S are \"on. After 10 'iI,'O,}nds, while lhe l;xhmque is sllU not r..~\"\"OuS, lhey are very real Dnd this dLl'lh of oonnn\"l'd, ;> comparNm is made of It.. rhythmic informalion mn be \"0$<\"'''<1 by 1I,I<'nll1l; and by pam. If it i, ;nc\"-'ilSlIlg. the t<'ehnique mar be con- tinuoo pro\\'ide.:1 ~ c~IT'ful w~lch is \",\"pi\"\", th\"t il responJit18 \",ith careful modificatIons in h<ondling the k'<hnlque. U the p\"ln still continues to \"\"'.-,;.en. d\",.os nol conlinoe lQ wors<:.-n Ih... S)'mptoms. If il then it is n...lly Sily\"'~ 'ItdndS off, yoo're making me ..........•·. dOlS, lhe techniqu... must be slopf't'd. When the phy:.iotherapi!;t i:l; CAITying oul a pa5Si\"e 2. A rtll'thmK p;ltn lTI4~ do=ea9l' \"-5 the ll'Clmique I-'> \"\"\"ernent techmque on a p<lracn,- she s.hould first eontinum with IheconstilIJl spet'd, rtll'thm. ampli- ~ln wheme.- the patient\"\"\" an) IMtn while pos- lttde~nd f'O'SIhon In raose, Ajudgt!lllf:llli;; madcof ih(Hl00 for tho.' lreatment technique 10 be Cilrrkod oul. !tie lUTIOUnt ...-.d mlc of change \",LllN to Ih\" Before tesling lh<' p.,tienl's mo....me\"'\" 10) a~ the amount ,Uld land of techruqui': reqwred to e1iect object,v\" ch~Il!l~'S. Ih.' qUl\"lion must be pul 10 lhe theeh.lnge. This gi\\\"l.\"I1lll id..-a of the hkelv p~no­ pati\"n;' 'What symptoms do YOt1 fed allh\" moment, 5;5, parti<:ulMly '\" hen the peKcnt.-,~c of impnwe- whil\" you ~rc stmlding th,'W. befoN- I test yOur move- m...nl rt1laine<J o\\--;:r 2~ hours b \",I\"ll>d to Ihe ki\".t ments\" 1101s ,,-,ltIC queslion must be ask.'\" ... hen the of IN-alment and the amount of Ir...\"tmcnl. pollenl \\li asked to stand (for asse:>smenl purposes) after a In...lmcnl lechmq\\Oil! hu JU5t been COI11pk,b~' 3. n .., rh\\thmic pain In,iI' increase /Qr the fiNt IlJ-.3O 'How does il feell1(7W compared w,th bel\"0I'l\" I dKl th.lt S«'OI>ds}x,fore then sl.3nbg 10 OOcrw~. 1l>e ~in tcchniquer.11><... lest tt.: n..'quin.od frlO'..,men15 for lhe m.>\\ ronlln<>e In ci«rN5ol' ..nd eo.cn dbaPp\"'ar. 11 lhl> 11llti.lUy irrrn,ins pain;'\" Q!Ilf p<>m of tt'G.'I.1 ph)~I.-...so!SSmt'nl origin.. ll\"l' rodVUqUl' l~ not eontmued fo< the 30 sccnods. Howl!'\\--er if it b local Sr\"lill p..l1n or Specialcarci:> .-..quirru who..on lhe p.otiml has Ialt'rllor ne~rby n..iem,-'<1 p.110 (p.ortJ.cularly If 'I IS ~hronic in Imgcring paIn. 1lIe lcduuque is then P\"rformed ,11 ~ n\"lull'!), lhe <:OIISl.3nt sf\"\"\"\"l. rhylhm, ~mrlitu,le chosen grad\", and lhe patil~>l isaskoo ....hdh.,r lhc lech- nique is caus\",!> any all~-'t','liOOl 10 th\" symplums. nus ~nd l'>OSition in t~ngc dre conlmued for the JO sec- inlonnali\"n is n\"\",~sary from thn.'\" points of vi,'w; ond~, prm'idL'<1 of cou •.., it is not .leAdily wor;.en· I. Th\" p..ltie-nl may h<I.e nderred pain while pos- in\" as ~ach \"'-\"<:(,,,,<1 ~<X!S by If the rnli~nt is \"\"\"ble II~ lor tN-iltmenl.As lhe l\",atmenIIL'Chmque\" to !<lle\",te the lIl11.'nSltv of palO b.,fON- the peak IS carried out, this pllln may gradually 1es'lCfl and go, rrocho....J (and u... naniplllati,·(! rh)'5iother:apist it may ,110......... 11.1 the san... \"\"'-.,I throughout. or ,t mllS! communic.. w f() know tIus). it m<I' be ....~. \"'1'\\ to \"\"\" e III <In .dp'rlI\"8 mort' comloruble mavworscn_~1during the ted\\rnquc \"''ill guide lhe deasIon.os to whether to conlm..., w,th joinl tl\"IDporarily When >he returns 10 the offend- the technique 0< p<!rionn l! \"\"\"\" genllv, 0\" ...hether ingjoinl it .. i11 \"f...'11 be ICflS hortful. AS6L\"SS-inl'l,ueh a change of k.:hnoquc IS indicated. d\",ngC5 n>qu~ not only verb,,1 communirntJOll aj Fm ex.,mplc, in the urly sl\"ge5 of t\",,1lmenl of a bul also .-.\"'\"........'.$.~ of lhe non-verb.:ll nuances of beh~\"iQUr, Ihe pJllomfs abilily to) relax rno\", and patient who h.,S p.lln radiatmg lhroughout his tl\", IL\"Chnique being ';~.l ...r top.-o<;luc.... - all I'Lly Ih....ir leg. if tre,1tmo.'111 initl3ily \"\"uses s1i8ht calf p.l;n part The deg\"'\" of coo<:enlnti(lfl ~nd skin required (.:md cst\"\"'ially if this (alf p.lin u ·~scs as the under Ihes.: circumstances is dem\"OOins. and tt... extenl 01 (il) tallang to tiM.' joInl and lbl feelmg for reehniqOl' is ronllfllll..,J), U>en tt.: ph~herapi;ll

As,~\"m~nt 77 should discontinu\" that technique. She AFTER THE TECHNIQUE HAS BEEN PERFORM EO should stand the patient and \"'ilss.ess th\" other (TO DETERMINE THE IMMEDIATE EffECT OF A movement signs before going on to the next technique. TECHNIQUE AND MAKE A JUDGEMENT ABOUT b) On the other ha\"d, if the condition is more WHAT SHOULD BE DONE NOW) chronic in natufl.'. it may b\" nl'Cl'SSoMy to pro- yoke this calf pain with the t\",atment teehniqul' Th\" main pomts to be coosidered \"nder this heading to gain impro\"l'men\\. On rl>,lsses.sment, it would be hoped tn,,1 Ihe pr<ln.(\\l!iO<l had ful\\'e atn)adj' bt.\"'tl con,,,-'Cl in the \"'-'Clion on '1\"\"\"'- brought about it definite impro\"ement in pain- h\"e range of active mo,em,'nt menl ilt the begiruli'\\g of each treatment ses-'ion (s.-e c) IVhJle performing Ihe t\",alment technique, onl} the back Pi,in (and not the referred pain) may be p, 71). Care must be taken; fir:st ,n tI\", manner of qlil\"S- \"'prodUCl'Cl, 11 this occu~. the tedmiqul' should be continued, Whether it ,hould b<' repea!l'd tinning, and secondlr in the Jccuraer of le>ting mon-- dl-pends on the assessment of its Cftl'C!. melllS. willeh form the I),,,,, of comparison 2. The patienl m,lr h,we nO p\"in whiie positioned prior to performing the technique. but during th,' Having carri,>d o\"t a lreatmenl technique at ilchOSl'I'l perform,11\"e of a 1,'Chni<jue he m~} fed (''11tre n>ck pain. It shouJd be determined whether it is the grade long enough to achie\"e the expectation f,om Ihe symptoms b<'ing reprodun-d, whether what is b<'ing felt \"\"ars any ll.'SCrnbl,,\"ce (itl kind or site) 10 technique chosen. the phy,iOIlll'rilpist <lsb the pilli\"\"t the patient's symptoms, and it should also \"\" dcter- minl>d whether the fXlin isdue to the pr\",\"u{\\' \"\"ing to sit up (M 'land up) for th\" assessmffil. U5'->d or Ih\" mOVl-ments bein!'; c\"'ilted, The physio- therilpist mar choo\"'-' tu LOIltjnue with the some The first mandatory qu('stion is, 'How docs th\"t k\",1 technique ill Ihe Silme grad.'. and a,k the patienl S('ver,,1 time> during the perform,,<lC\" \"hether th~ now1\". If there is no immedi,l!Cspontilrwous \"'5p\"n\"\", (('Iltre b.lcl pain \"'mains the same, ,mpro..\"\" or wo\"\"'-'TlS. JI l1<1in u'Creas.\", she may k.,,--sen the grade 5he' asks, 'D()f's it f\"\"J any different?', \"gilin, accur\"C':' of the t:l'Chniqu~m she mayslop. Jf there is no change itl tlw symptoms or they impro\"e, she m,w ne,x! to inquestim1itlg ilnd interpretation ~re important t\"sub- do the tl'CIu1ique mol'l' fim,ly. j,,,,ti\"e ,,,,,-ssml'!'\\. It must be rememhef>'d that ony TIlt'''' is on,' other \">sponse that can be determined during treatment, II is a difficult as\"\"S,ment to statement made in \",spun,., to these question5 must be make, because \"\"';:'understandings lx1ween ph)'si<>- therapisl .md Pi,ti\"nt occur eil,ilr- It is usefuJ to com erted to a comparison and clarified, know wh\"n performitl!' il tl'Chnique whether pilin is pro\"oked at the limit uf the oscilliltion only. and The pilHenl's m\",',-ment5 are then rc-tC'Stt!d, and\" the easie>! Wil} for th<' ph)'siotherapi>1 to make thit; assessmenl is tn 5.1Y to the pilti\"nt, \\\\'hilep\"rforming comp\",ison made with th05<e present bcf\"\", the treill- the tl'Chnique, ·Dvt-s _ 11 _ Imrl - cad, - Ii\",,, - f- p,,,'I,?', Anothl'r way to ilsk is 'ls it in rhythm with m.'nl technique was used wh\"t I'm doing or is it \" constant feeling that is increasing as J conlinue?'. The word, in ilali~s are When reasses.~ing the mo,·ement 5igns, the 5.lme \",.,.JSl.'q,,,,nce of test mo\\'ements must be ..,id in rhythm wilh the stronge,t part of thc' I\"\",'t- ~,«h tim\" ment t<::dmique. The pati<::ntlheneasily underslands Th\" 1\"('8son forthis is that one movement th\"t provokes Ihis queslion and has nO hesitMion itl ,mswe,mg pam \"'ill\" olter the signs for the next movement tl'St.x!, dearl)\" Simll\"rly, if ~r\"i(al mo\\ em,>nts were tesled in sland· Tht.'Sl' as,;o:.'SSm\"nts of \\\\'hilt is hap!\"\"n\",,; while every techniqu<~ is being performed \"''''l {)lilndalorily \"\" int; ilt th\" bt.-ginning. they should be reilssessed in recorded on the teNlment record (pp. 75, l08-t09, 225). stilnding, It is inconsist\"nt to test movements one time in standing, another whil~ 5itling in a dl.lir, ilnd a third time with the fXlt;~nl ,itling on the treatment couch wilhoul fOOl support II is hoped lfu,t the subje<:live alld physical assess- ments will agK'\" In principJe, when a physiolherapist is m the ICJrn- mg stages of tre,lt{)l~nl br p'1S-~ive mm'ement, this ,lsscssmenl should be made following eilch use of every I~\",hnique.As experience is gained, she learns to expect a certain impro\"em£tll when particuldr k'Ch- nique, are 'pplil>d to p\"rtic\"IM disorder,. For exam- ple, if she is treating an eJd\"'ly pilt;cnt with genemJ neck pilin tfull c~n be reprodlleed \"' Ih,' limil of ,11 mo\\'emenls, all of which M~ stiff. she can a,;.sum\" Ih\"t the.........iII not be much ch'll\\ge during One treMme\"t 'l.,,~ion although there milY be considerable impro,·e- ment o\\'er two trNtml~lt ,essions, In th<::s<~ circum- ,I\"n~es il would not\"\" necessar\\' to assess ,fter each kchnique, but ,lSSt',;,m\"\"t should be made by compar- ing th.. symptoms and signs at Ih\" ''Ild of the sl'COnd t....atment s.ession with those ilt the b<'ginning of Ihe first treatment Sl'S5ion

