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This classic text has become one of the foundation texts for all modern manual therapists. The fourth edition has been extensively revised by two authors who worked closely with Geoff Maitland and who have added invaluable and up-to-date input in the revision of this new edition. The accompanying CD-ROM contains videos of all relevant examination and treatment techniques. All line drawings have been replaced with high quality photographs which , together with the CD-ROM and the book's new layout, afford an in-depth and user-friendly experience for readers. New for this edition: • Text is extensively updated and revised • CD-ROM of examination and treatment techniques described in the book • High quality photographs replace line drawings making the techniques clear and easy to follow • New chapter on Contemporary Perspectives in Physiotherapy Practice • Additional appendix: 'Self-management Strategies: Compliance and Behavioural Change' • Existing chapters extended and enhanced with evidence-based information and current practice Features: • New user-friendly text with bullet points and summaries • New design and layout of illustrations • Chapter summaries at the beginning of each chapter, including glossary of terms • Clinically accessible • Evidence-based • Colour highlighted boxes to reinforce the key concepts and aid revision • Clinical pathology with treatments for pathologies made clear • Assessment and treatment of patients clearly explained • Case studies included Maitland's Peripheral Manipulation serves as an important resource for all practicing and trainee manipulative therapists, as well as providing invaluable evidence-based teaching material and case studies for undergraduate study programmes. ELSEVIER www.elsevierhealth.com This product is appropriate for: 9 • manual therapists BUTTERWORTH • physiotherapists HEINEMANN • undergraduates and lecturers • osteopaths • chiropractors

Maitland's Peripheral Manipulation

For Butterworth-Heinemann Senior Commissioning Editor: Heidi Harrison Development Editor: Siobhan Campbell Project Manager: Morven Dean Design Direction: George Ajayi, Judith Wright

Maitland's Peripheral Manipulation Fourth Edition Edited by Elly Hengeveld MSc BPT OMT,vomp Senior Teacher. International Maitland Teachers' Association, Oberentfelden, Switzerland Kevin Banks BA MMACP MSCP SRP IMTA Member Chartered Physiotherapist, Rotherhom, UK Foreword by Peter Wells BA FCSP DIPTP SRP Consultant Specialist Physiotherapist, Sports and Spinal Clinics, Fulham, London, UK ELSEVIER BlTTERWORTI-1 HEINEMANN EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2005

ELSEVIER BUTET R\\\\IORTH liEINEMANN C 2005. Elsevier Ltd First published 1970 Second edition 1977 Third edition 1991 Fourth edition 2005 Reprinted 2006 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic.mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road.London W1T 4LP. Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelphia, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: healthpermissions@e)sevier.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com).by selecting 'Customer Support' and then 'Obtaining Permissions'. ISBN 0 7506 5598 4 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloguing in Publication Data A catalogue record for this book is available from the Library of Congress Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the publisher nor the editors assumes any liability for any injury and/or damage. your source for boko s, joumols and muttimedia In the health sciences www.elsevlerheolth.com Working tOgether to grow libmrie in developing countries _.dlCVic:r.c:om I _.bookaid.org I _.s;Ib�.org Printed in hina

v Contents Foreword vii 9. Recording 237 Preface to the fourth edition ix 10. Peripheral neuromusculoskeletal disorders 249 Preface to the first edition xi 11. The shoulder and shoulder girdle complex 275 Companion texts to this edition xiii 12. The elbow complex 357 13. The wrist and hand complex 399 1. The Maitland Concept - an introduction 14. The hip region 445 15. The knee complex 487 2. Mobilization and manipulation - definitions, 16. The ankle and foot complex 525 desired effects, role in rehabilitation and 17. The temporomandibular joints, larynx and hyoid evidence base 25 (the craniomandibular complex) 577 3. Communication and the therapeutic relationship 39 Appendix 1 Movement diagram theory and compiling a movement diagram 599 4. Contemporary perspectives in physiotherapy practice 71 Appendix 2 Self-management strategies: compliance and behavioural change 617 5. Principles of assessment 89 Index 625 6. Principles of examination 125 7. Principles and method of mobilization/ manipulation techniques 165 8. Principles of selection and progression of mobilization/manipulation techniques 179