78 MAITLAND'S VERTEBRAl MANIPULAliON II the ph~tK'RptstIS ..loa.. lD ludge Ih.ol changt.'S ASSESSMENT OVER A 24-HOUR PERIOD in ,,'ympt0m5 and .'>Ign\" may\"\" l?i['ff\"llod to takl\" pIaa IMMWIATH Y FOLLOWING THE LAST TREATMENT SESSION (BECAUSE THIS IS OFTEN quicki}: slIe should \"\"'*....,. Iht'rn ilfwr f\\Jdl ilrrlicMioo THE MOST IMPORTANT INFORMATION PERrOO} ANO SUBSEOUENT 24-HOUR PERIODS UP TO of ~ Itrlmiqu..; if lhc fll~ of dunge is not il\" rnudo as THE NEXT TREATMENT SESSION dc:>,r..'<!- !hen a changl\" in teehniq....' should be mildl' thIS procedun': should be conlinueo.l thmughout tho' When a pah,,\"t's p<o;n ;s localizw I\" It\", ne\"r1w spinal t~atmL'Il1. chilnging from technique' to I,><:hnique 10 Mt'J, only ,..,prodll«.-<i at the limit of Ill'\" m<>,'('menl (Ot find the 0 ..... Ihal produc,-\", the qUlck\",t ,,,,d lx'St pt.-rh.,ps two). and immediately \"'1..\". · 1on \",le.1Sing the ;mprov('m('nt m\",emenl. th..., it i> 1iM'I,· lhal tW<l \" '\" (or c.,\"en olle) of a nrlmiqut\" rna\" tJ..'.'''l~gh to ..~~ il!t~e:;li,..\"...,,). ASSESSMENT AT THE COMPLETION OF THE TREATMENT SESSION (SO THAT THE PRESENT Ifth.. palient hMtlOSigru.of iOn) OlChmg ..\"hillSOe\\·er. EFFECT OF THE WHOLE TREATMENT SESSION IS nowmplOffiS at ni!;ht... IOtiIll)' k- di<onJcr. and no KNOWN, AS DISTINCT FROM WHAT MAY inclV.5C in the ~~ mpl\"ms \"';Ih I\\'l'l\"lih\\-e painful APPEAR TO HAVE CHANGED WITH EACH mOH.'r>enl. thcrl m.u>y d\",ng~'\" In 1•..::h,,\"'1.... un be TECHNIQUE) made atone m...:mem \"-\",,,.on. \"nd Ih,' 2-1·hour ~ m\"\"t I~ Ie:,., imf\"'rlJnl Thl\" ilmountof tn:alm('nt thai can I;l(' und~ko.'Il al anr On\" 5<$sion deT'.:nd~ up\"n\" \\\\ith all pil' ......,t~ who do not fit into lhe abme cat- l'j;ory. aS5e>Sing tIx·eU.....lof the'lrealln~'fl1(J<l·ef an inlet\"- I Th\" \"''''\"\"Iy nf th\" patient's pai... \\·ill 012-1 ho\",.,. foll,)\",mg tllet\",alment is.os.......\"tiaL The f\"~l thJt dl<' palll,,,t C,1lI fl'Cl \"\"\".....' on helling out of 2, The nMurc and ~I\"biht} of ttll' pilto...nt·s disotder bt.od th.. mominj: jollowing Ir....,llnenl. ,\"\" ., re;olt 01 th,,1 t,\",-\",Im..nl, d ...\",.1nd\" Ihal lh;~ U-hour l\\s\",-'S_ml~1t c\"u\"\"'S th<' Pilon. bo:- mnde before a »1>011 Juds,·ment.4._ 10 the effect of n 3. The 'itrit\"bilil\" of the p\"mful disorder. treatmenl \" .....~ion am bo:- made Tho<' more care requ;rro in trealment b<'ca1Lq> of IhI> All of thl\" d\"I\"I1s \"-1:\"'rding .my atlillylleal _ _ (Ot'l\"S0mg facto,.... the t...\".,c..n be done\"l (JIlt' __ion. If menl ollhe ~.w,en,,<,m.nges O\"cr thi:. interval hil\\\"e the \"ffi(>Ull1 of I....almenl i.. linutt.-.,j, Ih<:n \"'-' ..1...... h thoe alrNc\" bNon d.\"<rlbl>d (p. 72). 1M analytical as:><......... nummof cha~ III tcdmique thdt Coln tJ.. ..Ii<'mp'...... tncnl of iht' ph~sic..l findi~s. p;>rticul.1tfy as lhe\\ Un<!...- thCSol' cirrUllbWlCl.--S IhI> U-h<>lIt ~mcnl is \"\"ale todiff..... \"l components of the p;>lll\"\"'S dis<>nk..., critic..L beuu\".e t~ .oR' thep;>t...\"'b- woo\"\", likely lD h.J\\'e also be<.'Il ~bt.\"J (aste..\"i..s. pp. 6O-iilJ_ \"ulfet ex.aecri:latlon of th<.-lr ~ymrtvm~ following 100 much lrealmenl. Si!Cn~ 01 nan·rf>.lll'''' ma~ flOt ~ AS A RETROSPECTIVE ASSESSMENT ISO THAT ~pp~\",nt ..lth\" time oi Iwalment AN OVERALL ASSESSMENT CAN BE MADE OVER THREE OR FOUR TREATMENT SESSIONS) ,\\C,th II p.ll; ...\"t lillH1g Ihe JOO'C eJh'}:Ny, not onlr [\"m wh\"\" it is pllSS.t<I,· confidently to make a phys- sho.,lo an a,s<''SSrne'nt be m\"dc \"f Ih... dr~-.:li\\\"c[l[.oss of a i~al.bsoeS~m<.\"'1th.,t progress h.1s bt.'('f\\ 1t\\Ilde, it isst.H 01 /r.'Clm'il\"r. bul als<> at the l'nd of thl' l,\"\"tment s\"\"\"\"i\",, a ,,,Iue to know \"\"-\"\" tho> ratil'fll fl~'b he 0,; rrogressing. (omparison l)i lhe- \"bJ\"d\"'c and phYsinl findin,!:s \"hould be 1t41d,' \\\\1111 those Illat 1'.'0'''' present ..t the r, rn~ing I~e rlfect 01 .. l~al ....t't..1 ~ fUmtial ~mnin& of the IT\\'Jlmcnl \"\"\"\"ilm. In tht:> COIll\",,1 il is to eva~~ate p<OgA'SS fI'Ot'\\ the ~,~ of &e helpful it the palK'l11 Gln ,.ummari71· his <ObjectiH' paf~t as we is from plly;K:;Il uam,,'lat,on findi~q~ ch.on/=;.... \\thruol,iloutt.... In...tment _SKJfll. gi';ng om ,ndi<:;\"tion of ...N:tho..,. he fdt .. p;>rtlCULn Icdmiq.......... WI\",n qll...lioned n'J,;Mdil1g his symptom>, \" heiplul or wlvth<... he rn.ght\"\"J\"\"CI-om<! re...etion lat('!\". piltien\\'s an.\\\\'er may well be inf1\"e~ICl.J i:lr facmt~ Patients ,~ho fll mlo Ihl- group ..hen, one rno,·.... rdal.'<l to his work. his horne problel11~.coo'p'-'11Siltion, hi;, ..thnic group, his d.\",il\"t' 10 plms<: til(' I'h~ ..iothetap- nK'l1I pro\\\"oh'< onl~ a local pam.. wllICh gOl'S imme(!l- ~~L ct~. Ttwl\\'fot<' lhe ph}siolller\"T\"SI mllsl be su\", nll'l)' on relrnsinJ; the mO\\emenl. do nol need the s.m'e assessm..ntol th<' dil><:tll .'Ilt'Ss(>f the tol\"lt,e.otment a\" do patients in 111\" f\"TI.'~oing cilh\"j;orY. 110\"'-\"\"\"', it is oft...\" \"\",fullo know II the pati\"nllhink-< anyone pat- octicul.or t('(hmq~l\" hdpt.od mot\"(' lhan anothe'. 1I ma\" thnl he can .,15<) <lnte wh<.iher o\"e pMlicul ... t.-.:hni'lue 'g\"l~ al' thedlSOrJer mow Ihan another.

A»o:umtm 79 I.... pallenll;; gl\\ ing .occuril!eilll5wer.;.., her qUtilxlnS In .ct~.M: ~nl,ronl ...~r call1fl ~'\" lobe it'~ \"'osl s~CttSSful evd in ortlrl to .:ermlr< w.md th.ll interprets them as he mcilns ''''-'Ttl, In the cfllngtl h.\"., I~t pt~e of the pit1em ind 10 allllext of 'qtil\"'>t'OIl and ,,\"\"\"\"'....., ~h.\" must JII\"t\\'T ~\",\"\"~ (rtl delermin. further tr~.tm.nt ~!s a\"y,iliuli. At me begmning of t\",,,hnenl ,t i> not lmCum- In this \"'trOSpecriH' asscssm<'nt, 11 \" Ihe sul'/i-'(t\" e nwm for~ p.~l;enll\" l'l'Ply d\"y \"fl~r d~y thlllllt\": is f\"\"ling a~\"'-><;Sm<'nt lh.Jt rl~}'~ the g\",alo,'5t rok. It is lhe Mt'a much belt.'r. Tlwn, when asked \"fk'l\". >.'y, four t\"'\"I- '''\"\"n' c-..mmunicat'oo mu\" be al ,Iz; \"\"\",I st.IL~ful ments, '110\"\"' do}OlJ. fl\",1 noW«(>fIlp\"rc.:l with too.'fo\", \",e ...... d. and ,I,s an ,,\"-\"-I wlwn- e~~e makes juJj;L'- Sl~rtn:t rn,.,Imc:nt?', he may S<l\\' cautiously, dnd \"ftl'1''' lI'Il.'r\\t e.bi<.'I' and mor,]' rehable. The- «'CMiq.... 01 ,,\"'ing long ~riod of thooghl, 'I'm sun.' irs .. linl\" ben\"r: dl I.... qu.-slions. and In(l\\\\inf: the rvnnn.., why lho.· qut-..... lea:>l il n'l'lainl~ \",n'l any\" ....... '. Su<:h a ll'lro5pect1H' lion.• ....-.ed to be .l>\"-ed. CJI11 be 1rom..>J by an}'orM' \" ho nas>e<:n or wiln<\"''''''d ,j,> unport..nc.· Jnd is willing 10 answer mal.c> ttw ph\"......-:JIherap.:ot moliZ<' thai W is nQI: bl.'I',llient WIth p.lhl11l<'. rnal..ng& mueh .lady P\"'&\"-\"-\" a-< <lw thoul;hl she \"\"-_ In the ,dl'I;\",t \"'-Xlio\" nf Ch,'pkr 3 (p. SO) the dia· It un be ofhelp to o1Sllhc p;ltil'nl, 'Wh.>l pt.'IU.'I\\I,lgt' IO!:Ul' u,,-'1:I for '''In''I'lI;'(\"lh'e as..'l!'iSm~nt \\\\',,, u\",iu,-d, bl.-..:auSo:': il \"'liS consid\"red mol'<' ,mpc>rt.,nllo be able 10 of progreso do \"OU thinl you haH m.odo.' COfflpiln.-d in<;lude in the t..~t at 11>1. -lao... ,ht, kind \"f informallon with when we bl'i:'.m tn.'alm,.\"t?· Oft..... th..· p,Urnt finds it difficuillo us<' p'-\"TL\"\"'I\"~,-\"', but h\" rna .. an<wer bcin~ 0>001'1\"_ TIl<> ml\"rmarioo bl.'mg <oughl i, by Some \"Ih.'r '-\"I\"\"lly u,ef,,1 COtl1pJri\".-:m - c,,.::. 'On I. \\\\ hen does lhe p.ttit.~tC'Ofuki'-'I'.... ,t\"P'f\"-'<l a Ileale of ()...lO, if Q \",as I,h\"\", l'Ou \",ere \",hl'll I fir:,t 'It',mf\"'O'~ng' saw you Oil ,\\lundil}'lne 2Jrd of&'Pwmbt>r and 10 \",a, 2. \\\\11\\ tkoe. «\".\",tder L!\"e ilnpro\\~t \"torf'<'d? no rain dl all, \"hel'<' would Yilt, rul ~ou~lf on Ih..1 .collc.- nov.'?' 3, PKI he HII\\\"itkr he h.>d mitde progn..'SOo \",th eArlier m\",llmenl' The phy 'iot....rapisl ~kl rnall' her own rerc-ert- ~ Did hemrbid\"r prugre;;.s \"itS bmughtaoout bv agc as5<SSn'IeI\\t bclolP pulli\"l; the qu<!$lion 10 hun. If 'he treatm\"nl' 1\"\"-\",, .. ag\"\"'ITIt.'I\\t In [\\Idgcmerll, lhen obo\"\"\"\"'l} wm- 5. At \\\\'holl ,t\"Ii\" \"f ll'<'atmmt did the imprm'em,,\"t tilke pl'K-e? mun,cilbon.:oW .>sst.'S6mo'l'llar,]' good 6. \\\\'A' th\" impr'l\\'Cmenl rmgl\"C\"'io e~ Somebmes lhe subj«tke ~nd physical a,.\"....~m'-'I\\ls i. II In'atment \"dp..~ h,m. \"ell' then.·an) p.lrticular do not \"I\\n~. For '->XJlml'le. iI p.ll;\"nt's pleA<un' lit ;mpro\\'em~nl in his symptoms \"'iI}' not b<: '-'<Iua1 ..· K'dtniqu,\"\" 0. hm,'S th>! hdJ\"'d him mort' Ihdn rcfl<-'dl'd by impro\\'ement in his <ign:;. The COl\\\\W-.(' m,ly also occur. Ho\"-,,,'cr, thcsoo' al'<' e~e'-1'H('I'S 10 Ihe tlIhel'1'~ general rule, and usually' al a \"Iighlly Iatl'!' stil~\" uf tn'.. lmenll~' will agret' 8. W',,, It a I<.'\\:hmquedoni< in it f'Q,tic\"l.r, MJllnn tNt helped. him~ E\\'en when a p.~bo..'I\\t ha, (1l'ar obiect,,-e Sl~ns Cln 9. \\\\'as meT\\.' any p.\"ticuldr I\"\",hnl,!ut', or kchll\"l\"e \"e\" h.eh ~smen'\"eM! be made il ~ still importilnl to don(- in\" rarl'NL,. man\"\"., 111.'1 ,'~Til\"JlI,-'(\\ h\" ,,)'mplom. al \"''' St,'!:\"\" find oul how he ron:,id...-. ~ rn~>ing It i\" pocor pohq 10 jusl continue Il'<'db:nt.'I'l1 time dtler time w,th- 10. I !e>I' is he no\\\\' ClImp~rt'd \\\\'ilh bt!f\"\", rn,atrn,'1l1 bep;all? OUI milling this '''-'1mspectioc a,\"C'SSmenl' It IS 0' ....' rosy to COI1IlnU\" t\"'dtmenl 11\"\",-'O...,.\"..ril\\, 1.,,,,Jmg to 11. 11,,\\\\' do...\" h(' oompare now with how he wa, before the Of\\st.'l of lhis erL<nk~ p'--'I'po..\"u\"I,on of the Joint dl'''JrJer. T\" \",'oid Ihi, ~il\",Jtion, \" j:;ap of I\\I'icc as 10\"11 as 12. Does he co.\"Id.... he i<; back to/lIS nonna'? 13 \\\\hat lreal,.,....,,1 1:'-\",1- \"\",,'1:1 tu b.-aduo..\"n:t from us,,,,1 beh\"e.>n I~Mmcnts can elMif)\" the s\\,mrl<)nl\"tic revo,'S<'.md ckllr the \"\",nipul\"tin' phy~i\"lhcr.lr,..t' .. thos ~n on..-\"nls lespecialh' imrro,in~ Ihjnlin~ rrore<- certoin irr.p.llrments.md d,,,abllot>es) When the amount or rate of progress hilS slownl ()n(y\\'Qu h.1o·edC'll:'rmIfl<-'<d his opinion> III \",ldllOn 10Jil of IhI.' abo'e q\"\"Slil!O.~ it i, the right ~tJlg\" 10 stdrt iI full or stopped (to cktermine the te<lSOIlS and plan re-o;amin.'tion, both ~llbi'-\"Clio .. and phl\"Jeal, ,l> lhough he we,..,,, new P.1Ilt'nt. Ttl'-' '1nc.tlons wuuld then be the action fequirnl_J _ '\\\\ hal b your pmbJ.·m .. t Ihis sta,l:</:~' This is Ihe no<r ,n'FlOrlanl a_'SOon...·\"t ,l,ll and th.·o\",,' '\\\\'hro doe< il bother rou m\"\"t' in which the SF>Loci,d\"t m,lI\\'plll,l!tlt' ph}siother.lpist, 1\",rtkuJorly If her goal is to be a consultant, \"\",,1 bt: pt'rfL·d. It i, the , .•\"\"sment lh\"t ....quires the b......\"~\"! mental Jlgilil)', alerll\\CSS and d'seiplmt' in Ihe whol\" field of milnlpulati,,' phy.wlher\"ry

80 MAITLAND'S VeRTEBRAL MANIPULATION 'Is lhere anylhj,'g you can do here and now to ~nd pain can bE' ,·xpected. Lller during l\"'~tml\"\", a demonstrale 10 me a Wili' in which you can provoke point will be r~\"'lChed when the pati\"\"t'\" symptoms Ihe symptoms?' remain static and il is difficult to be ,ure whdh\"r the rallgl·ol movem~\",t is improving \\'Cry slightly or not at 'Are there anv other aspt-><:t, oi your symploms. all The physiother,'pi,t should kllow that a stage (~n ur the ways in which th.~} afi.\"t IOU. th..lt you be reached when, in fact. the mobilizing ;s perpetuat- Hun!< might bl' helpful lu my undersl;rnding of your ing the cnmpbinl. Al this point Ihe p<'lietlt (\"n be probl,'m?' asked Ihe direct qucstion, 'Do you I~'CI you hm'e am- linued to tmpro,'e o\"er the tJ,t thT>'<' or lour lre\"I- A \"\"lro.p\"\"li,·\" asoessmenl a. outlined above ,an menl~~' 11 t~ answer is 'NO', tlwIl tI,.. tn,atll\",nt l.. h as long as, if nOllonger thm, ..ny inilial examin- should be disco\"tinu~'<I for a period of approximately alion. The ,;earching 1M delail is much more imporl- 2 wccks, aiter which Ihe p<,tie\"rs signs ,md symploms ani at thi, point. tx'Cal''*' till' h,lure mana~ement01 the should be n~a,S<.'S..-.ed alld the follow]l\\1> action~ t.lken: p.ltient's disorder m\"y 1><, a big ,nd import,1nt decision to rna\"\"'. On it hang factors th~t m,,}' molke all the dif- 1. If lhe symptom:; ha,'c improved. II\", p.,ti,,\"t sho\\lld f\"'~~1(\" to his lultJn~ life. This may Si'<'m a ,'ery dr.l- be Iell for ~ f\"rther 2-3 weeks and thc·\" re,'sse,sed \"\",tic sl;,!c''''eTlt to make, anti it i, a major d.:xi,ion Ii there;'; then additional impro,·cment. thc pati,;nt only with ~ small percentage of patients. Newrlheless Can be di>elml'};l'd on the assumption Ihalthe sy\"'J-'- Ihe decision, when it has W be taken, is a \"ery import- toms will contimwlO imp\"we ,,,ithout tccatment. ant One both 10 the patil~ll and to the phy,iolh<:r,'pist, he,;;:ause her repulation on the one hand and her ~kilJ as 2. 11 the symptoms and signs have remained till\" '1 pr<lCtltion~r on the oth.'r depend \"pon it 'JIlle, the pMie\"t ,ho\"ld be given four Or five more trealments and lhen taketl off treatment ~gain for 2 Following a planned assessment-tlrc~k from w\"\"h. At the end of th,:; period it will be possible trtatm~nt (to ~st~blish the pla~ of further to determine whether 111<' extra tl'L~ltm<'ll1 produaxl trtatment) ony impron:ment, and whC'lher a further f\"w treat- ments should be \"dministered Many p\"ti\"nts have a disorder that the manipul~ti,'c l'hy~ioth\"r~pi5t realizes c\"nnot bf.' mad~ normal in This p,lltem of m\"n.lg~>n,ent must be ,,,rr accurately evcry r\"ga,d, UwJ\", Mll'h cirn\"n~l\"nce\" the t.'nJ- asses><.xl if it is to be tl'>('d con,trucli,·e1y. It may be of result of lre<ltm~nt will be\" 'cumpwmisc re\"\"It'. It is interl,,;t to mention here th~t when these patients ha~e not casy to know when th\"t compmmi,., result has fC'Currella'S (<1t,d they \"Iway\" do ha\\'e recurrenc~'S), v.\"!n c<·,1l'hlxl, \"\"d there is only one w~y t., d<'1\",min,' usually: it. First. ~ time w,1l be reached when the potient's symploms <wd signs do not C0\"tim,~ to impw\\'c, and t They \"\",k trealment at an e;ldi~'T stng~ of the in iact then; i, a possibilily Ihat the treatml-nl pC'rpctu- (·xacerbatioll ales the symploms. The 5e<:()fld sl~ge;s lor the p~til-nt to b<' given 3 bt\"l\\1k from treatment of approximately 2 2. They resp\"nd morc \"!,,dily to trl'atmenl wed\"\" \"fter which ,10 ,'SSl-ssmrnt of Ill<' symptom~ 3. They ha,'e pr<>gT..s~i\\'ely long.'r periods bdw('Cn ~nd signs can be made. The third st,,~e i, to dderm\",e wh~'lher another thr.,,' or lour tt\"l'atmL\"'ls should be exacNbations. g,ven tuS<'<' if further progres, c~n be made, or whether 4. M\"\"y of the.. eXolcerb<1lions l'L'Co,'er quite 'lutekly it would be better fo, the patient tu hd\\'e another 2-w.~k b,'('ak from tr~\"tment f\"llow\"d by \",,,>St.'SS- withoul treatment. ment. The folTowlng,,~\"~xampl€ of ,uch a pr<;>oX>s ATTHE COMPLETION OF TREATMENT EXAMPLE (TO MAKE JUDGEMENTS ON PROGNOSIS AND PROPHYLAXIS) This reIJl~-s to a p<1Iil\"11 who presents with symptoms arising fmm a luw-grJde aclive arlhrili\" where it IS A point to be cons,del'Lod in relation 10 a~se,sml-nl <1t known thai to regain a full painless range of joint the end of trealrnl-nt is, 'What Is normal in the w,'y of mowment is impossible, TI'e questioll i\" when do<.'\" p<'in ilnd movement for this patient'· one dis<:onlil1l,e treatment? People ha,·c widely dl/ferin~ normS. For eXempte, In tlwl'mly sta,;c'Sof p,,:>s;\\'C mo\"eml~,ll\",atmcnt for forwfird flexion or the tntnk in standing can ,'ary from such p.,ticnts, a gratifying impro,'ement in mo\"ement one person bein!> able ollly to re;>eh jL,,'t beyond the knees, to WTll('()OC else being ablc to put lr<1l1ds fl<1t on th\" flo\"r Sucll \\'arratrons al\", occur in other movements.