vii Foreword It is not difficult to see why this book has stood the test and clinical presentations, was illuminating and it is of time and critical appraisal to reacl1 its 4th edition. still, contrary to the views of a few who seem entirely to Like its companion volume, Vertebral Manipulation, it have missed the point, a valuable idea. was, in its slimmer original version published in 1970, a landmark publication. Other books on the 'why's and Sound clinical reasoning, long before that term was how's of manipulation existed but they were written by on everybody's lips, was the foundation of the pio­ doctors, essentially for doctors. Physiotherapists were neering work of Geoffrey Maitland, as recorded in his the 'also rans'. Not trained as primary medical diag­ books and articles. This was not only what he nosticians, unable to prescribe medication or inject or preached but also very much seen in what he prac­ carry out manipulations under anaesthetic, they and tised, as those privileged to watch him treating their skills were usually relegated to a secondary, tech­ patients, can confirm. nicians role in the assessment and treatment of mus­ culo-skeletal conditions. This approach was inevitably His saying that 'technique is the brainchild of inge­ centred exclusively on the medical model of examina­ nuity' was demonstrated on one occasion when an tion, diagnosis, and treatment but incorporated tech­ observer, watching him on a course treating a patient, niques of manual skill commonly viewed as 'fringe' or enquired what was the technique he was using. \"I don't 'alternative'. Some of these stemmed from osteopathy. know\" came the reply \"I've never done it before\"! this was not, of course, a facetious remark, but an enjoinder Whilst the skills of passive movement used in treat­ to \"go thou and do likewise\". ment of a wide range of disorders such as those within orthopaedics and neurology, had always been an The process of ongoing, continuous re-assessment essential part of the work of physiotherapists, a com­ at all stages of treatment and its follow-on, using pre­ prehensive text of sufficient substance and originality, cise, detailed questioning and retesting has remained written by a physiotherapist for physiotherapists was as a fundamental strength of this approach. This lacking. Maitland's Vertebral Manipulation changed all process exemplifies the enormous contribution made of that and Peripheral Manipulation (1970) followed by Geoffrey Maitland in his emphasis on the impor­ on in the same vein. tance of subtle communication as a fundamental skill to be mastered in the process of \"proving clinically\" The development of aspects of 'the Maitland con­ the value or otherwise of particular passive movement cept' as it became known, was fascinating to follow. strategies and other associated techniques. This is well Numerous ideas, such as 'movement diagrams' and the documented in Chapter 3, essential reading for all 'grading' of each technique to define its force and medical personnel of whatever profession. amplitude and mode of application, became valuable teaching tools for communication and were an attempt Another great strength of the approach described in at accurate recording, both in the clinical setting and in this book is that it is non-dogmatic. Consequently, an the process of teaching and learning. The conceptualiza­ evolving knowledge base has been incorporated, over tion of an imaginary (permeable!) 'brick wall' separat­ the years. It is not a 'method' or 'school' in the narrow ing, but not mutually excluding, scientific knowledge sense. Its 'open' approach has facilitated a develop­ ment and expansion of the whole, \"developing and extending\" as Maitland himself put it (Chapter I). With

viii FOREWORD no necessity to change its basic principles it has been The expansion of the text to incorporate referenced possible to add to and develop the work. Compare the research and other material, case studies, physiothera­ size and content of this edition with the first. pists thoughts and hypotheses, clinical profiles, pho­ tography of techniques and much else adds greatly to The authors are to be congratulated on their success the work as a standard reference and a course text, in developing the contents of this third edition to incor­ as well as a rich source of clinical guidance and porate, apparently seamlessly, the advances made in, illumination. for example, the pain sciences, in the last fifteen years or so. An osteo-arthritic knee is no longer viewed as It must surely have been an inspiration to the simply a painful, stiff joint, but a problem having, like authors that a growing amount of research across a low back pain, a bio-psychosocial construct, and this is wide spectrum of expertise in physiotherapy and the right. Peripheral nociceptive, peripheral neurogenic, field of manipulation has stemmed from the teaching central and sympathetically maintained pain are exam­ summarized in this book and its previous editions. ples highlighting variations within nervous system pain physiology which must help guide and modify The foundation of the International Maitland our use of manipulative therapy. Teacher's Association (IMTA) in Switzerland was due to the foresight and determination of a remarkable However the brilliance and originality of so many physiotherapist, Gisela Rolf. This organization has of Geoffrey Maitland's ideas have not been lost. For overseen the training of teachers who attempt to satisfy example, the concept of 'irritability' as distinct from the demand in Europe and elsewhere for regulated, 'severity', whilst it has been criticised from a narrow high standard, post-graduate courses in this field. They academic viewpoint, remains a valuable insight help­ will, without doubt, be encouraged by this new edition. ing the clinician make crucial decisions about the for­ mulation of their day to day treatments. The pioneering work of Geoffrey Maitland, reflected in these pages has, over the years, generated Likewise the perceptive subdivision of 'overuse', some heat in discussion but, most importantly, great 'misuse', 'abuse', 'new use' and 'disuse' to illuminate light. This present edition will illuminate further its clinical states is as useful as ever in gaining further subject. insight into the nature of the great array of musculo­ skeletal problems. Even terms such as 'unstable insta­ Most importantly it presents us with an absorbing bility' and 'stable instability' which have thrown some and comprehensive text helping to define a crucial moderate people into a rage, are supported by an part of the work of physiotherapists. underlying wisdom coupled with a wealth of clinical experience. Peter Wells, London 2005