Assessmt:nt 81 II I!o flC(I\"i\"ary lo I>o.·..r in mind I~ on11l...~n \"aria- to be \"x:lel~' approc~.tl\"d. Among lhe m.:ln~· f\"l\"I'Pk tiont. if ,lin ad.....te ob:oe»mcnt is to bl.•.-.:hl('\\ ~ who h.l,1' fft\"\\j..-l epbool'S 01 mechanocal ~p\"'ill p.l,n. [mill/lit 1. Considl'l\" .. p.lbef11 ,,00 pMll.....ts for there is a ,ignifl(\",>nt pt\"I'Cl\"Ilt.JS\" \"hu h.'H' .'P'-....oes ...... lrnenl of low bal:k pain. On \"\"amlllll!j; forward !>«al1'\" their joint mn'en'('Ilh M,e \"\"\"...... bo.....1 rn.\"k· fk:\"ion il;\" found !holt hecan onl\" Jl'ach h~ knees. \"nd ns good a, Ihey could\"'\" ;n their p.lon-fra' p.>riod,. \"I Ihls pomt his back p;tin is rep~uct'd. On fi~t see- o..~P'tt.> tho-\" fi'CIlh..t 'I nnl:-, rt'quire<.IWOOr IlIn\"\" tre.:ll- 'ug lh,,; it mighl be con~iden.,j Ihm f1e~i.,\" h m<1Tkl'(lIr nll'1lts I\" make tht:1l, sy mplotnaticilily ,,\"cU. they arc lilll'kd ..nJ P',inflll, \"od therd(,rt' thl' p\"lIcnt's cond,· .,1left with a 1'I'Sid\"e foint <igns which. illthOl,!:h they Ix,.\",tion is aS5esSlxl as b,,'ing quik t><\"l. Howe, er, if this Me not Cilusing \"1H\" S\\'lllploms, h'n' til<! p,'!lent', .\"\"hspill(' in ~ ,t~l\" p\"licnt h.,d a.,k\",l, '1 low far oo\"ld )'ou bend tt\",t\" combin\"ti\"\" \"f f.l(J\"'~ milY before lhe on.'i<'t of yuur pain?\", he nllght Jw,\"e replied, cau .... iI =urn-nct> of the .~mplorns.. HlW.CI'.... if Ill.,..,. 'I'H' nt...·er 1>0.\"\"\" abk' lu benJ much further lh.m Ill\" m\", ,'menl> ,,,ore m,we \"ymplom and ~ign free. \"ny \"\"\"-,,...'. This information pub the lIlt<:-rpreblJon uf!he (,)(I\"\"\" thai might 1l\\f1u~ the unSCI oi another flexion d's.o.bi!lly \"'to a difi.,..\",1 p<.-r<p«t'I...• ~ would ,~ 10 be mor<> ,·;S\"....u> bccauw of f.m\",p\" 1. An Mdffi'\" patienl \"ith no.'(\"k polin ..Iso Ihct-..1ter qaw-olthejolnl. TJw;. ... a '\"rvnommun find- sho\\\\-s radiological l-\"\\ Kk\"flO\" of l::\"\"\"\" dq;o.nerati, e ml; among r<'-rienb \"00 1\\;>,-.. tldd L~'\" III polin for lilange p..\"\".,~ ,nOH'O'l'lt.'Il1 trThltmerlt is ,.~. \"\"lpNI .. hieh thcv ....,.1' gallW\\l ,,'II..f ,,.,Ih d fu-.. lreatments trom Ll\\ ~ip\"lal\"\"'\" If tl><' manipuL>ll\\e physio- for a patienl such ali th,s, bul the ~ t must l.. ~ onlO con..ideralion 1M (,lCt !h..1 rotMiun 10 e'lher sid<.' !:hl...a!,i,t 'S able '\" coni\",,,,,, treatment be\\\"lmd thI.\" willlle\\·er re..dt 9lT, 1\"\" ...une w,lI \"pply tu ,111 h,.othe.- ,,·mptoll1·free sla~e I.> \"'ach !hI' point \",1I..n Ihe mU\"IL C('T~i(al mO\\\"menb. Thewl\"\", Ih\" \">Sl~'m.,nt m~1 mL'Ob a\",al>(>.ign Irre. lto..-n th<.' frequ\"\"'0 III episodes I\"h inlo account th\" r.lnlt\" uf mo,·emenl th,lt ;s likely i~ mMkedll ,dINI..:!. h' t>... nurm\"l fflr 111i, p~li\"nl. Th\" role of treatmmt wHi be to .'liminal\" the painf\"l a,jX'CI ot loint nln\"emenl 11,,, \"\",d-re;ull \"ill be ,hghlly imrrm-oo mo'emcnt, ASSESSMENT ASSISTING IN DIFFERENTIAL DIAGNOSIS ..lthuugh m.wements ,,·ilI T\\.'fll3in shit in all d,n...:hons At the initial \"\"\"Ill;>l.lri\"n of a patienl. the Utxlor may lmportanll,. me nLock p\"lIl\" III !la,e !'on<.'. nul oo.Jbll' ID rna),;,' a dd\"lIuu,.., d\",gno!ilSo Ii the pni>&em \"The Ile>'t flO\",t to bl·1Il.lde undo>r thb h\"adUlY;\" lh.J.t OS a musculoskeletal di<Mde'f\". lhen under some or- tho.- efft.'C1 of lrl\"i<lrn<-\"o>l cannot be de..rl\\· known until an curr<.t.ln<:e; pasol'-'\" mO\\·C,-\"mC.'(lt treatment c:nn be applied in such .. way' as tn .o5$'.t in makmg the dlagnosi' inlcnal of2-3\" eeks h.u p.b->«l tot\"\",\" illS !.he y>t treat- ment session.. Ii a. patlrol has \"\"\"'Il<.'l1 ruU-ranl':\" p.ru.. For example. a P.~rienl m..y !la,e p.lln on lhe ..-ginn of hi~ ~houlder and tlw ..~rring doctor may not be fn.\"C mun'mo>nls and ....~ oonrinucd lobes' ffil'kwn fra' renain\" tl<>lher lho! p\"m i~ l\"ffi.ul.ltinJ.: from thcp.>lil..\"rs ~hu\\lltlcr or fmm hi, lWeI<. The patient cnn b..- rd('<n'd oyer tIus inK.......... thcefl,'Ct of ITNtnwnt h,·l..ar-Gl1. In il m~nipulilti\\\"Cph)\">iollll'f,'pbt wHh., r\"'l\".\",t th\"t he b..' I,.mlro in .uch ~ m,u\"\",' as h' a\",j~t ;]1 forming ·1 N>IT arc occasion> wh...... pali~\"ll Wllh chronic l!>edb...\"..\"i,.. 'y mploms yet JiUI\" t\" find on e\",lJll,nal,Of'l of mo,\",,- Tudo th\"S\"CCl'Slif\"lh lhe ph,.\",olh«apist r>eed. to \"'.11\"101-' both tl>£> n«k and the shoulder in Ihl.> lind of mL1lts m...y nol sl,m,· an~' <ignsof S~mpl(lm.1ti(imprO\\'''' dda,l mentioned e.m1CT III thi~ \"\"\"'ptl'r SO 1....1all joint \"'S~. ~th cen.·kal and glt\"nOOu.......ral. an:' \"\"·....Ied on ment Ihmughout IT,'Jlm,'''!. HOIH,,-'<:r. th,ss.1m\" p.,tient detail. She oJ>ouId then In..'Qt thl- ct\"r'\\'>Q1 arca first and. a: lhceffed oIl~ Imllmcnl roth on the cenical.md. may find Ihat thl' 'fmplom, dis.lp~ar.,fler a 2-...\"\"k on In.· ~hould\"\"S<l::n~ lfl...,alml'l'll to IMCen·i<,:a1 spin'\" pmdoc..... fa,'ourabl... chanJ:\"S in both (Tn i<\"al and break from lre.,lment. This 's not uncommon shouldl'l' signs, then t....... cl'n'icdl t\",atll1t~,1 <hlltJld t>\" continU<XI HowI',\"er, if thl\"\" b flO ,mpn',\"I'n,,'nt ill th\" At t~hn.... \"(IN> I.l.'t trualmentand assessment. the sho\"ld\"r,i;;ns \\\\\"illul1 tb'I'\" tre.,tment ......,,,\"'s, dL'Spile rna\",p\"J..ti,~ ph\"<lNht'rapi'l m\\bl kno... tt1<: deg\"\"\" Ir)'it1g .,11 techniques apphc.'ble II' the cervical .pin<:. of Imprmement ~hc h.ls bl....... abk-\" 10 <>Ileet, ,md hem' tre.ltment to Ill;' ...\"\" ,hould b... di\",Olltml1l\"<l Th\" dose t~;\"; resull is !\\l an ocleal A'SIIII ~ 1Jlou1d .60 sh<,,,ld,,r should then be treated and its !\"C5f'OJI-\"\" as~. In this wal thl' \"\"'J\"O'lSI' 10 t....alnll'llt ..-iiI >JlO\\~ \"\"\". ,,~. il might bo.. f,.. tt... s,-mplom~ to recur. P.\"t flIf theJudS\"'\"'<-\"\"llIl!hlS rq;::ard would bl'b.ascd on the h\"hm' and dJ.S\"\"\"i. flIf tho> disorder ..' \"ell .... the <liability of the disoNI'!\" at m., Iim\"of 1n.... lm.....1 BaSl'd 00 these judgcl1\"-'1'ts, she should be abk to pred,ct hQ... C<lrdul lhe p,'ttenr ma}' nl..'\" to be '\" toolting: ..flcr h\"spi...,1 problem, It 'S in this arca lhat prophylactic treatnwnt. in I\"rms \"f re-educatiun, stabiJiz;n1\\ Ill' mobilizm!; exer<.:'!K\"!I. is oonsidcrOO. Although it i. outsid\" til(' \"\"'p\" 01 thi, b\"'ok to 1.h,- CUS, prophylaxIS. 111<:n' is Oll(' fao~ lhat does nul \"'-'t.\"lll

82 MAITLANO'S VERUBRAL MANIPULATION J;'H' !he ~ns\" ..et\" al> to ,,·hcthl\"l' the tt,\"...c~1 ~p'ne 15 d>an~-e may result but II may not, il mar le.l,c me in\"o/,-«I, UIlI!; as&sting the di.a~l105is in ex<>ctly the same pos,hon as afler the trxtion ANALYTICAL ASSESSMENT Thm.. do I ask myself, 'Wcll shall I In wch .nd ~t i'!i the l<'''hlonc of effecbH\", mfom\"'tl'~ Imltmml, \"·ilhourwlii.ch t\"'\"I01ml ~u~..nd f~ll· \"..rn .. I\"\"hruqur, O[ j\" thlS iust getting me dl.'q)ef U\"\"''lo a..., nol le;lming txperil\"l'lCcs. ASS('S8IT\\'''nl ean hi.\" po....fonned as a me.::hanical pl\"OCe'», and\", used to IDto confusion' P\"'''~ lhe 'alue of a Ie.::hniquc. Analytical a\"\",-,,»menl 11\"•.'511 st\"ge further. Jt 1ill~rally implil'S analysing onc'. OR thought>; about all aspC'ClS of II I'atient'. disordcr and tn'Jltllt:nt t\" arri,-e al dearly defined answers. 1\\' well 2. Would I bebetreroft to ..... .-.'~..t\"\"\"'t allhi~ point as \"nfum.'<1 diso:ipli\"e, it requi\"\"'S an agile, >ccpti(\\,1 and mclhodical mind, a mind with the ability H' be and _ the cif~'CI of lhe traction 0' ,\"r lho;, 2~­ op<-'fl-e\",k'<1 anJ accepl 'ouscand etkct' in op~'t1on (if ncN be) to acceploo pnnciple<, a reproadUul-of- hour assc»ment prriod' I mighl rlfld, ,{ I If\\' rot... \"!If att,tude aad an .. u'ludeof',.,ell- if \"00 think so- ho\". lhat Ihis product'S n mark«l chang... 111\" On\" pll>t'r ,\" Il,nvol,.,,; the rrocess of. THL-.iK. PLA'\" ilnd Ie\",,,,Ihing I do know for certain is thaI. if I In.·al· EXr-a..TE(to) PROVE. This does not ..I\",,) ~ mNn p....-fonmng a teclmi~ men' at Ir\"clion only {or loony,l cmJ>~)1 /J()SSII.'IJ Ii<-' to pn::I\\'(' its 'al~ al a p:>rhcula. st.1ge of .. pat>enl's d~ C<lItj\"U'f! H'JrfPl I i«f Irim lomo\"\",,,,'. ...-der; il may m(',,\" an~ of I....• folk.,.,mg One of the ,mparl~nl mental proces,..~ in ana;yl;':,,1 I, l'm'in); a rwgau't b), for \",~..mple, lreahng .. assessment is to rl,ln rod,lY'S lreatment with thought.. stnlct\"\", \\'igorousl' in il pa.rllCuLlf m.>nnl'r tu of ton,o..o\",', a...'e\";;Jll~'tlt In mmd. In otho.'r words pro\"\", th,lt there is O()\\hlng \"'n.:>n,l; with it '\"'\" foIkn~inS IS olfl e..... mple of daiding lu \"'tld a 2. Sl'lldmg a pali\"nl home wilhout In'atinl\\ him 10 p.olienl ho:ne w,lhool tMltmenl 10~\"i! ~ \"cry pro,e Ihal Ihe progress, \"'hich.l«rrus to /\\,,.,'\"' bl....\" ~\"Tlds. Thi5 m.1ll1\\3d \"Shl OOtloo::l, pain. Forward fIcxion achi\",,·~'<l, h,lS in fact Ix'('\" as a ll-\",u]1 of the tre~l­ Vto\"'C\\f ~ ,light list to the left, \"'hich, ,f C'OUIlt>en?d, ml'llt and /\\',S nol b<.~'11 ~ro\"tall~>Oll\"\"-'Covery. rq>m<iucro the pain. 1lleslump l<S1 .....lSpoo;lh\"\" \"'hen lhe right fDOC was dorsifk...«I, \"'ProdlJCUll; I~ bUllock 3. Ford\"g olK.\".,lf not to ).;i,\",-' Wily 10 Ihe temrt'1t1Un pi1in. n...:, paID .... ,>Ii mMl<OOly reproduc«l. when, while \"f trying il \"\"\"ond tl!<:hnique, S() thai the inte'rret- 10 fulllaternl f1elo.ion to the nght. he .... as fk-',,~. ahOl' of lhe \"\"'''I a\",«\"';';menl ca.nnol tw.> oonfu!lCd or be amb'guous On reasse5sinl\\ him at the tturd VISit. he s;'ld he was 70 pcr cent ~lIer. He did nol ha..e as milch ........ clioo nus litSl paml !Suilie..lh' imporl.1nt in the ptanningof ott\". Ihe ;<~ond treatment as that following the So,me l\",alment on II...• fin.t day. Following lhe s<-\"Colld In.'\"t- a ffCal,\",,\"t ~, \"The mosl ,mportanl soaI (oU\",r menl, he SIlid he fclt uncomfortable for half an hour ane! tlK'I\\ the paUl c1eart'd and had not rch,\"'l~1 since, lh.:ln relK-vm~ the p\"hcnt of h\", spnplomsl is to (').e- cute .. plan of \"\"'..Imrnt <Q tNt there is no !\"\"\"\"ibohl~ lt \"\",Id, bul m.. y not. bo.' as~umoo thai Ihe \"npmn~ of bei~ ronfused by lhe pa\" fs \"15\"'cr rothe imllill ment ....as from In., trealment. que.tion 'How han- )'OU tll- ?' \"'hm il mixturt' of 1Khnique. has 00en u~od. Although .. patienl mar bo,\" NEVERASSl.MEA:'lrTIn,G able 10 Sol)', 'I'm pn'll)' sure thc traclion helpo.'<i me but who-n )'ou did th.al \"\"\",hllg of m)- bad< I don't Ihink ~ follo....ing immedi.'Ie-n.~que.tlOrl wu 1>SIwd' Ill.tl did it any go()(f, me Stalem\"nt cannol be relied '\\\\'hl\"I'o .ou left I>en', d,d you do anrllung diffC'n'rlI or upon 10 be exactly righi, Wht.\"n\"as if, ill assessmg the unusual wIWh cook! ha,-e 00en n'SpOflSibk for the cff~'\\':1 of the traction, it did not St....'\" 10 /\\',.,e made implV\\~m('Iltin your symptoms?'. Aft\"r a long delib- milch immoo;Me chan1-;l' either subjl'Ctl\\ely or phys· .,.-.. hon he responded, '1\\01 thai I can dunlof'.On ask· 'r\"lly, Ihl! \"nalytical mind has to think and d~'Cide Ihe ing him if he had periods of fR....\"<lnm ltl<c thiS at other relnlt\\'l' va;u<~ b\"t\",,,,,n; tm>eshesaid, 'Yrs'. Thene.\\t ,mmediate-n.\"\"pon~(lue- lion was, '00 you feel the impro\"e\"\"\",t has Ix \" as .. 1. S1mtl I Iry rolation as a lrealmel1l technique 10 sec ,f l'-,,;ull of lre~tmcnf7' lhe ans....er wa., 'I'n, n sure'. ,t \"'III effect My lmmlodial\" Challgo'\" F,,, ourabl.. n,i. was a surprise bcc.. uSl' ilse.,m<-°d to connict with 5e\\'cr,l1thing•. hi> \"lillion at s.ly;ng he W<lS 70 per cenl b\"tte., th\" ttm;nl; of Ihe improV<'Ill,-'nt, nnel Ihe k\"!,S\" cnl\"<l reaction from the\"\"-\"Ctlnd trealmellt.1t S<-\"'rT\\<.-<1 the impro\"\"m\"\"t should h\",,, lx\",n from the trealmenl; he should !\\ave Ix\",n able tv say \"luile spnnlaneou~lr,

Alsesmenl 83 'Ott y''S' On ex.aminalion it Wi1.5 found lhat tN,.., ,,'as L...·o.'r}' pal\"\"''' \"'..ds to an in,-ah....ble accumulatian of slight improo.-eml-'fIt With !hi' slump oiI..-s<(l.,J<ion te;l experi'-'I'K'e and reliablhtv iI5 il consuItant_ This soal is a and abo a 'lltghtch.mg\"ln theqU<llityof the p\"ln when f1c>:lng from th.. liItl\"l\"..J flexion ri~\"\"l posIhOrl Furth..c re.ponsibility \"-I.' ha,~ to ....r pallftll< and 10 m., med~ quetions about otl\"\"c symptQmS ~-uch ;Iii stiff~ on ~Ihng out of b\"d in tJw.> mominJ;!' indka~ imrro...~ ;,;-..1profco.si..-._ m('nt, but again thL'S<! wen! ...aTh~bl .. ~rmptoms CONCLUSION Thinking <.:>f 'doll't ronfusc tomorrow' \"nd knowing tlmt if ho.' W<:'''' lr<:~k>d today and he th ..n \"'porte.) Just a~ Ihe,e ,Ire cumnl1lnic\"iion difficulti,-'S in normat tomorrow b<'ing not as gtlU<i thl;' curnmt u\"certainty convcrsation, arising out of mlsmlerp.et.1tion of the of 'CitllS<.' and ..ffecl' would be further cun(Iu;ed, mtiUlingo:; of things >iii ... or nol said, <0 thl'R' are diffi- colli~ in assessing the pJlllftlt'S sub]ect1,·... re:lpOIlSl.' to Would the 'nol ..s good' bt- du.. to tmatment? treattnl.'lIl- Bcc3us<.\"ofl~dlfficulb.,..,ltlol' ph)·siolher- apist ~ld be mOISt \"...ref,,1 in qIJeMianmg 10 iIS5eSl'l \\\\as the \\.ast impro\\C1Tltnl a 'f1ash-in-d'lt\"'p.ml\" an\\ \\arianon,,; III the patMmts s\"m~ \\\\o\\:luld I\"\" 'not as good' ha,-e been lust the 5o1rnc If Noneoftll,.,pati,·nr~f\"'hnpaboul his pain should .... ,or be \"-SSumro r \"'\" ~rle. If a patient is asked to ho:o h.1d nol had ~atment? bend ron..ard, and he doe>. so and ...~ 'Oud-o!', the ph~,othernpist should immedi,uel)· folio\", up with To make lhe bot'$t U>,l.\" of ~m'-'flt, it w,,~ decidf'd ·Did t..... t hurt?' - 'Yes' - W~le did you f,'t'l il\" tti tIlL' to gln~ flO treatmL'11t and 10 ..\" iL'w in .. d.. ,~ 1IJnc. e,ami'Mlion conhnucs \"',d lhe pati<:,n! ll.'JX'atL'dly fe..ls b,-..::ution of lhe plan would B>eall thai an unamfuiied p,lln with \"deh movement, itean ~ irrilntin~ to him to asscssmL'Ilt of th.. symptoms could be dearly associ.- be continually asked 'Wnero.' did it hurt?'. Undcr such ato.'d or diSilssociatC(! wilh treatment. ciR;umstmees, whcn lhe patient c,ingL\" while lestinl' mo'·cments, the phvsioth<:'rapi51 can ask, 'In the s.1me In fact the p<Iticnt ran~ on th.. th\"d day 5o,}'i\"g h.. .pcol?\". This 3,oid. lelt.....\"t.on \"hile .t,l] g..IImg W wasn't as good as\" hcn l.lst seen. The answer was then cOfn'd IIK'SSage_ A«ume nothing. If the ram alters in dL\\lC and treatm\"nt w ..s continued. l~.rea he will sa~ \"n..'f'C it 6. ,,'..en if ..nly ..\"ked, 'In The THIXKl\\JG and I'Lo\\i\\NI'\\G processc-; ~uire ~ full nppn...::i.100n of thl.' same spot\"!', [t IS this clo5e rnmmlmkatiQn bctwa-n. ph)\"\"iotheTapist and p3t1l.'nl that make:. olS:.l.'SSmenl so 1. Thl> p\",.....t's disort!« (ill; p.atholOb'}·,li It 15 patho-- mformatIve and , ..J\"'lbl.., and then'by mab:!s !real- k:lgic.tL and Its pM;m1 sta&e) mo.'fI! l1lO1\"e specir>c ~nd effectl\\e. 2. The effects t.... t p;!l1kular ta:hniqucs GU\\ be Although some will:>il~ this is too tin... consuming to !leo! ,-alue. sucCl.'SSful tn.\"ltment compelsthi5degree u...C'<pected to h.1t''', both m tl'nflSof ol111<lUnt of of ~ccur,1Cr; il i> L\"\"\"\"-\"ltial if the physiolho.'rapist is to remain in control of the lreM\",~nl Sill.:.tion_ CiY\"n change that can be l.'~p'-\"::l.xl and n'lained, and til\" Pr;lctice and o.'xperi~ncL',it is not a lengthy proco.'durc rato.' of chan!;o.' The p.:1tient as a person, and all that Il\\oltlmplies. Critic.,l roml}'sisof S<'lt ,md cuntinuoll\" .......'kLIlS for C<'r- tilintlCS, if applied conscientiou'<ly to tlw t~M[llent of

Chapter 5 Prognosis • au~slions regarding prognosis 86 What d.'. W~ und~.fSla.ndabou~th~ pati~nt andl l WhlllisthtdiagnOSiS? 86 his r~spons~ 10 injury? 91 HOWdoe.Slhttfftctoftreatm.entinfluen«: • Th~ clinical application of pr09nosi~ the prognosis? 90 How do predisposing factors mfluencethc making 91 prognosIs? 90 C~lVical spin~ 91 Thoracic spin~ 93 lumbarspin~ 94 Thischapler is writllm lor manipul.:iliv\"physioth<.',... Throughuut this book. I\"-',.\"\"a,i\"e and. I hope. apislSbya manipulative' physiothcr.lpist It ,wither convincing emphasis is placed un the importanceuf t.lkes the plact' of medical progn<J!;is, nord()CS it pro- rcpetiti\"e ASSESSMEW of changes in the p.'tienl\"s vide \"ru.we,.\" ,,-ogarding JX'rcentage, of di,,~bilily. nor symptoms and physiC<l1 e\"ami\",~tion findings. Th\" aim define Ih\" relative psychological/medical componmts is for the features of thesymptomalic beh.wiourand madisorder history tu ma]«' medical Sl'tl5t.>such that the phy'ical findinpcall bcad(k..:l to make featurcs fit (see pp. 57-56} 1'rog11tJ;;sl,rJreforrra;toflllrl'rob<1l,tecO\"l'SI'ofl1 ilnd then. by showing what eh'Ct each single modality C'/l>t ojd,...\",SI.' or i\"I'''Y, ,,, it is/ilearl a!making of trNtm('nt (or IMssive mo'-emenl treatment technique) 'urhajOrrm</. (Shorte, (h'o,d Diclion<uy, 19l1O) hasunthepahmtandlW;disordl·r.th('picturt·ismade morccomplctc WrilingaboutprognO>oi:>i,adauJ1lingtaskforamanipu- labsephysiOlherapi.>L and some readers mayconsidc, The m.mlp\"].,ti'·e physiotherapist mu.1 al .....ays prognosi<asbcingoutsidelhewlt'\"rl\"l\"Spon.ibililyof k\"\"p her mind open 10 ALL the incoming information the pro~si()fl. Howe\"er, the manipulMive physiother- andremainempatheticto'f,,,-,I'lhep',ti,,nt'ssymptoms ap~'tha5 more oollbct with the patiellt thall the rderring soshecan'walktheirwalk',butmaintainanenthusia5- medical sf't-\"Cialist and often 5el'S the patiellt ill the p\"-'S- tic and positi\"e altitude. Although it islempting to ence of other members of th\" family. Th\"\"\" visits can startformulatingaprognosisattheinit!aleumlnation. re\"eal much valu\"bleinform.,hOll that call cOlltribute to thi,isstilltooearlyforfocecasting.Atthe\"-1rosJl'<-\"Cth-e the mt..:lical specialist's final prognosis. lhe contribulion a5Sl.,;\"menl.after th ....'. l'or four treatm,mtse;.sions.the that the mallipulative physiotherapisl is able to make manipulati\\\"ephysiotheraplSthasl\"IlOughinformatioo depends upon her ability to romm,,\"icate, empathil\" tubeginforecasting .....ithand·feel·whatthepatient feels.alld to maintain all Ilo\"\",,,\"er.astrcatmcntoontinllCSfurthcr.themanipu- w\"nenthUSiastic and posih\"e attitude as ason herski1l lalive physiotherapist can refine the infonnation to make her foceca.,t more accurate and meaningful. The tumakeaprogll<>Sis. a.,.e.sing procCS5 and resuhant prognosis will also