ix Preface to the fourth ed ition The preface to the first edition of this book was written of physiotherapy practice. Guidelines for assessment, 35 years ago and is as relevant to today's physiother­ examination and treatment have been updated with apy profession as it was in 1970. The advancement of relevant evidence from the current literature, including: orthopaedic medical imaging and diagnostics, and the contemporary developments in physiotherapy practice advent of extended scope physiotherapy practice have (Chapter 4); clinical reasoning science; the biopsycho­ distracted the profession from the detail of joint pain social paradigm, including psychosocial assessment and the ability to deal with it at face value. The mes­ (Chapters 4 and 5) and fue essence of self-management sage in the preface to the first edition, therefore, could strategies with a focus on compliance enhancement be applied to contemporary physiotherapy practice in and behavioural change (Appendix 2). Appendix 1 is 2005. Read it and see. preceded by a review of topical issues in the definition of R], the definition of grades of mobilization and 'The Maitland Concept', as it has come to be known, manipulation, and the reliability of detecting and repre­ appears to be contradictory, exhibiting both the quali­ senting the parameters encountered during passive ties of stability and flexibility. The clinical basis and the movement testing. Concept's fundamental elements have remained the same throughout its evolution. At the same time it has Abullet-point method of presenting the text has been changed with the times and accepted contemporary used for clarity and to improve the user-friendliness of manipulative physiotherapy methods. The Concept the book. The line drawings so expertly produced by has maintained an unassuming, non-judgemental and Anne Maitland have been superseded by photographs. open-minded approach, which perpetuates a patient­ The main reason for tlUs is to complement the CD-ROM centred model of clinical practice. This is its backbone which accompanies this fourfu edition and helps to and the strengtl1, stability and flexibility of the symbolic bring to life most of the techniques of examination and permeable 'brick wall' analogy. treatment described in the book. The fourth edition of Maitland's PeripheraL Manipula­ Kevin Banks expresses his thanks to: Jukka Kangas tion presents an integrated, contemporary and evidence­ and Donna Ardron for their constructive comments on based model of manipulative physiotherapy. Such a the revised text; Robin Blake for sharing his knowl­ model is placed within the context of 'best practice' for edge and expertise over many years, and Nancy and movement-related neuromusculoskeletal disorders of the kids for their patience and understanding in seeing the upper and lower limb. Each chapter of this text has this project through. been revised and expanded to reflect advances in knowledge and the role of manipulative physiotherapy Elly Hengeveld wishes to thank everybody who has within contemporary clinical practice. This includes: given constructive suggestions to the texts, in particu­ the reference to the International Classification of Func­ lar Renee de Ruyter-Bouwman and Hugo Stam; Gisela tioning, DisabiLities and Health (rCF, WHO 2001); pain Rolf, as a teacher in the 1980s, for her dedication, mechanisms; biopsychosocial paradigms; the rehabili­ thoroughness and determination to give everything tation process and current definitions and descriptions for her visions; Franzi and Ueli, Catherine, Christin and Roland, Renee and Henk - thanks for being such

x PREFACE TO THE FOURTH EDITION L good friends, even in more difficult times, and most of our duty to be the custodians of their knowledge and all to Charles, Lijda and Kees, I remember what is truly to nurture and develop this concept into its early important in life. adulthood. Both authors thank the medical publishing team at Kevin Banks, Rotherham, UK Elsevier and their IMTA colleagues for their support Elly Hengeveld, Oberentfelden, Switzerland and guidance. 2004 Last but not least to Geoff and Anne Maitland to whom we owe everything and to whom we feel it is

xi Preface to the first ed ition Treatment of painful peripheral joints by passive move­ of his father, Dr James Menne1l2, who stressed the ment has become almost a forgotten art among physio­ importance of accessory movement (or, in his own ter­ therapists. In the present era active exercise, combined minology, 'joint play'). with heat or cold therapy, is the popular and estab­ lished approach. Passive movement is not routinely Even with these books, and others written by lay used because in the past its techniques have been used manipulators, there are still several facets of the field of too strongly, causing the patient unnecessary discom­ passive movement treatment which are not covered. fort and sometimes aggravating the condition. There are occasions when patients are referred for physiotherapy with joint disorders which require tech­ Hesitation on the part of doctors and physiother­ niques not previously described, or when the reasons apists to use passive movement arises from a lack of for choosing particular amplitudes and positions in the understanding of how and when to apply gentle tech­ range have not previously been described or related to niques, and of their effectiveness. P hysiotherapists, inex­ the examination finding of the joint disorders. perienced in handling painful joints passively, may have inadvertently aggravated the pain and thus The purpose of this book is to present techniques wrongly concluded that passive movement should not for all peripheral joints, to discuss in detail the relevant be used. This condition is unfortunate; when precise parts of examination by passive movement, and to physical signs of joint disturbance can be determined, relate the method of applying the techniques to the quicker and better results may be achieved using pas­ examination findings. sive movement guided by the signs. Often quite gentle techniques can be used. Most people think of passive movement treatment as a stretching process to increase the range of move­ Many books have been written about manipulation ment of a stiff joint. However, the application of passive of peripheral joints. Among these are important con­ movement to painful peripheral joints is far wider than tributions by Dr Cyriaxl and Drs James2 and John this. Its use in the treatment ofjoint pain, whether the range Menne1l3 Dr Cyriax's work is particularly notable for of movement is limited or not, has not been appreciated. This the presentation of accurate methods of examination. subject has not been treated in any other text published The treatment techniques he outlines are those of the and possibly may not have been considered before. For stronger type, some of which require the assistance of this reason alone the following text is necessary to fill a physiotherapists. Dr John Menne1l3 continues the work gap in the physical treatment of joint pain. I Cyriax, J. Textbook of Orthopaedic Medicine. Vol. II, 7th edn. Although some of the techniques will be similar to London; Bailliere TindalJ (1965) those published by others, many will be different, and 2 Mennell, James Science and Art of Joint Manipulation. Vol. II. some of the moving parts for which techniques are London; Churchill (1952) described have not been presented before. Also, some 3 Mennell, John McM. Joint Pain. Boston; Little Brown & Co of the movements described for certain joints have not (1965) London; Churchill (1964) been presented before. Diagnosis will not be discussed in this book as this is the province of the medical practitioner. However,