86 MAITLAND'S VERTE8RAL MANIPULATION give her the inform;l!ion with which she c~n empower gk~,ohun1t'r,'1components. It m\"y be impossible to is.ol- thepatienttoman'lgerusdis.order. ate one structure or e\\'en a group {e.g. a joint complex) ofslnJcturesasthecauseofsyn'ptomsandsigns.Thisis If this aSSl-'Ssing process is implemented by the where the manipulali\"e physiollwrapist can assist ml'd- manipulative physiotherapist. ,heshould reach a st~ge icalpractitioners, by hl'T manual skiJIs and knowledge, when her years of self-cntical apprai..al ,md clinical and can add tothcdOClor's knowledge in fonnulalinga eXJX'rienceenablehertocompileavaluablelcgaltypc prognosis. It is easy toundl'rstand thcdifficultil'S most of report within her field. This could contribute to a readers would cxperience in ha\"ing to gi\\'ea diagnosis physical prognosis of the patient\"s future and enrich for pali€l1ts with low back p\"in, unless of COuTS'-\" thl'y fit the m<.'CIicalspt.'Cialist'sfinal prognosis. The accuracy ~ck'arroulinepl'L-s.-nt.,tionofpatientsth<.'Ysccoftl.\". of a manipulative physiolher~pisrs judgl'ment in a final analytical aSSl'ssmmt dl1\"'nd, upon her skJlJs in Grie\"\" (1997) wrote most aptlr to the editor of l\"l<ami\",~tion and \"\"atmenl, plus her years of foCJf- Ma,,\"alrlr<,raP!l~bout'Diagnosisolspinalneuromus- analysis and cliniC.l1 expcricnce culoskeletal condHions', For my partlhe word DIAG- NOSlSmeansasceriainingthcloca!i!yand thc\"alllre, Anexcl'Jll'l1t text, which should be rl'ad inconjunc- in p.llho--analomical tcnns, of the morbid changcs that tionwilhthischapler,isEurigjeffreys'bookProS\"'n;;s haveoccurr<.>J,in which tissue, together with the con- ill Ml/SCl/losUletallllil\".lI Udfreys, 1991), The book is sequentdisorde~funcHonThatis,notonlyWHERE written forsJ'l\"2iaJist doctors and Jawrers and deals il is. but al.>O WHAT it b. Having n:ad l'L'Cl-nt obst.-rva- mainlywithinjurk'S,butanymanipuJativephysiother- hOnson thlosubject[fwomlj' and Taylor, 1987;JuJlelal\" apistinvolvedinprovidmgn-ports,opinionsorsug- 19&1; Durrell, 1996; Phillips and Twomer, 1996) then- is gl'StiOns should be familiar with it. Jdfreys Writl'S that \"ne..'<l for comment, ,incl' in my opinion many of prognOSIS' these authors are not wrilingabout diagnosis at all but only aOOullocali7.ation - which, while hIghly dt'Sir- isanart,orskill,notasci~n~,ITCONCERNS able,dOl-o. not amount to diagnosis. Simple localiza- PROBABIUTIES, NOT CERTAINTIES and it ,dmto tion is not diagnosis. Brewerton (1986)0 a cOf\\S\"lt,lrlt INOMDUAL not th~ g~n~ral.,. fortunat~ly, although rheumatologist wilh much cxpcrlenceof working with individuals diff~r in th~i, ,~n~ til insult, th~i, manipulativephysiotherapists,andwithpcrceptionof ailments follow rttOgniztd pallernsand it ispos~ible thcirspt.'Cialdinicalprobiems,remarks lofo,mGENERI\\LPREOICTIONSoflh~nalu,alhiSl\"'\"l' Ilfdi~,ders At IhlO final analytical aSSl-'Ssment stage the manipula- To make a diagnosis in terms that are meaningful to live physiotherapist, through careful rcp<'tili\\'easscss- thc manipulative phr,iother~pislwe must rcml'mb.:r ment. has collecll'd info,mation that can help her the brick wall, analogy (Sf/' p. 6), and relatl' the diniCill anSWl'T the followingqul'Stions rc);arding prognosis. e\"\"minahon findinb~andaSSl.'SSmentinitscntiretyto thcareasofknownmedic\"lknowledgl' QUESTIONS REGARDING PROGNOSIS Themanipulatiwphysiotherapi,tnl\"t.-..JstuaUcmpt WHAT IS THE DIAGNOSIS? todecidc' DiagnO'>is is a critical issue when making a progn05is, Whatstruclure(sj does she think isat fault? butilisnecC'isarytost~tethat frequently il is I10t possi- Whati>thest~gcofthcdis.orde,' bll' to m~\"e an 'accur\"te diagnosis' of ~ p.ltiL'Tlt'~ dis- What is thestJbility of the dis.order? order (Gri\"\"\", 1988b), For l\"\"ample. ~Jthough it m~y be Whatfactors\"rcaffl'CtingthcbchavioUfoflhc pO\"'~ible to slate that a patient has been diagnosed as disorder? having rheumatoid arthritis, s.om.. of the symptoms 5. Whatisthe'cauSt'ofthesourc€'? may be coming from an 05teoarthritic componenl Treatment to relieve pain due to the ostco,'rthrihs What structurc(s) does she think isat fault? might pro\\'idl' more relief than n-liC\\\"ing thc r11euma- toid pain, ,\\nother example ofdiagn05hc difficulty Fwm the initial examination, she l'I\"ili determine could be a pahenl wIth srmptoms in the l'L'gions of the shoulder,upperarm,scapulaandnl'Ck,withcontribut- The joinb that lil'undl'rthl'arca of pain. ing sources from theC<'r\"ical spine, neural tissues and The joints that do not lie under the area of pain but can refcr pain intothl' area

Progno5is 87 Table 5,1 Olfferenllationof51rutlurts aMly\"\" the raIl' of progresion oft~disorder,This willas5lSlmmalmgaprognoslS. \" '~\" \"L \" \"-\"\",.\",,, -------~ r\\ detailed hislory wIll inform us if the spnptoms w -S\"\"u'-t\"afl<altryt:a:~: - - - - al1'spreadingorwo~gmmtensll}'Considerlhe \"\"_\"'_\".\"r'\"a\"\",l followmg: &ltrafl\"'t\"t • Aretheattacls11'lOll:'frequentordlSllbhng' s..pportiw~lnrIol15 • Is there a familial h,Slorl, and did the S)-mplOtN ~ic IMriKlOlaI \"'or<en or d~palc ..-ith or w;lnoutl\"\",tment? if Ikmiating !rlNItml'nt was uwd, \"''''''I mcthod W,lS It> ~rn,atnl • Does our 'medical knowledgt\" help us 10 SpondyIol,sthnis u~lhcpal1ftll'SStory> • IsIISUb;ect>\\·.. Orstructuralimpalf'll\"lnlt? The natural histor}' of an epllKldc of non-traumatic onset IS of resoIuhon. Our aim is to !If'CO'd up the pnxalS. ideally by prm'olinK the body's own healing powt'fS.and re,!on'ffi(l\\I.'fl\\E'fl\\<oit .s full dnd JXlm free. Thfmanopulatvfplly\\MlthuaplSlwllllisulllfd,n 'th~<:on~pt'wiIiTfarnto~ndfrstandthfpa,thof progff5sillnofthfd,sordfr Repealed ~'Plsod,-,s eau~ imp.,irmcnl. which will furth('rguide the fOl\"«asl. l, The neural ~ra5lh.1t will be implicatoo in What is th~ stability ofth~ disord~_\" _ pilmmerral. Adl'tailed hislory of the cum.'fIt episode Will inform 4. The muscles that lie under the area of pain. ~ Ihl'..-apisl how easily lhe problem is pmmled and ~Tabk.'5.lfOf\"lhedifferL-nliationofstructu reIJc.,-ed.Forexample,didlltake.Iong ..~(3dap;) ofdlla,'1Jlg up a lawn and rrplanlins; ItlopmnJle After three of four treatments, and anal)1ical il.0;s(55- ment, II may be pa;sibk.'lo reduce these four possibili- symptoms such lhal the pallenl couldn't go.\"! out of !>eSll)on.eOf\"ma,\"bet....o. bed Ofl Tuesday mormng> Or did he bend O'er to pic:k !lOIt\\cthing off the floor.nct feel hIs tt.ck 'go? (Stf' Thettunklng process is then rrlated to:; Chapt~6,p.118). • \\\"i!h whal rn(rI·c.omenl and hQw is the pam The past historywm also ho;olpenorrnously: rrprodU«d~ • On p\"\"'Klus epISOdes, did the b«k t.M- more • Doesthern(rltmenlll1\\'oIwstret<hinsOf\" Kti,·;tytoprmoL-pam> OOInpte8lng' • Arepredisposlngfactof'slmphalOO' • Aretht-lO'nlsurfacesopposedorootractccH • IstheSlleormtensltyofpamlncrt'asmg' • With differentiallOfl k5l:s{Stf\"Chapter6,p. 162), Ire • lslhen.alle!ed~\\1OfIpenpherally? • By the third lreatment..re the 5)'mptoms Ies6ening the neural or mmcular elements '\",\"0\"'00, and If so to .... hat ..~I\"\"., or mracting centrally, or the oppos,te> • lsthert'mOn'lhanoneslrnctureimplical007 • Arelhcsymptomsl'lOWrI'I()n'orles5e.1§l1y Bycarefulassessmt\"l\\lllIcsequestionscanbeanswe~ prm'okaP NoI£' lhal in lhe \\'erlebral column, and in pilrhculM in • Is Ihcbac:kac:hc worse but the leg: symploD15 ha\\'e 1ht-lumbMspint',thcdi!lC is rommonly a source of \"\"\",' pain{lhcwmmonfcaluresofitspre5CntationarediS- With a low lumbar disorder, the spine'sabilily 10 m(we cu~latcrinlhi\"ch\"ptcr) freely during a rcpeatl'(i mO\\'l'm~'111 from full nexion 10 What is the stage of the disorder? full t'xlt'nsion will indicale lis stability. Once iI full rangc hasb<x-nllChic\\'ed,lhe mO\\lemt.-nt of the spine is lfil ispossiblt'IOlocalizclht'structure,tht'll we must oI:>s<'rvedduringlhemo\\lem~\"ntoffullnexionthrough thinlinlt'rmsofSlagl!ofthedisorder,and~;fically to full t\"lt-nsion.

MAITLAND'S VERTEBRAL MANIPULATION Bl:g1n by slopptng!ht\" mo~l'llK'll1 011 the upright sLogeso !ht\"dison!t-'I\"is noIaggra\\-ala! This can be progn.'§I*'d by not stopping the rTlO\\emenl in lho- middle andbyll'lO'NSlllgtheo;peedoftherTlO\\'<-,\"\",-\"'I.Y:stly.by SUSIillnlngthefullf\\exionf.,..looger(t'_g.205o.'l.:Onds) theeff«tl!i.lmpltfia! CAUTIO!'> This is not a te§I rTlO\\'ernentlo be d\"\"\"\" Iftthe\"\\ltIo11.l~tstage;.. Whilt filctorsilre i1fferting the behilviour ofthe' disorder? T1It'onsttofth~d,Slmkr [fthe~ l!icaused by a specific inju,)', l\"ebeN\\ iour ofthedisordL'I\" is It'S6predictable than if It t'iofspontan· wusonsct. Will\", the on.....>1 is ~ponlaneous, t...o paltcn>S ern.o,-,rg<:1llcf,rstgmupofpalienlSisoflhOSt'''hO\\>t' symptom~ bl.ogin gradually, without I~ being any known ~membmxl ~aSOn. By dd\\'ing inlt) the.. hi$- lory it isn-\\eakod thai theys\\lfferro an injury (spr,lIn, Slrain) many years previously.IA'Spite ha\"nll had a good nlSpon..;c to In-atment at the time, th,s has la,d down the foundation for gradually de\"eloping degen. <.'ral,,'e Jrthrilk chang..-s. The prewnt episode ma\\ haH'bl-gun'cryinsidiously_su(hthattheyil~u\",~ble pm::i§('ly to .....member its onset. This pattern (an «>m- monly occur In patients be-f\"..'et'f14'i and 'is yea .... uf age, although Slm,lar radiological (h'II18\"\" rna)\" bl.. seen 1ft /I 74-)ear-old who has bl.>eo s)'mrt0m lret.' for 74 rt'.:lrs(Fr.'{wrr5,1)' So!oIf: propk ha~ ~ ~nmcftl ...hat lMy\"\"OUld Qn\"\",plOm$,yrttnr!l_raa~l~cotrtMtit ~t_d\\alMjOa~obYiou5lywdl Dtabl*d The'iC'rofld~n:\"\"potpalientsror\\'>l5tSofthosewho N\\t'5\\·mptomo.lha result ofrqx-tlIJ\\'e funct,ons,.:lt \"orkortnsrort·\"hw:h/ll\"t'ine!<ct'!6ofwh.:llthctrbod· ~ M5can ...-cOl1\\....oo/lte. Examples include O\\'erose, new It'il', dlllU and ab~, If lhis ;5 supe-nmpo6Cd upon Fig\"\"'!>.l (\"'and(!lIX·~ofa7.~af-oldp;:llJ.\"IW\"ois tymptomf= d~at\"ec\"\"ng('!;from/lpre'\\'ious\"\"ury(possibly from childhood), the P!'Ob'l1OSiS mar \"\"'01\\1' rllOO' trc.trncnl~sions\\\\'ith\"IOf\\g·term(~vcral)\"c.rs) mlunh'nan«' programmc1nvolvingcJ<erdSL'5and/or Thr:nlJturr:ofth~in)lJry stretches ~lnally, th<'rt'arc those patients who an.'ll'COvcnng The naturc of lhc injury Is.if;nificant in terms of how from trauma, surgery or other medkal man,'gcn....nl muchviolenC<.'orforCl'i,transf,'rn.'<l.Thetypeofinjury furreasonsothcrtlt.~naninjury(e.g,l1ervcrootcom· itself is a faClor. Por e~arnrl.., in a CM accident, tl1<' pl'C§Sion w,lh neurological changL-s). This latterg\"'up ~itionofthecarsatimriI-Ct,thc,pt-,,-'<landdi..,.,tiOf1 I!id,seuSS<.>dsupcrblybyJeff....ys(I99I) Ofmo\\-ernenlofbolhc;'rs,thCpt'.-.on'SJX!'>i!ionin lhe

Prognosis 89 Glrandhl5~tun'an.'alifactor..aff<:\"ClIngthl>beha\\·· Tablt::5.2 R«ogn,ubltftaturtSoflhc:prtstnting iourofthedl5Ol'der.lnanottw.>r~mrk>,theiniuring d'SOfdtr rrlO\\'emeflt may hnc been a repelJtl\\l' mm-emcnt __ tlllood b),.:ulassoembly·..roe .. orloY ~twoe:ump1e5 biU; .. ,II1eadthettw.>r<lpist'sthinkulgintwodifk.>nmldm_,<:- fftCI!I\",zo,blo,l8 tllDloqy? lJOnS reganhng prognosis. \\\"flI'icalot ..typoall8nmo1 l~u_loil\"\"lionlS{~\"I\\pra,\"p I'rt-ulstmg Signs and/or symptoms IS it· 1'R\"-t'~~t,\"g Signs and/or symptOll1S rna)' indicate a ·...~...k I\"'k', \"hkh gi\\'e:.out when tfiluma (albeit minor) ....,m\"\"st? isf~lIponthechain. l\\tWu\\ot? In til<'! nQn-tr~umat;c c~tL'8ory, rl'I\"'Jted past bouts dlSU5tr may h.\\\\e an incT'l'.1sing frequt'llcy and/or st'\\·erily. causing the currenl diMlrder 1Obl.' particul.1rly dis· ~.tlllOf'l:thiI\"_compotltnt? abling. ,\\n inflammatory oornponent may be emerging ....'Ih succes,<,l\\'C bouts, or a prl·'.-iously dormanl sub- clinical inflammatory component may erl'll.'fge follow- Lng a trilumatk q>i5Ode. Assessment of the h'e<llm<.Ylt ~\"nd themcthodoflreatffi\\.YlI ~ (amplitudl' .00 depth of mO'.-ement) help to cl.mf) the prognosis. If. bo-,- aged IS,-e.,.,. can'l swing a golf dub without ~ than 25 per emt of the unpr'O\\oo /IlO'\\mll'nt b.KL p.lin, thc prognOSIS \"III be \\eT) d,ffCTffit to that if l¢\"I'ned ...te.ach!ieS6lOfl.B\\ch.mgJngthep~tof the same problem affects a m;ln aged 60 years IhI'rompulcr.md lhed'lolir used for intcn'......·~, he ..as fN!\\' (,f signs .md symptoms when asIieSIlt'd befon> the Gf:nt::ralht::alth filth tn.'illmt\"l\"lt.ln ma.ny caso.·... aslut.. minordwtgesGln Imprm'e the situatton by altenng the imtat'\"g tepo.'!'tl\\e A~sufft\";ngfromotherdlSJnl\"rs(notmuscuJo. mO\\'t!Tt1t\"l\"ll. skl\"t\"I) Ilhly bcbclow ,Wl'ragl' in t!1o'lfg\"'neral fihlCSS Once the irritating posture or mo\\emenl i:s dim' It'\\·d. whkh may increa\"\"lhdr \\'ulnerability loproblcms. il,atedlheinjul\\.-dSlructul\\.>{s)canhcal. Gt::ndt::r A physiolhcf.. ~-Sjlttific diagnosis is COfIttmcd w,th mO\\\"Cmcntd;so<dtf1;thcfCforcilis;mportanlto A man's physiquE' is usuaU\\' dif(~nt to a woman's of 60cumcnt the ,nju\"ng mO\\\"Cmcnl di~,ons and 1M Slrn,lar \"ge, and they will tiNl ..·,th ph}\"!;kal st~ d,fferefotl\\- d.fKIlOOoffunction~tltTlilolllon iJmJpotion FamifyhistOtY 'The pdtK\"I\"It'soccup.1ho\" mU5t beronsidered if it is A filmily hIStory of s'milar di5Of\"dc.-.., mflal1ll'J'loltory fM1\"OO Iobeil re<lsonthallhedlSOrdcrisper1ilStmg. conditions 0.- poor hl'ahng mUSl.nfluence progoosis. \\\\,th careful a~1 the marupulati\\'e rnysio- 0t00 queshons thai must be ronsidCf'l'd IT\"\"\" S.2) ~ari thasathoroughu~t,\"dmgofthe~'s include: pnl-;i('alability, ..ndshecanrcl.JlClhistolusworkClwir- onml>nt. For example, il may be thai the patit'Tlt is • What IS ~mI.ableilboul the pdtienl's unabl.. tolumh,sheildfurtt~rthJn7('f'totheldtwilh. wndition? oulcausing pain. although he can tum <)(f to the righl • Whatdoesnol:.o>emtofilintothcfaclorsthal wilnoutdi\".;omfort.In hiSQfficl'thccompulL-risplac\"d guide the diagnos,..? 10 thl' ldt of his keyboar..-l and hchasa chair placooon hl~ Idt \",I~redicnlssit wht'\" hi' int~'r\"iews them, whoch Whatistht'causc'o(thtsourcc? happens 5e\\'eral limes a da)'- Although he made good ~ afu..,. IWO 11\\.\"almcnlS. he was unable to relain To T'l'itCh the stage of being able to complete lft',ltmml and am,-eat a prognos.l5 is IoWlderstand theJlOMible

90 MAtlLANO'S VERTEBRAL MANIPULATION underlying ~ why IN>struetun!has b«ome IN> HOW DOES THE EFfeCT OF TREATMENT sou~ of lh.i! symp~ in other wonb, what is IN> INflUENCE THE PROGNOSIS? '(1lu~ of lh.i! !iOU~' IT\"\"\" U, Part Two). As ...~Il as tr\"um.lI,ili.'S~ryto~llo!m5lJU(:h.pIlII>­ Although il is tempnng to pnodict the OOIcome of cer- lure, musc\\e ...-e;okne.l or tightne!lS, h)~htyof lAin tre.ltment k'chruques, II IS import<u'll to ret.aUl .... one ~ of ;on lfIlef'-\\'t'rtl'bn1 ~I INking the open ll'IUld 10 IN>lrealmenl ~ llusl'l't5tlresthr othersodeofthl' srgmenl worlth;ofder.or Ihl'segrnmts 0lCCUr;K)' of the assessmenl, which is essli'1lb4l to prtW- aboo.'e and below ~ liUniLtrly ..«....-ted Some ing the ,aJoe of each tn!alment lechniq~.ll>e..._ up«'tsloberonsideredrelotetothestructuresthat ..... menl process IS c>cplalf.oo Ul det,,,1 in Chapler\" Ihesouroe(ortheCiluseofltwsource)oflhesymploms The idl'al n.\"Sponse.o treatment is gradoal imp..,....... 1T'/lk5.l). ment to full p.lln-froe mOH'1l1ent in thn.'t' to four 1lIe e~amination emphasis is on the d..t..rnlln· trealme.1IS spread O'l'TJ...4 .....\"\"ks If there is a quick alion of the range of mO\\'l'ml'nts and th\"';, symptom \"''Sponsc, e.g. full ,,--.:o\\'e')' afl.., one treatment, Ihen resporlSl'S,wilh: Ix,.,,,..ithcr the joint signs ha..... not 'c1ear\\><l' Or the dis- I. I'hysil)logialrno\\'eml\"flltl'lilS. order may r'\\'Cur with very lillie pro\\'(lCiltion. If lhe 2, Functionalmo...t'ttlt-'I1th.\"Sb rcspon5l' is slow, thto manipulatin' phYSiotherapist ), Combmed ll1O\\'..mmt lests. must ronstanth be \"sking herself if lit<.- tt-.:hnlqoe I> 4. P,,5Si\\'e xceI8Or)' mou..menl tests. the wrongcllOl<:e, if its method of application (sln>ngth and her tedmiq ....) ... wrong, if il is her poor oornmuni- c..bon!oIS6l'S6met1t sLlls .. I Loull, .,.. b the dlSOl'der I!IttIr~eaNrru\\,iti5PAI.PATlONth.llisth< bey'ondhftalUlofe:o:perttse? J\"\"* ;t'I tn!\"tment techniques inu,\"-I' thl' llSfool'SSITlent ..m i/ftp;lrbnt ~ tM \"'CSt cllfficuh ~ to Inm. To p~lopnn·~tIwlr .. orth.§Odo~~ ~thissti.itisMttWlrytobf:llbktofULby gi\\ingany person stmehesor~, thetr\"\"\"\",,tm,'\" plllpllt>on,tlw:d,~,ntlw:spin;ol~lMlllS­ I'OeSI5 musl be ~ , In many cao;e t~ proce!ii» \"o\"\"all or MlnorMil; old or M'O'; I'typomobile or !ohould COfltinueunlll the ll§efulne!illii of thee:>oerdsesor ~-\"ndthtnbll'ablc:toreltJtethet!'5pOllse. stretches is pro'o\"eO. \"..... manlpul;otw(' ph)'5IOIhet'aplSl Jlre,depthal'ldrtleYoncetoopot,ennJympt\\1m5 mUSI pro\\'e lhelr valoe, and thl' patlent .... ,11 am\\'e\"t (Slflldllfa,5OU=orldcollSe#ThIS~Il'<elO\"n their o....n COflv·ic!i....... lltis is importanl so that they will honnl,s-:lf-<ritial\"tlltll<le.\"nd\"l5o\"pplintot\"e 'own' the problem and take lhe neo:esary actIon. lltis tnting of functional ~men1S and combined IS particularly ...I..,'ant when we think in tt'Tn'lSofprog- ~vsio!og;ul tnl mQYemenl'l. nosis, as both ('Xt-rdses (spccific or grnt\"'a1) ill\\ll ~tl'\\'lches IT TAKES AT LEAST 10 YEARS FOR ANY CUNICIAN become p.,rt LJf tilt' nect\"S&lry lift..\"tylt' ch.,ngt'S. If the (tvtn fJ<1e whQ lias an Inborn ability) TO lEARN THE respons<.- to treatment ;s (a\"'LJurable and the joints are RELATIONSHIP BETWEEN HER HANDS, THE PAIN 'ck.\"art'd', the fO\"-'COlSt is good and the patL('n1 Can ft.'!'1 in RESfONSES AND HER MIND control. 1lIe pahent must underslAnd what promles the disonll'T and tht.........ore what to \"\"Old (SIT prt'd15- posing filCtOfS, below). ItlNy be possible 10 provide Comments by rrwly INmpuL1twe ph~lOtheraptsts the palimt WIth knowledge of whal 10 do in terms of 1N~'t~rytoemph;osw!..gainthat: l'iISing the p;oin (lnO\\emml, heal, rest, <':t<:.), should ~be.. recuTl'l.'f'OCe In other words, If a struct1.lre is limiled in ..... nge HOW 00 PREDISPOSING FACTORS ,t do6 not ha\\-e to be the Jimlm' of symptoms. On INFLUENCE THE PROGNOSIS? 1M other hand, it may wl'1l be the c...... of ...Lated o\\'erworked st\",ctun.'li becoming the !iQIlTCr of When \" tri\\';al incident 0IU5eS qUIte dl...bhng pain, symptoms, there may Ix-' faclors that prt'dispose tht- 5plOe to 'g1\\\" ing \"\"ay'. In takmg the history these facton; muSI be Relating this fact to prognosis, il may be nl'«'ssary identified so that the manipulativ(' phys;otllc-rapist to take the stiffn....~ into acrount when gr\"ding the and the !\",tient are aw~re of them - th.. patient can ~tient's likely future lifestyl.. (e,g. recur~n~ of thl'O ~\\'oid them in the lifL-stylc changes h.. m~h\"\" and epOOdes;TQI1k5.2) the manipulative rhysiothe'~pist can und..rstand more fully tilt' disonler she is discoH'rms. and 'make