xii PREFACE TO THE FIRST EDITION [ when he refers a patient, very careful examination of clearly the relationship between passive movement joint movement must be undertaken by the physiother­ used in treatment and the clinical signs. The concept of apist. The findings will guide the choice of technique a 'movement diagram' was evolved by Miss J-M. and the style of movement to be used (i.e. small ampli­ Ganne, MCSP, MAPA, DipTP, and further developed tude, large amplitude, avoiding pain or moving into in an article jOintly written by Miss Jennifer Hickling, pain), and the range in which it is performed. The find­ MCSP and the author, published in the Journal of the ings also act as guides for the assessment of progress. Chartered Society of Physiotherapy4 and the Australian Journal of Physiotherapy5 Thanks are due to Miss When any new form of treatment becomes popular, Hickling and to the Editors of both journals for permit­ people tend to think only about the new techniques; ting part of the article to be reproduced in this book. the idea being that once the techniques are learned, nothing remains but to apply them to patients. If this Dr D. A. Brewerton, MD, FRCP, has provided an idea is carried out by numerous people, it follows that invaluable medical approach to the many aspects of standards of treatment fall, results are poor, and con­ passive movement treatment, and I am grateful to him sequently the treatment method lapses. This idea of for his contribution. Much needs to be said about atti­ solely learning techniques and applying them indis­ tudes to and prejudices against this form of treatment criminately is totally inadequate. For this reason con­ which cannot properly be said by a physiotherapist, siderable space in the ensuing text is given to minute and I am very pleased to have Dr Brewerton's willing examination detail and to the ways in which the tech­ support and I thank him sincerely. Many amendments niques should be applied to the findings. The process regarding presentation were made to the text as it may seem tedious at first and may even emphasize the evolved and Mrs J. Trott, Miss P atricia Trott, AVA, points which seem too trivial to mention. However, Grad. Dip. Manip. Ther., MAPA, MCSP, and Miss M. J. this depth of detail is designed to prevent misunder­ Hammond, AVA, MAPA, MCSP, Dip.TP, have been standing of the reasons for the application of the tech­ patient, helpful and encouraging. The illustrations niques. Also, as a musculoskeletal disorder may drawn by my wife more than achieve their purpose. present different joint signs at different stages of devel­ They clearly and simply illustrate the text and avoid opment of the complaint, it is essential that examin­ the distractions often present with photographs. I am ation of the joint signs be carried out in detail. Different especially grateful for her helpfulness and suggestions joint signs require different treatment techniques. throughout the project. Without the willing help of the many people who carried out typing, modelling, and In the chapter on Examination appreciation of the drawing of graphs, the book could not have been com­ various factors which constitute the joint signs deter­ pleted and I extend to them my grateful thanks. mined by passive movement tests is discussed. In the appendices 'movement diagrams' have been offered G. D. Maitland as the best method at present available for teaching Adelaide 1970 this appreciation. The 'movement diagram' has also been used in the chapter on Treatment to express more 4 Hickling, J. and Maitland, G. D. Abnormalities in passive movement: diagrammatic representation. Journal of the Chartered Society of Physiotherapists, 56, 105 (1970) 5 Hickling, J. and Maitland, G. D. Abnormalities in passive movement: diagrammatic representation. Australian Journal of Physiotherapy, XVL 13 (1970)

xiii Compan ion texts to this ed ition Boissonnault, W. 1995. Examination in Physical Therapy Jones, M. & Rivett, D., eds. 2004. Clinical Reasoning for Practice - Screening for Medical Disease. New York: Manual Therapists. Edinburgh: Butterworth-Heinemann Churchill Livingstone Maitland, G. D. 1992. Neuro/musculoskeletal Examination and Butler, D. 1. 2000. The Sensitive Nervous System. Adelaide: Recording Guide, 5th edn. Adelaide: Lauderdale Press NOIGroup Maitland, G. D., Hengeveld, E., Banks, K. & English, K. 2005. Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Maitland's Vertebral Manipulation, 7th edn. Oxford: Medicine. London: Butterworth Butterworth-Heinemann Goodman, C. & Snyder, T. 1995. Differential Sahrmann, S. A. 2002. Diagnosis and Treatment ofMovement Physical Therapy, 2nd edn. Philadelphia: W. B. Saunders Impairment Syndromes. St Louis: Mosby Higgs, J. & Jones, M. A. 2000. Clinical Reasoning in the Health Professions, 2nd edn. New York: Butterworth-Heinemann