Prognosis 91 features fil'. The presence of these factors therefore THE CLINICAL APPLICATION OF inlluen~theforccast PROGNOSIS MAKING WHAT DO WE UNDERSTAND ABOUT THE CERVICAL SPINE PATIENT AND HIS RESPONSE TO INJURY? Headaches and the upper etrvical spine 1he manipulati,·e physiotherapist is not qualified to g\"·e a psychological/medical opinion of the patient For a complO\"le discussion of cervical headacht'S (and How\",'er, with experience, and often after th.rec to four diuinl'SS). the reader is referred to Lan~ (1993) and !realm...,t ~ions, she may haw evidl'l1ce of tl\\(> Bogduk(l994a) patient's respon,;e and his ability to communicate, and an understanding of the language he uses to communi- Many cervical headaches arise from Ihe uppt-\"T cer- r~le. This cert\"inly has \\'alue as a medical opinion. We vical spine, and th\", most common intervertebral \"'-1\\. ha,-e no conlTOl over tlw other person's attitude and ment invoked isCl/3_ Howe\"er, this level needs 10 be beh.wiour, but we have 100 per <:ent contoll over our dearly differenliatl'<l from C1/2 during the phy.icaJ own. Therdore to gain the best outromepossible forthe exami,mtion. Whl>O C2/J is t..... <ourc<', 0/4 becomes situation we must be vigilant in keeping our,.,ln'S in.-oked, but only as a secondary comp£>nent focus<-'llon: In Ihe subit-\",tiveexaminatoon.lhearea of symplOms l. Undersl~\"d\"'gthe situation from the patient's may not include the neck perspective Palpatiem is an important part of examination and i, 2. Making sure we are making our qUl'Stions elmr. enormouslyinlormati'lle 3. 8dicving the patient·s story. 4. Usmg wise ,um-verba/signals The main findings by palpation are Ihe following' 5. T~king the blame if there i5 \"\"sco\",,,,\",,ic~tJO\" • Thickening of tissues around the articular pillar, It is too easy to plato:- the blame for a poor outcomo:- on fn'<tuentlyunilaterally. f\"\"tors other thaH our own lack of skill, and therefore tocasl a poor prognosis • Thickt>oing of the ti,.ues in the interlaminar trough_ This interlaminar area is normally a Wilh this undeThtanding. the manipulative physio- shallow bony dip; abnormally there is no dip but therapisl must consider expt-'Ctationsat the conclusion rather a prominence, which may be Ihick and hard of treatment of the patient's disorder in reMio\" to (indicating its agel, soil and spongy, or cystic I. Thelik.,lyrestrai\"l:;onlif\"\"lyle. • Prominence of lhe spinous process of C3. 2. The likelihood of recurrences of episo<k'S of the • Limitation of Cl/C3 intl'rsegmental mo,·ement, disorder, and the pos<ible early warning signs especially with a unilaleral PA technique directed the patient must heed to minimize the severity 3lJ-.4O\"medialJyon the ipsilateral side oftheO-'Cllrrence;and the skpslhe patient then • Reproduction of at least part of the area of the nl\"l'ds to take cervical headache symptoms, or local DEEI' pain, 3. Thcnt'l-d for specific ongoing excrcises, Can always be found with at least one of the many intermittent maintenance lreatment or fnHow-up such palpation examination proct.'lh,O--< assessment. DEEP pain rcspons~ i, not acc<:ptcd a, bol:ing normal As Jeffreys (1991) so delightfully puts it, 'In few dlS- order5 Can prognosis be REVERSED (I dO-'SS<'<l him, Cervical spine headaches C,lO aris<- also from the God cu,,-'<l him - Ambroise Pare)\" occiput/C2 (0/C2) articulations, which require another important physical examination technique (compres- 1bc infom,ation thus gathered enables the mmlipu- sion) thai will provoke appropriate 'high' cervical Ioti,\"e physiotherapist to make a forecast of the probable (O/C2) symptoms and reveal limitations of range or course of the indi,~duai case she is treating. Howe,\"er. quality of movemenl. It also assists in differentiating while 'no two backs are Ih\", same' it is, a~ Jeffreys O/CI involvement from C2/3 ~tall'S, 'possiblo:- to form general predictions of Ihe nat· ural history 01 disordeTh'. In a very broad sense it is If the rompre;sioo is performed expertly (that is, with possible to look for guIdelines to direct one's lhinking liltle or no mo,'cn\\Cl'lt occurring below C2), the therapist will be able to feel if there is limitation to the fn'<' movcmt'l1t in the 13t<-.,.al f1exiondm.ction. From lhtosamc

92 MAITLAND'S VERTEBRAL MANIPULATION compm;s1Ol\\ por;itioo, bteral f\\el<ion is an Cilsio... r('SIri<\"- International dassification ofimpairmenl5, bQntOas6eS5th.misrotation,fIexion/eJllmsionorpro- disabilitit\":!o and handiCaps.=(la\"'D\"'HI'---_----=----= triilction/n.'tr.Iction. Any one cl ~ ~ mO'il\"'ll(\"nts will PfO''Oke symptoms cl which the patient is I(\",}dlly The World Ht...lth Organi...atooro ....tabll5hed the 1001-1 awoue.~hewillprolYblyreportlhemsponbl'lOOll§/l in 1980as the following (WHO, 1980) The Iw5tory may or may not lnvol~'e triilUJTIo1, If • Animf'4itJ'W?llisil\",'lossclnorm.Jlitycl triluJTlo1 has been a factor iiII'ld thejoint signs (pnmarily ps~·chologic.aloran;atoltllcal structure or functJon. paJpabQn) GIn be ·cleared'. the lil.ellhood cl recut- • Ad~i1ltliisanYl\"l\"!llriction.orlackoi..t>ilit),to I\"l\"I'lCe5l5dlftw\\lshed.HO\"o't\"\\\"ft\",Of\"IC'ethcpatlefltMs perform;octi\"itrinlhoemannerof,orw,thmthe suffeTed he.-d'Khe5 he has a propert5Ity IOsuffcr I1\"C\\lr- r.angeronsoderednormalfor... hllmdnbeing. renee, although treatment can Ies.scn their \"C\\ent) and~' It is important to detemlllle the cause • A htmdialp is. disach.nlage fora 1\\\"\"'\" indi\\tdual, resulting from an ,mpa,rmcnt or d_bill,)', t1wt cltheiKJUrce hmltsor J'1l\"'cnts the fulfIlment t-t' a rok, If thesymptoms uxIude \"isual dl5turWnct$ and/or dependmg on age, sa, <;()Cia! and cultural factors dizztneSll. the prognosis is k$5 clcar, ClbJIi\"cb\\'cly, wh,le for thai IndIl,dual ~rouhnetesl5maybeuseful.rompn.'SS,onishWy In 2001 a revist:d l'(hhon cl the ICIOH (ICf) \"as to be the mQl;t infom'liilb\"e published (WHO, 2QXI1 in \"hichtne- term 'lmpamncnt' Thede!lcnptJonoithemanyt)'pesclheadache(1..llnct\", Wil5definedasanimp.l'mlt.~,toffllnctionandtho:tomns 1998)hdJl5uslOputthecerviciillhead.:lcheintopco;pcc- ti\\~.Mllnyhei>d.:>chesuffl'TCr5wiUh.l\\'eaoomponentoi ·dis.:lbilil)~and '!l.lnlllcap' replan\"\" by 'iOCIilil)·'(Ie\\'l'lof pt'\",\"\"\",1 acti,'itics) and 'p.lr1icip.ltion' (concerns with cervical !lOUrceofsymptoms, bul lhl')' cannot be diag- \"'\"lCialrolcs),inordl'rtofocusmo.... on~rre.rathcr nosticallycalll'd 'ccr\"iciillheadachc'.and this wc musl acccpt as fact th.lnoo ddkils. The ICF l~ld('dl·Olll'll t\"describe le\"elsof 'disablcment' from tho' \"il'wJX'inl oflhediffl\"fl\"llt dimrn- ,iOl'\\5ofhc\"lthatbothbiologicaland~i.alle\\\"\"ls.ln Hc:adacheswith a neural component 2fXXlIC1DH-2 bl..:al11l' IC~: hu<'matiOlldI Classificaiton of l'ropk who ha~'e headaches wiJJ ~k t\"\"'dtml,,\"t be<;,UI~ FlillCtioning. of their selerity.thetrronstaocy(elenif mild,ift....'V bsllOOloogl.ifthcy .... not ...lie\\cdwithdruKs.or Many manlpuL't\" .. rhysiott.'I\"apisl5 will be mainly bK.USt' they .... disturbing and i,,,ohe other areas concemcd with thel\"\\aluation of impairments(V.mlMar MIdl ~ the (Me. 0')\"5 and tongue, or coocmlf.llton. \"al.• 1998). ho....f'\\'Cl'. (ha~ in focus towards I5tora- mood, diuiN'Sl>. etc, ~ral S)'mptoms lire dlff~t tionolfuJlfunctioncun,-\"\"tlyappea\",lolalepL:oce inthetrquahty from mU\"CUlosl<clcti1l~ymptorns.nd the other S\\'mptoms that \\ariously llIXOmpany pam/ The term impairment is lie\"cd slightl, diffcrent by Je-/fnoys(Jcffn\"l~,1991), Impairment can be subdi\"ided dis<:tln\\fort, into S!ntd,mlt ,mp.urMnlI .nd ~It!oi«lnY ,mpllitmnIl, Thec.ouseolthe,;e~canbe~-erubriillcanlll ...ndbothfOf11'l5ofimpaument ..... ' singl~·ortogetheT­ rontnbulCto dl5ilbibty, p a _ b... strnrtura.~CllI'1bediftcrenl;l.;ltl\"\"b\\' .lftheendre!iultis.an'~lintheheadache!i e:>ollrnuung and (Umpaf'inl;: Cft\\-nI mo\\\"\"\"\",,,,1S in \\'.n- and the ph)''5KlIISlgns, the patll\"nt 15 left ,,·,th an OU5po!i1l1On5(o:itl~Cft\\icalfIexion§upine,proneand 'imp\",,,,ml'. both sub,ect\" .. and structural. s.del)\"inglcftandrightJandb)'addingdiftl..\"'-\"fltcotnpon' • If the S)'Dlptoms 1IK\" not pl'O\\-oLed by the ...bnorm.1l f'll15 of thr,Jump ae\"t in the\"b1g§itlIng'po!iIlion and mo\\'Cn-.cnISlgns)'etthcsti\"lIl1\"Slilineuriillsigns.t notmg \\h(o ~~'mpklnl ..,.;ponsc diffcn.'T'l«5 lind diffen.>nt theappropll.iltelel\"cl,thepat-.cntisleflwilha r.l1'lf:~a,,,,bbJeinthedifferentpor;il1ons(Bn!'lg.I978) 'structural impaIrment' ThelK'CUracyclprognosisasafin.alan.alyticiillaSl5C!i!r- If there Ml\" no other oompliciltions or oomponcnlS, the mmt dl.opends on the manipulali,'e rhysiother.pist's UuJlI In examillation and treatment, plus her )·ca~ of roon-lraumahc hIStory 1:'1 nollongcr than,\"'r, 2 rears, and the pabcnt is young..r than about 1Oycars, it should cnt>c:alex~. bcpossiblctomakchimsymptom lroc. I lm'\"l·...er, ifthc\", The ideal gOiilI~ of t...atment \"\"\", to impro\\t: Ihe are appropriate Ch.1\"8CS presmt. such as ,ndicahonsof heJdache symptoms and 10 I\\'5tOl'1.' to normal. a~ (,le a~ hypcnnobility, inslJbility 01 a history of repc~ll'<ll),ld possible, the physical ~igns (especially the neural l'Pisodcs,thm the final prognosis might bc· signs} that wcrefound lobe abnormat at the ,,\"tsct Thehistoryoft~cer...icalhcadachl'Sisu'uatlylo\"l;, • Animpronodsubjl..:ti\" .. impal.mCrltrlus and thecnd result will probably bea compromise. This slnIctural impilirm..nt, bill not a dis.>bilityor c.n be an Impairment. acli\";tylimitation.