Chapter 1 The Maitland Concept - an introduction THIS CHAPTER INCLUDES: • Introduction to the Concept • Examination • The central core • Treatment techniques • Key words for this chapter • The brick wall approach to clinical • Assessment • A glossary of terms for this chapter • The Concept in context. • General themes of the book decision making KEY WORDS personal commitment, symbolic treatment techn iques, assessment, context. Maitland Concept, movement system, permeable brick wall, examination, GLOSSARY OF TERMS treatments that have been the source of symptoms when one admin istered. This collection of or more joints or structures is Accessory movement - accessory or information is analysed so as to involved in a particular movement. joint play movements are those allow understanding of the likely Disorder - any complaint from w h ich movements of a joint that cannot future of the patient's disorder. any patient may suffer and be be performed actively by the Biomedical engineering - the referred to a physiotherapist. This individual. Such accessory association between cellular and will include those disorders which movements include the roll, spin tissue biology and disease and can be given an accurate titled and slide which accompany a engineering as in prosthetics, diagnosis, as well as those that, joint's physiological movements. materials used in tissue healing though perhaps being recognized Accessory movements should be and replacement and, more as a syndrome, cannot be precisely examined passively for range and recently, gene therapy. titled. pain (symptom) response in the Clinical reasoning - the thinking Frame of reference - the context joint's loose packed position, in underlying clin ical practice into which the patient places their painful positions of a free range of through information gathering, experiences (of pain) based on their movement or at the end of a interpretation of information, present and past experiences of limited range. actions upon findings and similar situations. In turn this evaluation of such actions, each determines the manner in which Analytical assessment - assessment strand of information resulting in they will respond to pain and made during the episode of care or an ever-evolving understanding of functional impairment and the at its conclusion. It takes into the patient and their disorder. endeavours of health professionals account all details of the past and Differentiation testing - to help them. present history of the patient's examination procedures which Functional corners - combinations disorder, the diagnostic details and assess which joint or structure is of functional joint movement the response to the different

2 MAITLAND'S PERIPHERAL MANIPULATION which are regularly incorporated the disorder's history, symptoms Pain mechanisms - the complex into everyday activities. Such and signs. This mode of thinking interactions within the functional corners need restoring also takes into account diagnoses neuromatrix by wh ich sensory to their ideal pain-free status with which are incomplete or input is processed, influenced by passive movements in cases where uncertain. autonomic, endocrine and motor minimal joint signs are preventing Movement diagram - a two­ output and consequentl y full recovery (e.g. h ip flexion / dimensional pictorial or mental experienced b y a n individual adduction, elbow extension / image, a dynamic map showing the patient as pain. abduction). physiotherapist's perceptions of the Illness behaviour - during illness, pain extent and relationship between Paradigm - a model of beliefs based experience or functional impairment, joint signs (usually pain, spasm­ on a professional body of the means by which an individual free resistance, and protective knowledge, such as the paradigm can sample and express their muscle spasm) during the that physiotherapy is a feelings, thoughts and emotions assessment of a particular passive rehabilitation profession with an about their state of health or illness. movement direction of a joint. expertise in disorders of the This can be through verbal or Movement diagrams serve as a movement system. non-verbal expressions, including self-learn ing process, a teaching both actions and inactions, which medium and a means of Physiological movement - those may be either adaptive and beneficial commun ication. movements of a joint which can be to recovery or maladaptive and Movement system - an anatomical performed actively by the unhelpful to recovery. and physiological system that individual and wh ich can be Impairment - problems in body functions to provide motion examined for range, quality and function or structure such as a of the body as a whole or of symptom response, both actively significant deviation or loss. its component parts (Sahrman n and passively. Injuring movement - re-enactment 2001). of a particular injuring direction Overpressure - every joint has a Prognosis - the forecast of the of stress in the physical passive range of motion which probable course of a case of examination in order to reproduce exceeds its active range. To this disease or injury, or the art of symptoms or divulge relevant passive range, further normal making such a forecast (The comparable signs. movement can be gained by a Shorter Oxford Dictionary Mode of thinking - the separation of stretching application of 1980). th inking into a theoretical overpressure. This overpressure compartment and a clinical range has, in nearly all examples, a The body's capacity to inform - compartment so that thoughts degree of discomfort or hurt and the patient's perception of related to the theory of a patient's should be assessed before declaring their own bodily health, disorder disorder do not inh ibit the a joint movement to be normal or functional status and how, discovering of the finer details of or ideal. w ith guidance from their physiotherapist, they can express these perceptions through description and /or demonstration. GENERAL THEMES AROUND WHICH THE importance to the patient and the order in which 4TH EDITION IS BASED the physiotherapist should be thinking about them (Fig. 1.1 ): The fundamental components of the Maitland Concept are inextricably linked and interrelated. They give the • The patient-centred approach to dealing with manipulative physiotherapist a platform for the deliv­ movement disorders ery of a flexible and innovative clinical reasoning approach to the management of neuromusculoskeletal • The brick wall approach and the primacy of and movement-related disorders. The following sum­ clinical evidence mary reflects the themes which will emerge throughout the text. These themes are presented in order of their • The paradigm of identifying and maximizing movement potential • The science and art of assessment.